A24A 5�aiicatlon Date: � -C)
Amount �aid: �
Recai
(X�� C���
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3� ��3
3'�
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Parc�l �- �
APQlJCATiON i-0R SE3i111C�S �
IF THE INFORBflAT10N IN THE APP�LICATION FOR AN IMPR��IEMENT PERAAIT 15 INCORRE�'T. FALSiFiE�J.
CiaANGED aR THE SITE IS ALTERED THE�d i'HE lAAP1�01/E3IAENT PERMRAND AUTHORIZAilON TO .
CON�TRLJCT SHALL BECOAAE INVALID. G��R� �i� iZ--�G ,
/�
1) Pertnit requested by: Owne . gentlprospedive owner): �C C9 '�' �T° N�/ .�
Hame Phone:' S` �. Address: ��F S o�• N G 2�7�y0
Business Phone: S�9✓yl� -?>�� � _ �
2) Name and �ddress of current ov+mec L . ' 1�
� — — v`v � V�
� � � _ _ � �� � GV' �. �7�/v .
..- � � �, u��i�
3 �%��'�`�TownshlpJNN/A��fi� � � 5%[�
� Pro�xerty Description: LDt size: ubdivision: �C " Lai
D 'ons to the property (lndu g road nam �and numbecs): �'
�z o�z. /1�I • � ' �.tZ .� �
2� J����D�'j �� � � � ��� .
�
�'rl� Z2`.v�n
�� ���
4) Proposed Use d Structure Desariptlon: answer eacii of the f lowin questions: / " .s
a) Proposed � Existing . Type of Structure: /-�- -��fi/N� j�►�GY�I� Width: ��� Depth: .,3 C�
c)iNumber of Bedroom�: ,.� Number of occupants or people to beserved: � �
) asement Yes ✓ No WW there be plumbing in the•basement? -�
d �arbage Dispasal: Yes No ✓ �
5� Water SupPly Ty�e: Private �(new ✓ or exlsting ��, Pu61icJ Com�'nw�ity� . Spring _,
Are any welis on ad;�ining prFe�y? Y�s ✓ tdo _ I� yc�s, piease indicate approxlmate locatiori on the
'site pl�n. �
b� Does your prop�rty contain_prevlously identffled Jurfsdictlonai wetlancds? Yas No V
PLEA►SE NO'TE THE FOLLOWING:
➢ A Pl.AT OF THE PROPEi2TY OR SITE PLAi�I MUST SE SUBMITTED W17N THIS APPLICATI�N.
➢ PROP�TY UNES A�ID CORNERS MUST BE CLEARLY MARKED. •,
9 THE PR�POSED LOCATION t3F �►Ll. STRUCTURES MUST BE ST��D OR FLAGGED.
9 THE SITE MUST �E RE�DILY ACCESSIBL.E FOR AN EVI�LLUATION BY THE liEA►L'iH DEPARTMEiNT
STAFF.
i hereby make appiicatian ta the Person C�nty Health Department for a site evaluation for the on-site sewage disposal
system for the abave-described property. 1 agres that the c�ntents of this application are true and represerrt the maximum
faciii�es to be piac�d on the property. I understand ifi the site is altered or the intended use changes, the petmit shall
became irnalid.
�/l/��D��
Qate
PCc�D, rev. 06127/a2
05/25/2006 12:06 336-388-5940 EVANS WELL DRILLING PAGE 01
�� Q3
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`' , IL`1ti�Ji�;.� �..t� �� �� � r = / 1 • � 5
..��.-l`� � %.� �J��~��� C�1�n� (�y�yj�y�
�x+►•. ar��.u�.u�x, �oiRa��.� :��.�..a�.��&ar. W�M� tsA+un+r`*+
Cr�Out Lo#,
�, << r. T-.r /.� e r Tax Map�„2,�q.. Parccl #�,,,�
� a� ion: _ . ^
�
iu� �divi�ion: �_,t,h.G,s b,,c,�,�_ Lot #� �,,..�„r
� ' WaII Conitructlon
�iatanco Fr om nea ,�at ' rop: rty Lit�e (Minirnuni 10 feat) ✓
�istance from Snvtic !i . et�:m (Minimum b0 f t) �
I'ot�1 Depth: ,� o� t Yic1d: _� �PM Sc�ric W�tcr I.evcl: ��, R
Water Hcaring Zon��,: ilepth � ft___�,�_ ft ,.,^�, ft_____rr_ R
Guin�. F--,� g Disrnetcr- b` in
Depth: From _� ��—. • —�—
�C: �AIVSfl17':.0 JjCCI ��
Weigh+ ThiclmeaB:1„�� Haight abovt f3rotusd: in
Drive Shoe• _,,, es Nn Any problems auc�untared while setting caging7 _Y�a _ No
es" �c ri•ason:
� "y �' -
Grnut:
h er,r. Sand/Cement Concrete C��ar►eUC�mcnt
��u►ulac �Sps�ce Width _"�-� inchct W�a u� Aru�ular Sp�aa „�„�Yea ��%io
Niothod af Grout: Pumpcd Pres�urc � Poi�ed �. Dcpth f�. _ to �_ Ft.
Msterl��!y ilsed:
No. Aaga r'ortl�d cement Weight of 1 B�g � Pdunds
� Tf mixtur� (send� vcl, cuttinge) — R,atio ��to �(.�
' 1D platos; .�.�Yes � No 4 x A alab ,�,�Y�e �_ No
I.IAGF: •
�pth; � Dato Indtullcd' C3raut• -- Inetalled by: _
• ��p� �g Locadon Dra�w►ng
Fron� ^� '�'o :
� + �
— �- - .� �
,��---�
.Q ...3��
I h�:rc��y c� cd,°y that th� ab�va infom�ation is ooaect �nd that this we11 was conabuctnd in acoordencc with re�ulatiotte set fa�t}�
r j�1C PCC5�1_ COIUlty I 1a8I1,t1 DCt?L2�CiIt- � / 1 l
i�'''1 1 /fr 1 !
5lgnatur� 01 ContrA���r
�D # ,�,�,�,�
Pump Instaliment
ji1LtC � • ' �� . �r 'J �
Pump inafallation C:or� t�ctbr: Ststex Registrarian Number: ,�„_. _
Pump Depth�. ft Statfc Wster �,cvel: ft
T'ump Makc• & Modcl: _ �_ Pump 5ize and R,ating: _, hP ,.�.____� gPm
I hcreby cc tify that tk s pump wae installcd and the well head eompleted acaarding to the Peryan County Wcll Rulcs in effe�t
an t}►]9 aBT� and thac a;��py of thie recard has been providcd to tha well ownar.
Pmm� 1rr�t..flvr !Clv»Ar.�lre �itte: PCI'�D feV OI/27104
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�YEI�L PE�2MIT
gI,��SE SEE A'1'I'AC�D PI.AN FOR WE� SITE ?.�YOLTT
Tax Map #: c� Pazcel #� Township
APP�� �.G. r r y .� S I c�/
Subdivision: pr ��,S �o�'o(�y Ci �StG.'�.S Section: Lo� �
Loca�ion:
'I'�e of Water Su��lv: v Indivicival Community Public
Rec�uireffienis:
Site Approved bp � S'oZS— �
Grouting Appmved by , S aS
Well Log ,� �11G
Well T i� � �-- .� %i�i�j0 �T/�, f''
Air Vent 5 �� Z 7- � U
Hose B�
Concrete Slab t� f, f�
�u�"�p �ao� �S S "27 �0 9'
Well Ytiriller. � l�l �'�
Well Approved
'�See Attached Site Sketc�'�
Wells must be 10 feet from property lines.
WeIls must be 100 feet from septic systems. �
Wells must be ax least 25 feet from anp bwlding foundation.
Other conditions: -irt S�i, f I W � l� �S S� a t� r►'
PG`��, rev. 09/07/Oi
p`��, / � 1.Y ��� ��
` v � � � ����
��av�-��-��n.s�n.����.11. ���.�.11.�1Ea
Applicant:
Location:
e
'�:�j I°: ' � � � �
�x M�P !/ � F'�rcel # � �
Subci!ivision , � �. ., �,.
Ph�.se Section;Lot #
# of Bed�rooms
i
System Type (In Accordance With Table Va):
THIS SYSTEM HAS BEEM I[�ISTALLED IN COMPUANCE WITH APPLICABLE NORTH
CAROLIMA GE1dERAL STATUTES,� RULES FOR SEWAGE TREATIVIEAtT AND DISPOSAL,
AtdD AL:L CONDIT10iVS OF "� THE 1MPROVEMENT PERMIT APlD COMSTRUCTION
AUTHOR[ZATION. � �
. . `��7� tr �
Autho tate Agent Date ,
installed By:� Date:_�/y � � �
� �I- o�
t�T5- ro 0 0
� � �z
_..-�i�� � .d
/�1/s�-.s�/�
��i�� G� � n
c 30o t.�t/�-
�r��5
-.. �o _ ao �.
PCHD, rev. 07r'29/Q4
SEP�'lC TAN�C 1R�SP��`�9�� ��E��(L9�T ('d'�e 19 - !�
Tax Map # Parce! # Sysiem Type (Tabie Va) �
Owner/Applicant Subdivision
Address/Locatiori SeclPhase Lot #
Se iic Ta�k aast�a! ���� iVetr�a �ca ora anes ne�a ate
State�lD/date Trench �dth �" , ft.
Ca aci al. � � Trench De th in.
Tee and Fiiter � Trencii Len h ft.
Baffte � Trench Grade � � �
Seaiant Trench S acin
Riser if a licable � � Rock De th and Quai' �
Tank 4utiet Seal Dams/S#e downs e#c. �
Permanent Marker - Pressure Laterals �
Pump Tank Hole Spacing �
State a e . o e �ze �
Ca aci aL Pi e. Sleeve �
Wate roof /Sealant Tum- s/Protectors
Riser Required� Setbacics
Water Ti ht From� Welis � �
� PuYn From Prope lines
Checic Valve/Gate Valve StructuresBasements
Antt-si on o e �tc es raina e a s � �
Floats/Swiiches � Surface Waters
Alarm visable and audible Public 111later Su iies � �
Elecirical Com onents � Verticai Cuts >2 ft. � �
Rate m � Water Lines � �
A roved Pum Model VeMicle �Traffic � '.
Blocic Under Pum Ad'acent S tems
Pum Removal Ro elChain - �Easeinents/Ri ht:of Wa � .
. ~Distribution. Systern Other
Serial Distribution . Easements Recorded
ressure ani o e e era or on ra
Low Pressure Pi e . Tri-Partate A reemeni
A r. Pi e I�llateriai and Grade � �� �
Valves �
Coea�ment� . . .
. pct�d rev. 31'13/Q�I
��� s� ���.� ���T � � � �° � � t �
�►-.. ti, l a ��\ 4f �, yr"`�� � � i n cs bi S fi
1 � � � �� V ��
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� -*�%tY �,�'�' o � 0 � �
I���-as��.���.��.Il IL33L��.Il�I� ���
Applicant: L A � r
Location: ,5�7 n1 (
`/ Improvement Permit
Permit Valid for V Five Years No Ezpiration /
Type of Facility: i i c. Fa �n i� ( c � n. New V Addition Water Supply,Pri Vaf�, wc I 1
# of Occupants n'1 x# of Bedrooms 3� Projected Daily Flow 3(o a g.p.d.
Proposed Wastewater System: T n hUu-�1 c! C(�S'y� r� d u c,-�i o n,� . Type:
Proposed Repair: EXf� �Yl D� Type:
Permit Conditions: .�r1 �S�u I � 5
Owner or Legal Repres ta 've
Authorized State Agent:
EHS,
r SxStc rn t�, rt�.
. Date: 3 /Z- �'
Date: o�- � p 0.3
The issuance of this permit by �he Health Deparkment in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Lnprovement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants th�t the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (�.
Proposej� Wastewater System: �(� n O V C.�-� i V C, Type �� Wastewater Flow J� �o O g.p.d.
New V Repair Expansion _ Soil LTAR: •�� g.p.d./ ft 2
Type of Facility: � i 7 � c. FQm i I v ,D�..� �-( I i � k Basement _ Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: �,OCO gal Pump Tank: 1� � f� gal Grease Trap: �/ fi gal �
Ji ��P�;d �
Drainfield: Total Area: �� sq ft Total Length s�� ft Mazimum Trench Depth �_ in
Trench Width �' ft Minimum Soil Cover: �v in Minimum Trench Separation: � ft
Distribution: � Distribution Box Serial Distribution Pressure Manifold
Specifications: f }� i � i
c
Authorized State Agent:
Permit Exx
The type of svstem permitted is
the pernlit.
Owner/Legal
`� 5�i I coucr t,�i i1
'r
Date: � — I p —
nf
c�. OcPend�
Date: a-10�0.�
�
Conventional ✓ Innovative Alternative. I accept the specifications of
Date3 f� ��
PCHD7/30/2002
�.,���5 f ���.� ��
� c� � �J���
J�. � y JI: R V' Il. Il^ RD A"II.:ll"ILR. UL: 7L"R. [L,iJL.�l. .��� �E9.FIL. �I.tL.��"ll.
SITE SKETCH
Name �«� r y ��.5 i c� Tax Map #� Parcel # UL .�
Su dt is� n F+�cS bcr�:;�w h C-Stc��L� Section/L�t# S
�"1 i� ��.L3
Authorized State Agent Date
System components represent apprY�xinaate contours only. The contractor ncust flag the syste�ta prior to
beginning the installation to insuse thatpropergrade i.r maintained
� ( �nCS oJ �V
-- � �o" x 3 `
I(1�1C11C�`i,l Ut
_' Z� / �{'i' r 1 C�
d,�P.t,y� u�slapc
5 i<� c,�(�YT G�`` ;�� ���
-- � �ci i -t�i C,� cr I (o '`
Covc r t,� ► i l b�
�{cde� o�cr Sys���m
— T�;�s�� � �r�m b��scfn�n�
exc�c. �t�.-� t c� n�..� �� ( l b�
,.
��L I ��1 �j � C �- �- � " `
-- K c t,� �/ I G�� l c �t y�
� �St�cn�
15� I��v�',
, ���c� 5�0�
C u-�
�1, � ��'�`
� � ��.� , DR��n1
,
I �� _ ��
Scale:
�— I S �
�► K «.� s ysf� �
, � a�' a�i
. Fra�► ��
Q�,
\. `�� d ra i nS ,
'�`�1 5yy�c M I p� a�F
� ���
�1 a�� �ro�e.r-�/ �in�5
�
qo'
_ ►�°.
To
I�L
�5�
�5��5.
� �
� ��
��
4J
� K��.p 5�s�^^ 5°
FroM IaK�.
M;nimum
!V UPsfep�
ei ttic!'s��n
� �b
, �' la.�,13
� �Y�� -,
I � Z.�.,�
55'
� � � �� �
�2'
. W�TE�S Ed�t
PCHD, rev. 09/12/01
�
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