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A25 13' �� c.�� `�� �.- I i�--�����— The isf cf Health Depar�`menf Oraage, Person, Caswell, Chafham, Lee Couaties SEPTIC TANK PERMIT Name of owner: Name 'of contrac Address and Directions -I� ��+' � r� �' �i"�-1 t�� N;� ; t( - 1� .� y•y �: f� �'i �..' 2' F'I' t�'v��_ i-i;�i �'�� �- t'�i� ( .:a �'( �� t Person or firm doing installation: � Address � ���L'� • � "�� � � No. of persons to be serve� Bedrooms 1, 2,�4. Additional appliances to be used: Disposal, dishwasher, washing machine `� y� �' Recommended• Septic tank �� �=` � r�� � � � ,- - � .,,__' �l -�. �' ! p - � � � Nitrification line: � ��� � �� � ��,� {�, � �X Y�3e -t'r:�p Above recommendation based on information received`�nd observed soil condition. Septic tank and nitrification line must be inspected and approved by a member of the District Health Department siaff before any portion of the installation is covered. Date Approved: � - �b'�" By: Countersigned Signe� ' Sanitarian O. David Garvin, M.D., M.P.H. District Health Officer (Over) . - i.:u �`�' ��ti_���: Make sketch of installation showin�ocation of house, septic tanks, privies, water supplies on. �``��y �,,�" adjacent property, etc. Wri�e in ��ii'surements in order that installations may be located at later � ' date. � � � SUGGESTED INSTALLATION (Date f'�'� � �� ) FINAL INSTAI,LATION (Date " ) d (Road or Str t) • (Road or $tr�e'� � i � �� A�plication Date: i� 4 Amount Paid: � Recei�t #: �� 7� � -� 3 ����: � 1C' ��� �� ' z � � ��� �` � ��vaa-��,-,--...e���.a �a��a��. Tax M�n #: �� � Parcel #: � 3 APPLICATION FOR SERVICES � IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORFCECT FALSIFIED CHANGED. OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHO(xIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested b : (Owner/agent/prospective owner): /�J ��riti �= � Ll�f �� ^+ Home Phone: / _ Address: / L 6 Y o.Y c o. �Q C� f F� /r� Business Phone: �_ z�� „ y� 6� r-� � � z� S7 Y 2) Name and address of current owner: �/��yti .� s� � Li�,..:. �' <« y To �`* Z� a.Y c �: c� �i-� �Ico /��2 a Kf>s ia /�G L 7.r�.Y 3) Property Description: Lot size: /�« Township: ��k<<�h:�Subdivision: Lot# Directions to the property (Including road names and numbers� �'7 �y To G6N G E rv� G�fFa h� 4) Proposed Use and Structure Description: answer each of the following questions: � a) Proposed _, Existing �/, Type of Structure: 3�j'" �� � f�-- Width: �b � Depth: z � b) Number of Bedrooms: 3 Number of occupants or peopie to be served: Z c) Basement: Yes /, No Will there be plumbing in the basement? �/ d) Garbage Disposal: Yes _, No �/ 5) Water Supply Type: Private _(new _ or existing�, PublicJ CommunityJ Spri�g _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the site plan. 6) Does your property contain previously identifled jurisdictlonal wetlands? Yes,_ No -� PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �, ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAF(ED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for th e on-site sewage disposal system for the above-described property. I agree that the contents of this application are true amd represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall her.ome invalid_ iZ-o.r•�..; D ate PCHD, rev. 06127/02 . � . - . . . L���' )' �!l.d��J�� - • . . . •���tiLl�,� ^ /� �y�.' • • V' V � �i. .�.��a�i�-��'.,sw a��.�. ��m�.'� � S� �'�.�� - �� l�� � C � T� � # �s P��. � 13 � . � ______ snbai�on � . , se�,on/I.at�' � ' s�p 3 � ; �� s� � �- . � �� . � � � � s.����'������,► ���,��.���-� ' ������������ .S = 1��� S � � - _ � ��,.�� �-� . . - ��Y� G�:�,s � ST . � � � � . ��� G( ;� �iv�2. 2�� ,e�Q gS = �a .. . . m,n. - . . � �a' '��• - . vJ . � C�o�-�� l � ne� � , � „ . � �7�`�'� �� � e(f �� � � 0 ��. �a .,�, sT � .�-�, � �g����� � � � -�, � � �� ��� � An1an� P11Id: � �— � . � �� . 6 '� � % n�.o � ��� � � P�n�i � � ` . . . , - �� •_ ���, �� . �u�_� "'1 L_ __�=� � �� • �'ra �._ 1 • i�!. =i1.L r_ ��l ,l�• :±__ _ t • . 1 . �ai.� e�!.. i.: �_. ��::.L•1L..1-.1 - �: _��- _ — � .L-�� «..�_.�C�, r- �i - _��r - L:_- �! ya =. I.L �L"1:t��L=.1�=�1 :1=� � � llr�� ��� I • l� �•• �ll:t K - � � .._.. = e��._.__ l,, _-1,� �) F�n� rretuNdd �!r ��� � l'�G � yr ��- f..a �.►:. C L,�.� TQ w. tiom� Plwnec � 9 Ad�drae� �� C y C o f.— Lt.� F� v,��(.. BU�s Pfi�1e: S-r'i 9-7 �S'z _• � orQ � L ��. c-�..? � � � a1Ltl iL�M�M � G11l1� � f• 11' �.rZs.�.., ��Ay%o"' rM k e <�' L:. FFo �'�-L • � � y � ^ VP�,Y '�•1�"'"' 1. er .i�we I /� ` . 'R.ru1,r. • C. cl..+ M • s " ��,» D4ecUons iD �e 4) PrvpoNd Uw and Str�u�ue Da�ctipdbn: armwer �fi of ths �9 qu� ' o) �d 4�E�p ❑ � b) �tdc H�It�r Q�nQb Wds Q. Da�ia.Wtds ❑ c) I�mrdoa�' af _i,�, • • ��un6� of aa�rrts or people to 1� s�tec� � a) � Yes No � If of l�an�ud �urex ' � H/- y.- iGlts�t �.,� n ��Yea�� �1° � � 1 9j Dtma�ions at Proposed Stru�s�e: Widltr �� Dep�f: 2 6 �- ����-C�1��� `t- ���PPh►'Typ+: Pt�rate �itn+� � ar eoc�iag �Pub�c 4 Carn�aia�Y o, S�A� ❑ • • A�a atry v�e8s an a�ofrdng p�ly? Y� ❑ No I�If Yas. loc�ion � P� �. o�eitid 9ya�m �: is�a can b. ranioect ia orde� oryo� p�ii�u�1 ✓ � �� � _� � . •. . � IsP�I�� CLEARL.Y 9TAI� At.�. CORN�$1WD lJNE.9 OF 'i�lE PROP�RTY. 9TJ4KE THE CORNF�S OF ALL PiiOP08m STRUCT!lRE3. PtEA�9E ATTAf�i �l1RVEY PlAT OR S1TE PUW TO TiilB �1P��LlCATION � f JJ i �. . � I heteby malm anp� to the Paiaat� Cniatty Fte�ifh. Departrne�rtior a a�e e+ra�tlon ior tha an-ei6Q �ew�a dt�posai aydem �' ttte abcve�ed pncpaiy. �f agree tl�t tha � af th� app�ion a�e tn�s end r� the ttrex�mn � to ha Qi�d on the �per�y. i unders�nd it the s�e is atEe�ed ar ltte tt�d� u� c�anges, ths pe�mit shstl hec�ne �u�d. i �u�decabaiid� tt�t as ay�pNr.ant, 1 am �ibis for idartliy�g az�d maddn9 ProP�Y �. �t�s and mei�g tim sibo �bb �Or the Pesscnnd oi fhe P�aon Ccturty Heaith D� ta. cond�u.t their evelua�ona I �at�d that 1 a�n res�ona�e for noi�►8 the Haaith Dapsr�r�d � my piope�ty c�ina any we�nds as desigi� bll'�a �Y �� �� . . � � � . � � D l- 6 S-.D I - �' � . � or e . paie . . Person County Health Oepartment �:xisting Sewaqe System Report For: Hobile Home keplacement '1/Addition K;-4-c4.�� D�n�r� � ftequestee: � ���_l� Home Phone# � q 53b'I 1 ab �-1 Con p(�.� -�-C�� . B u s i n e s s�� -'%35 � 3 ���bo rn,.0 V��o'-�5�� 'Pax Mapx a1`� � Location/Uirections: ��� ��h �li�.b�" .E'�'� � � I a�y � � - . O riginal Permit Located L� Septic System Uesigned For: Kesidential Business Other (specifyj _ n Sedrooms � # Employees Other llate rnstalled �(��o�-ga- Water suppiy �► Type ot System Nitrification Line ��oU� )Cl� � ��,X � ��L�� k�� Tank Size �.i n , A Certified Operator Required ! V`�-t � On site wastewater disposal system sliowes no visually apparent malEunction on � � l�I�� t Yermission is granted to: � � �YL� � According to the at�ached site plan. Comucents : . _ _ . :. '�.���i�t!� �.r%/,^//�?���lr�r� � - � �. ���.�.� I������ -= ������ IE��a-�-R-r �,,,�,. �m�.I! IE���.Il¢I�. WELL PE�tMIT� . PI.EASE SEE A�'TACHED PLAN FOR WEI.L SIZ'E LA�YOU7C Tas Map #: �s Pazcel # l� Township �PPlican� ���''� � Subdivision: Section: Lo� Location: � - Ty�e of Water Suv�lv: � Individual Rec�uirements• Site Approved bp ✓C-�S �z'�� -�3 Grouting Approved by �iC�� I Z-31-� Well Log �/ C�� 1�-�1-03 We11 Tag, ,� ��� } a-31-�3 Air Verit ' Hose Bib Concrete Slab Well D ' �� Communitp Public Well Approved Bp: Date• �"�''' �y � _ ��rxtn,Q� we Il '75 � �2S' ��'� ��,�x;-��..,� :N,�1 '�See Attached Site Sketch'�* Wells must be 10 feet from propertp lines. Welis must be 100 feet from septic systems. Wells must be at least 25 feet from any build'mg foundation. Other conditions• - — o� ice' S" - c,,ra�-c Z �:.� � � '� uJ�zT��.�._.f ;� PCi�, rev. 09/07/Ol �,� S I,', '/\1/\/1'{\, o • ao � �5��8 ��'� • t .� �JS�LJ�� V � a . _ � � � � � � � �� ° �i ._ _ �7�7��r C�n_.%��Q � �rt C . o � � n�-vn�c�^.rnna�rn.�a�na.��.Il �'��.�n�tC-.hn L°l�dtfl5l� IJUllU�I�) �� �,��U� Owner: � Location: .� Subdivision: Grout Log Tax Map� Lot # Parcel # � Well Construction Distance From nearest Property Line (Minimum 10 feet) �� Distance from Septic System (Minimum 60 feet) �O Total Depth:��0 ft Yield: _ � GPM Static WaterLevel: as— ft Water Bearing Zones: Depth �ro ft�� ft ft ft Casing: Depth: From Q to �9- l ft. Diameter: �c in Type: Galvanized Steel � Weight: Thickness: �� Height above Ground: �� in Drive Shoe: � Yes No Any problems encountered w�iile setting casing? _Yes %No If °`yes" give reason: Grout: Neat: SandlCement Concrete Gravel/Cement � Annular Space Width inches Water in Annular Space Yes No Method of Grout: Pumped. Pressure Poured _� Depth �_ to � Ft. Materials Used: No. Bags Portland cement eight of 1� ag ���. Pour�ds If mixture (sand, gravel, cutti gs) – Ratio �j� to ID plates: � Yes _ No 4 x 4 slab .� Yes _ No Drilling Log Location Drawing From To Formation S 5 v � � v � d � � v (ri,�Gee� n�., !� � . - I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth by the Person Cou Department. Signature of Con rac ID # yQ8 Date �o�'�O "C�3 • PCHD rev 09/30/02 , = --- _ . � - .Nort�i-Carolin��� .. _� .... _. D�pariment of Envirornneat and Natura�l R�sotnces Division of Water 9ualifiy Groundwater Seciton p,p, Bmc 29578 - Ralefgh. N.C. 27626-0578 •�:!►�t eAANDONM�NT RF-rORIZ CO.�CI'OR REG. NO. 1. WELL LOCATiON: tShow sketch of the loc�cton oa ba�c of fazai.) Pc rso� Nearest Town: �0 X b f J Ca�inty► - (Road. Coaimuaitp. Subdivision. Lot No.) ,L DIAGRAM: Draw a detailed ekecch oct. avell shawia8 total d�Pth. depth and d3a- x cf screefls remai�ln$ ia the well. gcavel �val. iatetvals of cssinB Perfasaaons, and �hs and types of ttll maLa3als u�ed. / �uadraagle No. � 2. OW�tER ��V\N (ni�"'Y Ilt- C 3. ADDR�S:''��'4• C�:nc�r-�+ CxFFp � %cxbcr 4. 'I'OPOGRAPHY : draw� slope. hilitop. valley flat ► n K i n D;�►'I'E. I-�-c4 5. USE OF �i'ELL: � ` ,� 6. TOTA1. DEP'TFi: .S.,Z.!---DIAMETER � O 7, c;.�SiNG RE.'1�IOVED• tWr ai�,rRecer LiYr1 � �, .��'f�CJ .�.�� . 8, SEe�►L:NG MA"iEiZIRL: L�a[ eernent C�nei c�t+ment 5as;s at cement __. � ba�s of cemea: _ ga]a. af wacer __„ yds. of sa.zd __ ' ga15. of watu _„__ c..o�'Cr�tc, � ��� � ��tit �� �t�� .�mount ^' 3Yds � � o� �S� f�tt-d mix _ 9. F;X/�P_LAiY MEiI�OD E1�1PI �%ic[M�i1Lc� �GL�Cr � NT OF ?titA'IERiAL. ;r'l�nk tC� t Frv►�, foP _�1r�v► � � � � �Zr ��� 0 v � �, � �x�i: � Fc r ��v�� �Lf, 'I • c _ �f'"L.d ' Z O— c���. �-�.�. ����� b ����, i�:�t� t�bz���. J�� � C��l.� $' c l= HLt7 rc M� ✓ed bY PuMP�'��- I do i�ere�y certlfy thar this arell abandoniueat record ls true and �xact. ' � �` D �,� � � � v Sigaar�ue of Caatiact� or Ageat �r� � l� ��r � ,-•_ �w J D�te '' "' c ViiELL LOCATION: Dr'dW Z IOCatSOA 91iCtC$�OII C�1C n�ie se `d�tht� siieet. shaw"s$ the 3ira- tion and distatice of the well Lo at :tast two lZI aearby refe:eutx polub such a$ roads. iatersedioru aad streams. Idearify roads With State High aray road �dent3Scasion acuabers. Subr�ut orig�nal to the Div�sior. of Water 9uality, one eopy to the Drttler. and one copy to the ewaer• ' � GW-38 Re+r.�ed IlgB