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APPt1CATlatU FaR S�VIC��� .
(8" I�oD r�'r. � ��
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1} Permii recyue:sted by; (Owrn genilprospeciive owmer): � G JT' .
Home Phane: � - - � Address: ; v ,�.� � 0'�13�U
Business Pfione: �.3 � �� - b �Qd �
�) Na►vie and acidr�ess of current owner.
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3) Pra}�erty Descri�
Di�tions to the
�) proposed U� �(d Structure Descripti�n: answer � of e follnwi g questions: � � ..
a) Propased ✓ Existing Type of Strudure:_ _� NQ � 1�% �L , YVldth: � De�t1�:
b) Plumber of 6edrooms; � Number of oc�pa�or peoQte ta 6e serv, �d,: �
c) Basemer� Yes , No �, UViil tftere be piumbing in the basement?_1v �.
d) 6arbage Disposal: Yes , Na �, �
�) Water 3u�pQ1y T,�pe: Private �ew ✓ or exis#ing_�, Pubiic_, Camtr�uniiy .. Spring
� Are any wells o� adjoinin9 Pro�eriY� Yes �To _ tf yes, please indicate approximate location on the
� �. 'siie pian_ � : . .
6) �oes yoau� prope�.ty cantain ��eviousiy isden 't�i'c�d jueisdicfionai wetlatads? Yes i�o ✓
Pti�ASE t�OTE THE FaLLOW1IVG:
��1 Pi.AT 0� 7'}iE PlZOPS��Y OR S8'i� P.! .�td tV1llST 8E SUBflflI'1'TEi3 W13"�i T3�IS ,46'�Pl��A'3"iO�l.
? PlZOP�i7Y LllV1E� A�lD CL�RNEiiS MUS't' HE CLE:�►RILY IUiAR4�3], �,
S T�iE PROPOS� iDC.ATlO(d �F ,4LL S'T'�UCTURlES NillST BE ST.4KEi� OR riAG��i?,
y i�lE SITE ►iflUST BE �DILY �►C��S�BL� �flR }� EV�1.11Ai70�t B�( T}�iE i�3E�l.'it-9 i3EaARTiUi�lT
STAF'�. •
I here6y malc� appiicatic� to ti�e Persnn Courrty Healti� .Department fa� a siie evaluation fnr the on-aite sewage disposal
sys#em for the abwe-described property. I agree that ti�e cantents of this appiication are true and represent the m�imum
�c:lryi�i�s-��e plac�d on the �roperty. I uncferstand 'rf ihe siie is aliered or the intenderi use changes, the permi't snall
hn �TC �� li:i /i l► _
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Applicant: �r�� e 6��
Location: � , ,
� l,�l�j-fv ►� 1�� � U �
T�x Ma� / �
S�u�h cl'�i,s:i o ii
i
Farcel #
Ph�as�e Section•Lot �
Improveanent Permit
Permit Valid for � Five Y ars No Ezpiration
Type of Facility: ��� P�'� New � Addition Water Supply �l�
# of Occupants/1'taK # of Bedrooms Projected Daily Flow 3� g.p.d.
Proposed Wastewater System: �'y�ttl�E•� �xa Type: �'
Proposed Repair: �c�,/'o,- L�2_ Type:
Permit Conditions: �� sl� S�C-� �-,
Owner or Legal Representati i ature• � ` Date: -' �
Authorized State Agent: � r Date: —�ri
The issuance of this pernut by the Health Department 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 Planniug and Zoning and Building Inspections requirements aze me� This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement 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
Rule�or Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Hea�th
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
�Authorization to Const�uct �astewater System �Reqnired for Building Permit)
* See site plan and additional attachments (�.
Proposed Wastewater System: vl(/L�- ��`'�- i V ra�� Typ�a Wastewater Flow �6 �' g.p.d.
New � Repair Expansion _ Soil LTA�i: . 3 � g.p.d./ ft 2
Type of Facility: �� ���' - Basement _ Yes iC No
Wastewater System Requirements
Tank Size: Septic Tank: � �0 O gal Pump Tank: gal Grease Trap: ga1
Drainfield: Tota1 Area: �o o sq ft Total Length �d� ft Mazimum Trench Depth 1� in
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: � ft 0• C.
pecifications:
Distribution Box x Serial Distribution
�!2 ��-e �c �
Authorized State Agent: �
Permit Exnira on Date:
Pressure Manifold
Date: �'�`"�S
The type of system permitted is Conventional Innovative Alternative. I accept the specifications of
the permit: S
Owner/Legal Representative: Date: -
PCHD7/30/2002
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SITE PLAN
Name li �f � i e- ��� �, Tas Map #�! �` J Parcei # c R�
g� • '� Section/Lot#�
�
uthosized Stau Agent �� �
Sysrem componeats srpievmt spproximsre conmurs an!}: Tfie contracmrmustflag t6e syaum pdor m begraniag the ms�srion to
ina,,,,. �atP='�P�$nde ia msmr�raed
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Applicani
Location:
�x M�p Parc�-el # �
Subciivision
Phase Section: Lot #
# of Bed!rooms
:.., ,t: � . ;;� :; �' ,�.
System Type (In Accordance With Table Va): 1� a
THIS SYSTEIU! FIAS BEEN INSTALLED IN COMPLIAfVCE WITI-I APPLICABLE NORTH
CAROLlNA GENERA►L STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL COMDITIONS OF THE IMPROVEMENT PERiVIIT t4fVD CONSTRUCTION
AUTHORIZATION. � �
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Authorized Sta e Agent Date
Installed By: �a- � ����.�i�r-5 Date: ���/v.S �
0
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PCHO, rev. 07/29/04
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�7�7� 3�V �8�'lY�� �Itl�lr�� d 1�� i./���YL�7�7 1 c A��e ����
Tax IVlap # ZS Parce! # I9J Sys�em Type (Table Va) .,x�
OwnerlApplicant (}�.�r„l � ��,���,.� �_ l,�r._ Subdivision .
Address/Location Ar��,, ��,� A,��,,, r��: Sec/Phase Lot #
e
State ID/date �r� �,��> i-2s-os"
�.apac�tY �15'1Dou '
Tee and Filter
Bafffe
Sealant
Riser (if applicable)
Tank Outlet Seal
Permanent Marker
PumD Tank
Waterproof /Seaiant
Riser
Checic VaiveJGate Valve
Alarm (visable and audible)
Electrical Components
Rate (gpm)
Approved Pump Model
Blocic Under Pump
Pump Removal Rope/Chain
. � Distribution. System
Serial Distribution
Pressure ani o
Low Pressure Pipe
Appr. Pipe Material and Grade
Valves
� �itr�teca�on
Trench Width "
� Trench Depth
Trench Grade
Trench Spacing
Rock Depth and
etc.
Pressure La
Hole Spacin
i�o e �ze
Pioe. Sieeve
� urn-ups�rrotectors
Required� Setbacks
From Welis
From Propertv lines
Surface Waters
Public 1Nater Supplies
Vertical Cuts (>2 ft.)
Water Lines
Vehicfe Traffic �
Easements/Right of V
Other
Easements Recorded
Cornments
reement
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pct�d rev. 3/13/01
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WELL PERNIIT
PLEAS� SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map t�a s P cel #
Applicant:-�������
Subdivision:
Location:
R i ,_ , Townslup:
Lot #
. i � w — I% i �
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. s i �
Type of Water Supply: � Individual
Requirements:
Site Approved By:
Grouting Approved By:
Well Log:
Pump Tag: -.S
Well Tag: �'
Air Vent: ��
Hose Bib: �-`
Casing Height:
Concrete Slab:
Community Public
mer:
_ �fp''� � Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
Well Driller: u/"�'� 1-�' � �'�
Well Approved by: � `.ti� Date: /8 d S
****See Attached Site Sketch****
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD rev O1/27/04
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]E�si-v. aro�ariaae��.�� IE-3C.ey�.liEl�s� DD � ��m .�-- .�c — D.�
%J Grout Log nT /
� W:1�. ti- �1 n r/ i� � t 1�/"'l • / 1� Kti
Locetion: r e. ; -t % <, M�P �_ Parce] �! �/
Subdivision: Lot#
We0 Coiu�ctlon
Dietanca From ncan�t Property Line (Minimwn 10 f�et)
Di�ncc from Scptic Syetem (Minimum 6i} f�et
Total Depth .�p ft Yield: ,� �a f,PM StBtia Wata Level: 34 ft
Water Bearing Zanes: Depth �/G� ft 1 s'"ft ft � ft
c�i�: . .
Dcpth: From �'' to l�-� ft. Diameter: �� '
Type: Galvanized Stcci i/ -- r" m
Weight: Tfuclmesa: %�.�' Hcight ahove Grounci: %� in
Ihive Shae: :�Yes No Any problema enecou�tered whilo actting casmg? _Yas YNo
If `�res" �,rive resson: '
Grout: � /
Neat: V SandlCcmettt Concrete GraveUCcmerst
Annular Space Width ,3? icechc� Wat�r inAnnnlar 3p�oe Yas ✓No
Method of Qrou� Pumpe� Pressura . Paured Dcgth D to �� Ft
MAtetlais Usea: •
No. Bage Partland cement l�'' Wcight oi 2 Hag ���'' Pounds
If mixttu�e (sand, gn�vei, cuttings) — Rstio ' bo
ID plates: �/Yea � No 4 x 4 slab �Yes _ No
Liner:
Depth: Date lnstalled: Grotirt: Installed by:
DriWag Log
Locatfan Drawfag
From . Ta Formqdon �
�: �� '
.2� .�Gt .
I hcrcby certify that the abovc infflrn�ation is correct and that this we12 was constcucbed in accordanee with regtilations set faath
by the Person Cotuity Health Depattment. �
Signatare oi Contractor � � # 2'iG'�}' � .3" — 'S� —' US
�
Pamp Instaliment
Purnp lnstallation Contractor. ��'� `�, ��%���i' �LM�' State Regishatiaa Number: 2��'
Pump Depth: �' �O ft Static Water I,evel: 3�0 � �
Pump Mek� & ModeI: _�• � r..r Pump Size and Iieting: t hp / D gpm
I hereby ecrtify that this pump was insta]led and the well head ccympleted according to the Person County Well Ru1es in effect
on thia date and that a copy of this record he.s bcen grovi$ed to the well aaraer.
Pump Instalier Slgnature `,i��'�••~�i'`� Date: ��� w�PCEID rev O1/27/04
Zfl 9�81i6S9CL 4l1eaN �e�ueltuof�wu3 •o� uos d Mld EL�LO SOOd/9Z/►0
j-d doi=eo so �i �ew
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