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A25 193
,► � Amoun t r Receipt � F f f. �..:i a <>. �' . Im � O � � w U � a a.s'o .°d pd��� : � s- l-�� paid. T���� � 1 h� - l� ' ��, �� 't� w�+ ���.� � A� D a t e �,�, 0 � �-� APPI,I('ATION �OR SERVICES 4� °� :. s t '.. � fY '. - v�'£F, s.i� x- s� sa-. ,. � � . : f � . is x s � a�� �zi '�r. ,v,nP a E: �. = a� ° ° ;�� � t : ,k � �_� Serdvic�s�Reque"sEedR , z � �:.: � � ,:: � � 5 S f-3 :H f C.R � f>.: -.F ba3. g,N�.Af 1�'iZ..S. - � ' � . ' wH N ,.� u...� . . .. . ... .:: x . . :' . , r... .. .. .:. .. .. ..v... t ... ... , - ....: :�...< .x r, r... . ... 3vements Permit-(EstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing) Impxovements Permit (Unrecorded Lot) ,_ Repair/Replace existing Septic System Improvements Permit (Mobile Home Replace) ,_. Perrnit for New Well Improvements Permit (Addition) _ Replace Existing Well t `3 z , ; � y ��s = ;� h ` ` > ;��x > _ ��_�� �1'S�i�'a�er Sample�ia be' Coll�cted. t �.;_; , � w . r .w �:;., i .. . e. � � �- v,:..:w w h �.�,. . - �::„ ,� .., ..,, .,, , w.x , . x ... .. . . . ._. :....;.a . _.>�...»». .,..._.:c„ .,<,r. _ . . Bacteria _ Chemical _ Petroleum _ Pesticide 1. Permit requested by: of� 1o�ro N ome Phone #: usiness Phone #: � � Name and adc ____—�� �3q S of current ° . �, � 7. Dimensiops or Proposed Structure: ��/I�AI�P►? Width: g _ Lead ,� :� 8. What type (if any, additions, expansions, or � replacement is anticipated to the structure or facility � that this sewage disposal system is intended to serve? Nner: 9. Water su ype: private public ❑ community ❑ spring ❑ �,.�� Are any wells on adjoini roperty?Yes No �. If so, identify location: s � �-r n /v : �l� L „ ., c , Property Description: Lot size: I�� �2 . Tax Map#: � 02 Parcel#: Township: u � U � "� . Directions to property: Sta Road #& Road lames,�tc �- .� F-�5 h � N9 i;�h�" �, `�Ou7N � ►-� .�� :..is S�nn �. �u vt. � � � �4�� a,N otv Co2. Number of occupants or people to be served: 10. Type of structure/facility: Proposed: �Existing: Q I Type of dwelling: House: ❑ Mobile Home: Business: ❑ Type of business: Number of Employees: Number of bedrooms: .�— Garbage Disposal? Yes ❑ No�3[ �Basement? Yes ❑ No� If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PersOn COunty Health Department for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are true and 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 become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. z Signcc� Ow�r or Authorized Agent Permit Issued ❑ Permit Denied ❑ Plat Observed ❑ # � ��A�'� ... ,� e •,` .�t•,, �; �� ; • Signature "� '" �y Date ❑ i . ... . , ,„ �' � � 'J.. � � . . . . . y . � ';7 � t FAcroRs-s�sv�.unnox" .. °� ;::;. �....: �1lx�At::'�... : �s �:�t�s . : nA�+a ...: � x ,._ . <.�.. ., :: . . ,.:: __ .. ,_ ,. _ i. SwPecx) s s s s PS PS PS PS U U U U 2 SOIl.7'FJC7VRE(12•361N.) S S S S (SANDY, LOAMY. ClJ1YEY. NOTE 2:1 CI.Al7 PS PS PS PS U U U U 3. SOiL S77tUCTURE (12•361N.) 5 S S S (MYEY SOII.S) PS PS PS PS U U U U, S S S S 3. SOILDEFf}1(IN.) PS PS PS PS U U U U S. RESTRICT]VEHORIZONS(IN.) S 5 S S (IMPERVIOUS STRATA. ROCK) PS ' PS PS PS U U U U 6. SOILDRA]NAGFJGROUNDWATER 5 S S S (FJCTERNAL R IN7'ERNAL) PS PS PS PS u u u u �. son.e��s�un s s s s (PERCOLAAT70N RATE7 PS PS PS PS U U U U a. AVAILABLESPACE S S S S PS PS PS PS U U U U 9. SfCECLASSiFICATION(SEEHELOW) SOIL SERIfS S•SUlTADI.E PSPROV1510NALLYSUiiADLE U-UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �11 areas, wells, water bodies, slope patterns, CtC.� C:V�MIPRO�DOCS�APPSEC.S�t FINANCE.PC 0 �� L �,/ � ti h^�. . - .fit�{ . . ' . � �R "^r4qi .. . , ' . . . . ' .4 `Y.t .. � ` . . . ��': � . " . � . ' � . • ' ¢ . � � . . . . y �'(' . � � _ . i �,LL e x : . . • � � ( �� �.�� . .. v�'. . _ � , > .. .. _ � . - . . . , • . � . . . £ � . ... � � � .. � . . .. � .. . , . . . . ��_ � . . • . . ' ; .. . . • .. , - . . _ � . �. . ' ' i � . ' . , � � ' . , ' . , .. .. : � .. . . ` ' ' � ' ` �� . . � :_ j ' �' � � :. 40�. .�, . R. �.3 . � _ -- -� - . �r '`s. S so, R� _ Y _ , . 0 , �, -`.' � i�0.03 - � , N64�50,38••E '� � �� .66'�s����E : � :N � , ,. ' - � : rT67'1.3':�6'�� `N�6�46�03,' � ` 50.00 �. :, : 1V7,2'00 98', E:.�. . : _ . . � , 7 26 > ��� , ' _�� , 7 r 4f:93' 98:75 �<.; R 1 _ � ._� - . O t ,( �_ � � `-i I � � 3 � � � � � � � � �. .- ; -�"k "Y : `` � � _ , r ,, .. � r � , v a ''"3 ` .. 1 't � � � . ; ` � . .CO�,tno1 C � �w� � 1= ' - �� .- , `1 - � . �'. "i l j, f t �,,: ` � •, . .' � _ ' � _ ` N � ;� a �' . z : � � , - 1 • { , o 4 t o ' o . �. _ � � . � � � ,, l __ . _ . ,._ ; , � t � , ..� X,; ° � :-� � _ ► .� . � . _ . . . � � ,� . . .. � , �=�� � , � � . , _. , :� J lPa '' Elain � �� 02 > 00 acres :` . : ; D,�B. . ,y p C 1 . ' ,,� . t Z S - �:�; r � , . � '� o I o , : �� �� � I . �"F ' Y.: � � . . I . �. � �q.� - � . i � -� t - I . � - � _ �� � v 5a i ,,� . � a. �y;. �- % � 1 "_.. . !/ `z� � �1 - � - • �•...�:. � .:. ;.'N F .' . . ' , . . . . X � _,y y, 1 � I � � ' . ��. �( ���� .' . � . . . .. . . . , i . \�� . � . - .. . .' � x� , . . . � ' • � • . . .. i7� &4 ' ` � . S66'46'03"lf � ,:'a�'�� � �, 1 � �r_ -- . - . - 1 .__ x i � � � � � a W � a V/ 'U B 2400 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # � � � Parcel #_ Zoning Township Owner/Contractor —j��j [� Location/A�dress �'`'7 �1/ `7 i �I�' 1 �3 . ., �-, c � .� . � R.# Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area 1.�/�C Size of Tank_ �� SFD L� Mobile Home i/ Size of Pump Tank �i ,q Business # of Bedrooms�_ Nitrification Line L►� tX3 f Max Depth Trenche��o2a?-c��/'� Permits may be voided if site i alt ed or intended e chan ed. Well and Sept' ayout by Comments: � Date - — Installed by Kh Approved by o� I�,2S. 7-3/—`L � � Well Permit Paid WELL SYSTEM SPECIFICATIONS Individual �Semi-Public Required Slab ✓ ;Tr•� N Public eplacement Air Vent ,/ �nI �+ Site Approved Required Well Log �/ Well Head Approved � Well Tag ,/�N t� Grouting Approved — /-��� � „(r- , / � N ►� Comments: Date j— ZZ - 9y Installed by Approved by aa-r`1 This report is based in part on i�formation provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the e�vironmental health specialist warrants that the septic ta�k system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l � 'r � �' � I • � _ .a .. � _. i . . � ` ' , � . �c. � _ � - �' �-t �at� (�Qg�4� �, .� , . , � � � _-. , *y ' z � :` . r f�`�� _. .fa ��y1� ` _. ., {S� � �v.. .�7�,� ♦..h. '-�,+'.�r .H� `•"F�3 f.y�� "- ...:-� __..�.�rl-.`.Rr��ix.""i'w3kfA.,..:..7'.._ �' . .. �'.Y'Slry 7..Yb,�+[1�i:�';Z+ri-�. �, � / . ��y"*�Pd��fi��5,}�+ z."'�= —" 1`.'� q p',' �rt j3�,+ Ry�+' �y j � r ti � -�� ' !' ts • a ,�..J �; i��` ;.. iI`'�l •< A.. . . .. . y T� z, y - �`' . � � , �+ � ` ` :.. UU'09 ��' � t . � � - ; �' � � 1..EO.9b:9911T �. f .�+' � : `� - . �i . ° '. ol�,.{''sis , . - � � � :�..sE.-. - ;= M. o�E'� ��. � ::�.,... f{ �� K . .. . .1T3� 0�'�: . • ^ Y � � .. r ., � � . - ,,k � � . . . . . �S� 1 �ga .. 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O _ � 1�Y .r esF �qe� � f�^r�� i � ; � �„ ,+ ,,. . _.. . �5 . �. . :. � . ,Ly� {�'�'`ur . . . � �r.Y � .. - �.l� '�. � � - . a . � '`�� - _ � F�� � 4��'��7' .: -. � ��`n��� a `t f� r•,,,cY _ .:i � ,� - .�. � 9 s � �t - O .'. . � �y� � � �j1�� ��t. c'�,��a1C = ?L � `i',�'2iY�'�-^�,,' �� t �.*Yp'�N' 1 .. r^�� F'�'�'v"t,��`+7'd� $� 7;�.f .E'k�` j ,.. - -� � 0 3�`'�'rJt"'�� �_,, �+' � -. 'i �.� t� F� .� � 3'=k�,� � ra ' Si 7+i S C 'y,e s � s 'ti � �' �• / � . qy r�-t �,"}.: II z� � .r„ � . '` ,''� e�" � .rY f,,���` ��+t �.i y + ,y, �� Q[► a�• ��1`� �jj� /� a a C ±+ 1 '� � �-�. }`? 4- r v — { y,� ��a��s_ '� `},`.c�+ � k , � f � O O � , t33. �,� j X / �/; '. � ` � �� l Y I � �?F �'n�,6,�� ) ,o- +4 � i � � (� Y�` '� ;�r7Z ��``v�` � . {-� �.��9l1 s° 3i.-:86, OU.2',GN; ; k, , a y , �' �_ 00�07 '�' z� a� �/��g�.�i {.r�`.>,?��N94Y�+1 f: 3, ,< , � i S ' > . ��• � � +Y � �{�Of� s r.,. �... �"�' i3 C . . t `� t v a i 14.s�i x � f a: , ,� „�o,se:99K �,���� s -� s �f � , � ' , �-� � ;�� � ,: _ [� srr ' t A � ' � �.L � - � � . s� � .OV. , . . . I � CJ f .. � ti.' _ . c. '�(_.� •• �. Fi����F h� �� — i . • • � A - . . . ! u � ..� �JyT �� . � �'1 . . . � . �� '� ��Y � �� ' � �. . . •� :0� {� .�'.. � . _ .. � . `�, Y� ��'F: 0����, �_ �1T •�\ . , - . \i �✓ �:_ � — � ' � ti; . � . F .��_' — �. .. . ... � $ �d4t � . . . .r a r r . . .. . .. . .tl���� .. . , � � . ,} -� t,".i �€ < ' " • . ., . . b�� �g�a� �eY O ' - . - ..' . . . . . ' , � ' x.�s� . � Q - -. . . . • • i • . . . !�; , � M *' +^1�4����•1� +_ � �� • ... . • . _ .��i r�p � Q. . , � m- bac� �����p� - . 4 . , � �� �, r� , w : 1 ' ' �� �01. n ,—�' 1'� " ' �i � h . ] � f�. r ' �% � ^`'��^�/ �V./ .`���t '' ,f) � I�'f . � _ �4 . R � '� r IV — Ji.',.L:�� ✓'S'F '� ' � v\/�� � .■/�� � � ' ,{�`; . t;�� ' �a," '"`� � : �� /`_�)/,� � .b� -i, �- +� 4�Y� rJ�A�/�� 1� �r .-a ����(/� . .�f'.1:�. .�� - 11 Q�,J�+G./i V•_ 1 �f( {�,� .. � '�s . � � , �'�i. ' w +c � �.Jr � �\ � �� �./�����{M4+R'_' �� y� ,"�. - 3, �, . . . h. � .. � /'�� /� y .� ( � � jJ\ �/ 4 � t J �i4 � w�� L /: . -., � �V� �— ' .. � r�° 3 �'-! - � F �'_� �� . . � � /� .. +, Y ��n� YY'Y.'}� �* � .} " _ . - � � f � � . � \ I a � • - ' _ ' ��� , , _ . �:a� _ .�� . F: � , . -�-A P.�- . � �7��-�� �.� North Caroli�a - Department of Environment, Health, and Natural Resources Division of Environmental Management - Groundwater Section P.O. Box 29535 - Raleigh, N.C. 27626-0535 � . . ,. Phone (919) 733-3221 WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: � � , � ,/,��OS , FOR OFFICE USE ON�Y QUAD: NO. SERIAL NO. LaL ` ` �ong. RO Minor Basin` Basin Code ' Header Ent. GW-1 Ent. ? STATE WELL CONSTRUCTION DRILLER REGISTRATION NUMBER: J PERMIT NUMBER: 1. WELL LOCATIO (Show sketch of the location below) �d��O� Nearest Town: �f��� %1 � County: Cc>�uc.� � C-s�r�a IQ� (Road, Comm�%�'it,y,,,�or Subdivision and Lot No.) � DEPTH DRILLING LOG 2. OWNER 7[�"-� / �Y �%1�,P �; From To Formation Description ADDRESS (Sveet or Route No.) — � Ciry or Town State ip Code 3. DATE DRILLED USE OF WELL 4. TOTAL DEPTH 5. CUnINGS COLLECTED YES ❑ NO� 6. DOES WELL REPLACE EXISTING WELL? YES �,�NO[� 7. STATIC WATER LEVEL Below Top of Casing: ( j FT. (Use "+" if Above Top of Casing) 8. TOP OF CASING IS � FT. Above Land Surface* ' Casing Terminated aUor balow land surface fs Illegal unless a vartance Is lssued In accordence wtth 15A CAC 2C .0118 9. YIELD (gpm):� METH D OF T�ST 10. WATER ZONES (depth): �T � 11. CHLORINATION: Type Amount 12. CASING: If additional space is needed use back of form Wall Thickness LOCATION SKETCH � ept �,,� Dia�t� or Wes�� Ma� (Show direction and distance from at least two State From To � Ft. Roads, or o� From To Ft. From To Ft. 13. GROUT: From � T�o pt� Ft. ateri � M th� From To Ft. 14. SCREEN: Depth From To From To From To 15. SAND/GRAVEL PACK: Depth From To — From To— 16. REMARKS: Diameter Slot Size Ft in. Ft. in. Ft. in. Size Ft. Ft. Material in. in. in. Material I DO HEREBY CERTIFY THAT THIS WELL WAS COI� CONSTRUCTION STANDARDS, AND THAT A COPY GW-1 REV. 9/91 Subrr�oris�inal to IN ACCORDANC H 15A NCAC 2C, WELL :,ORD HAS BE P OVIDED TO THE WELL OWNER. �-! �/1`� ��� �� R OR AGENT DATE of Ernironmental Management and copy to well owner. �� L.