A25 197Appiication Date:
Amount Paid:
RecEipt #•
Tax Maa #:
Parca! #f•
_ ��'��_. � .J�'" ��� ��. �I
. . - - - _ --L �C � �Sl�T �LL" �
�a:a.va.a-oaa�-^'� <ea��.I1. ��+a.1L�71-�
APPLICATtON FOR SERVICES -
COIVSTI�UCT SHALL �IECOME INVALID. •
'� _�t) P�rtnit requesi�d by: ent/praspective owner):
� Home Phone: a-- � Address: GC ��Z C��S ��ti f�
Business Phone: � 5��t�,� �-� 1�s'� t/
2) Name and address of current owner. L/1IfL�'`'� �(/'`L(��'/�i��-
� 7 n v<< � v�-�`� �2---
iCJ� N L l�) 7��
3) Property Descrlption: Lot size: ��- Township: � �N �
Directions to the property (Including road names d num� )^
/' o ���, � r � r � ��
1,rtA l�- C- 3r�0 d ti L L- !' l
Subdivision: Lot #
L�. � i v.�-� 1,� c c...� c' �r�rl
- 4) P'roposed Use and $truc�ture Description: answer eac of the following questions:
i�T e of Structure: ��✓ Width: Depth: �
. a) Proposed . F�cisting yp
b) Number of Bedrooms: ,�_� �. Number of occupants or peopie to be served: � � _
c) Basement Ye�,� No _�Will there be plumbing in the basement?
d) 6arbage Disposal: Yes ��. No �/ �
5) Water Supply� Type: Private �new _ or existing�; Public� Community� . Spring _
Are any welis o� adjoining property? Yes ✓No _ If yes, please indicate approximate location on the
'site pian. � , � . �
6) �oes your property cantain previously identified jurisdiciional wetiandsT Yes_ No �
� . _
PLEASE NOTE THE FaLLOWING:
➢ A PLAT OF THE PROPERTI( OR SITE PLAiV nflUST BE SUBMITTED WITH THlS APPLICATION.
9 PROPERTY LlNES AND CORNERS MUST BE CLEARLY MARKED. �,. �
➢ THE PROP,OSED LOCATION OF ALL STRUCTURES MUST BE STI��D OR Fi.AGGED.
➢'YHE SITE N1U$T BE READILY ACCESSiBL� FOR AN EVALUATION BY THE HEALTH DEPARTiMEi�lIT
STAFP: �
I hereby make appFication to the Person County Health Deparkment for a site evaluation for the on-siie sewage disposal
system for the above-described property. I agree that the cantents of this application are true and represent the maximum
faciiiiies to be piaced on the property. I understand if the siie is altered or the intended use changes, the permit st�ali
become invalid. /
or Legal Representative
� 2 3 �� �
Date
PCHD, rav. 06I27102
�
Amount paid ���.
� Receipt l� ' �a,
. . � �3s
�
�
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a
/2- 7 -� �
Date
improvements Permit. (EstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing)
Imt�ovements Permit (Unrecorded Lot) Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permi[ for New Well
Improvements Permit (Addition) _ Replace Exis[ing Well
i�yr X S� �:�sS�x Xh�'�ySqul�Lki6 � x..: 3' fx� �'�' -h aw.,.a' a: "'� a :s Z :��.�,.v� v;+.T�:u.3,i.. ?%o_,e.wA..w��� f-.r x `'�.. i.i'F�"a'7.es;:i
t.�>f.�+..v/�..<ru�1a a�..������,...r,�M��. �� .� �����a�erSample to.:lie Collecied� h'�.�yM=4 .. <��•�,�.�h�.� < r���,�,:m`�=�..�.�.�=<s
_ Bacteria _ Chemical _ Petroleum Pesticide _ Lead
1. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospective ownedagent: ��,�a-� Width: � �
Address: • _ Depth: O
�� � '�- - 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?
Home Phone #: 3 3 G� S 9q- a 3 s-� �t/,�/f
usiness Phone #: �? 6-.t"44 - 3 Q��
2. Name and address of current owner: �'� 9. Water supply t}•pe:
' private q" public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �j.
If so, identify location:
3. Property Description: Lot size: �:� o A-� •
. Tax Map#: �- �-r 10. Type of structure/facility: Proposed: l�'Existing: Q
Parcel#: ��`� "7 Type of dwelling:
Township: e�y �•.k ��- k... House: ❑ Mobile Home: Cv� Business: ❑
5. Directions to property: State Road #& Road Type of business:
Number of Employees:
ames,�t �3 6 � ��e.� L� .
1-+� G � Number of bedrooms: 3
a � � � . Garbage Disposal? Yes No 0
Q � �,� r Basement? Yes ❑ No�f so, # of basement fixtur�s:
6. Number of occupants or people to be served: -�
W
�
z
CLEARLY STAKE ALL CORNERS OF THE PROPER'�Y AND THE CORI�IE� vr� ALL
PROPOSED STRUCTURES. -_�
� hereby make application to the Person County Health Department for a site evaluation for the on-site
�ewage disposal system for the above described proper[y. I agree that the conrents of this application are true
�nd represent the maximum facilities to be placed on [he property. I understand if the site is altered or the
ntended use changes, the pecmit shall become invaIid. I understand that before an Improvements Permit can be
;ssued, I must present a survey plat of the propecty to the Health Dept. I understand that in the event I have not
ielivered a survey plat of the propercy to the Health Dept. within 60 DAYS after the date of the evaluation of
:he site by the Health Dept., this application shall become void and all fees paid forfeited. �..
Signcc�
or Authorized
L. WILLIAM CRABTR�'E
TAX MAP A— 25, LOT 96
� CUNNI�VGHAM TOWNSHIP
PERSON C0. , N. C.
OCTOB.ER >9, >998
/7 ' �'� .
�-� ���
,.
T��t c o f
P.C. 1>-31-1
N84°20'25"E
�, .:
N84'29' S5" E
�
�
a -
Total — 46�3. 89 '
�
Trdct A �
2.10 ac. �
M �'�
� y��d
Total — 505.77' '
�
. �
T��t g
1 • 85 ac=
b� 0 30 60 120 �
( IN FEE1' )
1 inch = 80 f� � .
0 5 --�
,
C1
13'
�.� �� I
� I 1 � �� cz
9
0
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', r B 2823
� PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
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 #
Owner/Contractor
Location/Address
Subdivision Name
�� Parcel # �4�
Township C..�,� i /t Q
f �t r1 � ct l I�T� �rn QSan D te �� - 23 - Q 9
,
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area o( . �� f�L
SFD � Mobile Home ,s
Business # of Bedrooms 3
Size of Tank1�c-
Size of Pump Tank_
Nitrification Line �
Max Depth Trenches
Permits may be voided if sit ' altered or inte ded use changed.
Well and Septic Layo t by
Comments: SQQ -
. •
Date -�j- Installed b A proved by
_a_qq- �"�,� _
Well Permit Paid WELL SYSTEM SPECIFICATIONS
idual 1,� Semi-Public_
c Replacement
ite Approved�G
�ell Head Approved
�routing Approved_
Comments:
5-/b -
Date 7�-'?�_� Installed by.
S.R.#
�Yzj
Required Slab ✓
Air Vent t/
Required Well Log - ✓
Well Tag
�/l�J� ��f,ii �
0
Approved by
This report is hased in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The e�vironmental
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 environme�tal health
specialist warrants that the septic tank 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
�
ContTol Corner
0
Ben�,ie 8c Mdry �/
Odkley Etate
CUNNINGHAM T�WNSHIP
PERSON C�. , N. C.
OCTOBER 19, 1998
r
�L%t
N84°20 ' 25" E
/7 ' 2�
�,,�, l R '7
T��t c o f
P.C. 11-3>–I
Totdl – 46�,3.89'
,
�� I
I
Tract A � _
z. s �. �
U
v
M /� � -
,,� y�°a .
� yv�
N84'29'S5"E Tofcad – 505.77' ' __________. _
1 . ��_ . Q � �r.%%
` I ^ !
a :_
� �� •
; T�1.85 taB �% ) �j' � �
I
� , r �: i �.. . � � _ � . � � �. � r � ��.. .
r `� ; _
y , ' ;:' '' .,'
J_�i . .. � . . � .
N85'32'45"E' Total - 382.57'
- , .. �30.65
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0
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n
30.07' �
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� I
� I
� I
C1 I
I
I
).13' I
'
2 �
1
/
/
/
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Co�r.t�►-ol Corrcer C�---
Beruni.e & Mary
Oakiey Etate
k i�� �
i' + � l 'Y
` 4
4
L � ; ` �� .
�•
.-
,�.t
CUNNINGHAM TOWNSHIP
PERSON C0. , N. C.
OCTOBER >9, 1998
�� -
_� 3�3 0�
�--�q � �—� �.�� � of
�-� 1� i� �P.C. >1-31-I
�� --' � �'�'Z
N84°20'25"E Tot¢l - 4643.89'
/a'�'�
�. �a�
Trnct A
z. > a�.
NB4'29 ' S5" E
�
a
TTa.ct 9
� 1, 85 ac.
�
;
. i
b r `
I
J N85"32'45"F,
,,�,. .... .
a
M /-� � - �
�7 y G
� � S�0-
Total - 505.77' ' -_ __. _ 30.13' �
..
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TnfnJ _ '7n� �-.• ,,,, � _. ,
rF����;� c{�i,�,rti• ����; r►1,,►,�r��; . !i��nt �►
�•'FT.I ' • .
- , � f).�tc:,�-/d. -.9`�'..--
, (�wnCr: i�a�,�G. �i� �, _. „ � ,
. _ ___. .. .. ..
I.�x�:�ti�.►r�/l.�ll'C(:U(�ili: G �. " /. �- �_...... ' � ..
...
i�
�-------�dL�.�.GC_.• �'Jc� •l. =G" ���4`��` � .�'' .. • - -
• - ...- --- ._.__. � C��l�
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�.�;1,:���,�,�•ln�; ?':;lip��. ------•- � ��-- .. _ ... ... _.. .. i __. _ ._ .
� . .�Q�j �- �%�� i�`'�'`.' .� > f #1 . � _
!>►-illin�; (:c�r,tr�Ctc�r: --;���':.���� /' . ... .__ _ . ._ ...
�_�� ��.�.
_ ._._� _ ._ . , . _ .
WE1,i, C(�NS'i�itUC"�f(U; � �
1)i�.�.�nce fr��rti *Jr:�r�: ;l )�i„ .,.t�`, l.in� _. � -- r
F ... f. ���:�n� f�►� .�1 ����i:r.r �,
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Tc�::�l I):�}��h: �.�Q_-- F�. 'i icld GN ��t
, , -- ��.___ �'� I. ic� �����cr 1�c•••r.1. 1•I.
«:�!et I3earu�g ,Lonc;: Uc�tl� _ _�=t.____ ��. �:� ��! . —..-- -�
(: �Sing'
i�e�th: I�r��rn .�_ � -�--- - . _._ --- � . ,
.. _ . n��__�FL �)iarrlClr.t : �o ��.—. l��c ��.•S
7�1'I'F�.: Steel _ . _ . __. . . C;alvani7ui $tc�.�l � `--�.
If Stecl, dc�es nwj��r arprove: Ye5 rJ� .__. __ .__.. _. .
�'ei€he:1�,1��_ i�I�ic.kne:ts� /8 � }�eight .Aix,�.',,. -- /
����e .� t�:rn�inc�:_....� _ Innc�s
Sh�r,� �C'�� v N�.
titi'ere 1'r,�bi,�mc I•:��r;,��terKi in Settin che �'��in �. , -_ `
1� ., „. K F. S e�s_._._. _. N� �.--
. �
}��� �.���� ii.�1.;1,'i":.
��:c�ut: 'r����e: i leat_--- � . - S�n�i� .._ __.__ __.._._. .__...... ____ � ._... _._..__
_ _ ICemcnt _____.�..._.. -- _':',,:�c�rctc.. •
Annular S��acc Wi�jth_. _ � __ Inchcs ..—... --
�vater in Annular Space: Yes � No ✓
?�1�th�+.1: Plunped._.�—...._._. �rpssure � i'our� d
[�c�th' f�r�,tn.------�.. . to o2l�w -- F.`-- _.._..._.._ �
'�lateri�ls tJse�i: ,�t,�. �3ags I'onland Cemerit ti�'cigl,c c�f 1 1�1�, _�3 i�,;.
I� f11LXttlre i;c1:��i, gra�cl, c��rtin�s) - Ratio:_ �J. .�� �
li.) �'Iates: '�'es � ........_._ _
_ _ No ----� - _ ..._
<� x 4 slab Y es�. � No ��
_.. _.�. �
_ . �_ ._.____�R i �,Lt�tc; LO�_ �
. _ . --_ .
-�.� /�� . .___ �
. `-- .._. ._
T�rom_ .r� -..-- -- Formatio �.�. .___.�. -- ..r._ . ___ _ �
- - - - _ _... . n L escr� ���on - --,
I----- � o_. . ��`�D � ___.._�_ .__. - --�-------._._.__._
� ��- --- �G' __ _ �-a ��___ ---.---- _. .. _. .- -____. _ _. -.- --
-- l� .. _ /�'o � a�� -. .. . .. .- --- �- �----- � --- �—_._._. __ . --...
- -- ��. +
_ __ __-- �.___.._._. _ _. _ .. _ ~_ _�_._ . __ 1
� _ ___ ..__.. .. _.__ __ - ,
- --__ . . _ _ --------- � --- _.. . __ . .. . _. _. :
I}IERI��'i�' C!'R'1`�}'`� �1'HA�I"1��EA,�U1�'F,TNFOk��i:\'1'1();•: l:� C:()Ftltl:r.-'�C ��;JI'�'1'}Ir"�'1'
�r�11C WFL.1.. V�'AS t ()NS"1'Kt�!~fFll �,�I ACr�C)�',P:��;�'' � .
Fc)��rl� �1�' TE1� �'�".F �(��; �'�1�'��;��- l�EAl:i' , �-�C'. `.�-; H I>,i=.c-�t �1:,� ► !r �.:ti �:�� �
. t� �.Fr;t�.. r���;��-��.
. �-�. %��-k. � . �
-�-� . _ � =/o _9_i
S�gna�vrc of (.'��:;cr�ct�,r . _
,,
n��,�
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFA�E WASTEWATER SYSTEM MO1vITORING REPORT
���! � '7- 3��� � � �5 l q
Date of Ins ection System Installation Date Type Tax Map Parc 1#
P �
�
�� �r�s �r-' �l
Property Address
Instructions: Check yes or no for appropriate items and explain inspace provided for remarks and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in the permit are to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible,free of
infiltration and surface water diverted ?
Septic tank needs pumping ?
Inches of solids:�
Septic tank filter cleaned ?
YES / NO
❑ � �
��
❑ � �
� � ❑
EFFLUENT DOSING SYSTEM:
Required pumps present & functional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ? �
Effluent free of excess solids ? r�
Inches of solids(pump/dose tank):�
Elapsed time readings ?
Counter readings ? � �1
Drawdown rate: �_
DISPOSAL FIELD:
Evidence of effluent surfacing ? ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted ?
Diversions/swales properly maintained ?
Vegetative cover maintained ?
Protected from traffic/unauthorized uses ?
Distribution devices in good condition ?
Field free of settled or low areas ? �
PRESSURE DISTRIBUTION SYSTEM:
Turnups/cleanouts/valves/taps intact &
accessible ? ❑
Pressure head properly adjusted ? ❑
COMPLIANCE:
Compliant �
Non-compliant
Needs Maintenance ❑
i■
■
■
■
REMARKS
.—C(re�,�� .f-�� � d-e,�
— � �(�cr Or���+� �����
�C��l�wvt � •as r( ( M� �I' 1 �� �,5� �)
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/ ❑✓���i
/ ❑
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/ ❑
.- . Ap �a,� � i D� C�, ��91 NGti( �
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� ❑��g — �lu/ir�� S�'ar�'� -% r ✓t{-o �Pr�ct � Ul��� �"�
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