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A25 200
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" 0 ° R�raw S8a Plen - 575. �. . - g , . - . . , _ : �, _ , -. . _ ,, , ._ i _ . . . :� . . : . _. _ +� , _, ` � . ,�. . - j , ` � 'IF TIiE INFO�TION 1M THE APPLICATIOPI �FOR AA9 If�PROV�IEidT PER�AlT IS FALSiF9ED. CI;APIGED OR-THE S11'E IS ' '� �. . ALTEIiED. YH@PI THE lNIPROVE�AF�+IT PEttMPf AND AUTHORIZATION TO CaNSTRUCT SNALL BECO�AE tl�I1lALlD ��': g. . . , _ ., -:• , , . : „ . , �, . . , £ , _ _. . _ .� , 1) Aemutreq t�; (Ownertag e�: �rd .����r*�./� � ;3 � ` . . , �Haene Pi�an��� ' � .� , `- q a 9 9 �f Addnass: � �� i �— ,! ,�+� _ . ,.. _ Busie�s ` ` , _ ... _ � . � c� �-�`— : : . . Phat . t �r��,� - � � $ (� / Z ` --c' �' �-'y'�� � �. � ��`�" � �� r ` . � 3 . _ . -. � , - � . . ° Z, P�. a�d � oi c�rt ow�ie� cN i�o l ;• .-T : L� k-�1.o /�. f . . � � 5 ;�. 5 , �- �i1 c� ;� m u. A • -�-� . � , �"� . ` �, x � . .. .ai.Ly. AI=L . �j �, . t� t7"c,� � :y� ;-,,c=-- � � ., ��1 !�`�;n � f:l1{��+�o $ ���s' 3, Pro�rty ` on �ot size:� l, ��`icTownstdp: �' �r:+ti., ` , ; � , � � . � . Dtreclions to;the ProP�p1�1(Induding` road naen.e¢`s' and n��iunb�s): ��� �,�I� '.��•�r-� � f� , � . ' � ' .. .. „-� . � V� � ;, � � �� . 7 :Q � � • .� : �^� �. • It � `� �. � l� ' - z n-. ' %yqnt� �' � . 3- a , _ , ,. _ , . .- , . - , - . _ - . . �, , ,, - � . �-�e-�-�-d�- • 1 I l)v ` �-+�. � � � � �1 A . • � , � -� -~ C � �a :, ,: ` �''t'"�'� . p � ,C,� �' rt.. I � � _ , �.� � , 4). Pr,o�ased t�ee and�Struc�ar�e Descriptlan:'adswer eac��of the.fol . g qu ns: �. '�-, �e2x.��►�` � �) . P� � p . � �c. - C� � � t � . ._ . , . , , " . b) Stldt Buiit CI. Moduiar []. Singie lAltde q Double Wide�' , � ,. . , . c) . �Idumber;of 8edrooms: .�� � -. •: . . . - �: t � Number of:occupar�ls ar people to be served: � .: � �,_ . e) 8a�me� Y�,Q No�1f Yes, # of basernent BZture� ' , �� _" �- " f1 �Garbage:pi�Sai: Ye� �, No� , . � � . ,�. �' Dtine��ns of: Proposed Struc�ure: W�dth:'� Depih: � . � -,�.. _ . , . '.'� �����PPSY TYP_ec Private`�(neuv�o�axistlng �,.Pub�c fl, Gommunity o, S�pring.� . � � , ,. ,, . Are any virells an adjoining p�npee�ty't Yea�:No �,Ifyes,'Elocadon Le.f -�►-� �a�-'�'L ; `` ' .. � , • aw�wo 1�{d1C� �� _l_�__ �� ���..Cdit �9 �d�B� �BI G�YV� O�{y011�.�J�@ hC9� S� a'. C y �P � �,� ��iq 9 � � -� � � ,� conve�iona� ��d c�erticna _ � _innovativ.- , � . , ,. , . . . . � f A11�ve ,. : , . . . . .. � _ . . : . ._ . . � , . � � . , .: , , ov v � .. , ,, . , .. . . . : :�' i�r)� . ; , , , � � . .. �. . , . .. . . z . , . . . _ , ., .. .. . , ,, . ,. . . ,. _: . . , , . , . . � . , � . , , _ .. . . . �. ������: . .,,. . . . ` " CLEI�ii1.Y,3'TAK� ALL CORNERS A�ID LJNES OF ` '� . L . . � � � � � . THE PROPERTY. • - � - . � . 3TAKE THE CORNER9 �OF ALL PROPOSED STRLJCTURES`, _ . , _ . V`� ``, ' � r, P�.EAS RVEY�PLAT OR StTE PLaW TO'��THIS APPUCATION .� ;� , " `¢ . � .: �, _. .. .; � • _ . E ATTACH SU . , I . � �� ; . , ... . a 1 hereby �ake a�iic�ion � the,Petscn Cowny � Heaith Departrnet+t for a site evahiation for the on-ei�e seurage, d�posai sj►s�em for: ��' �� .� ifie above-d�ed pnoperty.� I agree ttiaf the conterrts of this'aQPlic�tion ar+e, ,true and represent the maximum fac�tiea to be, �� �� � .. piaced an fhe properiy. I unde�land,if.the site is aiteretl o�the irnended use changes, the pertnit;shail.become invaiid I undersland: ��_ ' �t as �Piicanf; I am �esponsibie for iderrtitying and.maridng. proQeety� Gnes, camees and maldag ttie ��e�'a�ibte=for the= �� peasonnd:of the=Person Ccuriiy Heaith :Depariment to c�nduct their�evala�aiions. Yunderstand' that I.am re'sporisible'for noliiyuig the�� ��' �' Health Departmettt if my propecty corrtau�s arry wetlands as�desi ated' b the ; Corps of Engineers. '. .,' _� � . .. ., . . , �-. . �. , 9� Y . , �. , . ' , _.. - . : Qt.=�Y ` , - �;. f 0 � �' - r3t�- , a �3 � � � Oartter:ar'1.�9a1 Repre"seritath+ pste � �x �' � ::. � � . ' ` . ; �.. � . . _ , , � ... , ; ; . :PC}iD rev.10l12199; � ' � � 'I� - .a _ . � .. . . � . Tax Map ii: toning _, AppUcant: Locatlon: Subdivlsion: SEE PERSON COUNTY ENVIRONMENTAL HEALTH �ACHED PLAN FOR SOIL ARFA AND SYSTFM I Pareel # � . � Townsh(p �� . / � fz'}.Q�-,C�C'��- �%�����J��� �! Improvement Permit A buildinq permit cannot be issued with oniv an Improvement Permit New � Repair Addition Type of Structure� � Water Supply C�� �`� # of Occupants # of Bedrooms � Other Basement? Basement F'uctures�_ � �� Projected Daify Flow: �� g.p.d. PeRnit Valid For. �'Five Years ❑ No Expir Proposed Wastewater System Type: Pump Required? Yes _�No ProposedRepair: �(,�w-�.n �,�il,a��`J�,Q�',c,,�,�,COrO��i`3-Ui`� Permit Conditions: Owner or Legal Representative Sig Authorized State ■ � � nnoV���, : I • r � � - �' �- - � / _.� -- Date: Date: � " The issua�ce of this permit 1�y the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for chedcing with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. To C uire Type of Wastewater Systerrti�' �� Wastewater Flow: ��' .p.d. Facility Type:,,��J; � J11�� New �epair DExpansion ❑ Basement? 0 Yes �,A10- Basement Fixtures? 0 Yes C9-�dff' Wastewater System Requirements Septic Tank Size: ���gallons Pump Tank Size: `" I�f-� gallons �� ,�C� Total Trench Length: -.�`�eet rench Depth:1�linches � . � Maximum Soil Cover: � inches Trench Separation: �, Feet on Centei �, / � � , i.,�� /li� Aggregate Depth:,�in. Other: Permit Expiration Date: -o� D 'LJ`J Authorized State Agent: Date:LdO '� � �o� The type of system permitted 0 does ❑ does not differ from the type specified on the application. I accept a, � the specifications of this pecmit ��� OwnerlLegal Representative Signature: Date: � - PCHD, rev. 11/18/99 � �` � �, r� A e Application #: Tax Map #: � 5 Parc�l #: .�"���_ Person County Health Department Environmental Health Section SITE SKETCH ;; r�QQ ( I`�i�am�D►�, L-a�-1> �' SubdivisioNSectioNLot# i . r � .� � _ - System componenis represent approximate contours only: The contractor must f lag the system arior io beginnin� the installation to insure that proper �rade is maintained J O � _ (� `� . �`Ci � K ��- �`�-' � �� �� ��� �-e.p�- - o�°���. � • �s°` �C� �-� ���� � i � � � . �,�" ��- � ; ��- � �h,� L�- � � , �c�� ���,� 3� b0 0` .SCd�B: � I � v I � � PCHD, rev.10I12J99 . , ,`1��y� /' .i�����/'�� .. , . 9 . f ' �" rs 1 �. �����71���7�•�� . . �r -.�7m'P71a.`emTM++r'++'n �Bffi��.1L �L �I.iO.�.�I�JIT. Tax Map #: 1�1 a� . Parcei #: � Zoning: Township: ��n �n �`�� Subdivision: ��da-�� ��'%ml���(1 Section: Lot: � Applicant: ��c l�rn [�.0 �nc � � - Location: lil G�icrS /n � �� l�' �peration Permit ; System Type (In Accordance With Table Va): � THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPLICABLE NORTH CAR�LINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION AUT IZATION. � � � .� a� -�a uthorized State Agent Date � �E P,Carrr��tan Co n5 �- I�c.� c�I 3 Qt : s ys£�.n � � R (�,rao i ty W �-S �" a;� Co���n�ianc 5�,�ec� W�s �PP� a 6 pTS r000 S76 3�� a-i5-oa (�i�c I - 100 ��'08, 3- �3s' q ' ...�— q� la' SnStu.licd by ��Curr�`�-�an q� a3-�a 0 (JD7E�k` $jr,�cm inskk ((cd Zo - ZZ" Ticncl. d t�l► Cor�tr-ac�or d,,�� Z P i t5 i n ar'c a-�o ✓c � i ry S a i 1 S, So�IS ucr�'Fi�d 6y ?� H� /.S� O,C. 21, N1�5":3 ?' �5" l.' '/'-r'��.t:t (: ,, 5.5.. c�.�:. N89°13'33"E � '�� zif 1y�� o r l Tract D 1.3___ 6 a�• er , `�. � N86°58'37' yy, � 470. 40 ' I � ( Ceffv Volunteer Ftire Dept. � � D.B. 216-772 � �e f� Volunteer Fire DePt. � D. B. 216-770 _ � CHORD BEARING DELTA �ADIUS LENGTH TANGENT 1167.18' 188.35' 94.38' 188.1 �, S03°30'12"W 07 22'40,. 1 i67.18' 150. 29 ' 75. 25' 15Q.1.. 27.63' 13.82' 27.63' S07°52'13"W 01°21'23., 1167.18' 6�.5,q' 123.08' S09°02'04"W 00°25')2., 16785.18' 123.08' 91.38' S09°24'a2"�' 00°1B'43., � IR7R.ri 1R' 91.38' 45.69' - : ��-"- � - _ I T�,t�zi, 3t�,�. ,7' ; ir�. r; ,' 1 ] � (�.i �'�y1�.1 �" � .1 _2� � � � 1 �:� ��9q � ��� �a 1�`O 1 ��1 Tot¢l - 375,25' 30.47' 1 f . � vs o� i� c� � M" Z l � l � � Q N85°17' 47" W � � 4.51' � ,Q o � co —��__ N85°17'47"W � o I 25.75' � � � � � PERSON COUNTY HEALTH DEPARTNIENT 3��A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SA!'�IPLEANALYSIS Name of Owner or Tenant ��� Z � '�-6�;^� ��— GQz�' .a.iw�+ ��r, Address `Z��c7 n'`�C�� '(�-�� Courtty ����-� C��� �� Collected By �1 �- Date Collected ���3—�4 Time Collected 3' 2c7 Source: C�'Well ❑ Spring ❑ Other Location: C�'�Iouse Tap �No Charge C9Charge pWell Tap ❑ Other ���:�**�*���****���*�***�***�*�**��*�***�**�**�*�*�***�****�*���*�*��***���*�** *****�*****��*�*���**�**�***�****����������***�******�*�*****�*��*�*:�******�** Total Coliform FecaVE. Coli Results Present Abse ❑ ❑ C�' Reported By � � \��� ► � � bactreport PERSON COUNTY ENVIRONMENTAL HEALTH P�EASE SEE ATTACHED PLAN FOR WE1.L SiTE LAYOUT T���� �-�s ��# a �c� Cc���n, Zoning — TO��P � APPUcan� ��(.�--r� l�( 1� �a r�� 1 - i /1 . n i+ � ,� 1 . - - - � LoCatlon: Su6dNislon:. Sectlon- � � � Well Permit Tvae of Water Suaalv: individuai . Commun'ity � Public Re4uirements• Site Approved by �`�'� c�����a Groutin9 APProved by �J�31-1� s� �-�a Well Log �/S � 5-� � � Well Tagj' f�a �'-�-.� Air Vent C- 7-��- Hose Bib C'-�s `� .3-.�t- Concrete Siab�� �_�-�- Well Driller• ���5 �� � �r�1`, Well �Approved By. Date: "7- 3-.�`- """`See Attached Site Sketch""" Welis must be 10`�et from property lines. ells must be 100 feet from septic systems. � Weils must be at least 25 feet from any buiiding foundation. Other conditions: PCHD, rev.11/29/99 .��� s� ���.��� - -i- � � � ���' � IE.nrn� �-o �aa�rn. � arn. �G.�n:�l I�3L ��.11 iCl�n. Driller ID # Com��ny N�me D�t�e Drilled Owner: �ell Log Location. � �—'�-r'�`' rax Ma�� Parcel #�o d Subdivision: _�_���T T'h Lot #�_ ' � Well Construction Distance From nearest Property Line (Miiumum 10 feet) �-- Distance from Sepric System (Minimurn 60 feet) `� Tota1 Depth: �i,_ $ yield: �_ GpM Static Water Level: Water Bearing Zones: Depth �� $ ft ft — ft ft Casing: Depth: From d to ft. Diameter: (,� � Type: Galvanized Steel �`-- Weight: �_ ���ess: %�� ' Height above Ground: �Y in Drive Shoe: � yes No An roblems encountered while settin T casin � If `�es" give reason: Y p � � • =_Yes � �—I�'o Grout: Neat: Sand/Cement t/ Concrete GraveUCement Annular Space Width _�_ ill�hes Water in Annular Space Yes No�— Method of Grout: Pumped Pressure Poured ✓ Materials Used: Dep� d to �-v Ft. No. Bags Portland cement __ �teibht of 1 Ba� ;� po�ds If mixture (sand, gravel, cuttings) — Ratio �— to �- ID plates: �Yes No 4 x 4 slab — Yes _ No Drillin�; Lo� � .. � _ 1 hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth by the Person County Health Department. Signature of Contractor � `' � . ,.�/. ID # �,��-� � I)atc s . �L --c�=---4 PCHD rev O1/16/02