A25 207Appiicatton Date: � � �� ��
Amount Paid: 4 • �
Recaipt#- ;? R7��
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Tax 9Aaa #: "
�arca� #: .
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APPIlCAT10N FOR SER1/IC�S �
IF THE IIVFORMATION IN THE APPLlCATION FOR AIV IMPROVEMEiVT PERMIT 1S INCORRECT F�ILSIFIEfl
CHANGED, OR THE SiTE IS AL7'�RED, THEi11 THE 1MPROVENiEiVT PEi�MIT A►iYD AUTNORI�►TION TO
COfVSTRUCT SHALL BECOME INVALID. �
1 Permit requested by: Owrner/a ent/prospective owner): ��� �"� �'� s� �
Home Phone: 33b5�7 50�1� Address; l�g �� ����i 2of�
Business Phone: I�i 1 5�� 1Z� x� ai'0 ,/v. a� +•�a 2-�5 � y
2) Name and address of c�rrent owner. ��.,�
. o-- - ., . . —
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3) Property Description: Lot size: �'� Township: �� �� bdivision
Directions to the property (In ud�ng road names and numbers): � 7/V
N �_ � r =7 r� n �.. ... �►,-n V 1/.� ,.'
�
Lot #
4) Propcsed Use aryd Siructure Description: answer each of the following questions:
a) Proposed ! Existing , Type �f Structure: M o r� U � c�;ii Width: � Depth:
b) Number of Bedrooms: �, Number of occupants or people to be served:
c) Basemen� Yes , No !Will thele be plumbing in the basement?
d 6arbage Disposai: Yes , No �
lAlater Supply Type: Private ✓(new ✓ or existing�, Public . Community� , Spring _
Are any welis on adjoining properky? Yes_ No ✓If yes, please indicate approximate locatiori on the
''s �site plan.
Does your property cantain previousiy identifled jurisdictionai wetlands? Yes_ No ✓
PLEASE 1dOTE THE FOI.LOWING:
➢ A PtAT OF THE PROPERTY OR S1TE P.LAN MUST BE SUBMCiTED WITH Ti-!IS APPLlCATION.
➢ PROPERTY LlNES AND CORNERS MUST BE CLEARLY MARKED. �
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE ST.4i�D OR FLAGGE�.
➢ i'iiE S1TE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HE.�LTH DEP�►RTME�IT
STAFF. �
I hereby make application to the Person County Health Department for a siie evaluation for the on-siie sewage disposal
system for the above-described property. I agree that the contents of this applicatian are true and represent the maximum
faciiities to be placed on the pro erry. I understand if the site is aitered or the intended use changes, the permi� shall
became invaiid.
cJ h�vl �Q •�/�/Y�Q w � 1 � C� l D S
Owner or Legal Repres�ntative Date
PCfiD, rev. 06127f02
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Applicant
Location:
s
PeYmit �Ialid for �
Type of Facilit�: '
# of Occupants ��c� �
Proposed Wast�water
Proposed Repair: �
�tS
�
�
1 �
T��x NT��F� � �,rr : I �' '
S�et:f�.cl i v i�i c� ia
Pi�i,�s.���5�crio�a�L.a�t �
�pro�e,a�eni P�s-�t
Nq I�sgirat�n �� �
„ � - New �t�ddition ��ten� �upply � IA/e ��
# ofBedrooms � � Prn�
r.�m: �'i v� ds ` �.
.m
, �� � v� s•/. d�
Dai1y"Flow �� g.p.d.
Pe�it Conditions: ''�P� Sz � :S�'�-� � •
. . . . � .
Owner or Legal Representative i
At�thorized State Agent:
�
Type: � �
'l�pe:
Date:
Date: �C�'� s
'I�►,o issuance nf tt�is permit by the Heslth Dapartmont in does not guaranbeo the issu�nca of other pee�iita. It is the re.sponsib�lity of the
$PP��P�P�Y oainer to in sure that all Pezson Couniy plamming and' ZoniaS and Bw7ding InsPections requiremeats are met 'PLis
Improvement P.ermit ia subject to revocatlon if d►e pite P1an, Plat or the intended use chsnges. �'he Lnprovemeiat �ermit i� nat affecte�
by a'ehange ion o�vnerahip of the propertg. This permit was i�sued m comgliance with the provisio� of the Nurth Carol�ua `Lrrws and
��or Sewa�e T4'eatment u►id D,�sposul S`vstem�' (1SA NCAC.I8A .1900). Neit3ter Person �o�ty nor the Enviro�emtal ]�ealt]i
3pecialist �varrants that the septic tank system w3II conWtue to fanc�ion satieiactorily in the future or that the vqater s�aPPly will remam
potaLle. - � .
��IIt,�lO�izat�olD $o COl'�tin�'�a3�v�a$eg� S�stegii �fl�equired fos �uilaing Pea�it) .
* See site plan and additional attachmertts (_,). �%��...'�'�� �� �
��sea w�t�w� sy�:�s �.��,� � Z ����,�i �rm��_G w�Wat� �o� ��g.P.a.
New � Repair Eapansion �. Sa.7 LTAit: x�� g•P-d.! $ 2
TypeofFacality:. �1�� ��'- � � �Basement �Yes�Na
. �as�water Syateffi Reqniremea�ts . .
Tarik Size: Septic T�uk: f1 c7 gal ,. Pnmp �anl�: � g�1' . Grease Trap: ga1
Drainfield: Tatal Area: �t't�� sq $ Total Length �Dc� ft Ma�mu�'Y'�eia liept�� a�fn
'�rench w�th � ft i,ni•*���n S�il Cover: �'� in Minimum Trench �eparation: � ft�. C.
Distriba#ion: Distn'b�ztion Boz � Sea�i�l Distri%ution �Presstae Manifold
�, /_J/. -
spec�cat�ona: Fla G f ti � � �1 0�0 - .02'� � � %�r-eKC� � �//�'J� S
Ate�aor�ed Sta#e �igea�:
Peu�it F.x�
Date:
�
�
Date: ��- ��% "� �
The type of system permitted is Conventio � vative Alternative. I acxept th� specifications af
the peimit ' . � � 1 ^�
��teslg.�e a1 �pr�entaiave• . Daie: `5i Cs� C3�
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. . PC�ID7/30/2002
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Name � � s ��
Subdivi
r� r�
Authorized State Agent
SITE SKETCH
— �
Tax Map # �°2 Pa.rcel # �� � �
Section/Lot#
-��-� s
Date
System components represent approximate�contours only. The contractor must, flag the system prior to
bebainning the installation to insure that propergrade is maintained
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Applicant: � � ��' �
Location:
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:�, �,�= ' ;. � �;�: � �;.
ax Map I��'�. P��rc�-el , •
Su�bcilivision
Ph�se Sect,ion- ot #
i� of Be �!rooms
System Type (ln Accordance Wifih Table Va):
TH1S SY5TEl1fl !-lAS �E�N INSTALLED IN COMPLIAIVC� WITH APPLlCABLE�` ORTH
C'AROLI�4A GENER�►L STATUT�S, �tULES FOR SEWAGE TREATfl1lEi�i" AND DISPOSAL,
APID ALL CONDITION� OF � THE IMPROVEiV1El�T PERNIIT �11�ID COfVSTRUCTI�N
AUTHOR[Zr4T10[V. �
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Authorize e rrt . Dafe
lnstal(ed By: �-� � Date: L r� b� �
bUN�A'T�d�1 � "
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PCHD, rzv. 07/29/G�
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����'i� ��,�� �����'��°��� �u�����si `i�'��� �� � �
Tax Nfap # �L� Parce! # 2� 7 Sys%m Type (Tab�e Va)
OwnedApplicanf f�/i�t/y�L�-r� Subdivision �
Address/LocafiSon Se�IPhase Lot #
• Z9p � � � TI�
� � � � �n�,��o�t/
Se�tic Tan�t ni�aa �at� it� ica�ao n�s lna�a ate �
State � ID/date / �-o,� �'r� ?�- � - �� Trench �dtf� 3 ft � .11i_ S , �
z
Capaciiy �� ��Da 9ai.
Tee a.nd Filter
Baffle -
Seaiant
Riser (ifi applicable)
Tank Outlet Sea!
Permanent Maricer
Purno T�nk
e
Waterproof /Sealant
Riser
Che�lc Valve/Gate Vaive.
�11arm visable and audible
Elecirical Com onents
� Rate m
A raved Pum Niode!
Bloc,ic Under Pum
Pum Removal Ro elCt�ain
. � Dis#rii�ution. Sys#ern
� Serial Distribution
ressure Man o
Low Pressure Pi e
A r. Pi e 1�111ateriai and Gt~ade
Valves
� Trencf� De th ?�in.
Trencii Len ih � o � �t.
Tr�nch Grade �
Trenc#� S acin
Rodc De th and Qual'
Dams/Ste downs etc.
Pressure Laterals �
Hofe Spacing �
o e �ze
Pipe. Sieeve
Tum-ups/P.roteciors
Requi�d' Setbac9�
From� Welis
From_ Propertv lines
�-�-�� ° , �iruczuresitsaseme
— - - � c es raina e
� Surface Waters
Public Water Su I
Verticai Cuts '2 ft.
Water Lines
EasementslRight of
Other
Easements RecordE
Coanmen�s
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WELL PERMIT
PLEASE SEE ATTACd3ED PLAN �OR WELL SITE LAYOUT
Tax Map ��� Parcel # ad� Township:
Applicant: `u S
Subdivision: Lot #
Location:
Type of Water Supply:
Requirements:
�Individual _ Community Public
Site Approved By: � 5�' o"�O-oS Liner:
Grouting Approved By Installed by: ,
Well Log: JS � 05 � Depth set: _
Pump Tag: � Grouted: _
Well Tag: Date:
Air Vent: ./ � -%-o��'O�
Hose Bib: ✓ Water Sample:
Casing Height:./
Concrete Slab: c/
Well Driller: �� � �11.
Well Approved by: �
****See Attached 5ite 5ketch****
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:
—
Date: '7-- �ta ��
PCHD rev O1/27/04
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DQ600c�rr �D � ,.�.,��
_ _ _. , � Gl�;ac� ������
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� c� ��CT1��C�- o� o �,�,,� �"- �� 1'- C�,�'
� �n�n�c-��rn�rTM�+ �aa.�m� ���.m�.��:n. . � ��lll�l4J
Owner �
Location:
Subdivision:
Grout Log
Tax 11ilap��Parcel #aO 7
Lot #
Well Co�truction
Distance From nearest Property Line (Minimum 10 feet) �
Distance from Septic System (Minimum 60 feet) (�U
Total Depth: � ft Yield: U GPM � Static Water Level: � ft
Water Bearing Zones: Depth � ft C� ft ft ft
Casing:
Depth: From �� to � ft. Diameter: ,�Q _ in
Type: Galvanized Steel /
Weight: Thiclrness:l�� Height above Ground: l. �i in
Drive Shoe: Yes No Any problems encountered while setting casing3 Yes /No
If "yes" give reason:
Grout: � �
Neat: Sand/Cement Concrete GraveUCement
. Annulaz Space Width � inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured / Depth C) to�C� Ft.
Materials Used: �
No. Bags Portland cement Weight of 1 Bag Pounds
If milcture (sand, gravel, cuttings) - Ratio to
ID plates: �/4'es _ No 4 x 4 sla� i'es _ No
Liner: -. ,�
Depth: Date Installed: Grout: Installed by:
From
Drilling Log
To Formation
C%
� �c�
�v2� QfLr�l
Location Drawing
4' �`
7
�.�� c.� ��„ ��
I hereby certify that the above information is correc that this well was constructed in accordance with regulations set forth
by the Person County Health D �
Signature of Con or ID?� � Date V�' - 3(- ��_
Pump Installment
Pump Installation Contractor: � State Registration Number: ��(Q� ��
Pump Depth: L U ft Stati-c/� ater Level: � S ft �
Pump Make & Model: �E� Pump Size and Rating: �hp � gpm
I hereby certify that this pump was installed and the well h completed according to the Person County Well Rules in effect
on this date and that a copy of this rec as� r � to the well owner. .
Pump Installer Sig C �J Date• � 1'� PCHD rev O1/27/04