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A25 207Appiicatton Date: � � �� �� Amount Paid: 4 • � Recaipt#- ;? R7�� -� Tax 9Aaa #: " �arca� #: . � �-���_�� ���� �� ' -; ���Tl�T��Y � aa�a.a-amaa,-�-�- ��.�mI1 ��.a�.7L�hx� 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-- - ., . . — � ,� 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 �_1����� ���� �� �i �.,' � � �lJ �� �L � IE��-��-^ �^--^ ���.IL IF-7L�:�.]I.�II�. 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� � . . PC�ID7/30/2002 . l �.9S� � ��N����3 � _�,?, j'� �Lld1l\l� �� V � �� � � �� ���� 7�., �tYA u- � a,a ��,8 �;. � �, ll IE7T ,� .m.Il �ll1 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 ,� e� �`�� � �e� � �-s �� �` ��� �� , � _ �.�c ( S Ci� � �-� U�v�u�?9� G�`V � �,,,, Ca�e� • 12� p « ��O f �g � fi��� �o�s� �� ��� a� 2� �� ���� a �, � �� ��� � �� .�.� <<�. ��� S�� • % �� `_ � � -- -- f) _ � • ;� �'r� L� �� � N � � i I�dSO,L�o�L S 6t'06Z 1� �� � '� t �!-� i �-,,a' �B� 3n �o� � C�v''� a��;�- � � �.a�a �"--_-----'"�'' `. .-- -� I ________-- � a' � � 6I'06� �dtiO,L�e�L N oo. '�p�s, r� 9T N �wZC M0� �i�� (n�� I. �N'S) 'p� �.�� �� ���� �� �..� ~ � � � ���� � aaw�.a- � �*-++ ,.-�-�, �� ��.�. �� � �.� ��. Applicant: � � ��' � Location: e , � :�, �,�= ' ;. � �;�: � �;. 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. � � / _ �-� g' 6S'' - Authorize e rrt . Dafe lnstal(ed By: �-� � Date: L r� b� � bUN�A'T�d�1 � " . �v�- � ��. � � i�_�_o�' . '�`t-5 1 O oa �-a �� � ���i/L �. iD� _,---- — � . . • � ���r/L` �i7" _� � � � , � O �. � ����l�z� _ � ,� . x� _ _ � � �O' // ' �^ ��l l ��Z ` / '�"" _ —" -' �--„ — ��� �tl�/ �� , � �� Z f, � /�— -�c — x ' �'% � �� �z � / ��.;� �a � � ,� , v�l-�. ��� � � l .,__, ; �/� : i/ ��G� ��/���u�'���/ PCHD, rzv. 07/29/G� ." ����'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 �i'i�ld �v. 311v�Q� . ��� .; :�� ���� �� �;: �. , ;>� ..:_`....... ������ ;: : :. �.�a,-�9.�rs�;.-,�;,.,.-,,;q����.]L g�a�,a�.Il.�lia. 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 ��� Sf ���� �� DQ600c�rr �D � ,.�.,�� _ _ _. , � Gl�;ac� ������ .. • � 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