A25 51Apalicatton Date: , �%.�—d�
Amoun Paid•
Recei �
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Tax Map #• ft Z�
Parcel �: J �
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APPLICATION FOR SERVICES
�
CONSTRUCT SHALL BECOME INVALID.
1) Permii requested by: (Owner/a ent/ rospecttve owner): �• l'
Home Phone: �$'D 4� 3�`4� -�� Address;;� �
Busi�ess Phone: LF - D 3 2) � o `{
c�.0
2) Name and address of cunerrt owner. _ �- C.�t.� r'n e-�''
. Tau�nShiP
3) Properly Description: Lot size: I�c� Township: �.�ubdivision: Lot #
Directions to the
�CP{�� ��
4) proposed Use and Structure Description: answer each of the following questions: � �
.... � a) Proposed _, Existing ✓Type of Structure: ��I C�C � m �.cse Width:� Depth: G �
� ' b) Number c5f Bedrooms: �� Number of occupants or people to be served: �_
� c) Basement Yes��lo _ Will there be plumbing in the basement?�
. d) 6arbage Dtsposal: Yes � No �
5) Water Supply Type: Private _(new _ or existing�, Pubiic_, Community_, Spring _
Are any welis on adjoining property? Yes,�No _ tf yes, piease indicate approximate locatiori on the
'site plan.
6) Does your property car�tain previousiy identifled jurisdictlonal wetlands? Yes_ No �
PLEASE NOTE THE FOLLOWING: �
➢ A PLAT OF THE PROPERTY OR_ S1TE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LJNES AND CORNERS MUST BE CLEARLY MARI�D. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAl�D OR FLAGGED.
➢ THE SITE MUSfi E3E REx1DILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF. � �
I hereby make application.to #he. Person County Health �epartrnent for a site evatuation for the on-site sewage disposal
system for the above-described property. 1 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 pertnit shall
a /,3 �oo �
Date
PCHO, rev. O6l27/02
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Tax Map �_ Parcel # J� Tournship:
Applicant: � u�4-P� T o YnP✓
Subdivision: Lot # �
Location: �71�) ->- �j cx, CmCp,rc -Ce a Rcr -� I 191 C�� Co-�, ,ed
'�ype of ��ter Stnp��y�: � Individual _ Community Public �`,� /��
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GQavr���j %��at,%
�eqaa�effien�: � . `y/� C�✓� w.f5 ��i��
�!��i !e��i 9�a•r�a►✓.t,G
Site Approved By: �I - Z�- oCQ Liner: Z� y� C✓I�✓�9 �� —y
Grouting Ap roved By: s-� c. -�c. ,C /g� �Installed by: � ' �/E�
g
Well I.ag: ��' �5-1cn-��� Depth set: � ��
���. �� Pump Tag• � Grouted: . �G/����
Well Tag: . I�ate:
� �'�' Air Vent• � � �
� Hose Bib: � . ���
Water Sample:
� Casing Height: �
Concrete Slab: � �
Well Driller: �Q,�� � �\\: �.. 1,J�4\ ���,�
Well Approved by: � Date:
*�**�ee A�ac�aed S�$e 5ke$ch�**�'
Wells must be 10 feet from property lines.
�jWells must be 100 feet from septic systems. �G
Wells must be at least 25 feet from any building foundation.
Other canditions:
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SITE PLAN
Name�l-l� \^�u.�1'le� Tax Map #�Parcel # `� �
Subdi ' ' . Section/Lot#
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Authorized St�te Ageat D�
Sysrem camponents repsrsent apprn�mare canmvrs oa/y. The coau�cmcmuattlag t6e sysum pdar to br�fioaiag the ias�atiaa m
iasutr t6at propergrade ia maintaraed
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STTE PI.AN
Name�Ll`ri ` � U ��'let� Tax Map #�Parcel # `v �
Subd�i �' ion . Section/Lot#
�n'�51.m,� �o c�;o
Authorized State Agent Date
System compoaents reprrsent appmximsu coamure onfy. T3e coarractotmust tlag t6e sysum pdot to begianiag the inar�l/stioa to
insrm rhat pmpergrade is mamtaiaed
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Scale: r v �i�
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C�n-�ac�- E nv� ���
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PCHD, rex 09/12/Ol
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Owner: 1��1
Locarion�
Subdivision:
��
or�oocc� o� � Z
C�p�� • ��J 1�lP � � t �LtAM �J�.
D�o �oo� 5— t I-66
Grout Log
Tax M� Z,� Parcel # �
Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet) �
Distance $om epti System (Mini um 60 feet) �
Total Depth: � h Yield: �� GPM Static Water Level: 3� ft
Water Bearing Zones: Depth � ft I1 O ft i�i5 ft f95 ft
Casing: ' '
Depth: From � to � � ft:. � Diameter: �� in
Type: Galvanized Steel t�— '
Weight: Thiclrness: �_ Height above Ground: � 2, in /
Drive Shoe: Yes No Any problems encountered while setting casing? _Yes . No
If "yes" give reason: _ _ !
Grout: -
Neat: Sand/Cement ✓ Concrete GraveUCement
A.nnular Space Width ,�_ inches Water in Annu�ar Space Yes No
Method of Grout: Pumped Pressure Poured �� Depth � to Z� Ft.
hlaterials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sa , gravel, cuttings) — Ratio to
ID plates: _ Yes _ No 4 x 4 slab �Yes No
Liner: —
Depth: Date installed: Grout: Installed by: _
Drilling Log
Location Drawing
From To Formation
,
, ,
I hereby cerrify that the above information is correct and that this well was constructed in accordance with regulations se: forth
by the Person County Health Department. °��
�' ' � -
Signature of Contractor`
IA# 23 � � Date' ��� `' Q�j
,, _ Pump Installment � �..
Pump Installation Contractor: State Registration Number: �� ��
Pump Depth: ft Static Water Level: ft
Pump Make & Model: Pump Size and Rating: . hp gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of this record has been provided to the. well owner.
Pump Installer Signature Date: PCHD rev O 1/27/04
MAY-19-2006 09:54 PM P.01
.
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Owner: l�
Location�
Subdivision:
Distancc From n
Distance from�
Total Depth:
Waur Bearing Z
Casing:
Depth: From �
Type: Galvanized ;
Wcight: �
Drivc Shoe:
If "yes" give reasoi
j�� [�, I�� �(/� �� Driller iD a ��
c c�► i \ �`� Com�any Namc�� � �
- -. i � � ._ _. i , i , D��Ge Dri:l:leci � .
Grout Log
� Tax M�� parcc) # �
Lot �
�
�'elI Construction ,
:st Properry Liae (Minimum 10 foet) � '
Syscem (Mini�o 60 feet)
� ft Yield: GPM Sta— h� 'c Water Level: 30 �
�: Depth „�i.�'�.., ft � � p ft 145 ft iq � R
� to� �, � Diameter; ,�! ,
:el � in
� Thicf�ess: ,�� Height above Ground: �?. �
ts No Any problems encountered while setting casing? �,yes .�No
Grout:
Neat: Sand/Cement ✓ Concrete CrraveUComent
Annu ar Spacc Width - 1 Z„ inchcs Water �n' Anna�a �'' Specc • y�s � z•
Meth d of Grout: Pumpcd Pressuro Poured ✓ .D�pth _Q �'�(� F
?�faterials Used;
No. gs Portland cement Wcight of 1 Bag `_ pounds
If mi e(sa , gravel, cuttings) -Ratio to
ID pl es: „_, Yes ", No 4 x 4 stab �_�o�
Liner:
Dept Date installed: Grout; Installed by:
Drilling Log
m
n
Locatioa Draw
I hcreby cerrify that 1he above information is correct and that this well was consaucted in accordance
by the Person Count� Hcalth Department. ��
Signature of Cont
r ID;�# 231 � Datej �-�� �
, , Pump Tnstalimcnt
Pump Ins�allation Co aac�or: State Registration Number; �� �
Pump Depth: R Static Watcr Level; � '---
Pump Mafce & Mode 1'ump Size and Rating: _�
I hcreby ceRify that t's pump was installed and the wcll head compieted according to the Person Coun'ry '
on this date and that a copy of this record has been providcd to the. well o�vner.
Pump Installer Sign ture � . ��tL.
regulaAons se! forth
�
.. �
g}�rn
ll Rules in effe:t
rev U I/27/04