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A25 7ApplicatiQn� Date: 1�—I � _v I Amount F►aid: _ RecEipt#: � d °. '� Jj O ��' Tax Map: # �� s . '-� . �� .. r7� . a, . ParcEi'#k / �-� ��4�� . I�I�I�..�� T � �0 �1 - �C ��1�T'�� - . �.�.��.,.-,.-,..��:�� .�:� � APPLJCATiON FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT, FALSIFIED, CHANGED OR THE.SITE IS ALTERED THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: ( wner/ gent/prospective owner): �� c��s �e�. M or4e: s Home Phone: ..�5'�'� ��6 � Address: 3 a x��& Business Phone: s"�is� �//3 cq re �`� � n/. � a�-�I 3 2) Name and address of current owner: -�4m e � 3) Property Description: Lot size: 1�+ Tawnship: C4ua• � Subdivision: — Lot#: Directions to the property (including road. names and numbers): _� T, ►�. �c .�.�a '_ 2�Q T 2,�_ 2:•..+�- Fr�s-r + eao.� 4) Proposed Use and Structure Descriptio�: answer each of the following questions: a) Proposed '✓, Existing _, Type of Sttuc�ure: 1? r,� :.�.� Width: � Depth: 3 � b) Number of Bedrooms: � Number of occupants or people to be served: 2 , c) Basement Yes _, No�Wili there be plumbing in the basement? d) Garbage Disposal: Yes _, No � 5) Water Suppfy Type: Private �(newk or existing �, Public_, Cammu�ity _, Spring _, Are any wells on adjoining praperty? Yes _ No _ if yes, piease indicate approximate location an the site plan. 6) Does the praperty contain previously identified jurisdictional wetlands? Yes _ No X t PLEASE NOTE THE FOLLOWING: �➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARL.Y MARf�D. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR EiJ�GGED. � ➢ THE SITE MUST BE READILY ACC�SSIBLE FOR AN EYALUATION BY THE HEALTH DEPARTMENT STAFF. I� hereb� make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this applicatio� 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 permit shali become in�alid. _ Owner o Legal Representative � 21 .�. Date PCHD, rev.10h7101 �'--��, ; , �.� �� , �--�_ � � �� I��.�a� � ��.��¢�.11 IF3C � �.]1�1�. T��x M�� i P�rc�el # Sc�hrlivi�s�ioii IPh�•s:etS.ec,t�ion Lot # Applicant: W eS �� f Yl S Location:., . � . , r, _ _ . .� _ . �E'��.'�1�a1�� Improvement Permit Permit Valid for F've Ye rs No Egpiration � Type of Facility: � 'p� New �Addition Water Supply 1�/� �� # of Occupants ►Ma # o Be rooms Projected Daily Flow 3�Oo g.p.d. Proposed Wastewater System: � . Type: Proposed Repair: COUII/� Type: Pernut Conditions: U/�1'�vl L` �'�n Owner or Legal Authorized State a�.q c��e ►a�� a� c�'�� s �55-� Date: � �L � � a Date: 2 ` ' D `o� The issuance of this permit by the Health Department in does not guarantee the issuance of other pennits. It is the responsibility of the applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permlt is su6ject to revocation If the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina Zaws and Ru[es for Se�vage Treatment and Disposal Systems' (15A NCAC 18A .1900). �� Authorization to Construct Wastewater System �Required for Building Permit) * See site plan and additional attachments (�. Proposed stewater System: C0+�11• Type`� Wastewater Flow �� g.p.d. New � Repair Expansion _ Soil LTAR: • 3 a r g.p.d./ ft 2 Type of Facility: _'3 B� /�,e� .� Basement � Yes �No Wastewater System Requirements Tank Size: Septic Tank: df� gal Pump Tank: gal Grease Trap: gal Drainfield: Total Area: l� sq ft Total Length �f� ft Maximum Trench Depth � in" Minimum Soil Cover: �_ in inimum Trench Separation: � ft Distribution: Specifications: Distribution Box Serial Distribution Pressure Manifold � %�� '�Cl`r l. Authorized 5tate Agent: � Permit Expiration Date: 0 Date: � ^ v �� The type of system permitted is �LConventional Innovative Alternative. I accept the specifications of the permit. , � _ �,o Owner/Legal Representative: '- Date: � Arthur R,Wlley,Jr, D.B, 154-662 Llne Surveyed by Neal �/ � C,Hamtett,PLS-2465,Sept,,1980 Ref,P.B, 24-174 W i�,U ��" � a'a'-� S� S�"' o 0 �r ��,{�� '� � r 1�2�v.e, ;v�S� � � � � n' � � � ,� C��,�u� �_e o �, a � �� °� � z � K�� pe ` �� S S� a�- ��e.�.s� '� . � � �o`b ��". ' l� p�� J �� / � �f�� Rr'� �i �� ^��- �- .� , ,� �� r P 5 � �C' .� ��D ac_ ��`��-- �, � S '�� 73 e�'4'1j� 3�1,�n E -X i _� �� . Q� � % �,s , � i � � � v � � \. i� � � � S �� . � � � �� S �� c� ,�fc js , . � a� 9��'� �,,� � s�� r's �1�� wl � � �fS��s- �/� C �r,.� . \ c� j 4c�' P// Plf%f I�� SR N 68, I�S6��(��4rsa �� te �t,�� ,� �.r; .;; ; , ;1-. ;',; : ' I `,` ; <! :.F t,, ; , '�i'c� �� ., t''Y ;�,. , � 3�, . `� '�a , �� 1 �' r�� Q� rP,�� Llne Surveyed by PhllUp J,Hall, \/%CG PQ. ��'� 1378,Septer�ber,1975,Ref, 6Q' \�%�PS P,B, CP&L,pg, 27 �Q�\M�(/ ^ � �.. � c{ ��_ ��T ; a ' � F i � . a'' • -n � (J , <�J�%! �L ` ✓ ..F , D=02-44-08 R=�na�.4� � 1 ��1 •' � J•�� , • . �� •7~ 1; nII • . 1 � •. �i��•`�� a� ��'Rw �!'1YT �Q�.�� Q�L� - - aA... � #: OC � . . . . __. _.'iiu'L �....,. Parcai #• 1 Znning: Township: ' � SUbdivisioa: � : �::�: •:: � �� .Section: � Lot Appii�ant �" �� r 5 � iccation: C��1-�S : t � �' -� 4P�"� �� r I✓'2 3��' 6''� � ( _.� s - . O eratian Permit � . System Type (In Accocdance With Table Va): �_ THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPUCABLE NORTH CAROUNA GENERAL STAi'UTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITiONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTiON AUTHO ON. - � � � �� -�� Authorized State gent Date ; � � `v V' �� ° . 1�' - j��c� � � vP � �� y � � � Q\ _ 7 a" .� q'��' � � �� . �� . �, �s -- _ _- _ _ - -��5 �<< . _ ---v_ �- - -- - - - ��.�� .�� -= � � � �� ° s��aa-��ana�n.�na��.�. ��a�.�.��a WELL PERMIT PI.EASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: �_ Pazcel # �� Township Applicant: �✓�s /�D/'/"�S Subdivision• Section• Lot• LoCation: 11%n �+��v_P� �,�/`«i' ' TXpe of Water Sunnlv: �dividual Communitp Public Requirements• Site Approved bp '�G� �l � �d�' Grouting A proved bp �� 1-D:L Well Log .�- - C� Well Ta.g �� z- — Air Ver�t i��' N 3'�'a Z Hose Bib ✓� 3' q ,�2 Concrete Slab s- �-v� . Well Driller Well Appro, � 3 --�}--o Z �SD 2 �ee riiracaea �iie Sketch'� Wells must be 10 feet from property lines. Wells must be 100 feet from sepfiic systems. Wells must be at least 25 feet from any building founda.tion. Od�er conditions• - PCHD, rev. 09/07/01 . ��,5� ��.�� 1 �� na�na-o�aaa-n_�aa��.�. ��m��a: D� aD � �,�2�/ �U�1C�tllUUl� ✓�:_�IK � LvC// -�f��/. Oq - 0 -o Well Log Owner: �G��, �� z ,�� lir��^ Tax Map �,�`r Parcel #� Location: fl�,• c�J,�c� ,;�%'/� :�'� Subdivision: Lot # Well Construction Distance From nearest Property Line (Minimum 10 feet) Distance from Septic System (Minimum 60 feet) Tota1 Depth: ,�R�� ft Yield: y0 GPM Static Water Level: � ft Water Bearing Zones: DepthQ'��,,�ft ft ft ft Casing: Depth: From �_ to ,� � ft. Diameter: � in Type: Galvanized Steel ?�t�; Weight: T1ucTl�ess: . i� Height above Ground: %,>> in Drive Shoe: i Yes No Any problems encountered while setting casing? Yes t/�io If `�es" give reason: Grout: Neat: Sand/Cement Annular Space Width Method of Grout: Pumped _ Materials Used: Concrete GraveUCement inches Water in Annular Space Yes No Pressure Poured Depth to F� No. Bags Portland cement Weight of 1 Bag If mixture (sand, gravel, cuttings) — Ratio to ID plates: Yes _ No 4 x 4 slab _ Yes _ No Drilling Log Pounds Location Drawing From To Formahon C�7fJC Gi - �`,,�,�c� � - �' ✓7C l � I �S U.� ti• �, c �� w, • ru � �;��.�< c��,��.� ��1 F�,`r 1 ��. r � ,��1 _ � � / ��b:,rt� I 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 Dep e. Signature of Contractor ��/ ID # � Date ,� - �� -�� PCHD rev O1/16/02