A26 103Aoplication Date: � � �� � Tax 1VIaa �•
Amount �aid: ���
Rec�ipt #: � �I � Parrxl �:
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APPlJCATION Ft3R SEii1AC�5
�IF'T7i� INFORMATIOM IN 'iHE APPl:1CAT10N F�R AN INFPRO�IEMEAIT PERMR IS INCORREC�'. FALSiFiE�.
CHANGED. OR THE SiTE IS ALT'ERED. THE3N 'tHE 1NIPROVE�IAENT PERMTP AAID AUTHORIZ�►'�IOfd TO . ���t-�
CONSTRUCT SHALL BECOME INVALID. • �,$' O' i1
A)" Permit requested by: (Ownerlager�tlprospeclive owner): it /, il„n.. Tti ...�.b• �� s� h e r
C `�
Home Phone: .3�G sq? S?a � Address: 33 �zc�C. /�IA;�� �, � k �.
Business Phone: sy � 3y 3 S ,�'-n xG� a r� a, � tZ �/
2) Name and �dclress of currerrt owne� s�kt e
3} Property Description: Lot size: �gc ��Townshlp: o� �� l�i /� Subdivision: Lot #
Directions to the property (lnduding road names�and nurr�bers): I.l_�.��� � � r��=�� T� ►n� ����� P�, N, ��..,
4tt• �r�v<wAv v�tiTl.e �2���,r �
4) Proposed Use and Structure Description: answer each of the foliowing questions:
a) Proposed � Existing , Type of Structure: ma �(c �1 ��� f Width: � a Depth: � O
b) Number of Bedrooms: � Numbe� of occupants or peopie to be� served: �_ �
c) Basement Yes_, No �, Will there be plumbing in the•basement? ---
d) lSarbage Dispasal: Yes , No � .
5) Water Supply Type: Private �(new _ or existin , Puhlic_, Cammunity� , Spring .
Are any welis on adjoining property? Yes�o _ If yes, piease indicate approximate Iocatiori on the
'site pian.
6j Ooes your prope�ty cantain_previousfy ider�tified �urisdictional wetlands? Yes No �
PI.�ASE NOTE THE FOLLOWING:
7 A Pl.AT OF THE PROPEiZTY OR SITE PLAPI IIAUST BE SUBMIT�E� WCTH THIS APPLICATION.
➢ PROPERTY UNES AND CORNERS MUST 8E CtEARLY MAR�fl. -,
9 THE PROPOSE� LOCATION OF �1L1. STRUCTURES MUST HE STAiCED OR FLAGGEU.
9 THE SITE MUST BE �iEA►DILY ACCESSIBLE F�R AN EVALUA770N BY THE HEp►.l.Ti�i DEPARTMEiVT
STAFF.
I hereby make application ta the Person Courrty Health Department for a siie evaluation for the on-siie sewage disposal
system for the above-described property. I agree that the cantents of this application are true and re�resent the maximum
facili�es to be piaced on the property. I understand ifi the site is aitered or the intende� use cnanges, the permii shall
become invalid. �„
oc Legal Representative
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ate
PC3iD, rev. 06/27/02
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SIfiE. S�SETC�I[
N e�� � liar►-, Tl�omaS �.rnnc�
b 'o ��l
Authorized State Agent
Tax Ma.p # cZ�P Parcel # I 03
� � Section/Lot#�
� fo a3-��
. � Date .
system cumponents repr�ese�rt upproximate�con�vurs only. The �iractor musr, flag the system prior to�
begarnrng the installaiiots to �insur�e thatpropergrade is maintarned
Scale:
_�—
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i, rev. 09/12/01
Application Date: o" I'"Q� Tax Maa #: A' ��
Amount Paid: __�4 / /�i
RecQipt #: �"/ �� Parca! #: l 63
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❑ Improvements Pertnit (Recorded
Improvements Permit - $150.00
(Mobile Home ReplacemenUAddition)
APPLlCATION FOR SERVIC�S
❑ Well Pertnit
$150.00!$200.00
Permit Revision f
for Septic Systems-
IF THE INFORMATI�RI IN iHE A,PP�ICATIOIV FOR AP! IMPROVEMENT PERMIT IS IIdCORRECT, F�LSIFIED,
CHANGE�. (DR THE SITE IS ALT�REIa. THE�I iH� IMPl�(?VE�iAFNT p�iRMIT Al�D �UTHORIZATIOEV TU
CONSTRUCT SHALL BECOME INVALlD.
1) Permit rec�uested by: (Owner/agent/prospective owner�: ��������. f`tz.�ns ��/�"^ PT
Home Phone: S�} '1 3?�3 Address: b s' j�c k l� n,v. r,� f �'�c� .
Business Phone: Sa9 3�,� � ���,,ro rUC .
2) i�lame and addres� of current owner: �' �►v�e
3) Property Description: Lot size: oc Ac2��1'ownship: o%,,� 1���� Subdivision: Lot #
Directions to the property (Including,road names and numbers): /�,.,��,_S7 h��t� ��► �/�,' � �
W1���u+'� /��.��ia.+• �l � Ii1llU�wAl� 01v /tiib�t � � �%�vfc�lZ.4.�_�__
se +Y� �n /�r �s OKe on �[r n��i �
4) I�roposeci U:�e and Structure�escription: answer each of the following questions:
a) Proposed ._, Existing Type of Structure: jii.. �!�. l�lo w�e Width:_�_ Depth: F, U.
b) Number of Bedrooms: � Number of occupants or people to be served: �'
c) Basement: Yes_, No � Will there be plumbing in the basement? ---
d) Garbage Gisposal: Yes , No i/
5) Water Supply Type: Private +/ (new _ or existing�, Public_,, Community , Spring _
Are any wells on adjoining property? Yes� No _ If yes, please indicate approximate location on the
siie pian.
6) Does your pro�erty contain_previousty identified jurisdictional wetlands? Yes_ No ✓
PLEASE NOTE THE FOLLOWING:
➢ A P�AT OF 'THE PROPERTY OR SITE PLo�iV AflUST BE SUBMITTED WITH THIS �►PPLICATIOM.
➢ PROPEFtTY LIIdES APID CORNERS MUST BE CLEARLY MARaCED. ,
➢ TIiE P620POSED LOCATION �F ALL STRUCTURES MUST BE STAKED OR FL�►GGED.
9 THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION �Y THE liEALTH �DEPARTMEWT
STAFF.
I hereby 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 application are true and represent the maximum
faciiities to be placed �n the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid_ _ ,
Cwner or L`�gal Representative
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PCHD, rev. O61'17102
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Ph��,s_elSect�i�o,m�Lolt tt
Applicant: �,i/I` � ll�t�'�, �(►M�l�+�
Location: , _ _ —/1 � � �
Improvement Permit
Permit Valid for � Five Years No Ezpiration
Type ofFacility: �X New DLAddition Water Supply ��I
# of Occupants J'�1-u� # of Bedrooms Projected Daily Flow � v g.p.d.
Proposed Wastewater S stem: ,('s��,� ��. �
Proposed Repair: ��el����
Permit Conditions: Kr� �l
Owner or Legal Representativ S
Authorized State Agent: �,
�� �b�� S�, S �P,n-, ��-
; �►- S _
_ Type: �-q
_ Type: .�
�- C� ` ��.
Date:
Date: � —
The issuance of this permit by the Health Department in does not guar�ntee the issuance of other permib. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Bu�ding Inspections requirements are met This
Improvement Permit is subject 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 `Laws and
Rules for Sewage Treabnent and Disposal Systems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the sephc tank system will continue to function satisfactorily in the future or that the water supply wi71 remain
potable.
Autho.rization to Construct Wastewater System �Reqnired for Building Permit)
* See site plan and additional attachments (_�.
Proposed Wastewater System: �oM,�✓L��^� � Type�4 Wastewater Flow ��.p.d.
New OL Repair � Expansion _ Soil LTAR: `� .��.p.d./ ft 2
Type of Facility: Basement _ Yes 'i� No -
� Wastewater System Requirements
S
Tank Size: Septic Tank: �� gal Pnmp Tank: gal Grease Trap: ga1
Drainfield: Total Area: ��a � sq ft Total Length ��__ ` ft Mazimum Trench Depth l� in
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: � ft 0` C'
DistriVution: Distnbution Box �Serial Distribution Pressure Manifold
S�� Sr'�� S� �
Authorized State Agent: /��r
Permit Expiration Date:
�'c e�r,�
The type of system permitted is '�'� Conventional
the permit.
Owner/Legal Representative:
Date: �` ZZ � ��
Innovative Alternative. I accept the specifications of
Date:
PCHD7/30/2002
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STTE PLAN �
Nam �I'�Q�'1 �itil�'l,� Tas Map #� 2 Parcel # 'O �
Sub ' n Section/Lot#
. �
Authoriz tate Ageat Date �
System wmponents rrpresmr spprvaimatr coamurs only. The coaa�vrmust tlag the sysum prior m bPg_ n�ino tGe insr111atioa ao
- iasurc t6atptopergrade is mafnMiaed
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Applicar�
Location:
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Pfa����e�Sec�t�iai�'Lat ;=
C)�perat�on: Permit
System Type (In Accordance �th Table Va): . �
THIS SYSTEM HAS BEEN INS?ALLED � IN COMPLIAPlCE WITH APPLICABLE NORTH
CAROLIN�► GENERAL S'iATUT�S, RULES .FOF� .SEWAG���:7'REATi11AENT AN� �DISPOSAL.,
AND ALL CONDITIONS OF THE IMPROVEMENT � PERMlT . AND CONSTRUCTION
AUTH 170N... � � � �-�
. . . _ . - ....� .: . . � . � . �: �: . (����--� � .. . . ..
Authorized State �Agenfi . � � . � � � . . . . : � Date � - . . .
c., . � V . . • � .
Installed By: �l �% n��M� P� Date: . � d`' 7. .
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PCND, rev. 07/29/02
0
S��C �'AAi�C INS�E�TiON Ci�E�9C1.IS� (Type !1- i�
Tax AAaQ # 1���' Parce! # l03 System Type (Table Va)
Owme�lAp�iicant Su�division
AddresslLocation � Se�lPhase Lot # � "
. St�te 1D/date
Capaci
Tee and Fiter
Baffle R
' Sealarrt '
Riser if ap iicabl
Tank Outlet: Seal
. Permanerrt Marker
� � Pu�p Tank
/Sealarrt
� I Riser
. . . �....g.
��edc Valve/Gate Vaive .
-�. . ti-si on oe . ,
�loatslSwiiches � : : � � .
Alarm (visable and audible)
Rate (gpm)
Ap�rvved Pump Model _
Btocic Under Pump
Pump Removai Rope/Chain
Distribution System
Serial Distribution '
ress�re an o �
Low Pressure Pipe •
Appr. Pipe NRaterial and Grade
Tr�nch Width 3 ft.
Trencf�. Depth in.
Trench Length � �,� ft.
' Tr�enct� Grade
Trench S acin
. Rodc De th and Qual'
� � Dams/Ste downs etc. �
Pressure Laterals
,�. Hole Spaang
� o e �zs .. . .
� Pipe Sleeve . � - - �
� Tum-ups}Protectors
�Requined Setbac�cs
� � From Wells �. �
� From Propert� lines �
� ._ _ .StructuresJBasemerrts.:�: •
� rt es rama � e ays �
- . - • : : . _ . �SurFace` Waters � - � - �
Pubiic Water Suppiies
Verticai Cuts �>2 ft .
Water Lines
Vehicle Traffic
EasementslRight of W�
� Olher.
Eas�ments Recorded .
I
Camments�
.;..
� � pc�►d rev. 3J13/01
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I���a-��,m„ ����� a 3L�.�.71�1�. Do�-0 �6�1 / /�
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Owner: ��,(,(„ ,�... cf�,�„ r., � r Tu� Map�_ Parcel # f��
Location _�a��,� 1�� �/'-'` ��; .�C o h
��'�2,nL-�-��c.l`e -, , l.C;� �
Subdivision: �� Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet) c� �7 _
Distance from Septic System (Minimum 60 feet) _l�iG
Total Depth: ��_ ft Yield: si�'� GPM Static Water Level: �_ ft
Water Bearing Zones: Depth foo ft� ft ft ft
��•d�.. 3 ,oi...
Casing:
Depth: From p to
Type: Galvanized Steel
� L� ft. Diameter: G%y _ in
Weight: Thickness: ,/�A Height above Ground: �, 5 in
Drive Sho�: Yes No Any problems encountered while setting casing? Y� No
If "yes" give reason:
Grout:
Neat: Sand/Cement Concrete \ GraveUCement
Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured i' Depth to Ft
Materials Used: -
No. Bags Portland cement�l {x tih�_;, Weight of 1 Bag r-{"j , Pounds
If mixture (sand, gravel, cuttin s) — Ratio Z to I'
ID plates: Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log
Location Drawing
From 'To Formation
v
c
/novto.� Pu�,t:�.,..
G
� �
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I hereby certify that the above information is coirect and that this well was constructed in accordance with regulations
set forth by the Person County H alth Department.
Signature of Contractor � ID# ZLl� 5 Date /� �L !? �
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WELL PERMIT
1'I.EASE SEE ATTACHED PLAN FOR'WELL SITE LAYOUT
Tax Map #: rt o� i.P Parcel #�_ Towaship v � I V C �i i I �
Applican� � I�� 14m �OMC�S Jl.t rn�'t �r
C..1.r1:■ricinn• � I � Se�1�11: �t! .
Ty�e of Water Su�nlv:
Re�ireanents•
Jlndividual Comm.unity Public
Site Appzoved bp
GroutYng Appzoved bp ���" ��� ��� �-
Well Log � �- �-s--��--
Well T ' . t - —� �-
Air Vent
Hose Bib
Concrete Sla.b
ell Driller. � � � �^��-� �-����"
W �
Well Approved Bp: Date:
'�°5ee Attached Site Sketch'k*
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be ax least 25 feet from any bu�ding foundation.
Other conditions: �/L s`� �� I„-> C L l ( n 4l rc a. , j�, c� W r1.
Can-�L-t perSon C���-�Y' Er�v i TOn M�rt`L�
t1(.6t �� )� � l.� c s-l��bn7:;: � r� S C�.
• ,�
PC�ID, rev. 09/07/01