A26 168A lication Date: g���� �
Amount Paid: DO .�
eceipt #: 2L �
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Person Countv Health Department
Environmental Health Section
APPLICATION FOR SERVICES
Tax Maa #• % f-� Q
Parcel #:
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CHANGED OR THE SITE IS
ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Owner/agent/prospective owner): � � /� «- <� �, � � -r�, r� r= S
Home Phone: h'� �' - 5-�_3 i Address: ��`c4 I"� K�r,,�c c��..*,�. �-i l�'��.
Business Phone: ���� Y•� <� ��.= .
U�'. d C.-�".:" ,'--A'.�;;'. � -, �,.. _,,� ��
2) Name and address of current owner: �//�w �u <� :T o��= s
3) Property Description: l.ot size: �• �`/ Township: G:!-f.
Directions to the property (InGuding road names and numbers): l/�/�= l`�/Li= /� i= Yo f��,�
�iiU/= f-�/�< /�.1C� ���iz��. /i-i� i �a�i T"v /�/.�o�K-S
/J/1�/?.i 1.� ✓J. . �^.nii= /�ii .= %,�lr"' li�r �
�.; /7�� l 3o r
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed �3�Existing �
b) Stick Built ��ulodular ❑, Single Wide �, Doubie Wide �
c) Number of Bedrooms: -3 d) Number of occupants or people to be served: �
e) 8asement: Yes �, No � If yes, # of basement fixtures: ��
fl Garbage Disposal: Yes ❑, No ��
g) Dimensions of Proposed Structure: Wdth: �� Depth: j�--
5) Water Supply Type: Private t3'( ew 0 or existing �), Public 0, Community �, Spring ❑
Are any welis on adjoining property? Yes ❑ No ❑ If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
�'
�Conventionai _Modified Conventional _Alternative _Innovative
- Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
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 facilities to be
placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand
that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
perso el of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the
Hea D paRment if my pr e contains any wetlands as designated by the Army Corps of Engineers.
�'—t�U�
Own o egal Representative Date
PCHD, rev. 10l12/99
� �` -� � �
A lication Date: � � Tax Map #: �' �f
Amount Paid:
RecEipt #: � Parcal #�: f � �
`„ � � •����� �� .!�'" ��� ��
1�g - - - --_ ������
� a�_va.ro��-�--�-�• .Daa�m11. �3Lo.m.7L-�7�a
APPLICATION FOR SERVICES
CO(�ISTRUCT SHALL BECOME INVALID. �
Permit requested by: (Owner/a�gent/prospective owner): �
Home Phone: 33 6-S�"1-�1 �.3/ Address: �L,.�
Business Phone: �-�.� S`��
2) Name and address of currerrt owner. � �f/
- �� �
• ��c�c�r�� '?'� C— ���
[
3) Property Descrlption: Lot size: ��[ Township: G � f. Subdivision: L� Lot #�—
Directions to the property (Including road names and nurp�ers): _
4) proposed Use and Structure Description: answer�cl� of the following questions:
a) Proposed �sting � Type of Structure: /� �,/Iv-r��.-� Width: Z-� Depth:�J
b) Number of edrooms: �� �. Number of occupants or people to be served: :
c) Basement Ye� . No _�--�IVill there be plumbing in the basement?
d) �arbage Disposal: Yes ;_, No _ -
5) Water Supply� Type: Private �+�ew _ or existing�, Public� Community;_, Spring _
Are any wells on adjoining property? Yesf No If yes, piease indicate approximate location on the
'site plan. . , �
6 Does your property cantain previously identifed jurisdictional wetlandsT Yes_ No �
,
PLEASE NOTE THE FOLLOWIN�:
9 A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. -,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAfCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBL� FOR AN EVALUATIOPI BY THE HEALTH DEPARTNIEAIT
STAFP: �
( hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposal
system for the above-described property. I agree that the contents of this application are t�ue and represent the maximum
facilities to be placed on the property. I understand if the site is aftered or the intended use changes� the permii shail
�
Owner o�egal Representative
�- �U
Date
PCNO. rev. 06i27l02
& ORLEY W. SE :
D.B. 297-� ;
P.C. 11-5E';
TM#: A26-`�;;
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JS LIFE ESTATE
95-389
1-56/F
�26-169
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Building Additions/ Ndobile Home Replacements
Tax Map #: �- a(o Parcel#:
Approval Requested for: Mobile Home Replacement
�� Building Addition ( 13R. �A-�����
•.� .� .��- . c.-L• �.� ��s • � �. �
' � • ,... . • .�c�.. .� C i��
�_ �1:r •� —' '71
'i��- � � -
Pertnit Located: Yes No
Installation Date: a-1 Design flow: �CQQ_ (gpd)
Current Contract with Certified Operator on file (if required): �_
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: �� �o�n N�E +.stS(date)
(Applicant's signature if site visit is not required)
nri�,,n—r�-�- c' �—�"T�tJS ML7S'T � C+ fl..�m1P �"C�YJ � S"�-C'��LO C;F'F
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Addition/Replacem��nt Approved
�-F'
Env�ronmental Health Speci ist Date
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T��x M•a� � P�rcel # .*
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S�u�,hcl'ivis�ion �
IPh�as•e SecGioia Lot #
Applicant: �-in (�� �flncs
Location: S�I t� (�i�oaKS �Oui ry �,d , L�t�n =. 3 mi Ic.,
Improvement Permit
Permit Valid for �Five Years _ No Ezpiration
Type of Facility: i n G Fam i I W �l � i n New � Addition Water Supply ri vaf;t. l,t:t( (
# of Occupants a, # of Bedrooms �_ Projected Daily Flow �� g.p.d.
Proposed Wastewater System: � OVa-�i V (,aS t� rc:ciu-c- `On . Type: � G
ProposedRepair: Tir1/1DUG�-EiUc, o Z,Syo r� du.� t �'on 1 Type:
Permit Conditions:
Owner or Legal Represe
Authorized Staxe Agent:
Date: � � '� �' -�-�
Date: p- -C�
The issuance of this pernut by the �iealth Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that a11 Person County Planning and Zoning and Building Inspections requirements aze 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 Sew�e Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
Autho.rization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (�.
Propose Wastewater System: Tn n a/a�i V c Type � G. Wastewater Flow i.� O g.p.d.
New � Repair Expansion 5oi1 LTAR: ��S g.p.d./ ft 2
Type of Facility: ��� C, Fc�, m i l � W �( � �� n Basement Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: � gal Pump Tank: N(� gal Grease Trap: /�/ p �t,��`q
Drainfield: Tota1 Area: � O sq ft Total Length �_ ft Magimum Trench Depth � in �d-t-'
Trench Width 3 ft Minimum Soil Cover: i.p in Minimum Trench Separation: �_ ft
Distribution: � Distribution Box Serial Distnbution Pressure Manifold
Specifications: �0��(Y1inIrnU.M J10� � CDuCr mus-� b� �h�iu�t-d f`n, Tll,
nrt�.in o45 �Sa�i,Jn_. On 5ifz. 51Ccf�4►, �O�Stdc OF `l-�cnc..�, wi
Authorized 5tate Agent: _
Permit Expi
The type of system pemutted is
the permif.
Owner/Legal Representative: _
Date:
�l
Date: % �"8'C�
Alternative. I accept the specifications of
Date: 1 � a 4 -Q �
PCHD7/30/2002
� 1� �� ���� �� V
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Applicant ��ir��t�x-,� �ri.�.��� �
� - —,.5--_ �� i � � . �
T��X fv13!� I I EI:� C~E I 1
Suf�e1!ivi�s�ioii
Ph:�s� Sec�t�ia��i Lot �
i�VVMMV�• � /I
. . t��peration: F'errr�it
' System Type (In Accordance With Table Va): ��� �
THIS SYSTEM HAS BEEN IN�TALLED IN COMP
LIi4NCE WITH APPLICABLE ORT�1
' CAROLIN�1 GENERAL STATUTES, RULES .FOR .SEWAGE��:YREATMENT AN� �DISPOSAL, ��
AND ALL CONDITIONS OF TkiE IMPROVEMENT ' PERMIT . AND CONSTRUCTiON .,
AUTH�F�IZIRTION... ' � � :� �
. . � �.� .�. . . ' . .. � , ... .. _ . � .� ..'.. . .. � . .. . .
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iPh��se Sec�t�ior�`Lot ;=
. O�eratson: Permit . �
System Type (In Accordance �th Table Va): �
THIS SYSTEM HAS BEEN IN�TALLED - IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES .FOF� SEWAGE��TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT � PERMIT . AND CONSTRUCTION
AUTHORIZATION. � � � .
Authorized State �Agenfi - � � . � � .. � ' : � Date � • � � �
Installed By: � ac%A�. Date: � ( 'O �'� . . . . .
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PCHD, rev. 07l29/02
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S�3��iC T9�P1K INS�EC'f1ON CN���{L.1ST (Typ� 6d -
Tax MaQ #�� Parce! # System Type (Table Va)
Owne�lAppiicant� �';n�,.>� c� .�s Subdivision �/, /� %�s�
AddresslLocation SeclPhase � Lot #
� Septic Tank ni a a� � cat�on ines ra�t�a ate
. State ID/date S�g 3a�} 5-�'0� � Tr�ench Width ft. � u�.�y�
Capacity. O�� . gal. Trench. Depth � in. �^ y_�..�;�.r •
�° , Tee and Fiter Trench Length 36� ft• _,_d•�
Baffle Trench Grade ✓
� Sealarrt ✓ Trench S acing �
Riser if a licable / � Rodc De th and Quaiiiy
Tank Outlet�. Seal f � � Dams/Ste downs etc. �
. Permanent Marker Pressure La#erals
� Pump Tank Hole Spacing
tate ate � � o e �ze � � �
Capacity . . gal. � Pipe Steeve . � - - . .
Wate roof /Sealant Tum-u sfProtectors
� � � . Riser � � �Required Settsaclss
Water Ti ht � From Welfs �. �
� � Pump- From Property lines � �
�heck Valve/Gate Valve . __ _ .Structures/Basemer�ts.:: � . .
- t�-si on o e.. .. rtc es rama � e ays � ..
� .� �'ioats/Switches � � � � � � . . . : : _ . SurFace` Waters - � - �
Alarm visable and audible Public Water Supplies
� Electricai Componer�ts Vertical Cuts {>2 ft .
Rate m Water Lines � �
Ap roved Pum Model Vehicle Traffic
Blocic Under Pum Adjacerrt�Systems �
Pum Removal Ro e/Chain Easemer�ts/Ri ht of Ways �
� Distribution System Other
�-- � ' ' y �-�{ Easements Recorded .
ressure an o ,, e erator ntract
Low Pressure Pi e • Tri-Partate Agreement
Ap r. Pipe Material and Grade �
Valves �
� Comitnents"
�
C� -'� -��� - �esid � U-r�c�` G��,�►u- c�:�
pchd rev. 3/13/01
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'I'�te of Wates �a���.v: � Individual Communitp Public.
I��s��a�ea�aemm�•
Site. Approved bp �%� s' 6�°�
Gsouting A.�oved bp �� S-6 - �
We11 Log �'i S -lo �- o `f
�Tell Ta� .
Air Vent
Hase Bib
Conc=ete Slah
Well �snlles
W�l.�pproved ��: ���:
'�°5e� Attac3iesl Site SB�c�� �
We�lss must be 10 feet from property liaes.
Wells must be 100 fe�t from septic syst�eems. �
Wells must be at least 25 feet from anp bulding foundation.
Other conditions: Tns �a t f �J�.( � Ce� "�� D W/1 70 /Yl a 1 ��G r�
Scf6ac-K,S �o c� f I N-�� � l ds �
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Owner: �1 � � V •�cS • Tax Map� Parcel # �i�
Locarion: R 'O
Subdivision: W l� Lot # 5
� Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Mini um 60 feet)
Total Depth: 2� ft Yield: � GPM Static Water Level: ft
Water Bearing Zones: Depth q0 ft( O ft ft ft
Casing:
Depth: From � to �� ft. Diameter: 6�_ in
Type: Galvanized Steel
Weight: Thiclrness: L Height above Ground: in
Drive Shoe: Yes No Any problems encountered while setting casing3 Yes . No
If "yes" give reason•
Grout:
Neat: Sand/Cemen ✓ Concrete GraveUCement
. Annular Space Width �_ inches Water in Annulaz Space Yes .� No
Method of Grout: Pumped Pressure Poured ✓ Depth 0 to �D Ft.
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (s d, gravel, cuttings) — Ratio to
ID plates: �Yes _ No 4 x 4 slab �s _ No
Liner:
Depth: Date Installed: Grout: Installed by: _
Drilling Log
Location Drawing
From To Formation
� s-r w Rox�
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I hereby certify that the above information is correct and that this well was constzucted in accordance with regulations set forth
by the Person Counry Health Department.
Signature of Contractor —" ID# Z-3o� Date' " 3 �"��
, 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 Ol/27/04
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Applican�
Locatian:
T�x fVlra�� �� • ' �rce( � • �
Su��bd�ivi5ion
F'h a.s�e; S�cti o n'LQ�t +�
�. Ymprave�ent.�ermit
P�nmit yalid fu �e_�ear� .. , _IYo_ �a�ira�e�n . �
Type of Faciliiy: �1�.zST�� �a � 3;t�-�� M� � New Addition (�/ � �ate� S�xp��Y �_ X�ST���
# of Ocxupants # of Be�rooms ___�___ Proje� Daily Flow 1�_ g.p,d.
Proposerl Wastewater Systesn: r�- -�.�J (�c-r�-C��L��_��-I�o -r�t-�� Type: �S ►3
PmPosed Re�air: . ` Zj�'e: .
Permit Conditions• � . . �
Owner or Legal Represeutative
Autharized State Ag�t: _�
Da#e: �— - o
Dats:
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The issuance of this pe�it by the Health Depaztmeirt in does not. guazantee the issuanca of other parmais. If is .the respons�iiility of the .
aPPli�P�P�Y owner to in sure that aIl Person Cau�y Pianning and. Zonmg and Bn�ding InsQections req� are meL This
Improvement Permit is sabject to revocaiion if the site plan;�plat''ui�'the intended nse cLanges. The Imppove�ne�t Perm�it is not
affected tip a r.�aage in owner"siup of the propertp. This permit �vas issued in cumplianca wit6 the prnvisions of the Narth Carolina, .. -
�Laws aad Rules for Sewa�e Tre�tiner�t and Disnosal Svsteras' (�5A NCAC 18A .1900). Nerther Person �ounty- mor"tli�`- �� �
Environmental �Iealth Specialist warrants that the septie tank �pstetn w�3i cantinne to function satisfac#on'Iy iri the fnl�e�or:#�t.
the-water snpply will remaia potable. � • •
• Anthorization to Construet Wastewater System (Requared for Bwlding Permit) �.
* See site plan c�td addit�ional atteu:hments (_). � � � . :
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Proposed Wastewa.tet System: � -�z� V� �}�Q_._�L Type �, Wastewater Flow j�,g.p.d. _ , _ . ;_ .
New Repair Expa�� .• Soil LTAR: � 2 rl S_ g.p.d1 ft 2 �ygp ���
Type of Fac�ity: � �C��'-r-st.l • �� �1��iZ_� �-YIIF=- � Basement _ Yes �, No
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�asie�ater System �iu�rements
Tank Size: Septic'�anlc� C�. gai P�P Tan� `'-- gai Gre�se Trdp: gai ��� .
Iarainfieid: Total Area: � 1 � sq ai T�tai Length ,� fi ' Maffimnm �renc3► D�th 1� i�► ��'
Trenc.�t Width � ft i1�Yinm�nm So� �overs C�, mt 11�in�tuuri �enc.�t Separation: �1 #t o(L
`3 �'�ttT �tJ _ .
Dist�ribuiion: �I)istr�i��tion Boz Serial D��ion Pressnre 19?a�ifold . .
Speafications• • � ' - ��
S#ate Agea� � �/l
Permit Exgiratiaaz Date:
Date:
The type of system perinitte3 is Con tional �Acc., Alternative. I acc�t the specifications of the
p�- � , L f_ � p-_
i�r�ae�l�eg�I �E�a�s�tatiee: Date:
' PCHD r�. .11/10/QS_:
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