A26 169v� ��f
�Ap�licatfon Date: � �6 �6� � � � , Tax Map #: ��` �
Qmount Paid• e20 � o � 3� A.-� � '
Recai t•_74 I_ �� ParcEl #: 16 �
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� APPLICATION FOR SERVICES � •
CONSTRUCT SHALL BECOME INVALID, . •
� . . .
Permit requested by: (Owmerlagentlprospective owner): .�✓
Home Phone: 33� sy���� Address: , . �• �� /
Business Phane: � _ f7 �-� -t"�,-b , �r
Idame and address of curre�t owner.
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3) Prope[ty Description: Lot size: /_Z� Township: G.,C/. Subdivi
Directions to the property nclu�ing road names and numbecs): ,S7 "YI�
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4j F�roposad Use and Structure Description: answer each of the follgyvin questions:
a) Proposed _,�Existing � Type of Structure: .7�o-��-u' �J :. � Width: G' � z-- Depth: .3�1 . �-:,, � °
b) Number of Bedrooms: _,� Number of occupants or people to be serv�d:
c} Basement Yes_, No �alVill there be plumbing in the basement? �c�
d) l5arbage Disposal: Yes . No �- �
.. � , . .
5). Water Supply Type: Private �(neirv _ or existing_), �Fublic_, Community_, Spring _
Are any wells on adjoining property? Yas �-PJo „_ If yes, please indicate approximate location on the
'siie plan.
fij Does your property contain previously identified jurisdictional wetlandsT Yes No_
� •. �
QLEASE NOTE THE FaLLOWING: .
➢� �► PLAT OF THE PROPEfiTY QR SIT� PLAN MUST BE SUBMITTED W1TH THIS APPUCATION.
➢ PROPERTY L1NE3 AND C�RNERS MUST BE CLEARLY MARKED. •, � �
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STA�LED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBI.� FOR AN EVALUATiOPI BY THE�HEALTH DEPARTMEiVT
� STAFF.
I hereby make application to the Person County Health Department for a site evaluat(on for the on-site sewage disposaf
system �for the abov�described property. I agree that the contents of this application are true and represent the maximum
facilitles to be placed on the property. I understand if the siie is altered or the intended use changes, the' permit shall
or Legal Representative
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Date
PCND, rev. 06127102
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S�uhcllivis�ion /� �� -'
'Pta�s•e`Sect+ion Lot # ,
Applicant: �^:r ���iTr�s� � c�yc2S .
Location: „ „ � , , ,n
Permit Valid for k
Type of Facility: _
# of Occupantsy��C
Proposed Wastewat
Proposed Repair: �
Permit Conditions:
Five X�
!� # of
System:
�
Owner or Legal Representative
Authorized State Agent: _�
Improveflnent Permit
_ No �zpiration
�• New � Addition Water Supply �� r
ooms_ Pro_jected Daily Flow `3 � g.p.d. �
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Type: �
Type:
I3ate: g �`�-��
D ate: �'�- y� �
The issuance of this permit by t�e Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met This
Lnprovement 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 5ewage Treatment and IDisposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental HealtL
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
pota6le.
�Aut�loriaation tO Const�'uc� Was�e`vat�r Systeffi �Reqnired for Building Permit)
* See site plan and additional attachments (�. C�ar� � v�' �'2 �(�
Proposed Wastewater System: � 7�e¢Q o�.�� � Type �G Wastewater Flow ��d g.p.d.
New � Repair Expansion _ Soil L'I'Alt: • 02 s� g.p.d./ ft 2
Type of Facility: ' 3$� ��S' • Basement _ Yes g No
Wastewater Syste�► Requirements
Tank Size: Septic Tank: l�%dvgal Pump Tank: gal Grease Trap: ga1
Drainfield: Tota1 Area: D`7fD sq ft Total Length � ft 1Vlazimum Trench Depth �Si in
Trench Width � ft Minimum Soii Cover: �P in Minimum Trench Separation: � ft �• G•
Distribntion: SC Distribution Box � X Serial Distribution Pressure Manifold
Specifications: j�—(��L �N SPr; Q( i S 0•K, " T-t Ql3o� i NS��� equa� ��-1� l rhPS'.
Authorized State Agent: __�1�
- Permit Exnira bn Date:
Date: �' �"fl S�
The type of system permitted is Conventional Innovative Alternative. I accept the specifications of
the permit.
Owner/Legal Representative: Date:
: / �
PCHD7/30/2002
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SITE PLAN
Name f�' � ��PS , Tag Map #� P #�
S � ' n � Sarion/I.or#
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� Authorized State t�geat Date '
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• Application #:
• Z4 3 Tax Map #: 1 C��1
�_� Parcel #• i � i�a�1'Sb�
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� ? ( � Person County Health Department
f � Environmental Health Section
3 � SITE SKETCH
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Applicant's Name Subdivision/Section/Lot#
�oa \:. Fou� ��:Es , R.S _ � �- `� -qq
Authorized State Agen Date .
Svstem co�nponents represent approximate co�ttotrrs only. The contractor must flag t1:e system
Scale: � !� = �Or
PCHD, rev. 10/12/99
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Swbdlivision �' '
Ph�se Sectio�a- ot # �
?� of Bedu�ooms
Applicant: /�►�� �) ��^� �
Location: �
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Syst�m Type (In Accordance Vi(ifih Table Va): ��`
THIS SYSTEi�! H�4S �EEA9 iNSTALL�D IM COMPLIA(VC� ln/f iTH APPLlCQ.BLE . NORTH
G'�4ROLIRIA GEIVER�►L STATUTES, RU �LES F�R SEV1tAGE TR�TMEiVT AhID DlSPOSAL,
�►(dD - ALL COI�IDt?iONS �F � THE fiV6PROVE1VlENT PERI�I[T �►i�ID C�i�STr�UCT10N
ACITI-IOR[ZA 1 . .
. �„ � vv'C/ l � �S'-� � -
A orized State Agent Date
installed By: r►� . Av� S Date: � /Z < S�� � .
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PCHD, rev. 07/29/0�!
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Tax Map #��� Parce! # � System Type (Tabie Va)
Owr�erlAppi�cant � � Subdivision
AddresslLoca�ion SecfPhase Lot # � �
� Se�tic.'Tan� I�it"sa Da% Nota�rea��osa in� nH#aa �#� �
State �ID/date 4lC �, �' Trencf� Widfh� '3 �t. .
Ca aci
Tee and Fi]ter -
Baffie
Sea{ant
� . . � Riser ifi a plicable
• - Tank Out9ef Sea!
Permaneni Mar6cer
. Purnp Tank
State /date
. Ca ac'
� Wate roof /Seal�nt
Riset-
Checfc ValvelGate Vatve
� Anti-si on o e
F�oatslSwitches
�-1larm visable and audibie
�lectricat Com onents
� Rate en ...
A roved Pum �/iodei
Blocl� Under Pum �
Pum Removal �Ro elChain
. �Dis�ba.r�ion:Sys�m
� Serial Distribution
E'ressure Nlan ol
i.ow Pressure Pi e
A r. Pi e it�ateriai and Gra
1/a6ves "
� Trench De th J in,
Trenci� Len 3 6� ft.
Trenctt G�ade �
Trench S acin
Rocic De th and tauai"
Daens/Ste dov�s etc.
Pressure Laterals �
Hole Spacing �.
o e rze
Pi�e. Sieeve
Required' Se�a�9zs
From� We!!s
� From Propertv fines
� � Surface �W�ters
Pubiic �Ilater Su i
� Veaticai Cuts >2 ft.
Water Lines
. VeFiicle�Traffic �
Easements/Right ofi V'
- �er
Eas�ments Recorded
Comrnen�
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pct�d rev. 3l'13I01
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map ,�
Applicant: _
Subdivision:
, Parcel #� ^ Township:
.�-
Lot #
Type of Water Supply: � Individual _ Community Public
Requirements: �
Site Approved By: Liner:
Grouting Approve y: �o?c�O � Installed by: ,
Well Log: � Depth set: _
Pump Tag: Grouted: _
Well Tag: Date:
Air Vent:
Hose Bib: Water Sample:
Casing Height:
Concrete Slab:
Well Driller: nf� l •
Well Approved by:
****5ee Attached Site 5ketch****
Wells must be 1.0 feet froin property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:
PCHD rev O1/27/04
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Owner: L:
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Locarion:
Subdivision:
Dr��oc� �D � Z3
c�p�� � � �1` '� t �.1uAm �1c.
D�� �Oo� I 2-- �- o s
Grout Log
Tax Map ,�� Parcel # ,�Q
Lot #
� Well Construction
Distance From nearest Property Line (Minimum 10 feet) '
Distance frorr},�eptic System (Mini um 60 feet) •
Total Depth: � G.�i V ft Yield: GPM Static Water Leve1:3� ft
Water Bearing Zones: Depth � ft 1� ft ft ft
Casing:
Depth: From � to ft. ' Diameter: � in
T e: Galvanized Steel �
YP
Weight: Thiclrness: ��e Height above Ground: �2.. in
Drive Shoe: Yes No Any problems ehcountered while setting casing? _Yes .�No
If "yes" give reason:
Grout:
Neat: Sand/Cement ✓ Concrete GraveUCement
Annular Space Width i2. inches Water in Annul,ar Space Yes No
Method of Grout: Pumped Pressure Poured �� Depth to
Materials 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:
Drilling Log
From To Formation
'$�2�J
1 d
Ft.
Installed by:
Location Drawing
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 DepaFtment.
Signature of Contractor
~ ID# Z� I O Date� ��'" 6� � S
Pump Installation Contractor:
Pump Depth:
Pump Make & Model:
�
Pump Installment
State Registration Number:
ft Staric Water Level: ft
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: PC�-ID rev O1/27/04
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