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Anplication� Date• �r� Q � . .. �. � � � s��6 � Tax Maa:�
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APPLICA'i10N FOR� SEI�ICE3
1) PeRnit requested by: (Own r/ager�t/prospective ownerr�J �rn ���5
Home Phone: �-5 Address:'' �w�,j
Business Phone: �- �'
2) Name and address of current owner: �Yc:� C'�S �� �1�Y�
3) Praperty Description: Lo# size:
Directions to the propertv (I�dud
���ii ���* J
��Township:
�g road na�nes ar�d numbers):
Lot �:
� � �. . ..., . . -�
_ �bY-�DYI �17 � L�i czn-.- �P �" h » �'s�. � � e�� U� � O-�
Y'� 1�-�- ��i,�o�}vn 1�' � 11 � wri-��p ��n � o�3� � a- k� r� �,.t �}�I�ovs
-_ . �11 In�n.r�aa� ��s�.�� ,�--:��.c_�,is`�-Di'��4l;'��C��'?s a!'�'�r.�at'�l,e��l�-�!n++�rir��:n P�nn�� � _ , --�,,t�1r��•. -
� a) Proposed �/, Existin9 �, TYPe of Strudure: �a,v�L.����,v�d 11.�_ Width: � Depth:�, O1dR-`'
h) Number of Bedrooms: ,L Number of occs�pants or people to be served: � ����5
� c) Basemen� Yes _, No �„ Will th re be plumbing in the basement?
d) Garbage Disposat Yes _, No� ��� l� I O� . ��r.— �r 1e,�
� 5� Water Supply Type: Privat�v (new �or existing �, Pubiic_, Cammunify _, Spring ,_
Ar�e any weils on adjoining property? Yes _ No _ If yes, please indicats approximaabee location on the site plan.
6) Does the propetty cantain previously identifled jutisdictional wetlands? Yes _ No _
PLEASE NOTE THE FOLLOWING:
�➢ A PLAT OF THE PROPEl2TY OR SiTE PLAN NUST BE SUBMITTED WITH THIS APPUCATION. �
➢ PROPEi2TY L1NES AND CORNE�tS MUST BE CLEARLY NWRI�fl.
➢ THE E�ROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR Fi.AGGED. �
➢ THE SiTE MUST BE READILY ACCESSIBLE FOR AN EYALUATION BY THE HEJ�LTH DEP�►RT�AF�VT STAF�.
I• hereby make appi'ication ta the Person Caunty Heaith Departrnent foc a si�e evalua�on for the on-site sewage disposal
system for the above-described p�opetty. I agree that the contents of this appi'tc�tion are hue and represent the maximum
facili�es to be pla n the property. I undersiand ifi the siie is aitefed or the intended use ct�anges, the permit shall
become i id. ' � �D
ner or egal Representativ � Datie
PCND� rev.1ol17101
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Applicant: h � r�
Location: 1� k
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Ta�x M�E� �� - Parc�el � � �
Sll'h(�'IVIS'1011
Fha�s�e Sect�ion Lot #
-/ Improvement Permit
Permit Valid for 1� Five Years _ No Ezpiration /
Type of Facility: jYl Db 1 � c, i-FOn1 L New 1/ Addition
# of Occupants �p �,X, # of Bedrooms 3 Projected Daily Flow 3100
Proposed Wastewater System: �nn�Ja-�ivC, �aS`�o I"c�du-c--E�°�n�
Proposed Repair: '� 7n n 0 va-E i Vc, (�" 1� 1'col �,c,�,fl'on �
Water Suppl�r`i11�� wcll
g.p.d.
Type: �
Type:�
Permit Conditions: Tr16-�'i.�l On ��n,-�ou-r ok5 Fla�y�cd O�� i� by ��;s� I�c,�o SY�-in r`�
��cciFicd a�cti, �r►�-�(f c.�c 1( r`� Gtrc�_ ShownF n��E_� ( ��S�nOt d.iuc�-S�'on
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Owner or Legal Represe
Authorized State Agent:
Date: '� � � � � �-
Date: '1- � (n -Oa
The issuance of this permit by th� Health DeparhnF:nt in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inapections requirements are met. This
Improvement Permlt 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 p�rmit was isaued in compllance wtth the provlsions of the North Carolina `Laws and
Rules�or Sewage Treatment and Disposa! Svstems' (15A NCAC 18A .1900).
� Authorization to Construct Wastewater System (Required for Building Permit)
* See�site plan and additional attachments (�.
Propose Wastewater System: Zn n o �a-�i v c, Type �_�. Wastewater Flow��,i Q g.p.d.
New � Repair Expansion _ Soil LTA�: • a�� .p.d./ ft 2
Type of Facility: m ob � i L h o� c '' Basement _ Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: � gal Pump Tank: N I A gal Grease Trap: Nf l�' � a�l�f �� S��je,
Drainfield: Total Area: -1 F � sq ft Total Length �� ft Magimum Trench Depth � 8 in
Trench Width 3 ft Minimum Soil Cover: �_ in Minimum Trench Separation: � ft
Distribution:
Specifications:
Distribution Box
c-�i. nr,� I u� 0 i
Authorized State Agent:
Permit ExX
v Serial Distribution Pressure Manifold
Date: "1'1(p� Or1
��
Date: �' � (o � O�„?
The type of system pernutted is Conv ritional �nnovative Altemative. I accept the specifications of
the permit.
.
Owner/Legal Representative: Date: 7 D
Operation Permit
System Type (in accordance with Table Va) �W �
The system has been installed in compliance with applicable North Carolina General Stalute, Laws and Rules for Sewage Treattnent and
Disposal, and all conditions of the Improvement Perm d Constntction Authorization. Issuance of this permit does not guarantee that the
wastewater system will function properly for any g' en eriod of time: � A
.
Authorized State Agent:
1
Date: � �o ✓�a
PCHD rev. 01/23/02
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e� rau �5 C�.y�an �S�crry I�� �rS Taa Ma.p #�°2� Parcel #� 8 .
ub ' ' 'on N / f� � Section/Lot#
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Authorized State Agent � � Date . �
�. , sy� ��o� ��� �pro�� ��u� �y. The confiactor must, fTag the rystem prior to
begissning the i�rstarllat�ion to insure that pr+npergmde is maintained
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Applicant: ��c rry (�'c, f �'�S
�ocation: /Y)�rton P�•.l! ia�-, P�
O:peration Permit
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System Type (In Accordance With Table Va): -� � �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES .FOR SEWAGE TREATMENT AND DISPOSAL,
A ALL CONDITIONS OF TkIE IMPROVEMENT PERMIT . AND CONSTRUCTION
U HORIZATION. �
. . . . . . ... . .. . Vy�1� � .. . .. . .
Authorized State Agent Date �
Instaued By: ��1 mY �—�-c� ti 5 �ate: ��" �0 �"� �
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PCHD, rev. 07/29/02
SE�TIC TANaC dNSPECTION CHE�BCL,lS�' (Type IL - IV)
Tax Map #�(� Parcel # 8$ System Type (Tabie Va) Z�T p
Owner/Appiicant I,c�rY l.�c� (-bu'.-5 Subdivision
Address/Location i1'1� rf.vn Pcc.11�'a�n. �� Sec/Phase Lot #
Septic Tank n�t�a ate itn cat�on mes n�t�a ate
State ID/date �7',� ��� 5=7-c� �tf 8��-� Trench Width � ft. �'}� �-(�-�
Capacity. � p(�p . gal.
Tee and Filter
Baffie
Sealant
Riser (if applicable)
Tank Outlet. Seal
Permanent Marker
Pump Tank
/Sealant
Riser
Water Tight
Pump
Check Valve/Gate Valve
nti-sip on ole
Floats/Switches � . . __
Alarm (visable and audible)
Electrical Components
Rate (gpm}
Approved Pump Model
Block Under Pump
Pump Removal Rope/Chain
Distribution System
Serial Distribution '
ressure an' o '�.
Low Pressure Pipe •
Appr. Pipe Materiai and. Grade '�
Trench. Depth ) rn:
Trench Length � O ft. L
Trench Grade v
U' Rocic Depth and Qualiiy
Dams/Stepdowns etc.
Pressure Laterals
N � Hole Spacing
o e ize
Pipe Sleeve
Tum-ups/Protectors
Required Setbacks
From Welis �.
From Property lines
.. � Structures/Basements : �
�- Ditc es rainage ays
. - : . _ .' ' Surface Waters - � �
- ' � � Public Water Supplies
Vertical Cuts . >2 ft.
Water Lines � � �
Vehicle Traific
Ha�aceni �yszems �
- Easements/Right of
. Other
Easements Recorde
ert ed erator -
Tri-Partate AareemE
Comments
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pchd rev. 3/13/01
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WELL I'ERNIIT
I']LEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: �°� b Parcel #� g a Township � G, /
Applican� �5�� r r� (�J� I-�c t'S
Subdivision: Section: I'°t
Tvne of Water Suv�lv:
Requirements•
I'�
V Individual
Site Approved by v�� 8"�"O�
Grouting Approved bp � � " (� - C�
�lell Log ✓ � t� �"�--c�a
Well T
Air Vent
Hose Bib � ��'�
Concxete Sla.b ✓
Community Public
�
Well Driller. �� Y VLSt�
Well Approved Bp:, ���' " Vv �,1�1�� Date: �"1��%
'�°5ee Attached Site Sketch**
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septi.c systems.
Wells must be at least 25 feet from any bu�ding foundation.
Other conditions: fSU.fl l,.�t.(� Lo�� p I� �rom �cp�ic ,�S`pl u.5 �a�, � o M�,
/ C�� t�e,ll �-� � �-x��s{���.. 5a' ��s'crrtcnt.
PG��, rev. 09/07/Ol
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1 1 • `i.J � �� � �% � .' � YVISYIYYttJ LG�%% � (/L/� //
�]La�n7L ��7l.'a'��7Ya'��.� ���.�'�� � � � � �
Well Log
p��; ,S ", � Tax Map/�� Parcel # �
Location: �c;/ hex �- �3 �/��� T/ �'
Subdivision:
Lot # �
Well Construction
Distance From nearest Property Line (Minimum 10 fest)
Distance from Septic System (Minimum 60 feet)
Total Depth: ft/0 ft Yield: GPM Static Water Level: Z� ft
Water Bearing Zones: Depth y . ft[��� ft ft ft
Casing:
Depth: From �_ to (� � ft. Diameter: � in
Type: Galvanized Steel
Weight: 'ckness: ./� Height above Ground: � in
Drive Shoe: �� Yes No Any problems encountered while setting casing? Yes �1Vo
If `�es" give reason:
Grout:
Neat: SandlCement � Concrete GraveUCement
Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure _�oured Depth to Ft.
Materials Used: -
No. Bags Portland cement y�' � Weight of 1 Bag z0 _ Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: � Yes No 4 x 4 slab f/ Yes _ No
Drilling Log
Location Drawing
From To Formation
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I hereby certify that the above information is coirect and that this well was constructed in accorda.nce with regulations
set forth by the Person County Health Dep t. `
Signature of Contractor ID#� Date �=0a
PCHD rev O1/16/02