A26 191' Application Date: 6'i� b�
• � 'Amount Paid: 60, DD
r R�ceiat #: ,� 3/� A Ld�
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Pertnit
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Person Countv Health Department
Environmental Health Section
APPLICATION FOR SERVICES
��.>.:a S�Fuices-f�e4u�sted�z;: :�, "'
1 Lot) - 5150.00 0 Well Pertnit (New/I
ded Lot) - 3150.00 ❑, ExisUng System In
improvements Permit - 5100.00
(Mobfle Home ReplacemenUAdditlon)
Sfte Pian -
Tax Map #:
Parcei #•
t
s
1) Permit requesbed by:(Owqer/agent/prospective owner): -� �P ` �E v,��r 1,�i��� M, /�1: �
Home Phone• .�6-- (� —7-7 $-�j Address: v v �
Business Phone: —d(-,'7 / � 27Sc( �
2) Name and address of current owner. .��r1 �,4 �� c� ✓��
3) Property Description: �ot stze�• �V Townshlp: �L-i l�� /��� 1 c..ini�h �'P— �j� /I�d ; 5/
Directions to the prope (Inciuding road names and numbers): ��4�1/1�✓ o�� v�/ ���}/ S`�
� 2� ,' ,� ; � � : s^ v � /�5 �Zc c..1
OL-1 : sc � � — Gv v+ v Scl�o;� /L �•.
��,� i✓��.J
4) Proposed Use� d Structure Description: answer each of the following questions:
a) Proposed fS, Existing O
b) Stick Built�Modular �, Sin le Wde 0, Double Wide ❑
c) Number of Bedrooms: ,��F d) Number of occupants or people to be served:
e) Basement: Yes�{ No 0 If yes, # of basement fuctures: O •
fl Garbage Disposal: Ye ��o �'.. ,6 Zv-5i2 - � -..7 -p� .
g) Dimensions of Propos Stnfc�ure: wdth�C7 Dep Q
5) Water Suppiy Type: Private 0(new � or existing �), Public 0, Community �, Spring 0
Are any welis on adjoining property? Yes ❑ No � If yes, location
6) Please Indtcate Desired System Type: (systems can be ranked in order of your preference)
_Conventional ,_Modifled Conventional _ Altemative _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
' STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATfACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
I hereby make appiication to the Person County Health Department for a site evaluaUon 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.l understand
that as appGcant, I am responsible for identifying and marking property lines, comers and making the site accessibie for the
onnel of the Person Cour�iy Health Department to conduct their evaluations..l understand that I am responsible for notifying the
Hea partment if my roperty contains any wetlands as designated by the Army Corps of Engi ers.
�-d-� G �� a y-
Owner o Legal Representative Date
PCHD, rev. 10/12/99
.
r y ���� ; .! � ���5. �1.� ��
— � � ����
��n.�na-o�a� ��a��.11 IE—���.I��I�n_
T��x M�a� � - - F�rcel # �
S�uhciivi•s•ion �l►1 l� �
'Ph�<�•se Section Lot #
Permit Valid for
Type of Facility: _
# of Occupants 11�
Proposed Wastew
Proposed Repair:
Improvement Permit
� Five Years No Ezpiration `,,�,
�,�{� � New�Addition WaterSupply WL�
�t � # of B drooms Projected Daily Flow �G g.p.d.
it System: ��/� Type: �
lY�li Type:
Permit Conditions:
L
Owner or Legal Representative
Authorized State Agent:
�
��5 • .
�_``� �fo�rs`,� �'��-e Z' . Date:
/`e� Date: � `v Q
'The issuance of this permit by the Health Deparhment in does n8't guarantee the issuance of other permits. It is the responsibiliiy of the
applicanbproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met This
Improvement P.ermit 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 �vas issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sew�e Treatment and Duposal Svstems' (15A NCAC 18A .1900). Neither Person Couniy 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. `
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional a#achments (_�.
Proposed Wastewater System: p;N,� f�,�,��� I Type � Wastewater Flow �[ �g.p.d.
New Repair Expansi n_ Soil LTAR: ,�� g.p.d./ ft 2
Type o acility: , �- �=l�ks} Basement � Yes _ No
�J
`
Wastewater System Requirements •
Tank Size: Septic Tank: �(� gal Pump Tank: gal Grease Trap: gal
Drainfield: Total Area: � 6 7� sq ft Total Length �,�-� ft Mazimum Trench Depth �� in
Trench Width � ft Minimum Soil Cover: _� in Minimum Trench Separation: � ft
Distribution:
Specifications:
Distribution Box � Serial Distribution
Authorized State Agent: _
Permit Expi
The type of system permitted is
the permit.
Owner/Legal Representative:�
Pressure Manifold
Date: $ lS� `� �
Innovative Alternative. I ccept the specifications of
Date•�
P HD7/ 0/2002
s��,S.f ���.���
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I��n.�n���naxn.�:�a�.�a.]L 1����,ll�11�
Applicant:
Location:
T��x M�C� F�rc�ei #
S����hci!ivi�s�ion
Ph��s�e Sect�ior� Lot #
Improvement Permit
Permit Valid for _ Five Years _ No Expiration
Type of Facility: New Addition Water Supply
# of Occupants # of Bedrooms � Projected Daily Flow g.p.d.
Proposed Wastewater System: Typ.e:
Proposed Repair: Type:
Permit Conditions:
Owner or Legal Representative Signature:
Authorized State Agent:
The issuance of this permit by the Health Department in does t gua�
applicandproperty owner to in sure that all Person County Pl "ng an
Improvement Permit is subject to revocation if the site plan, t or the
by a change In ownership of the property. This permit was In c
Rvincinr.CournnnTva..�...�..�,...,ITd..,.,...,.ln....s....__inr♦ i►rr� �o �nn
Authorization to Construct
* See�site plan and additional attachments
Proposed Wastewater System:
New Repair Expansion _
Type of Facility: �
W
Date:
Date:
issuance of other permits. It is the responsibility of the
and Building Inapections requirements aze met. This
use changes. The Improvement Permit Is not affected
e with the provIsions of the North Carol[na `Laws and
SyStelll �Required for Building Permit)
Type Wastewater Flow _g.p.d.
Soil LTAR: g.p.d./ ft 2
Basement _ Yes _ No
System Requirements
Tank Size: Septic Tank: gal �'u Tank:
Drainfield: Total Area: sq ft Totr�l Length ft
Trench Width ft Minimum Soil �Cover: in
a
Specifications:
Distribution Box Serial Distribution
Authorized State Agent:
Permit Expiration Date:
gal
The type of system pertnitted is Conventional Innovative
the permit. .
Owner/Legal Representative: �
Grease Trap: gal
Maximum Trench Depth . in
Minimum Trench Separation: ft
Pressure Manifold
Date:
Alternative. I accept the specifications of
Date:
Barney S.Coates
D,B, 279-62
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Control � N 87°53'18°W
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Contr
Com�
REFERENCE
p,g. 275-�
P.C. 6-24-
p.C. 8-69
T►� A26-;
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Appiicant: ��r`I ' "(�N�-
Location: _____,,,_1_ „ � � „
•
Ta�x M�p � � � F�rcel #
S�ubci.ivi�s�ion
. .
Pha�se Sect�ion� Lot #
� of Bed�room�s
Op�ration�Perr��t
System Type (ln Accordance With Table Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEINAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZ T N.
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Authorized S.tate Agent Date
Instailed By: t� � �� Date: �' l2'c� S
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WELL PERMIT�
P]�SE SEE A'a']CACHED PI.�N FOlt WELI. SI'I'E I.AYOUT
Tax Map #: �°2(O Parcel # � �
Applicaa� ��iYV1 1[�
�
Snbdivisiori: r � ' dY'�
i.ocation: �
'�ownship �
Secnion: Y.o�
'Tvue mf Wa.ter Su�nle: � Indiviclual Communitp Public
Reanirements:
Site Approved by C� I�'o�c� -oS
Grouting Approv�ed by C'�S � d o- �-S
Well Log <'� ( - � �! --v s
Well Tag____✓
Air vent � �i
Hose Bib ' �
Concrete Slab ✓
I�,I� �'� ��;'�'T i
�►�,i��
,����
��
, � �Z�,
WellDriller: ;f�c�r►'�Q�-�c: �Q � .
- ��
Well Approved By:. �C�1.C�(.Q,(�I/t/� I)�te: 2r(0 ' 0� ���.
1
. �
*'�5ee Attached Site Sketch'� �
Wells must be 10 feet from property liaes. �--
Wells must be 100 feet fram septic spstems.
WeDs must be at least 25 feet from anp bu�ding foundation.
Otlier conditions- - -
PC�ID, rev. 09/07/Ol
BarnetYe Well Drilling Inc �36 598 9275 01J24105 10:41A P.002
.�.��� ( - (� aG�� 0� � �r �
.'7�)� ���� `iJ�� a o ^c L �" �S�- � i
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��x�::a..��..��.m�.�:.�.A � z���a�:a� D� Da��1 1- � �o �
Owner. �
Locahon:
Subdivisioni:
GrduC Log
Ta7c Map ,� Pazccl # ��
Lot #
" Wel1 Co�� uctian
Distaz�ce From nearest 1'roperty Line (Minimum 10 feet)
Distancc from Scptic System (Minimum 60 feet) C:l'� .�
�'otal Depth: � ft Yie1d: �Q GPM Static Water Levcl: G� 5 ft
Water Bearing Zants: Depth� ft�n S f� ft ft
Casing:
Depth: From �T to ft. ]]iameter: �_ in
�pe: Galvanized Steel
Weight: 'clmess: � Hei�ht above Ground: � in
ririve Shoe: �/ Yes No Any problems encountered while seifiing casing? _Yes /No
If "yes" givc rcasan:
Groat:
Neat: SandlCcme�nt Concrctc CrtaveUCerncnt �,
. Axinular $pace Width inehes W�tcr in Annuiar Space 'Yes No
Method of Grout: I'umpcd Pressure Po�.ucd _� Depth (s� to � � k't.
IV�aterials Uscd:
No. Bags Port�and cement Weight of 1 Bag Founds
If mixture (sand, gra�el, cuttings) -Ratio to
zD p]ates: �Yes _ Na 4 x 4 slab -� _ No
�,i�ner: .
�ep�; Date Tnstall�d: Gmut: Installed by: _
From � To
Drilling iog
Y,ocation Drawing
Formation
���' .57�1
-� ..� �� f
�' �rt
i�4c:�e
i hereby certify that the above information is oorrect and that this wcil was constructcd in accordancc with regulations set forth
by the Person County �iealth Deprartment_ ���
Signature o�
Pump �nstalyation Con'
Pump Depth: % �C
Pump Make & MadeI:
iA # �,�' r rr� Date ���' `� ��
Pum� Installmcnt
State Registration Numbcr: ��� �
Lcvel' � , t
Purnp Size and Rating: �hp �� SPm
I hereby eeriify that this pump was installed and the well hcaci completed according to the Pcrson Co�mty Well Rules in "
an this date and that a copy of th�is re�d�as bocn pro � to the well owner. � ,
pumu Iustayler Si�na xe �� ..
' "�'-� Date: � �7�^'�f �� PCi�7 rev