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�lmaunt 3�aid: O—O � � �� ` � .
Rec�i� (0 3�.��� �arcal��: ------`
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�tg THIE INFORM�1710N IN i�lE APPL• ICATION �OR AN IAAPROVE�AENT PEi�Mfl' iS� 1NCORREC'T P,4LS�F�E�
CWt1NGED OR THE SITE 15 AL'i�RED THEA1 i'HE iRAPtiOVEiNE�iT PERMIT ANO AUTHORIZA►'i1�P17p .
CON9TRt1GT SHALL BEC01diE lWV�1Ll�. -• „
1j Pennit reque�ted by: Owneelagsrtt/pros�ti+re cw�
Home Phone: • ��7 - B.�G � Address:
Businea�s Phone: „
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2) INante and alddress af current av�rn�e; 6U-L-��- Ji�✓�-�f"�u-�,
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3} Pro�erly Des�cription: I�# size: ��� � Townshlp: Subdivis�
DU�ns to the property (Induding road�amea-and numbers):,� ��
Lot
�0) Pno{�o�d U� and Sfructure D�scrlption: answer each of e foAaw(ng questUons: � a�su��- �„�'�
. a) Proposed ✓ Existing T�p S c�ure: �� Width: �� Uepth:�
b) Num6ec of �edroam9: �..5 ��8� of acra�pan�s or peoQle tn be� senred: Z �j�,�, .
c) Ba�ment Yes , Nn _ Wi�l ther� be plumbing in #he•basemeni? �/D (�I���
d) tSarbage �tsposal: Ye� � . Na '►-:
� W'�tee' S�PI�F Typ�: Private �(neiw _ ar exlsitng_, j� Public_, Communfty____, SP�9 � .
Are any wells on adjalnIng peoperty? Yes ✓ No _ If yes, please indtcate appcnxlmate i�atiori �n thae
.siEe p1�n. -
� Does yaur propeei.y contain_previousty ldentifiied ]wrtssd[cti�nai w�lands? Yes_, No '�
, ei! u � � .
➢ A Pl.i�T OF TWE PROPEiZTI t�R 31TE Pl.�►N iIAUS'f HE SUBM[TTE� WRi�i 'THIS AP��.1CJ�►710N.
➢ PlZOPERTY LlNES AND CORNERS MU9T BE CLSARLY MAR�. •,
➢ THE PRaP08ED LOCATION OF ALL STRUCTURES ddUST BE STAkED OR Fl.AGGED.
9 THE SITE MUST BE REJ�DILY ACCESSIBI.E FOR AN EVAI.UATION BY THE HEAl.TH DEPARTOflF.�1T
STAFF. � • �
I heraby make applicatIan to the Persan County Heaith Department fioc a site evaivatlon for the on-sifie sewage disposai.
system for the above-described prop�rty. I agree that the contents of this applicatian are true and represe� tha maximu�.
f�ciii�es to be placad an the property. ! understand ifi the site is altered nr the intended usa ltanges, t�►e Permit sf►alY
became invaiid. �
� �
Cwner or Legal Representa�ve �
PCiiQ� rev.OB127102
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PROPERTY SKETCH FOR
RAY ROCKWELL
SCALE: 1 INCH = 40 FEET
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Applicant: �Ylt�n�'lOrl � 1.50
Location: N or'tc
r�.t,St hcForc. TranSmi,SSo��
n
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Ta�x M�a,� � � � F�rcel # ' •
S�uil�c,ivi.s�ion
Fh��•se Sectioro Lot #
�/ Improvement Permit
Permit Valid for Y Five Years _ No Ezpiration
Type of Facility: m ob ►��- f-� OM � New � Addition _ Water Supply r- i vuEc („)cf I
# of Occupants ( nmax # of Bedrooms _�f Projected Daily Flow r,Q_ g.p.d.
Proposed Wastewater System: C�nJc.�tio.lccf ��"a� +'tY . Type: �L
Proposed Repair: Tir1 r1 O v0.�:i � L �a�`�r /1cd i,�c_r� ��-� ) Type: ��
Pernut Conditions:
c .� _ _ .,. _ �
/L
Owner or Legal Represe
Authorized State Agent:
✓1�
n an �S i fc
Fro m
Date: � �� `��
Date: �-�,� O��
The issuance of this permit by �e Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicanbproperty owner to in sure that all Person County Planning and Zoning and Building 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 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.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (�.
Propos Wastewater System: �n Vcn�ti onal (arav i tY � Type � Wastewater Flow �.p.d.
New � Repair Expansion _ Soil LTAR: �' g.p.d./ ft 2
Type of Facility: Mobl It- Nom � Basement Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: � gal Pump Tank: N I� gal Grease Trap: ��_ g� Lc�
Drainfield: Total Area: �4� sq ft Total Length �}ao ft Mazimum Trench Depth � in 5od�
Trench Width ft Minimum Soil Cover: �_ in Minimum Trench Separation: �' _ ft
Distribution: Distribution Box Serial Distribution Pressure Manifold
�,
Soecifications: .� Lin�,S � 9s 1[3l"�� Lcnk �, �,�`r�fR�� �g Fu(( pt,-
�
Authorized State Agent: _ �. _ _1�I
Permit Exnirati Date:
�r.e
vc r.
a'i u� ��DD l Y L.I�L.
Date: 4'�� O�
J
The type of system pernutted is � Conventional Inno ative Alternative. I accept the specifications of
the permit. 1'' �
Owner/Legal Representative: Date: "f r "�
PCHD7/30/2002
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JLs7t�.�a���e-n �*'e'n �gb'��.� ���1.���
Applicani
Location:
Ta�x M�� ; - - F�rc�el = ' '
S�uhcl!ivi�sioi�
Fih�s_e�tSec�t�ion Lot #
Operation Permit
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,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT . AND CONSTRUCTION
T ORIZATION.
_ C�� ..
. , . .. . .. . . �".��'��
Authorized State Agent � . Date -
` S-�a�3.
Installed By: � Date: . . !
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� ?anK 1�3 raiscd 4" � �t��a(aons
bctwcsn Tanlc .� 0�6ox Wc.r�
L�.Kc� on 5-��t-�3 �. uc�� h�d �`�ca�cr
���r N-tr��c.s .
: i:: ; n��s . insPc.x:�x.d
. .. �-p;� s,�.�_�3 . .
PCHD, rev. 07/29/02
S��YIC TANK INSPECiION CNE�@�CLIS� (Type I! - IV�
Tax Map # a(.n Parcel #�,_�_ � System Type (Table Va) T_L
Owner/Appiicant , hann On 1..� i ISon Subdivision __ N 1�
Address/Location `3uc(C }�,-,� brr C K(Z.o�ec/Phase Lot #
Septic Tank ni ia ate �tn cat�on ines nitia ate
St2te ID/date �57 ,4a 10-1 -� =H 5-ia Trench Width ft. S�{ -ia_�
Capac' ��DOO . gal. ✓ Trench. Depth � in. �/ ��
Tee and Filter ✓ Trench Length ft.
Baffle Trench Grade �/
� Sealant Trench S acing
Riser if applicable Rocic De th and Quality
Tank Outlet.Seal Dams/Ste downs etc. rJ �}
Permanent Marker Pressure Laterais
Pump Yank �J ��} Hole Spacing
/Sealant
Riser
Water Tight
Pump
Check Valve/Gate Valve .
Anti-sip on o e
Floats/Switches � �
Alarm (visable and audiblel
Rate (gpm}
Approved Pump Model
Blocic Under Pump
Pump Removal Rope/Chain
Distribution System
Serial Distribution '
ressure an� o
Low Pressure Pipe �
Apar. Pipe Material and Grade
r��iv v�c.c
Pipe Sleeve .
Tum-upslProtectors
Required Setbacks
From Wells �.
From Property lines
... Structures/Basements ::
itc es rainage ays �
. . � : . _ . Surface� Waters - � -
Public Water Supplies
Vertical Cuts >2 ft.
Water Lines
Vehicle Traffic
r Easements/Right of Ways
�- (3px Other
t� � � Easements Recorded .
/` ert e erator ontrac
Tri-Partate Aqreement } •
Comments
' ` pchd rev. 3113/01
�
f�1����� • ��.�.r `i�i/ �� •
~_ ' � ' � � �.J' 1V` ��
1E.a�va�ma* � aaa�m.11 7E��eo.7L�L�a
il
ized State Agent
SITE. S��C�3[
T� �P # Aac� P�� # I�� J
<
� � Seciion/Lot#� 3 '�
� �
� 4-�s o3 a� �
� � Date � . . '� �—
U �
sy� ��� ,�� �pm���� �y. The uon�iz�dor must, flag the syste�n prior t�� \
begrisrang tha iststallation to insure tlratproper',grade is m�ed � �
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�� �� #: �_ ��� # Iq 4 �o�P
�P�� ��7hun n t� i,.J i I�S�n
Subdivision: ►� l I� Se�tion: I.o�
��no�: SzC- �c:rm i t
"I� .- � �'I , . :r i . � . • .F • .. .• . � � ' .
�s�uireffi�nts•
Site Approved bp �� �' I 9'� 3
Gmuting Appm-ced by �'i, 1�1 ��1; o�
�Well Log �/
Well T �N S-
Air Vent � N '
Hose Bib � µ _
Coacrete Slab __�
>'� - I '� , .'1 - 1�, 1�1���
,,���-1• •(�
'�s05ee A�taChe� 5rte 5ketc�a�`
Wells must be 10 feet from prop�rrtp lines.
Wells must be 100 feet from septic systems. .�
We11s must be at least 25 feet from anp biulding foundation•
Other conditions: f�� W L �� I n GZ,1'�C�, s�OWrl Q11 Jl' P�- ��C�C-h � .
�i�F�rt, (�c' !�c a-��•� �,.�c� l� Ct�nsult c,3 i�-d-, �HS Firs�t !
�
PCF�3D, rev. 09/07/Ol
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�� � � �.J � � �
IE��s��,.-„-„ ��,��.Il IF��.�.71¢1�
�WII6I: ,S �'lanvic�.�r
I.001t10II: � �
Subdivision:
� �,� �/ �
� �- 13-�3�
D�� OD � ,302
/ ,-
0 0 � �c. rn t�f � �t �tn�,
�D�t�e Drillled : �
GroutLog
Lot #
Tax Map �2� Parcel # �
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: / D ft Yield: _ GPM Static Water Level: � ft
Water Bearing Zones: Depth ft ft ft ft
Casing:
Depth: From 0 to y2 ft. Diameter: � in
Type: Galvanized Steel �A G�
Weight: Tlucl�ess: .� Height above Ground: � in
Drive Shoe: �Yes No Any problems encountered while setting casing? Yes
If "yes" give reason:
No
Grout:
Neat: Sand/Cement Concrete GraveUCement �
Annular Space �dth inches Water in A►n�ular Space Yes `� No
Method of Grout: Pumped Pressure Poured �� Depth �Z to � Ft.
Materials.Used:
No. Bags Portland cement � 1�.+�J-.Weight of 1 Bag
If mi�cture (sand, gravel, cutkings - Ratio Z to 1
ID plates: � Yes _ No 4 x 4 slab �G�ies _
LI "7 Pounds
No
Drilling Log � Location Drawing
From To Formation � �
D � v�t ' _
7 �.,�.6���; (
� �c- c'o
2v�-
. N, ,,���
Pwll,��6�-
0
s�ri
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 Departme t.
Signature of Contractor ���/ ID#_�1�_ Date �j - 43' a�
PCHD rev U1/16/02