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A26 86The District Healfih Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PE IT .._. _ � _ �P:_-�-�— Owner: p, Contractor: --- } � � Water Supplp: Private Sewage Di 1 Facilities: No. bedrooms ..�— Dishwasher, Disposal, washing machin ther automatic appliances Size oi tank: NitriBcation line: � Other disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years an3 shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPAR.TMENT . STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. - Date approved: Well: Sewage Disposal: By: � � Signe � Sanitar an :� � Counter � signed eT h' epresentative) Certff'icate of Completion Date Approved: � By: � Sa itarian (OVEft) Location of well and sewage disposal facilities sketched on back. �,�d��n�: 4 —� 8 -�.2 . . , , r�.�a� �02.� � t ..... .~ . . .. � . �� 8'� � . V - � • • � , • . . �! �- �`--,`'�� I�I��T . . . , - . - - - -� ��:�� . . . . . � - -----�. ��-��. � 0 . . . , . _�� .�i� r�l'; -, , ., - _ - :,., _ . � „. 1� . . �� . , , , ;��ra� ,- � � : , . � � : � . , , .! i r ,'., �� .r ,..�.`�� / �.� A . I�/�� 3� �!'iy �017: i� S�ZCC Diredioas bo ths ProP�I i�� hip; �.� fj5�: Lot�kk � „i�' ,, r/. • ,� ' � . 4) E�rop��d Ua and �t�tttrs �a�ptla� a� attt�e ib0owing q�6ors� i�� •� l/ � ei �P� _.. E�19 .� TYPB � �n.�n� ��, i��.,o. 1AIk�.� �� bj N�ur�r of Bed�notr� ._____ tWatt�ber of oc�rrb �r PeoP1e io be aacva� ; c) 8� Yes _, No ,_VIAQ th�re be �g in flua �� -- ,.. � ��Y�� . . . , !!j YIF� Suppty'typ�: Privsb� ✓(t�e�r ,_.. cc eoda�n9 .�. �.� C�ut�u�l.._. � _ . p,�s.�y y�s on ad�o�n�g p�� yes,_ No _ if ye�a.. pi�+se indk�e ap�aoa�n�s loc� an �e s�a p{an. �j owe tiu peop.rLy � pheviousiy ZdaN�sd j� � Ys� _ No _ . Pl.E!►9E N01E TNE Ffl1.l.OW� , . � . . • � � . . . '�➢ A PLAT CP TFIe Pt�OP�T'r OR Sf �E P�.AN 1W9T HE �TT� YIRiM TF� APPLI�CATt�L' � i�OP�i'!Y l.1NE9 ANt� CO� 1�ST � Cl.EARLY 1iAR�. . ➢. TtiE � L.00�1T10N OF A�l. 9TRliC�lRES f1�1ST 8E �TAIt� OR AAGt�. • . � THE 9i7'E lWJBT BE liEAD11.Y A�LE FOR AN EYAW!►'T�N BY TME i�ALTH DH'!1�'18Ei�f �'TAFf. �' � (• .� ,. � •., . �, , :� .:..r, � �:� � ., - - - _��,. ., , �_ _„�_ _ - �i�= - .-:.:w ��_.. •i •�• . _ �� _ _ t �'1 1 - �-�� t-. t, • 1 �� _'.� � �'.r-1��• ' _ 1 ' _1 �• ' _ _:..i•. 1 _ :-��i11� 1 � �� :1 `� � _. ':r_ • l t 'n�_ _ (i_ _.• • � = I �-: i• ��• = w _ •• c= �1 = - n � r_ / � /�A. //'/1 �i � _!��!� ��.:� r_; i = S .1 A - p�p, �.10tt7lD1 0 ,��, �, � ' 3 �� :'� � G 3 �?�--� � . ,2� . ; _ Improvements Permit. (Established/Recorded Lot) � Improvements Permit (Unrecorded Lot) � mprovements Permit (Mobile Home Replace) Improvements Permit (Addition) Bacteria 1. Permit requested by: . owner/prospective owne� Address: - � � Tax Ma� Parcel#: Townsh G �- �. eguested: �� .<_.: �.,: _ Reinspection of Existing System (Loan Closing) RepaidReplace existing Septic System Permit for New Well _ Replace Existing Well ,. ,. . :.: . _ . _ Chemical Petroleum Pesticide _ Lead 7. Dimensions or roposed Structure: lagent• Width: Gc pp/�oXI �a�e � r�o„►►,• _9�/ � �/ 0 �L 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage,di�sal system is intended to serve? of c rr �t owner: 9. Wate{s pply type: , private ►�. public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No � ' � ��,2� If so, identify location: n: Lot size: 4•� C� � C-- a - �I e .1�-.; l Directions to property: State Road #& Road _. _ ._ _ ._ _.. __ ._._._ mes,�tc. � „ � ;. 10. Type of structu �i Proposed: DExisting: �d ' Type of dwell'ng!��"'a� House: �Mobile Home: CJ Business: ❑ Type of business: � Number of Employees:_1�� Number of bedrooms: Garbage Disposal? Yes � No E7 - - Basement? Yes�No�71f so, # of basement fxtures: �, . _ 6' Number of occupants or people to be served• �� -� CLEARLY STAKE ALL CORNERS OF.THE PROPERTY AND THE CORNERS OF ALL : �: _ _.. _. . � __ PROPOSED_S�RUCTiJRES• 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 ___; arid re�resent 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 before an Improvemenis Permit can be issued; I must present a survey plat of the property to the Heal[h Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of Ithe site by the Health Dept., this app�,ication shall become void and all fees paid forfeited. _. _ �I A A, �/ i...� � ui � -_ �¢ . - z fluthorized Agent Permit Issued ❑ Permit Denied ❑ Plat Otiservec� ❑ Signature Date � �' . J r .. r �:;q�.'�E n� �`r ,x $iJEEVALUA Qtiwe.,ti•w�i:+'.s afwr �3ii.,zM'i-r !it" e �i 'b6 a3-� '� es�� .4 >c..'s. a ,c �c� �?�3 ;A� r �t S -� f : r� "`SF � ��.�. �....�„�,�� F,��ro�.s... .- .??. � �.x.. a�: �. � ..,.� Y.f. �►:;��,. .,�r .K � �4:��: � � ,�., ��:.�� ;� , y ,��;,>�xY..r � .. _. i. swe� cx� s s s s � PS PS — PS PS U U U U 2 SOII.7'IX7URE U2-36 [N.1 S � • S S . : .. -._ .:. _ . _"' S _ .-_ . (SANDY. LOAMY. CLAYEY. NOTE 2:1 M1� � PS PS PS; PS . u u v = '�- v �. SOILS7TtUC7VRE(12-36iN.) S , i S S S (C[:AYEY SOII.S7 � ' pt . ' . � PS PS PS U U V U �. SOII,,DFP'IF! (W.). , S S S S , � .. , . : � PS PS _ -. . _ � _._. . pS .' � U U U U S. RES77tlC71VENORRANSRNJ S S . . � , s._... .._,. _.., . ._�. S _:-.: . IQdPERX10US 57RA7A. ROpq _ PS PS PS •-. PS . . _ u,. . ._:- _- - v " . _._ . . v • � 6. SOII, DRAINAGFIGROVNDWATER S �' , S S��' S , (E7C1'ERNAI.� WiFJtN/W PS ., pS pS `.•' : pS . u u u u �. son:p�xMEAHlury . • . s s s s (PERCOLAATION RATfl . . PS' , �. ' PS • ' PS • � � i : - � PS . R r-.r. ')LR.S - ' . . u u . . � . ., . . � , b. AVAILABLESPACE S . S , • S . • . S ' . . � ' PS PS . . PS ! . PS _ � ' u U . ,. . p 9. Sf1EC1.AS$IF7CAT10N(SEEBEL01h SOILSERtES;'• • ; , . � SSUITADLE PSPAOVISIONALLYSULTABLE U•UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns� C�C.� C3AMIPRO�DOCS�APPSEC.SM FINANCEPC .Y��.�1�M: ;:�::: . r - �q c..� - t} ,� , , '� � �� . � � . Jf..��;' U �-+� . ._.'_____ . . � � 96 foun��r�c Se�� \ i' '' ' • a . — � �� -� � � I I 77� I O Oii Tank S/0 Conc Orive � / � , / i _ _ � ', �V NL ``� � is" �a� eiock wall � � � - - ' 96 32 � � Ap�� O � �� I �� Q � C Oil Tank Vent J � � � - � 99.01 � BozNoods 97.30 � �I O Q 6 .�I grick , ' Patio � ' � o n i i1 � � �; - 9 j , � Window Wells Ceiiar Steps `. I Q 724 Brick Wali , � � Foucet � � O\ , O Ground = 97 B7 0 Oak ToD of Faucet = 99.60 I C �' � � �eradrord o G �,�� o Pear � Nollies �J I 1 .� o �� I _. o i � � i � u�' =: .08 � ,-� I Sev��c Tonk I O � � �, � � `' I < i e O Boxwooas ' �-�� o 97.83 96 6 i 97.85 � � � Assume F F E. to be 100.00 � � I , � / � v a / 1 � 3� O 3 ! I I �` o I m� � m i I�� Dopwood I I I i 97 — -- --- — - - -- ---- 56 5 7 , � � �� 97.58 � '� I 4� �J v POfCh I � 11 I 1 O 99 83 96 53 � 1 . � I 97 2 --- - -- 99 i5 1 j�•--`� l: C' --� � l7 0 96 60 � 97. 19 . ��.. . �50 Wi�low Oak ,- � ' . � . Siafe waM i � I o L , � �- - � � � ; � --- _ -- _ , , , �_�` � Conc ..��ve �\ 1 / I � - - - - ---- --�-..__- _ � � �� ' �--.- - _ �� .�\� � � � � � � � / � \ i �� //�� j � Doqwood Ciuste� �.� i � �� / Nnod , � � � ��\ , i v Foucet - � Ground ° 95.36 , \ Top of faucet = 96 80 i / �� / � / i / / _ - � i � � / I� �v � � a 40�� WillOw OaK I /�r�� t 1 \ I � " � 3 DOQWOOd I / o � ��.i �i � � 4�i�� WIII W (�Ok � .� � _ �� I �' I � / - 1 � . � ° 4" Dopwood 'i � - 1 I � �' � - 8rick Column O �93 1, riCk ColUmn _ - - - - - - - - - - - - ' 95 � Rock wa�, 94 , i � � --0�.-:---_ _-=___ -=-- ----.----� ---- ------ 5�� R�P -- -- -- - -- � ------------ ---- -- - ---- �---- --- - --- ------- - --- � -- -- - -- - � -- - --- - — . . - . . - - _ -. - - -- - - - - - - _ _. _. . . _. - - � _ — _ - - - - - - - -- � - _ inv. in 9i 00 � � our = 92 27 - - - �'� - - _ ----- - --- -- - ------ ------ - _ 94 - . . 93 1 � � � .-� ,,..� I'�� a w � a� �B 1097 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # � i, lo Parcel #� Owner/Contractor Location/Address Subdivision Name SFD r 0 Date Q ._ / � - Lot# ' SEWAGE SYSTEM SPECIFICATIONS _ Lot Area Size of Tank �, �f�,,p Mobile Home Size of Pump Tank # of Bedrooms Nitrification Line l�,� f,.,.' �� '#�h e�� u„�� S Max Depth Trenches Permits may be voided if site is Well and Septic Layout by Comments: Date , ,r-� - Installed by Well Permit Paid ❑ E Individual Semi-Pu Public Re cen Site Ap oved Comments: Date This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditio�s on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. 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. c:\amipro\permit.sam O1/95 rev.l.l �� ' � ' ' PERSON COIJN'rY � � � U � a HEAL'TH DEPARTMENT A �s78 WELL E1ND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT � Tax Map # �2� Parcel # Zoning Township � J 2 ; J Owner/Contractor �O S�� Date 2 -� — Location/Address 5`i — S S.R.# Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATIONS � Repair 1� Lot Area SFD Mobile Home # of Bedrooms 3 Size of Tank �D(� Size of Pump Tank N%� Nitrification Line y C�' X t� � Max Depth Trenches 6�� Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is a ed or intended use ch n d. Well and Septic Layout by Comments: I WELL SYSTEM SPECIFICATIONS � iividual Semi-Public blic Replacement te Approved ell Head Approved •outing Approved_ Comments: Date Installed by. Required Slab _ Air Vent Required Well Lo� Well Tag„ Approved by This report is based in part on iafonnation provided the homeowner or his/her representative in the application subc�iitted for�pennit The environmental health specialist is not responsible for false or misleading infortnation contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the applicatioa Neither Person County nor the environmental health specialist wartants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. ORIGINAL c:�amipro�pecnut.sam 01195 rev.1.0 �-.��4?�,) f �� .._-..� � � �� I��n.v�ng-Qb�n�n.a��n�.�n.11 IF� �.�.11�l�n Applicanl Location: Ta�x M�� , � F�rcel � • � S��hci'ivis�ion Fh��s�e Sect�ion Lot # � � Improvement Permit Permit Valid for 1/Five Years _ No Ezpiration • Type of Facility: ��, j,,_,�yy�.. New Addition _�Water Supply {J r,,��, # of Occupants �►t�o8 # of Bedrooms �-i� Projected Daily Flow �� g.p.d. 1 Proposed Wastewater System: � n� -� Q_ T C� (' �� Type: _�'..� Proposed Repair: ��Y(_,� ��e� �'�:., Type: . . � ,, . ; � � Permit Conditions: Owner or Legal Representative Authorized State Agent: � Date: �"� �^ 6 � Date: �i a � �OZ The issuance of this permit by the Health Department in �es 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 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 Caroltna `Laws and Rules for Sewage Treatment and Dis�osal Systems' (15A NCAC 18A .1900). �' Authorization to Construct Wastewater System �Required for Building Permit) * See ite pla and additional attachments (_). Proposed Wastewater System:_��l'r1p�iA�, Type�� Wastewater Flow ��g.p.d. New Repair Expansion t,/ Soil LTAR: g.p.d./ ft 2 Type of Facility: � Q(Z_ �'� Basement _ Yes -�e Wastewater System Requirements Tank Size: Septic Tank: � 1 Pump Tank: � gal Grease Trap: , v� gal � Drainfield: Total Area: � S sq ft Total Length � c� ft Mazimum Trench Depth �_ in Trench Width � ft Minimum 5oi1 Cover: � in Minunum Trench Sepazation: � ft Distribution: Specifications: Distribution Box _]�S�erial Distribution 13S' k3' -� Authorized State Agent: �� Permit Exnirat on Date: Pressure Manifold la, Date: y�o�4'�2, The type of system permitted is Co ventional Innovative Alternative. I accept the specifications of the permit. Owner/Legal Representative: Date: '� �6 � �- .��,� / �J..1..GJ+� �� V � ! /�� .,_ �J �/ �O�..T1�7'I�iY IE ��a-�,*„ ,.,,-„ ,e��.11 IE-Z,g�.Il�]� SITE SKETCH ,.- •II ��/. .!� ,. .... . � �%': � / .i� . / _ �.1[�L� / ' �./ -,. _ _. , ,�. Ta.g Map # Parcel #�_ Secti.on/Lot y-2� -o z Date System components represent approximate �contours only. The contractor must flag ihe system prior to beginning the installation to insure that pmpergrude rs maintained Scale: � .• � c�� r�r K3`(�K � -� �a� PGHD, iev. 09/12/Ol �palication Date• ,�'(�� emount Paid• � 4��' �� Receipt #: __c�a��Z Tax Map #- Parcel #• Person Countv Health Deparbnent Environmentat Health Section . APPLICATION FOR SERVICES . IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED, CHANGED. OR THE SfTE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORRAl10N TO CONSTRUCT SHALL BECOME INVALID. 1} Permit requestsd by: (Owne�lagentlprospective owner)• o� .� �� Home Pho�e: � '97 - �/ 9,6 Add Business Phone: ' 7 -a2s��2 2) Name and address of current owner. , � �� . > P •., � � 3j Property Description: Lot size: 5,�. .•�s Towashtp: 'y .�� Diredions to the property (Indud'u�g road names an� nurqbeys): , 4) Proposed Use and Structure Descriptton: answer each of the following uest�i s: ,p a) Proposed 0. Exis�n9 � �D.� �(% J�,'rh,ini �� /oo � / � b) SGck Built �. Modular �, Single Wide 0, Doubie Wide � �,,� f� s�„ /�;u�� v h� ii�s'/"�� c) Number of Bedrooms: cn Number of occupants or pep�le to be served: ii! ��c e) Basemen� Yes �, No � If yes, # of basement f�dures: Qu,-�,r � Garbage Disposal: Yes �, No ❑ v %7ou,s c3 g) Dimensions of Proposed Strudure: Width: Depth: _ � Water Supply Type: Private �(new � or exis�ng �)� Pub(ic Q Community �, Spring 0��.� �� Are any wells on adjoining propert�? Yes Q No D if yes, location , � l� � I7G �/J S u- � 6) Please Indicate Desired System Type: (systems can be ranked in order of your prefe�ertce) ,�o S�/i'vi� c�y, �Ccnve�ttonal Modified Conventionai _Altemative innovative POD � u�� / ��p"%L Other (spedfyj: � h .q�r�%s� �jo � �� -% 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 APPL1CA7iON I hereby make applicatlon to the Person County Health Department for a site evaluation far the on-site sewage disposal system for the above-descxibed property. l agree that the conte�ts of this applic�tion are true and represent the maximum faa'Gties to be placed an the property. 1 understa�d if the site is altered or the intended use changes, the permit shati become invaqd, l understand that as appGcarrt, I am responsibie foc identifying and marking property Gnes, comers and making the site accessrble for the personnel the P on County Heafth Departrnent to condud their evaluaBons. I understand that i am cesponsible for notdying the Health p t if pe tain " ds as designated by the Acmy Corps of Engineers. Ovmer or al entative ate . � . N � f • � , PLEASI Tax Map #: _ Zoning Appilca LocaUo Subdivision: HED PLAN FOR SOIL Parcel # D SYSTEM LAYOUT Townshfo � � 1 �e- � 1 ` � SecUon: Lot: Improvement Permit A buildinq permit cannot be issued with onlv an Improver 5w�n�vv��l New�Repair _ Addition _ Type of Stn,icture� er Supply �p (�Yk�"� � # of Occupants � # of Bedrooms � Other . Basement? �Basement Fixtures? Projected Daily Flow: �l% g.p.d. Permit Valid For: �e Years ❑ No Expiration Proposed Wastewater System Type:�bV! LK,In%f7C�� —q}r� � Pump Required? Yes ✓ No V .. . r1�'i��r��7r�r�.��r�.� !►�� . r i i , , , �� - � '�. �-• ' , , � , j�� • ' --sa� • ' • . " ' � ' �!� .� �� II� �.�%�� Sw�r�m�� P�o l �zz�Iii �V1 Du� W � I �l�d�'o��1 Date: �' �6 `a� The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be affected by a change in ownership of the site. This permit is subject to compliance wiih the provislons of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Authorization To Construct Wastewater Svstem (Required for Buildinq Permit) Type of Wastewater Syste Wastewater Flow: �g.p.d. �swiw�n�� o � �r� Facility Type: � �tm� w B�Repair DExpansion ❑ Basement? O Yes o Basement Fixtures? 0 Yes G�o Wastewater Svstem Requirements Septic Tank Size: 1, obt� gallons Pump Tank Size: /UJ�}" gallons Total Trench Length: �_ feet Maximum Trench Depth: j 2 inches Aggregate Depth:L in. Maximum Soil Cove�� inches Trench Separation: � Feet on Center Otf �t Pe Ol,�.� f1� 1Gb tfD!'Ul �1�1�i7 Authorized State Agent:��/1 r�. nA�/�,fll/liil(.C�(/y I Date:�'t _�0 _�� -- �- The type of system permitted 0 does Q does not differ from the type specified on the application. 1 accept the specifications of this permit. Owner/Legal Representative Signatu • Date: ��V PCHD, rev/ 10/12/99 � •. . r . Application #: Tax Map #: � � Parcei #: Person County Health Department Environmental Health Section SITE SKETCH , 55��tora � � - I Appli nt's Name Subdivision/Section/Lot# .�iIL ' - /�.i/ .�I�/1/ ' , � I �• • -• - '.- �- " System components represent approxi»iate contours only. Tl:e contractor must flag the system to be�innin� the installation to insure tliat proper graae rs ma�n�a�nea. �,1,4F5u � � (5a' � l l vl� �-- '� ��, r i Dyl CC7Vlili2(,I� y� �� a�' I�aSt ° 2� �L'W) -�a � � u� ° � � �,�YDDw� - I �, �� .� �� 5� PCHD, rev. 10/12/99 . _ �.:. !0-1� ��o Date: Owne:. _- L,o�auon/Directions: P�RSON COUNTY ENVIRONMENTAL H�ALTH �� WELL LOG SR# . L�t � Subdivision Namc:. � ;ry ��.�� , �,nn t� T.►, � Drilling Contractor. �x�T � �,�N�.�R��ON 7T i�l.e Distancc from Ncarest Properry Linc_ _. - D�st;uicc from Source of Pollution � �0 GPM Static 1�%ater Level F� Total �epxh: .�Q._. F� Yie.d:_ . � FG_ Ft. Water $earing Zones: Depth Ft. Ft. O to Ft. Diameter• � Inches Casing: Depth: From Galvanized Steel '� � : 'I'YPE: Steel ' . � If �Steel, does owner approve: Y�s NA� G o�d:_ Inches � 1T1%eight• '1'hickness: Heigh � Drive Shoe: Ycs No • Were Problems Encountercd in SettinS th� C��g� Y°S No _ . - ;, "ycs" give rea.�or�: Concrete . � � Gmuc: Type: Neat _ Sand/Cement . . Annular. Space Width 1 ___�ches Water in ,Annular Spacc: Yes_ No_______ . � Mathod: Pumped � _ Pressure____._ Poured �� : ��. Depth: From � to � Ft. � Materials Used: No. Bags Poztland Cement_.. Weight of 1 bag______lbs. to Xf mixture (sand, gravel; cuttings) - Ra�o: - . 7D Platcs: Ycs '� No _ � Y a �� ah Y�s ✓_ No _ . T HEREBY CER'I'IFY THAT THE ABOVE TNFORMA CE WITH REGULA ONS SET THIS WELL WAS CONSTRUCTED IN ACCORDAN �ORTH BY•THE PERSOI�I COUNTY HEALTH DEPARTMENT. . . � 6--(� ��o� Signat�irc of Contract • Datc 'r . Tax Map #: Zoning _, PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT �� Parcel # � � Townshlp V' � � �` � � Applicant:1/�� `' ' � "�� ' �V �� i�m�� Locadon• ,.�� Subdivislon: TYpe of Water Supplv: ReQuirements• SecUon: Well Permit �ndividual Site Approved by � — Grouting Ap proved by , S'� v Well Log ✓ S _ Well Tag Air Vent Hose Bib Concrete Slab Well Driller: ��'�1.�1 � i�`IaMS�� 'CJ Well Approved By: Lot: Community Public Date: **See Attached Site Sketch** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions:�A�DI U�VI,l,�S)' ��i PCHD, rev. 11/29/99 Person County Health Department Environmental Health Section Tax Map #: �� Parcel #: �n Zoning: Township: �� l � I Subdivision: Section: Lot: Appiicant: l Location• ;,)�(/�5 ��{� �J�-fi� ' 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 AUTHORIZATION. . � , uthorized State Ag nt �� 7-�� Date � , (;e�v �s .. `��a�� Tax Map #: � (� Parcel #: �lSl ' PCHD, rev. 10/12/99 Person County Health Department Environmentai Health Section �( ( Zoning: Township: �� U� t'll � 1 Subdivision: Section• Lot: Applicant: Uv Locatiom Operation Permit 1. LOCATION AND SEPARATION DISTANCES / A) System meets .1950 setback requirementsi �� B) Distance from system to any wells .� C) Distance from septic tank to foundation � D) Distance from system to property lines ��D 2. SEPTIC TANK ✓ A) Visually inspect the exterior walis and top of the tank B} Visually inspect the interior wails, b ffle, tee, filter, riser, lids, air vent, bottom, and water tight outi� � C) Date of tank manufacture � D) Tank serial number — '[�7i E) Liquid capacity of tank �(� gallons 3. SUPPLY LINE TO T ENCHES A) Grade 1/8 inch per foot minimum) v� B) Materiai supply line i constructed from f� C) Diameter � 1� D) Length i � � E) Distance from tank to drainfieidldistribution device �,_ 4. DISTRIBUTION DEVICE(S) A) Type B) Is Device water tight �(� C) Distance from the distribution device(s) to the trenches ��\ D) is the device on a level foundation E) Does the device pertorm according to its design specifications F) Record the inlet and outlet elevations 5. NITRIFICATION FIELD A) Trench depth inches B) Trench width inches Of/� C) Distance between enches �� j�� ,��'Vl' D) Number of trenches E) Length(s) of trenches F) Aggregate depth �_ inches G) Aggregate material and size H) Record septic tank ou let elevation � 1/4° er 10' I) Trench grade L P ) . J) Step downs a. Minimum of 2' of undistur ed earth b. Proper rise over step own c. Solid pipe used d. Elevations of step downs ��e (Record elevations and show on as built) See "as buil�plan� attached sheet. PCHD, rev. 10/12/99 Mdy-15-00 08:31A P.02 E N COUNTY ENVIRON T L HEAI,TH � P EASE SE TT LAN FQR L SIT UT � t�:M�p�r: �a�t7 P�rcNM � l� zonlnp TOWntMP I I( r� �PVticant: , u� �fn ��/1 1'�' • l�.i��`J�� _ ��.�,: �� .�2UY. � � � fubdlrMlon� , S�ctiwr �ot �� Tvae f Water Supalv: Requireme�ts: V�,fell Permit �ndividual Community ^..Public Site Approved by,��_7dP�R- Grouting Approved by _ — � . WeU l.o� Well Tag Air Vent � Hose Bib Concrete Slab ' ` '�1fgfl C�riiier:_, . .�_ , Weli bpproved By: � � � Date: ,�. ••$ee Attached Site Sketch*" WeUs must be 10 feet from pro�erty (ines. iNei9s must be i O�i fe�t from septic sysiems. Wells must be at ieast 25 feet irom any buiiding foundation. Other conditions:� nB� �n • j� -v � _ � � PCMl7, rev.�11/29159 �- .----� M�ly� 1b-00 O£i:31A Appltcatfon #: - Tax Map #: -� �_ Parcei #: Peraon Counry Haalth Departrnent Environmantai Heaith Section SITE SKETCf-� ' � �- c �„�b.5��Y1�tvra � � -- A pli nl's Name Subdivi&ion/SectioNLot# P ,� �� . -��i1'L -g �` zb ' C'C� Authori=�d State A ent � Date System co»tponents �epr�sent app�oxlnwle contour.r n►rly. 7'he conlrnctor �nust flag lhe syxtem tFa ittstkllrll6or_ lo is �cr�� t�o' �i 11�'k �-- t�1 G��l�'ot�i� �� ' �% at.��ast (,(� � � ��o�+�. z�l� wjt�� v ��C�� . ,-- �� u� . s�a�e: �j� -tZ��C� _ - ^� � � t-ic. �SFCG`Vl ��ro�r Gti�uS� , �� P.03 PGHD, rsv. 10/1?J99 . , , 0