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A26 97�aiication Date: / "��� Tax �iaa #: � `�� Amount �aid• G� � Ree�i�t #• Parc21 �: � ' ����'�� ���..� �� ��p �� � � . � � � ����- ��.1 1�aa�-�a-.�aa--� maa��.I1 �3ima.I1�7� A P CAT10N FaR SERVlC�S ��� I� P u �Gp ,�} IF THE 1NFORMATIOM IN THE �,PPl:1CATION FOR AN IMPROr1ElIAEAIT PERAAIT IS INCORRECTLF�,LSiFiED� CHANGED OR THE SITE IS ALTlERED THEAI THE IMPROVEMENT PERMiI' AND AUTHORIZ14TiOfd TO . CONSTRUCT SHALL BEC011AE INVALlD. � 1) Permit requested by: (Ownerlagerrtlprospective owner : �� ^ Home Phone: ��lS'�e Address: �� Business Phone: � 2) Mame anc9 �ddress of current ovmer. 3) Property t3escription: Lot size: Township: Subdivision: Lot # Directions to the property (1ncluding road names and numbers): • 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed . Existing , Type of Structure: Width: Depth: b) Number of Bedrooms: Number of occupants or people to be� served: � c) Basement Yes , No Will there be piumbing in the�basement? d) 6arbage Disposal: Yes No _ . 5) Water Supply Type: Private !/(new '�'sting�, Public , Community� , Spring _ Are any wells on adjoining praperty? Yes_ No _ ff yes, please indicate approximate location on the �site plan. 6) Does your property contain_previously iderrtified juriscltctional wetiands? Yes_ No_ PLFASE NOTE THE FOLL0IMNG: ➢ A PlAT OF THE PROPERTY OR S17'� PLAPI MUST 8E SUBMITTED WITH THIS APPLICATION. ➢ PROPEiiTY LlNES �►iVD CORNERS MUST BE CLEARLY MAR6�D. �, 9 THE PROPOSED LOCATION OF ALL STRUCTURES NAUST BE STAiCE� OR FLAGGED. 9 THE SITE MUST BE READILY ACCESSIBLE FOR API EVALUATI�N BY THE tiEALTH DEPARTMEAIT STAFF. I hereby make application to the Person County Health Department for a site avaluation fo� the on-site sewage disposal system for the above-described property. I agres that the contents af this application are true and represent the maximum facilities to be piaced on the property. I understand if the site is altered or the intended use changes, the permii shall ^��� Date PCND, rev. 06l27/OZ � Aoailra��• �afe: '�� V �' ;... . � 2��� ,r-� ' ' ' •- � QD . . / � � i p� . ,�, � !, � ��34.� . . � � �.�' � . ��' � ��) �. ._ � _ — � �,� � � �. , �. � � � _ �_. �yi_ L..:ilL?L �• � '=:�i_'I=^� � � T� �a� P�rcai:� ' �' � � 0 - � � . ,���� . i�. ��■Ij��J� � I/�'����� ' � •� � _ .�•I - �-i`.ZS��'a�r/.7!S%� i, � - � �� II� �� . r- �� i �: � �_ v a/�V 1' . •� � �•- �� � /i • . _ � _.�.��• . i• 11 - ".L:' �_ � f w� •II n ���:.• c _ • L� _ :7 , _ ���.�{ � �-� 4) Prop��d [�e aad �rin�urs O�ptlo� a� es ���PJI�J ,tii�-s`_ �. t�pii� . � a) Pt�o��oeed _1-�9 '�'ype of �� b) Nwn6er of Bedtaorr� .� l�tmber of acatpani� people t� be � ' , c) Bassaen� Yes _, Nc L�II� thers t�e �g In i�s �e�rt�! � ._ di �� � Y� _+ � .l�� . . � �' �PP�I'�I[� Priva� S,�(f�r _ or , P�.� �I._.. � _ Ars-m�y �b an a� p�iy? Yea _ No _ tty�, �e indi�0e a� lo�tian an �e s�e pmn. 8j Dc�s m. p�p�rly r.on� phavio�iy 1�d I� �4 Yea _ No� PI.E1►9E NORE'� FOI.I.CW Wf'� . . • . � � . . '�➢ A PiAT OR 7i1! Pt�OP�TY' OR S[1� PI.J1N 1tI9T BE �TTE.� WRH'�HtS AF�PLf�CA'T[�L' ➢ i�ilOPBi'tY 1]NE9 AAID COR�9 l�I9T BE f�.BARLY 1iARl�7� . ➢. THE L�OP09� LOCAT�ON OF ALL 9TRUG71lRES 9�lST 8E �'CAItE9 OR AAt�. • . D'tHE St7E 11�lST BE l�ADU.Y A�IBLS FOR AN E�/ALUA'i�N BY TME ilEALTH DH�!►i�lE�1T giTAF�. 1• l�erebg msloa �pSca�ad tc the Pesson Caw�+j Heeiit� De�tt i�Cr a�a �ua�a�oc� f�Or ihn cU-eii� �+e �! gY�n �or the abave-d� propeKy. 1 agree #ltst the c�n�nfac af U�is �p�on ar� true and �p�'�e nmo�wm � ba b� plecad an th� pro�per�j►. 1 under�attd i� fhe s�e is al�d at the hnt�ded u� chartges,lhe Pemui shalf or Legai . �� �� v 2 ' Datis u - p�.�p, � 10t17101 0 ���� )� ���� �� �... � � ������ I��n.�n� �r �raaaaa�aatE.�.11. IC� � <m.11.v�lEa Applicant: Location: Permit Valld for � Type of Facility: c # of Occupants vl�a X Proposed Wastewater Propvsed Repair: � Pert�tit Co 1 b �/z Owner or Legal Representative Authorized State Agent: 5 ` T���x fJl�ip d• 1 p�irc���� � SL'Fi�) ilVb51011 Pl,rci e 5ect�io�,r Lot " �` �� . Improvement Permit -: _ No EzpiraHon � : � � . New ,�Eidition r Water Supply �� �� rdoms o� Pro'ected Dail Flo�w ` g. .d. � J Y _�� P a � V2, � Type' _ a �U.w� P Type: � � C Date: �'�' 6 � �-- Date: ,5 2q�oz The isauarice of this permit by the Health Deparhnent in does not guarantee the iasua�ce of other permits. It fs thc reaponsibillty'o£ the applicandpropetty owner to in eure that all Pereon County Planning and Zoning and;Building InepecHona requirements ara mat. Th1s Improvement Permit ls aubject to revocation'If the elte plan, plat or the intended nae changea. The Improvement Permlt is not affected by a change in ownerahlp of the property. TWs permit was Isaued in compltance witi� tho provlaiona of the North Carolina �Laws and �tules for e ge Treahnen� and Dlsposal Systems, (15A NCAC 18A 1900) �` Authorization to Construct Wastewater System �itequlred for Bnilding Permit) . ,; * See site plan and additional attachments (_ j. . 1��,,� � � �� Propose astewaterSystem:��t- �'1►°�I���" Type�� WastewaterFlow���'g.p.d. New �,� Repair _ Ex ansion � Soil LT�R: � a .p.d./ ft 2 Type of Facility: �,���t � Basement � Yes �No Wastewater System Requiremen�a Tank Size: 5eptic Tank: ��� gal Pump Tank: � gal °; . Grease Trap: gal Drainfield: Total Area: f�''�_ sq ft Total Length ���� ft Maa�;xnwn Trench Depth �'�^v2o in Width � tribution: Speciflcations: _ ft MlnLnum Soil Cover: � in Minitr''►um Trench Separation: ` ft _ Diatribution Box � Serial Dietribution Pre,�sure Manifold� ►�n,��- ,�,��a,�- ��OcQ, rn���5�c�..On„ �n;, �M,�1-rR.(r IiiXIZJVY IUS���� Authorized State Agent: /�jf�'''� l�( C�fVer Petrnit Expiration Date: _ �-' �q- d .- The type of system pernutted is �,r�i;onventional � Innovative the permit. �� y� Owner/Legal Repreaentative: 5�����l1 ���1 � ��L2�� � Operation Permit Date: ✓� oZ-�� OZ Alternative. I accept the specifications of DSte. �-3 Q-'� 'L_. �yatem Type (in accordance with Table Va) �� • � The system has been installed in compliance with applicable North lina deneral Statutr.�; Lawa snd Rules for 3ewaga Treatment and Dieposal, and all conditions of the Improvement Pertnit and Cons on Authorization. Is���anca of this permit doea not guarantee that the waetewater syetem will function propetly for any given period of time. Authorized State Agent: � Date: �-7�0 - o z � PCHD rev. Ol/23/02 i e .�1����� � ����.1�� - � ���0 ��1��� 7E���-��,..�.,,��¢.�,.7� IE-���.Il� i � � , �� ' � .. . -,.. 1 ��j�i11�i i.. • • � "� Y. �:�f SI'1'E. S��E.TCH Ta$ Ma,p #' ��02 � Parcel # ` 1 � Section/Lot# r,—z Toz, � Date � sy� ��o� �� �pro�� ��� �y. The coniractor must, fTag the system prior to� begissning the mstaAation to i�rsure that jiropergrade is maintarned � � � ' .� ''� . y : , n . �� Q � �u IIWM �����;�� � � � l7l � � 5 �'��e�� ar� e�5�i� �� . �� a� � C���- ��� d� ���'�, � . � scale: � P��� . ���� r � og/�/o�. � ������f . ������ � ' � � �.J� 1V` .1L � �.aava�ma*�**�*eaa�m.� �omIl'��a N e�c�l'�Yl (1 y Q ��i�l � S b ' ' ' t�1 i� . Au�orized St�.te Ageut Sl l F J�1 �.17, T� �P # �ac� P��. # q � � � Section/ t# � �—g�� � . Date . � system componen�s r�preses�t approxs�e�contours only. z�ie conrractor mresr.t�g ��' begrnn:ng tl,e i�nstaAat�ion to insurrs that prnpergrade is maintarned � . �v `}� . � w ��� �� � �� ov � �v �L• � � � �' � V �O U � � l `r� u \*' � � � � ' •` � �.+ � `'�' �b �� 3� y" o�� �-�� � y� � . � L "' ' � h� C,�, Q�' ti• Z``'� �r� o- �J �� C� �<: �(/ Jv / s�e: \ � . . Pir�on CauM�{ Haaith �e�rt � � . E.�viro�er�i H�th Se�liot4. • . ' � : Tacc �p � � � � T� . � ' �8e�ib� l.o� �PP� � � � . I.�iioie � . • . � �pefation ��.Permi�t � � � � � . � . ,, s�m � (�n �� w�t► Ta� ve): hes srs� t�s s� asrau� w co�uaHc� wrtti �c�►e� � CMOLlNA GENERAL STATUiE9. RlJLEB FOR SEWAGE TREATI�NT ANO DISPOSAL: .AND ALL CONDIilON9 OF THE IYPROYBIEM' PHiYR' � AND CONSTRUCTION AIJii�1O�A77CN- . q�d gt�e qpa� � � Da�e . . �� .• . . . A . '' � � , ���y )��� ���� �� V `�� � � ���� ��.'�.��'fr++�rn'n��.'I��L� �aer.�.JL�� � WELL PERMIT PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: �v�� Parcel # � � Township 1lpplican� ��� n n�e I3�� n KS Subdivision: N I ia�►�► c��l � V��c� rC �t�-�ScG-�t D � . T�e of Water Suvnle: Reauirements• - ���: ) �'a.tlC �mbr�`e,K 1-c�� V Individual Communitp Public Site App=ove d by �`� ►�- 3-- 0 2 GzoutYng Approved bp CS� l0--3-�'Z.. Well:Log(►"�, ir�-7-oa, Well Tag Air Vent Hase Bb Concrete Slab Well Driller�� >�rnQ� e �e ! J �r`�,��' Well Approved By: Date: C��: wc.�t 3 s' d`c`� �F� m� n i mc,�v►� 9a' ea-s �� - �ns-E�.[tc.d� e��w�Gi f�b�onmc.� (S hot (�li.n��-�o�j� 6v'� f�coMM�dt.d.. *'�See Atrached Site Sketch'� Wells must be 10 feet from property lines• Wells must be 100 feet from septic systerns. Wells must be at least 25 feet from anp bwlding founda.tion. o,�� � ta�l1 t n arc�. S�aWn � �b�n.dan b� 1 c.xlr. t„��t1 dri��tr 5��+-�-(d �ncc.-c EEfS c�n .Sltc. ` � b(,FOrc. ci �I I I/►��. . L 0 UC,r( �'% 5���'�GlC .�I �" �7�D JI L f/''�: PC�ID, =ev. 09/07/01 -f� 5����' Barnette Well Drill�ng Inc �"". 336 59$ 9275 l�/�/OZ Fi5:�6A P.�02 ���/�l: C a, Ss i e ��� ! � �I��.� �./ ��T � YV � h ��� .r _ �'"` �' `, � II�/C3�111NL^! � � �.T�T�C�Y ° ° �,.,,�. :-�c1�f 1.L.�� 7�k�.. o•-ux��a-,. �,.�„ ��+��.Il 3�3L�cmIl,�]Ea. � � ��-� � � 9 -.__ w�u Lo� Owner: Tax Map��� Parcel f� �,.,� Location: . � i S�ibdivision: - Lot � 'Well Construction Distance Fmm nearest �'zoperty Li�ae (Minimwm 10 feet) � 27istancc from Septic System (lvlinimum 60 feet) Total Depth: �,�, ft Yield: �_ GPM Static WateT I�evel: �_ ft Water peari,ag Zones: Depdi �_ ft J�_ ft fi i� Casiag: Depth: From a to �/7 R Aiameter: �_ im Ty}�e: Gatvanized St�l Wcight: �hickness: ,��,_ Hcight above Ground: f L/ in Drive Sho�_� Ycs ___,_ No Any problems encountered w7tile setting c�si�g? Ye's� No If `�+cs„ brivc reason: Graut: Near.: S�nd/C,�-aent Concretc GraveUCemcrat�'�'-' Annular Space L�%id:h inches Water iu Annu(ar Space _._Yes __,_„ I`'� Method of Gros� �'umpec3 __ Pcc.ssurc I'ourod Depth n tc //) F� --�-- Matcrials Uscd: _ •- NQ, Bags �'octldnd cc:ment Weight of 1 Bag Povnds � If raixiure (s�•d, Szavel, cuttings) -- Ratio to ID pl�tes: � Yes „ No 4 x 4 slab _ 1Ces _ No Drillin� Lo� � Locatian DrawinK �ronu '�'o k'o�Cwn � � � ' � � . - .. � _.�,...�- - —• .fa J.j I hcreby certify th�t litc: above infortua�ion is cotrect and that this well wa.s constructed in accordance with rcgulatioas set fonh by thc Pcrsou County �-Iealtki Dcpart�ent. 5ignaturc of Coatractor 6,� _ .l ��i� S�U/1� ID # _ �� / .£� Date /� -� ,�9 „ .. , �, _ �� / ��.- - �✓� � -� - '> �- - �/ �t/� i'✓s,:¢ % �' � �,�,�.ds - v�✓T��'�fU��� � -4'�� �� �`'�`�� � ��1�l�'fh�'P'i � -/ _ I � / �,.L . � r�/N N X.� ��'�''�� �%r,�-- � �s, / �, a �—