A26 97�aiication Date: / "��� Tax �iaa #: � `��
Amount �aid• G� �
Ree�i�t #• Parc21 �: �
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A P CAT10N FaR SERVlC�S ��� I�
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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
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Date
PCND, rev. 06l27/OZ
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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�! � ._
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� �' �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
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' Datis
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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
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T���x fJl�ip d• 1 p�irc���� �
SL'Fi�) ilVb51011
Pl,rci e 5ect�io�,r Lot "
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. 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: �
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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)
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* See site plan and additional attachments (_ j. .
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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
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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
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sy� ��o� �� �pro�� ��� �y. The coniractor must, fTag the system prior to�
begissning the mstaAation to i�rsure that jiropergrade is maintarned
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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 �
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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
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� 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.
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� 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
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Barnette Well Drill�ng Inc
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336 59$ 9275 l�/�/OZ Fi5:�6A P.�02
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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 �
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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 „ .. , �, _
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