A27 179�j}U �
Amount paid. �� _ �
Receip� .�� ���j�%L/ Date
�
H
O
�
�
w
U
�
a
s
PermiG(Established/Recorded Lot)
Improvements Permit (Unrecorded Lot)
improvements Permit (Mobile Home Replace�
ts Permit (Addition)
Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
Permit for New Well
Replace Existing Well
1, permit re uested b:. 'rC�A SvLo�fk�` 7. Dimensions or ?'roposed Structure: I
owne rospective ow� /agent:� QSP��T► �E �� Width: i�_�
� aa_,...,.. � �,c� m�,,.iTPF_�, iC�2 R�IE . _. Depth:�� _--
W
�
z
ome Phone #: �.�Y� Z�v[o�
usiness Phone #: �Q3`!�/Z
Name and address of,current
Tax Map#:
Parcel#: _
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility .
that this sewage disposal system is � ntended to serve?
�a veY G
ner: 9. Water su t}pe:
LC—C(��5 � private .public❑ community❑ spring❑
Are any wells on adjoining property?Yes ��o
If so, identify location: '
ion: Lot size: �- � z
Township:,1� � .0 /�v r� v
. Directions to propecty: State Road #& Road
10. Type of structurelfacility: Proposed: �xisting: Q
Type of dwelling: or Mct��a�,���
House: � Mobile Home: L7Business: ❑
Tyge of business: � �%�
Number of Employees: .
Number of bedrooms: _ �
Garbage Disposal? Yes ❑ No �
Basement? Yes❑ Nofl'�so, # of basement fixtures:
6. Number of occupants or people to be served: �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUCTURES•
I hereby make application to the PerSOri COun�y Health Depat'tment for a site es aualication ahe tcue ite
sewage disposal system for the above described property. I agree that the contents of th pp
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. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to-the Health Dept. wi�iin 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become vo'rt� and all fees paid forfeited.
Si�nc� Owner or Authorized Agent
Permit Issued ❑
permit Denied ❑
Plat Observed ❑
Signature � Date .�� 9 / . � -
/
RECOMMENDATIONS/COMMENTS: -
SITE CLASSLFICATION DIAGRAM (Include� Soil areas, property lines, roads, streams, gullies, wet areas, �ill
areas, wells, water bodies, slope patterns, etc.� C:V�MiPROIDOCS�APPSEC.S�1 FINANCEPC
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Person Countv Heaith Denartment
Emrironmentai Health Sectlon
APPUCATiON FOR SERVICES
ImP�o+ro�ner�
(Ma�s floms Replapme�Add�an)
iaX 1�eD #:
1) Rem�It requested bll: (Ownerla98r�ProaPe�ve ownerj: 'S
Home Phon� '� /e {_„�99� 88 qcldr+�ss' " "1
Busi�s Pfiane: � � � �� 9_ �f 89 D _ _ ._ ��
2) Name and address of carrer�t owner; .�,o
3) Property Descripdon: �ot size: ,,��Townst� ��,.
Directlons to the proPeci�► {Indudtn9 � names aAd numbers��
l o-�
4) Proposed Use and Structura Descriptlan: answer each of the follawing quest[ons:
a) propcsed �; �d�g a
b) Sticic BuBt Q Modutar �. Stngie 1Mde Q Double Wide 0�'
c) Number of 8edrnoms: �• c� Number of oa�pants or people to he served:
e) Basement Yes �. No yea� # of basemetrt �durex
i Garbage Dtsposal: Yea�, No
9) D(mensiona of Propoaed �: Width: Depth: .
5i Wafier SuPPhI TYPe� Pdvate fl(n' ew I] or e�dstln9 �� Pub�c 0, Communityy �. Spring ❑
• Are arry we�s on adjoining property? Yes ❑ No � If yes. locatlon
6) Ptease Indlcat� Desirsd 3yabem 7jlps: (ayatema can ba raniced in order otyour prefee�ence)
✓Carnerttlonal _„Mo�fled ConvettHonal _, J�ite�tive Innovative
..other (apediy);
' CLEARLY 3TAKE AL� CORNERS AND tJNES OF THE PROPERTY,
STAKE THE CORNERS OF ALL PROP03ED STRUCTURES.
PLEASE ATTACt! SURVEY PLAT OR 31TE PLAN TO THIS APPl1CA710N
� �� �
� ,� c�u-�¢�t.a� �,c„c,
.e/
� he�ebY ��ca�on� to the Person Caunty Neatth Department tor a site evaluatton for the on-site sewage d(spasal system for
the abo�e-descxibed property. 1 agree that the conterrts of thls applica8an ar+e true and represerrt the maxirnwn faaGliss to be
p�� °� �e ProPe�Y• ���+'S�d if the site is albered or the intended use d�anges. the permit shall become irnralld I under.rtand
that as a�Piicant, 1 am responaibia for identlfjring and marid�9 ProP�Y �nes. comers and meldng the sifie accessibie for the
personnel of the Person CoeuYty Health Depsrtmertt to c�dud thelr evalua�ons. I understand that I am responsibie for noii(ying the
Heeltlt D if my AroPertY contains arry weHands as desi� by the Army Corps of Et�gineers.
, .
lc . � • � � I p
. Owner or Legai ReprEserrtat�e .
PCHo, rev. �an�rss
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PLEASE SEE ATTAC9iED PLAN
Tax Wlao #: � I
Zoning
� 4
AQPlicant: . � r m m � �e � � -S
Locatlon: �7 � ��w ��
Subdivislon: j�UlfJ�_ �e4.P� Sectlon: ,
C�7
Parcel # �
Township � C��%` �
�
cor�. /o7L � Sc/,�Q�;�
improvernent Permit
A buiidina permit cannot be issuea witn o�
New ✓ Repair _ Addition _ Type of Structure _ Wate� S
# of Occupa�ts �# of Bedrooms J Other
Basement? �j,gZ_ Basement Fixtures? �_
Projected Daily Flov��.�� g.p.d. Permit Valid Fo�ive Years ❑ No Expiration
Proposed Wastewater System Type: �Dilc:'�►�-(-��
Pump Required? Yes No /I1.� �{p P w.-� : F
Permit Conditions: 1 O I/O � s%�e- .`]' �°=�c-r�+ •
,��P�;J�
��
Owner or Legal Representative
Authorized State Agent:
/��.�-e. a-�C � c�n.�. � S �
up S/o� ,
Date: �b 'a '%-Od
Date: f D 1 O O
The issuance of 4his permit by the F�ealth 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 �evocation 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 with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Type of Wastewater System ��ll
Facility Type: ""
Basement? ❑ Yes No '
� Wastewater Flow•3� g.p.d.
New�epair OExpansion ❑
Basement Fixtures? 0 Yes � No
Wastewater Svstem Requiremen4s
� �
Septic Tank Size: �_ gallons Pump Tank Size: � gallons
Total Trench Length: � feet Maximum Trench Depth: � inches Aggregate Depth� in.
/�7 �n_
MaxCmum Soil Cover: � inches Trench Separation: �. Feet on Center
Other: �--�''���'-�-� i%%� �--$Q'D �� '�' � -�c.�-- i�--
��e � I
Permit Expiration Date: ���c�.7/�'T �� ,
Authorized State Agent: Date: 0 d �
The type of system permitted does Q does not differ from the type specified on the application:
the specifications of this peRnit.
OwneNLegal Representative Signature: pa�; �b °2 %���
t
�
I accept
PCHD. rev/ 10/12/99
• ' '' . ' � � .
• � ' A Ifr.ai3on �
�
AP • —�—
. Tax A�ap �:
� Parr.e! #: �
• Person Coutrty Health Department �
� � Enyironmenial Health�Secfion
. . � S�TE SKETCH
�, � m � C.-� ,;.� -
• �Pjj S NS[!1@ SUL7tjIV�5i0�IS�tOM.C�
� � /D DO
riz� State Ager�t �
systera carnponer� represalt approximate cnntorus oniy. The cant�actvr must flag tbe spst�
--� ._ L:..:_..:.... .aa :..��n�n,e te i»sr�e that DroD� �'� is mr�
�
� � Sc�ie: � �� % ��C�i �
� ,. � .
��.h �� �o .
,� ,�—
�ef
T��\ i�JG`.y
�w�P �r
���� �
3as, a �
pCt�i�, rev.10H2t99
. � Person County Heaith Department .
� Environmental Health Section �
Tax Map �: �} a� P�� �: i� �
Zoning: � Township: �,� X � � /` �''
Subdhrision: ��UP� �-%� Sedfon: Lo� �
ApplicanC � � ,w/YL»^-� �-- L� Wr -S
Locatlon: ,S � �nn S��-e... --> �'.>c a v�. �f'� C o�nw. �-
� . /S c�,
. �� �o,•�-
4pe�ration �Permit � _
System Type (In Acxocdance With Tabie Va): � ���
V
THIS SYSTEM HAS BEEN tNSTALLED lN COMPLlANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FaR SEINAGE TftEATMENT AND DISPOSAL;
.AND ALL CONDITIONS OF T}�E IMPROVEMENT PERMfi AND CONSTRUCTION
AUTHOR1ZATiON.
- �
Authc �tate Agent D e
�
� ?n� �
�.,',y„ ��i'•
.�
�, �so � ;," : ,. �
��5� �� s�
g• ••
: ��:,;::
L,"�. r = � � �
c., � a � Ss-' .
��.. 3 � 8� � .
Li � y = 83 . � � .
<<�..�.. S = 9 y
,
c.�� � ; �o �
ro� _ �37�
. � PCHD, rev.10/1?J99
Person County Health Department
Environmental Health Section,Q
Zoning: Township: f'��� k�/`��
Subdivision: Section: Lot: �
Applicant: .��-vrr�.►�--._ �-r�c.� r S
Location: /�% — --� �-G A- �/�- C��-�1 C
Operation Permit
1. LOCATlON AND SEPARATIOIV DISTANCES
A) System meets .1950 setback requirements ___`t-
B) Distance from system to any wells /or� �
C) Distance from septic tank to foundation 5 l �
D) Distance from system to property lines �D
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank
B) Visually inspect the interior walls, baf�le, tee, filter, rise , lids, air vent,
bottom, and water tight outlet ���d
C) Date of tank manufacture 3� /d- OD
D) Tank serial number S 7!3 /5��
E) Liquid capacity of tank ���D gallons
3. SUPPLY LINE TO TRENCHES
A) Grade (1/8 inch per foot minimum)
B) Material supply line is constructed from
C) Diameter �
D) Length
E) Distance from tank to drainfield/distribution device
4. DISTRIBUTlON 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 perform according to its design specifications
F) Record #he inlet and outlet elevations
5, NITRIFICATION FIELD
A) Trench depth �_ inches �
Bj Trench width ��_ inches n� f Qn �� y}---
� C Distance between trenches _�> T �—��-��
Q) N u m b e r o f t r e n c h e s � � � � a �� ��
E) Length(s) of trenches ' � � 9 y �
F) Aggregate depth inches �� 7
G) Aggregate material and size
H) Record septic tank outlet elevation '� `�/''
I) Trench grade 5ec. ac� ` (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth �
b. Proper rise over step down 1 f�
c. Solid pipe used ���� ��
d. Elevations of ste downs �,� (Record elevations and show on as built)
See "�s built" �lan on attached sheet.
,.
PCHD, rev. 10/12/99
• � ' • ' PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE �LAYOUT
Tax Map #: Parcel #
Zoning . Township �8.����
_/' 6
Appliun� J i m�� �
Loptlon:
Subdivision• Sectlon• �-0�
Tvpe of Water Supalv:
Well �ermit
Individual
ReQuirements:
Site Approved by �
Grouting Appcoved by �5'
Well Log � D
Well Tag ✓ �
Air Vent �
Hose Bib ✓'"
Concrete Slab ✓
WeU Driller:
Weil Approved B�: � r �/1�
Community Pubiic
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 fo�ndation.
Other conditions:
PCHD, rev. 11/29/99
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: //• /�/ �v '
Owner. y►-.
Location%Directio s:
s�-
Su�division Name:
Drilling Contractor:
�
SR#
Lot # 3ti
� WELL CONSTRUC'I'ION �
Distance from Nearest Property Line 1 v Distance from Source of
Pollution ( G a
Total.Dep.th: /�v Ft. Yield: � GPM Static Water Level a?.r" Ft.
Water Bearing Zones: Depth /yU F[. F� F�. Fc.
Casing: Depch: From 6 to /av Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Yes No
� Weight: � Thickness:� '� Height�Above Ground: /�/ Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
Ir "yes" gi� e reason:
Grout: Type: Neat Sand/Cement / Concrete
Annular Space Width � Inches . �
Water in Armular Space: Yes � No
_ .. Method: Pumped � - Pr�ssure � Poured � . . . � �
Depth: Fr�m O to � O F�
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (sand, gravel; cuttings} - Ratio: to
ID Plates: Yes � No � �
� 4 x 4 slab Yes i No
I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED II� ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�ui1TY HEALTH DEPARTMENT.
ignatura�of Contr�tor Da�c
9