A27 238Amount paid� S-0 O
} Rec,tiipt .�� � �J �3�
� 3 `7
Date
�
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Bacteria
1. Permit requested by: .
�u,ner/nrosoective �vnei
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_ Chemical ._ Petroleum _ Pestici e
ome Phone #: �%T �-1 �Ol�!/
usiness Phone #: - 7~
and address of current ow
, , . �„ , > >,
. Property Description: Lot size:
. Tax Map#: �. ` � 2 �
Parcel#:
Township:. ��;. •� _
� 4-� �g 3 .�
p �.,1 7. Dimensi s or Proposed Structure:
I �n!�J Width: �D�
_ Lead
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility _
that this sewage disposal system is intended to serve?
��� ���
�er: 9. W ater supply t}•pe:
��,(}c c � private�.. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
Directions to property: State Road #& Road
mes,�tc. T I f-A
1 < � , \�c� I��., �IOW �J �U � � S �''��
��
10. Type of structurelfacility: Proposed: �Existing: Q
Type of dwelling:
House: [�. Mobile Home: L Business: ❑
Type of bustness:
Number of Employees: .
Number of bedrooms: �
Garbage Disposal? Yes ❑ No �
Basement? Yes❑ No�If so, # of basement fixtures:
6 Number of occupants or people [o be served' �_� �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNER� OF ALL
PROPOSED STRUCTURES• .
I hereby make application to the PerSOn COuniy I3ealth Depa � th e oncencs of th s application ahe t�rueite
sewage disposal system for the above described property. I agree tha
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 propert to-the Health Dept. wi�in 60 DAYS after the date of the evaluation of
the site by the Health Dept., thi ppl' ation shall become vo[t� and all fees paid forfeited.
Si�nc� Owner or Authorized Agent
Permit Issued D
Permit Denied ❑
Plat Observed ❑
Signature
Date
v�"P�` a'�"�,�ol�c���rfz°.A��k :9F�Gi'ORSSliE�ALUA770N,�`�t4Exi`. �?��c�<-� �w«s-.�x€�1�RF�;I s�' ? s;, AREf�-T "i, a, �':,'��'x�ARFhZ�'ws�,y i�` �'.i:c..f�A�'% zaxz s�
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1. SIAPE (%) S S S S
PS PS PS PS
U U U V
L SOII.TFXTVRE(12•361N.) • S S , S S
(SANDY, LOAMY. MYEY, NOTE 2:1 CLAI� PS PS PS PS
U U � U U '
3. SOiLSl'RUCTURE(il•161N.) 5 S S S
(Q�1YEY SOILS) PS PS PS PS
U U U U
3. SOIL DFpiti pN.) S S S S
PS PS K PS
V U U U
S. RE57'RICIIVEHORRANS(M.) S S S � S
QMPERVIOLS STRATA. ROCK) PS PS PS PS
U U U U
Q SO(LDRAINAGF/CROUNDWATER S , S S S
(DCIFANAL R Q:iERNAL) PS PS K PS
u � u u u
7. SOII.PERMFJIBIIJiy S S S S
(PERCO[AATION RA'fE� PS PS PS PS
• v u v u
E. AVAILAB(E SPACE S S S 5
� PS PS PS
U U U U
9. SCfEC1aSS�F7G1710N(SEEBELO�
SO1L SEW ES �
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S•SUITAIIL£ PSTROYIStONA11.YSUTfADI,E lY-tR1SUICABLE
RECOMMENDATIONS/COMMENTS: -
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �ill
areas, wells, water bodies, slope patterns, etc.� C:�AMiPR01DOCSAPPSEC.S�1 FW/�NCEPC
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B1667
� ' • ' PERSON COUNTY HEALTH DEPARTMENT
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WELL AND SEWAGE SITE, LOCATION Ilv1PROVEMENT PERNIIT
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 #_� � � Parcel # 3
Zoning Township / ' e / r' %
Owner/Contractor � r c Date S= 13 - 9�I
Location/Address
S.R.#
Subdivision Name r� Lot# � n f ��' �
✓e Go�n � �� n e �l .
SEWAGE SYSTEM SPECIFICA�'ION3
epair Lot Area .�, � c u-rs Size of Tank � v� �J_
SFD Mobile Home Size of Pump Tank N tra
Business # of Bedrooms�_ Nitrification Line �OQ � 3�
Max Depth Trenches � � ��
Permits may be voided if site is altered or
Well and Septic Layout by �
Comments:
Date
ell Permit
Installed by
use c
Approved by
WELL SYSTEM SPECIFICATIONS
✓ Semi-Public
�blic Replacement
te Approved �
ell Head Approved �
Comments:
Required Slab
Air Vent �
Required Well
Well Tag ✓
Date 1� - Installed by Approved by
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 speciaiist is also not
responsible for concealed condiiions 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 sepiic 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
N36 •�5"
628.26'
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�o�y�� �,' '�ISrING 5 � ESS EpSEN► , � �
� ���` _�-- 0__ACC _� �
P�r��n C�un�j Heaith Depaa�ment
�r�vironrnen�al hteal$h �ecJon r�
Ta3c Mar
#: � � ParcEi �: �J�
Zaning: Township: •
Subdivision: Section: Lot: 5_��''}� � . �
t/ _ � 1 t� ,. � _ � (��1i1 p� �`"`�
Appticai
Locatior
� Op�ration Permit
System Type (in Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPLlCABLE NORTH
CAROLINA GENERAL STATUTES, RULES FaR SEINAGE TREATMEiVT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTiON
AUTHORIZATIO .
��,�-a-�� r
Auth �zed State Ag t �� Date
�`�`` '��`.
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Parcet #:
�c C,�,�l� (�,�( L✓�.� ik-S�iC
�"�f5- � ,¢.� �,,.P,� ��
' PCHD, rev. 10/12/89
Oct-14-�9 01:59P Barnette Well Drilling 336-598-9275
� � ' - PERSON COUNTY ENVIRONMEiiTAL HEALTR
Date: /D- l.3 - �1' '
Owner: .
Location/Directions:
Subdi ision Nune:
DriUing Con�actor:�
WELL LOG
Lot # ,�_<
V�'E!.L CONSTRUCTIOI�f�''' - .`�_ -�
Distance from Nearest Properry Li.n�_.,�v Distance from Source of
I'ol3ucion_ /O�; '
��ot��I De��th: �� ; _ Ft. Yi�lc��._.____��__ ___ G1'M Static lVater Level z_� ;=�
Watc:r $earing Zones: Ucp[h�:,,__�. _ F� �t__ Ft.
Casing: Dcpth: F;om�_[o_ � _rt. Diame�cr: ��}�,�;
TYPE: Steel ' G:lvanizeci S�cel-_�
If Stecl, does owner app-o��c: Ycs Na
Weight: Thic}:ness:__��___ Height Above Ground:- I�{ _.Inches
Drive Shoe: Yes ✓No
Were Problerns Encounter� in Setting the C�sing? Yes No_�
If "ycs" givc r�ason:
Gzout: TyFe: Neat Sand/Cement ./ Concrete
ArZ�ular Space Width Inches
Water in Annular Space: Yes No
_ iv�ethod: Pumped - Pre.ssure Pourzci � - . - - •, .
Depth: Fr�m__,Q_...� ;o � o Ft.
MateriaLs Used: No. Bags Ponland Cement Weight of .1 bag"lbs.
If�mixtui-e (sand, grav ], cuttings) - Ratio: to
ID Plates: Yes � No • �
4 x 4 slab Yes�No �
7 HEREBY CERTIFYTHATTHEABOVEINFORMATION IS CORRECT ANDTHAT
T�S WELL WAS CONSTRUCI'ED IN ACCORDANCE WITH REGULATIONS SET
FORTH By THE PERSO�I COLi�'T'Y HEALTH DEPARTMENT.
3 -�L�
ignaturc of Contractor Datc