A27 247-^.
AqAlication� Date• � I_�� Tax flAap:�k
kmountPaid: � - �� . . . : .
RecaiQt#: � � ' . . �'arcEi'�k
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1 j PeRnit requested b:(�wn rlagent/pr+ospective ownerr � G'� ��✓ �
Home Phone: - D � Address: �
Business Phone: -
2) Name and address of current owner: ���-� 1
l
3) Property Description: Lot size: Trnvnship: ,�1� Subdivisia • Lot�:
Directions to th� property (Induding road names and nuAmb�): 7 '
_.,_ _ _:4► _ ������ �!e� ��€� ��c-t�!� n��-��.,A- a�n�s e�� ef th� fca!!�►+� � ���sn-s._ , -- - - _ _ -,-. _ -. _ -_� _:.
a) Proposed [�, Existin9 � TYPe of Strudure: � r��,��rn� 5�� Wtdth: Depth:
b) Number of Bedrooms: T Number of ocapanis or people to be served:
� c) Basement Yes _, No �Wiil ther� be plumbing in the basement? �
d) Garbage Dispasa� Yes _, No �� _
� 5) Water Supply Type: Private ✓(new � r exis�ng �� Pubiic_, Community � Spring _
Are any welis on adjoining property? Yes ✓ No _ If yes, piease indicate approximate IocatIon an the sifice plan.
6) Does the property cantain previously identifled jurladidional wetlands? Yes _ No � �
PLEASE NOTE THE FOLLOWING: � �
➢ A PLAT OF ifiE PROPERTY OR SiTE PLAN NUST BE SUBMITTED WITH THIS APPLDCATION.
➢ PROPERTY L1NES AND CORNEI�S MUST BE CLEARLY MAR1�9.
➢ THE PROP0.SEU LOCATION OF ALL STRUCTURES MUST BE STAKED OR ELAGGED. -
➢ THE SiTE MUST BE READILY ACCESSiBLE FOR AN EVALUATION BY THE HEALTH DEP�►RTAaENT STAF�.
l� hereby make application to the Person County Heaith Departrnent foc a site evaluation fnr the oc�-siie sewage disposal
system for the above-described property. I agree that the car�tents of this application are true and represer�t the maximum
facilities to be placed on the property. I understand ifi the site is aftered or the intended use ct�anges, the pennit shail
become invatid. _ . , / -, , �
Owner or l.egal
�, ..,,f�-�)�
Date
PCND, rev.10M7/0�
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Applicanl
Location:
� .. _ :.•������
i
Ta�x M�� I� Parcel # I
S�u�:hc!'.ivis�ion
Ph��se Sect�ioia Lo# �
Improvement Permit
Permit Valid for Five Years No Ezpiration
Type of Facility: '� ��, 5�� New ��fldition _ Water Supply p �, �Q�2_.
# of Occupants �� # of Bedrooms Projected Daily Flow �nQ_ g.p.d.
Proposed Wastewater System: V.� ' ; Type: �
Proposed Repair: p� �� �n� e�� Type: �c�
Permit Conditi
Owner or Legal Representative
Authorized State Aeent�.,
�
Date: -/% D.z
Date: % 11 Z
The issuance of this permit by th�Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are mek 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 Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). 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.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�.
Proposed Wastewater System:� � j� J P,(l'�i a{�Q.., G� {�W ��t.► Type�_ Wastewater Flow �'�( (Zg.p.d.
New �/ Repair Expansion Soil LTAR: ►3 g.p.d./ ft 2
Type of Facility: "� �j � �]j Basement _ Yes �IVo .
Wastewater System Requirements
Tank Size: Septic Tank: �,� gal Pump Tank: �� gal Grease Trap: N�_ gal
Drainfield: Total Area:�� sq ft Total Length ��� ft Magimum Trench Depth �� in
Trench Width s� ft Minimum Soil Cover: 1� in Minimum Trench Separation: � ft
Distribution:
Specifications:
Distribution Box •�3�rial Distribution
Authorized State Agen .
Permit Expir ' n Date:
Pressure Manifold
Date: � 7
The type of system permitted is ✓Conventional Innovative Alternative. I accept the specifications of
the permit. .� U
Owner/Legal Representative: �_ j ,, Date: -
PCHD8/28/2002
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I-�+�na�nm�aami.a��rn.�,to.Il �Hlms.11�E;lln '
SITE SKETCH
Name SC�� �-c�c.�r�f�P Tax Map #_ Ir o� , Parcel #� T�
division Section/Lot#
� - �1 �I� -U2
Authorized S te Agent Date
Systena co�nponents represent a1bproximate contours only. The contractor �nust, flag the system ptior to
begi�aning tlze installation to insure thatpropergrade is maintained
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IVV'T 1 V .+v ••
IF
Scale: � � � _� ��e
CUN��`�� '
�naNFR I
N85°18'56"W
PCHD, rev. 09/12/01
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SIT� LAYOU'7C
Tax Map #: �� Parcel # O� `�'� Township ��' v�- ��' 1�
Applicant• � � ��"�r- � _i � 1���'P,l� C'�
Subdivision:
Ty�e of Water Sup�ly:
Rec�uirements•
Section: Lot:
✓zna��a,� co���y Public
Site Approved by '✓ ; � � �'a a ` ° a
Grouting A roved by �� lo "aa --o�
Well Log �� tk i�-� - o�
We11 T ` �b�b `� �.
Air Vent 5 dL��a`a• E
Hose Bib Ci3 � , E �
Concrete Slab S - � ` 6 -
Well Driller. �-% U f� S�/7
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c�o
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Well Approved Date• 5 `��`��
'�See Eittached Site Sketch'�°k
ells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anq building foundation.
Other conditions: -
PC�ID, rev. 09/07/01
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Applican
Location
�
T��x M�p , F�rc�el : �
S�ubd�ivi�s�ion
Fh�s�e Sec�t�io�a'Lot #
Operation Permit
' System Type (In Accordance With Table Va): . ��.
THIS . SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL 3TATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE . IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION. .
,.__.
; _ � , �.. ��� - �..
uthorized State Agen � Date
,
Instailed B : ' Date: � ��o �c ,
____. ...._ _ ,__. ._ _ , _ _ __ __
___ _ .l . ._ _ _
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PCHD, rev. 07/29/02
SE�'�1C TANK 1NSPEC'TION ��iE+��CLIS'� (i'ype Il - li/
Tax Map #��� Parc�l # �"1 � System Type (Tabie Va
)
Owner/Appiicant SCDi-f- LG�i�Ir��nC� Subdivision
Address/Location .'S�,YY1p r'� ��', Sec/Phase Lot #
Septic rank
State ID/date t i5-�DD��t
Capacity. � � .
Tee and Fiiter
Baffle
Sealant '
Riser (if applicabie)
Tank Outlet.Seal
Permanent Marker
Pump Tank
0
Z�i 3bZ Tr�ench Width `% ft.
Trench. Depth in.
Trench Length 2,5 ft.
Trench Grade
� , Trench Soacina
Rocic Depth and Quali
Dams/Stepdowns etc.
Pressure Laterals
Hole Spacing
o e ize
Piae Sieeve �
Waterproof /Sealant Tum-ups/Protectors
Riser Required Setbacks
Water Tight From Weils =.
Pump From Property lines
. _ _ _ _; Check Valve/Gate Valve _ , - _- Structure.s/Bas
_
Anti-sip on o e itc es rain�
-; FloatslSwitches � _- . .. _: , � : .: :: :�. Surface Water.
Alarm visable and audible Public Water S
Electrical Components Vertical Cuts =
Rate gpm Water Lines
Approved Pump Model Vehicle Traffic
Block Under Pump
Pump Removai Rope/Chain
Distribution System
Serial Distribution '
ressure an oi
Low Pressure Pipe •
Appr. Pipe Material and Grade
ft.
Easements/Right of W<
Other
Easements Recorded .
Comments�
�
�
�
pchd rev. 3113l01
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`_ " ---- c� � ZCT�T� � ` ° � a�o _ � t I� ���►�' �.ti L-- L�
I���aa-���.-,r„ ����.�1 IL-���.Il�I�. ��'0 �0� f `��-��
Well Log
Owner: .� (' �-�{- � W�P y�� e Tax Map r"�27 Parcei #� 7'
Location:
Subdivision: � � _ �,. r e {� � ,� � Lot #
Well ConstrucHon
Distance From nearest Property Line (Minimum 10 feet) �(�
Distance from Septic System (Minimum 60 feet) 1 o Cj
Total Depth:�_ ft Yield: � GPM Static Water Level: �'� ft
Water Bearing Zones: Depth�� ft ft ft ft
Casing: � `� �j
Depth: From �- � to � 3 ft. Diameter: �'%i in
Type: Galvanized S el X ,
Weight: f� Thiclrness: . D 1� X Height above Ground: _� v� in
Drive Shoe: � Yes No Any problems encountered while setting casing? Yes X No
If "yes" give reason:
Grout:
Neat: Sand/Cement
Annular Space Width �
Method of Grout: Pumped _
Concrete GraveUCement �`
inches Water in Annular Space Yes jL No
Pressure Poured L Depth to _
Materials Used:
No. Bags Portland cement � Weight of 1 Bag � Pounds
If mixture (sand, gravel, cuttings) - Ratio �--to l
ID plates: �L Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log Location Drawing
Ft.
From 'Y'o Formation
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Ca / �
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I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person County Health Department.
Signature of Contractor '?1?J) ���,� jr„�� � ID # dG � U� Date ��Z �'Q�
PCHD rev O1/16/02