A27 257:
Apaiication Date: 7ra6"d� � �`1 f . Tax Maa #:
Amount Paid: �I�� � � 37 � ��U''���5
RecElpt �: 2 �3 `) � Parc�l #:
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APPLlCATiON FOR SERVIC�S
IF THE INFORMATION IN THE APPt1CAT10N FOR AN iMPROVEiIAENT PEF2MIT IS INCORRECT, FALSIFiED,
CHANGE� OR THE SITE� IS ALTERED THEiV THE IMPROVE�VIENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.. �
1) Permit requested by: r/a rospecttve owner :� e�
Home Phone: � ��� (p Address: I �
Business Phone: pC�t'1 {� �
2) Name ar�d .address of carrerrt owne� �� %i �Y •
3) Properly Description: Lot size: o��STownship:
Directions to the property (Induding road names and
Gj1 GLVeI ��'` U�} qt Q.55 � bL,(-t l,�O�IS aE?U') (� GL
4) proposed Use and Structure t3escript%n: answe eact� of th foli ing que�tiom
a) Proposed � Existing . Type of Structure: � i'Yl a n�r� arr-�I hornp
b) Number of edrooms: Number of ocr.�pants or people to be served:
c) Basemen� Yes� No �Will there be piumbing in the basement?
d) �arbage DisQosal: Yes . No ✓
Lot
S
� Vyidth:�_ Depth:�_
�_
5) Water Supply Type: Private�(new or existing_), Pubiic� Community� . Spring _
Are any wells on adjoining property? Yes ✓Na _ If yes, please indicate approximate locatiori on the
'site plan. !Z ,Qc� c�wo�y
6) Does your property carrtain previously iderrtified jurisdictional wetlands? Yes_ No� �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT aF THE PROPEi�TY OR SiTE PLAN MUST BE SUBM1Ti'ED WITH THIS APPLICATION.
➢ PROPEiZTY L1NES AND CORNERS MUST BE CLEARLY MARI�D. -,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAi�D OR FiAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
i hereby make aQpiication to the Person Caurrty Health Departrnerit for a site evaluation for the on-site sewage dispasai
system fo� the above-described property. I agree that the cantents of this application are true and represent the maximum
faciiities ta be placed an the property. i understand ifi the site is altered or the irrtended use ct�anges, the permit shaii
became invaiid.
or Legal Represer�tative
PC}i0, cev. U6127J�2
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Applicant: ��,��r' fiS
Location: „, . .
Permit Valid for
Type of Facility: _
# of Occupants �
Proposed Wastew
Proposed Repair:
�
T��x M�� �. P��rcel � �
S'llih Ci�l V I S�I Otl
Ph:�,s•e Section Lot #
� Improveanent Permit
� Five Years No �zpiration
�(� �p�'+ New � Addition Water Supply �_
x
# o Bedrooms � Projected Daily Flow 3!0 � g.p.d.
tem: [�o.n�.t/
Permit Conditions: �op St''� S�2^��
Owner or Legal
Authorized StatE
Type: � �
Type: �
Date:
Date:
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the reaponsibility of the
applicant/property owner to in sure that all Person County Planniug and Zoning and Building Inspections requirements are met. This
Iuiprovement P.ermit 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 Svsfems' (15A NCAC 1�A .1900). N�ither Person County nor the Environmental Heaith
Specialist warrants that the septic tank system will continue to function satisfactor�ly in the future or that the water supply will remain
potable.
Autho.rization to Const�uc� Waste`vater 5ysteffi �Reqnired for Building Permit)
* See site plan and additional attachments (_).
Proposed Wastewater System: l'ot,�� �`� f (9r��v�� Type �`� Wastewater Flow �6o g.p.d.
New '� Repair Expansion Soil L'Y'AR: • 3f� g.p.d./ ft 2
Type of Facility: �l� i- Basement _ Yes 4C No
Wastewater System Requirements
Tank Size: Septic Tank: -�OdC� gal Pump �ank: gal Grease Trap: gal
Drainfield: Total Area: �Zo v sq ft Total Length ��� ft Mazimuan Trench Depth ���, in
Trench Width � ft Minimum Soi� Cover: � in
Distribution: Distribution Box �• � Serial Distribution
Specifications• -�r�'e S-r r`� 5 � ��
Authorized State Agent: f'✓� � �^'��
Permit Expirati n Date:
Minimum Trench Separation: � ft �� C.
Pressure Manifold
` C�
Date: ����� 7 _
The type of system permitted is i'� CQnventional Innovative Alternative. I accept the specifications of
the pernut. ,, ` •
Owner/Legal ltepresentative:JC �/`�, , � Date:
PCHD7/30/2002
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.[�uthorized Sta.te Agent � Date � �
System components represent crpproxirnate �contours only. The contractor must, flag the system prior to
beginning the installatzon to insure that j��vj�ergrade is maintained
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Applicani
Location:
�x M�p �_ F�rcei #
Subciivision
Ph�se Section;Lot #
# of Bedrooms
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System Type (in Accordance With Table Va):
THIS SYSTEM HAS BEEN ItVSTALLED 1N COtVIPLIANCE WITH APPLIGABLE NORTH
�AROLINA GENERAL STATUTES, RIJLES FOR SEWAGE TREATIVIENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IN(PROVEMENT PERi�I1T AND CONS i RUCTION
AIJ.TH�RI�T10N�. � �
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Installed
Agent
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Date
'� Date: _�/-�/d�S"
PCHD, rev. 07/29/04
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�E��1C °�'ANaf 9��P���'��R� ��E��fL9�i' (iY�e 6� � �
Tax Map # 2 Par e! # 2, Sys�em Type (Tabie Va)
�wner/Applicant Subdivision
Address/Location Sec/Phase Lot #
State �ID/date 5� j�Z
Capacity �S -lU��
Tee and Fiiter
Baffle
Sealant
Riser (ifi applicable)
Tank Outlet Seal
Permanent Marker
Puma Tank
/Sealant
Riser
Pur�p
Check Vaive/Gate Valve
Alarm visable and audible
Elecirical Com onents
� Rate m -
A roved Pum iViodel
Blocic Under Pum
Pum Removal Ro e/Chain
. � Distribution. System
� Serial Distribution
Pressure ani o
Low Pressure Pi e
A r. Pi e Materiai and Grade
Valves
� Trench Width " ft.
� Trench Depth -Z� in.
Trench Len th ft.
Trench Grade �
Trench S acin
Rock De th and Qua('
Dams/S#e downs eta
Pressure Laterais
Pipe. Sleeve
Turn-ups/P.rotectors
Ftequi�ed� Setbacics
From Wells
From Property lines
Surface Waters
Public 11Vater Supplies
Vertical Cuts (>Z ft.)
Water Lines
Vehicie Traffic �
Easements/Right of V�
Other
Easements Recorded
e t te pera or oi
Tri-Partate AQreemen
Coenenents
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pct►d rev. 3/'13/0�1
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WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map � `7 Parcel #
Applicant: �yn�
Subdivision:
Location:
� S�
Township:
Type of Water Supply: � Individual _ Community
Requirements:
Site Approved By: s �7 / I o�_
Grouting Approved By: �� �_
Well Log: ,SS Z�Q
Pump Tag: �5 , � '
Well Tag:
Air Vent:
Hose Bib: �'S o os—
Casing Height:�5
Concrete Slab: 35 �
Lot #
Public
Liner: �
Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
Well Driller: t.v
Well Approved by:
****See Attached Site Sketch**** y���_
a..
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 foundation.
Other conditions:
Date: /d 'Z d '
PCHD rev O1/27/04
a
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�m�.vaa-.osra.�rsc�azs�d;.ea� ��cr�n.]ld-�s
Ck�OD�_ r.
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�� � J.�L�,� r• I �� n�,.
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Grout Log
�� �p�.-F�- � � , c Ta�c Ma Pazcel # S 7
Pti ,' ��,._ � h p .,�a� ��
Location: .
Subdivision: ' Lat #
._
Well Construction
Distance Fmin�nearest Property Line (Minimwn 10 fcct) _ �
Distance &om S tic System (Minicnum 60 feet) L�
Total Depth �ft Yield: _3 d GpM Static Watcr Lcvcl: � ft
Water Beanng.�oncs: Depth � ft, 30 ft� ft ft
C�.
.
Dcpth: Fzom o,�_ to �� R. Diamctcr: i in
Type: Galvani�rd Steel '
Weigh� �',�_ Thiclmess: �_�Height above Ground: ,/ �--in
Drive Shoe: ,���i'cs No Any problcros encountered while setting casing7 iYes No
'if `jres" give resson• —
Gront:
Ncat: SandJCement � Concrete GravoUCement �
. Annular Space Width �_ inches Watcr in Annuler Space ycs �'
Mrthod of Grout Pumped _Pressure ✓'Poured ' Dcpth t� to _� Fi.
Materlal+ Ussd:
. No. Bags Porttand ccmcnt Wct�ht o� 1 Bag � Pounds
If, mixttue (sand,�a vel, cuttings) – Rabo _� to �
ID plates: �s _ No 4 x 4 slab �s _ No �.
L1ner: •
��p�: Datc Installcd: Grout: Installed by:
Drllling Lo8 Locadnn Drawing .
�.� T�— FormaNnn �'—'-1
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a , � / % ., �' - - •
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I hereby cerafy �hat the above information is correct and that this well was c�nsrructed in aecordance witb, rcguIadons set fatth �
by the P�rson C�cmty Health Dcp � ,
� .
Sijpuadue of Contractor ID# DAte �
„ o��-�. 7 /1 s2�"
Pamp InsriWnent
Pump Iastallatian Contractor: Statc Rcgistratioa Numbcr: �
Pump Depth: ft Static Water Levei: $
Pump Make 8� I�lodel: Pump Siu and Rating: hp 6Pm
I hcreby ccrtify t��at this pwmp was installed and the woll hcad completed according to the Per�on Counry W�II Rules in effxt
on this datc and tl.iat a copy of this record has ber� providcd to thc wcll owncr, .