A27 30� �. 7
Application Date: 7'" �� 'Z Tax Ma #: �
Amount Paid: 1�� �
Receipt #: G� Parcal #:
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APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT. FALSIFIED,
CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Ownerlagentlprospective owner):
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Home Phone: i"'j 9�—�� 1� Address: � VG �1 �—
Business Phone: �Tqrq�� �(c(� L Pu,.,,, jt,1 N N)
2) Name and address of current owner: �., ;,,,� �^s,� i a h u v�'
3) Property Description: Lot size: Township:
Directions to the property (Including road names and numbers):
4)
5)
Subdivision:
CC 0. I 1, w; �-e
Pa.ti � 4.s�.—
C�.oM�'�
Lot # U �
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 plumbing in the basement?
d) Garbage Disposal: Yes No _
Water Supply Type: Private �(new _ or existing�, Public_, Community_, Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No_
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAfV MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAf(ED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true 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. �
_ -,
7
Owner or L al Representative Da�e
PCHD, rev. 06/27l02
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SITE SKETCH
: � ��� �
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Name 2 �� � � IG �; Ta.g Map # �1 � � Parcel # 3�
Sub ' ' ion `SU3 (.,�� S�.e ��- Section/Lot#
? - 15'� 02
Authorize Stat Agent . � Date
bc;rn
System co»rponents represent approximate �contours only. The contractor must, flag the sy
beginning the installation to �insure that�iropergr 'ned �
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SCale: (�nq �-1-fl� ��
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pG�, rev. 09/12/01
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WET�L PERMIT�
PI.EASE SEE ATTAt'HED PLAN FOR WELL SITE LAYOUT
Tax Map #: �a � Parcel # 3c7 Townshig
APPlicaa� j�:��.,� l�,h�
Snbdivision: Section: Ln�
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s � �v � � � c� �-�- '�'- � ��
.a, - � �'� . . � .. • .
Re:auirements-
Site App=oved bp C''ss -� - i s-�Z
Grouting Approved bp �/2�102
Well Log ' �
.-� ,,...., .
��,�7� �� . .--- .. . .
Air Vent �
Hose Bib
Concrete Slab
DPell Driller. �
Community Public
We11 Approved By: Date:
'�tl5ee Attached Site Sketch**
W must be 10 feet from propertp lines.
ells must be 100 feet from septic sys .
Wells must be at least 25 feet from anp bu�ding foundation.
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Other conditions: I—� I(o�.� s; �e. s�¢-,
O .. . . � �. . 1_I � / n�,.-"_" �n/`.
PG`FID, sev. 09/07/01
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IC srn.wn �r-� ac�a�.-n. �c ���. tL..:n.11 1�(.c ..n.11. �i=lln.
Owner:
Location:
Subdivision:
Driiler iD # _ �c
Com��ny N�me ; , �
.�
D�t�e Drilled , �
i�'ell Log
Lot #
Tax viap �� Parcel # _ � a
Well Constructiou
Distance From ncarest 1'roperiy Line (Minimum 10 teet) `�
Distance from Septic System (Minimum 60=�fect) L
Tota1 Depth: �� yield: �_ GPM Static Water Le;vel: g
Water Bearing Zones: Depth �(,so tt �r �$ �1v _ it �_ (�
Casing:
Depth; From ____�1___ to �� �}, Diameter: 6% in
Type: Galvanized Steel -� �—
Weight: ! � _ '����5: % � �- Height above Ground: � in
Drive Shoe: �'es No Any problems�encountercd while settinb casinb? _yes `—Na
If "yes" give reason:
Grout:
Neat: Sand/Cement �-- Concrctc Gravel/Cement
Annular Space Width _ 3 inches Water in Aruiul�u Space Yes t-- No
Method of Grout: Pumped Pressure Poured De th
Materials Uscd: " p—_� to � o Ft.
No, Bags Portland cement Weight of 1 Bag � Pounds
If mixture (sand, gravcl, cutrings) — Ratio �to _�_
ID plates: _<<Yes No 4 x 4 slab -�—Yes No
Drilliu�; Lob r ,,,...+:,... �,�--------
I hereby certify that the above information is correct and that this well was constructed in accordance with regularions
set forth by the Person County Healtl� ep�u-tment.
Signaturc of ContracYor Ill # r, ��
I)atc r7. �-3- o �/
PCHD rev O1/16/02