A27 338m
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Amount paid
Receipt �� �
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�, � Date
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Improvements Permi[. (Established/Recorded Loc) _ Reinspection of Existing System (Loan C[osing)
ImpFovements Permic (Unrecorded Lot)
_ Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Repair/Replace exis[ing Septic System
Pecmi[ foc New �i �II
_ Replace Existing Well
. Permic requested by: . � 7. Dimensions or Pro�osed Structure:
wner/prospective owne:/a�ent: t� r� �� � �Vidth: 3�
,ddress: - S � ' Depth: 50
�
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� Home Phone �: ��i �'j= ��D �,
� usiness Phone n: s�.1 � SS S�i
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewa;e dispesal system is in[ended to serve?
) o �J c�
�ame a d address�o .f_current owner: 9. Water supply t5•pe: �
� r,t � ��jC' . private�j . public ❑ communiry ❑ spring ❑ �
Are any wells on adjoining property?Yes ❑ No �. i
If so, identify location: �
i
Property Description: Loc size:
Tax Map�:�=��
Parceln: �
Townshio: � iU F . i �/
� 5. Directions to property: State Road n& Road
� ames,�tc.
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Number of occupants or people to be secved:
10. Type of structureliacility: Proposed: �lExisting: Q
Tyge of dwelling:
House:�.1 Mobiie Home: C7 Business: ❑ �
Type of buscness: �
Number of Employers: '� �
Number of bedrooms: �_ � �
Garbage Disposal? Yes ❑ No �l
Basement? Yes ❑ NoQ If so, � oE basement fixtures: ;
�
CLEARLY STAKE ALL CORNERS OF THE PROPERTY Ai�ID THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make appiication to the Pet'SOri COunty Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the conten[s of this application are true
and represent the maximum facitities to be placed on the propercy. 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 propeRy to the Heal[h Dept. I undecstand that in the even[ I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date oE the evaluation of
the site by the Health Dept.. this appll�tion shall become void and all fees paid forfeited.
/
Signeei Q�wner or Authorized Agent
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Applicant:
Location:
TI r�
�n
/
Ta�x Ma,� �� P�rcel # �
S�uuhcliivi.s�ion ►•.. ,.
Fh���s�e Sect�ioni Lot #
Improvement Permit
Permit Valid for �ve Years No Ezpiration
Type of Facility: 3(�� 5�'r� New �/Addition _ Water Supply�
# of Occupants ��, # of Bedrooms � Projected Daily Flow 3�� g.p.d.
Proposed Wastewater System: C1'Y���,(��;O�Ct�► Type: �-�-
Proposed Repair:
Pernut Conditions:
Owner or Legal Represe
Authorized State Agent:
Q�i,t1�v
�
Type: ��,•,
Date:���� � 3
Date: ,� -�
The issuance of this permit by the �alth Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicantlproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met. 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 Sewa�e 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 suppiy will remain
potable.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_).
Proposed Wastewater System: C�fl��'1�►�� Type � Wastewater Flow 3�Og.p.d.
New _� Repair Expansion Soil LTAR: - g.p.d./ ft 2
Type of Facility: `?� �^� �r � Basement _ Yes �o ,
Wastewater System Requirements
1 Grease Trap: �� gal
Maximum Trench Depth � in
Minunum Trench Separation: '7 ft
Tank Size: Septic Tank: �� gal Pump Tank: � ga
Drainfield: Total Area: �� sq ft Total Length �_ ft
Trench Width � ft Minimum Soil Cover: �-P in
Distribution:
Spec�cations:
Distribution Box
Authorized State Agent: __����(/�
Pemut Expirati Date:
�erial Distribution
Pressure Manifold
. U<«:c� � �� � 9� Date: �—'p��
The type of system permitted is l�Conventional Innovative Alternative. I a cept the specifications of
the permit. ` g
Owner/Legal Representative: C���r'/��L �`�'v Date: G c�l, �,3
PCHD8/28/2002
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Name D��i �� �� Tag Map #� Pa.rcel #��0
Subdivision OIV� Section/L t# �
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Authorized Sta.t gent � Date .
System components represent approximate�contours only. The contractor must, flag the system prior to
beginning the installatzon to insure that�iroj�ergrad�e is maintained
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CAROL.YNA GEN�AL.�STATUTES, :RUI.�S ��l� SE�f11AGE.'.'FRE�.T11�Ei�IT AND F��.Si�OS�1i, .
AND ALL CaNDlTIflNS� . OF . TH�. C1fd�Rt3YE�A�if� PE3�ti' �IND. •CDNS"FRUCTi�Iai '
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SIT� LAYOU']C
Tax Map #: � Parcel # 3�J� Township l� �� U� L� � �'
Applicant• 1 � v
Subdivision•� QJ����1 S�o� �t' �
- - c� n I T I. 1 �,. � c Ci.�,.� �(>Q T � O %�M 1 � r' cP
T e f Water Su 1. Individual Commwnitp Public
Rec�uirements:
Site Approved by i !D%3
Grouting Appr ved by / ia�,3 zZ'
Well Log �L �6 0
Well T
Air Vent
Hose Bib
Concrete Slab
�'� - � !ic'. �•rs
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'�°5ee Attached Site Sketch**
Wells must be 10 feet from property lines.
ells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
�
PCI-iD, =ev. 09/07/01
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Grout Log
Owner:� Tax Map� Parcel #s�
Location:
Subdivision: Lot #
Well Construction
Distance From nearest Property Line (Minimum ]0 feet) v
Distance from S_ eptic System (Minimum 60 feet) /aa .�
Total Depth: ��� ft Yield: GPM Static Water Level: �s ft
Water Bearing Zones: Depth � ft ft ft ft
Casing: �
Depth: From a to �a-C� ft. Diameter: � in
Type: Galvanized Steel
Weight: Thickness: � Height above Ground: `�� in
Drive Shoe: _� Yes No Any problems encountered w�iile setting casing? _Yes �`No
If "yes" give reason:
Grout:
Neat: Sand/Cement Concrete Gravel/Cement �"
� Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured � Depth �_ to 2� Ft.
Materials Used:
No. Bags Portland cement Weight of 1 Bag
If mixture (sand gravel, cuttings) — Ratio to
ID plates: Yes _ No 4 x 4 slab �' Yes _ No
Drilling Log
Pour�ds �
Location Drawing
From To Formation �
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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 Cou e artment. :
Signature of Co tractor ID # �� Date ioZ� Q'D,'�_
' PCHD rev 09/30/02