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; ;,:. � f ..,.. ry . ,. �.�:�-�,Sec�•ices RequesEed • _ r � ��>.
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Improvements Permit. (Estab(ished/Recorded Loc) _ Reinspection of Existing System (Loan Closing)
ImuFovements Permic (Unrecorded Lot)
_ lmorovements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Repair/Replace exis[ing Septic System
Pecmi[ for New izrell
,_ Replace Existino Well
l. Permit requested by: . � � 7. Dimensions or Pro�osed Structure:
owner/prospective owne;/agent: � r� w'N� � ��lidth: 30
Address: • s � �. ' Deoth: 5D
i
- 8. What type (if any, additions, expansions, or
replacement is anticip2ted to the structure or facility
�� � d that this sewage disgesal system is intended to serve?
Home Phone �: _ �'j_�_� �, _�� ) d� c
Business Phone �: S"/ ?�SS 4ki _
ame a d addressrf cutrent owner: 9. Water supply t5•pe:
� ,,J � ��jC • private �j . public ❑ community ❑ spring ❑
Are any wells on adjoinin; property?Yes ❑ No L�
If so, identify location:
. Property Description: Loc size:
. Tax Mapn:�` / �
Parcel�: �
Township: r� ' U�, . i l/
. Directions to property: Scace Road #& Road
Iames,�tc.
S � � o r��i
. Number of occupants or people to be served:
10. Type of structureliacility: Proposed: l�Existing: Q
Type of dwelling:
House:�I Mobile Home: C7 Business: ❑
Type of busrness:
Number of Employe:s: '�
Number of bedrooms: �_ �
Garbage Disposal? Yes ❑ No �Sl
Basement? Yes ❑ NoQ If so, � of baseme�it fixtures:
CLEARLY STAKE ALL CORI�IERS OF THE PROPERTY Ai�ID THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COunty I3ealth Department for a site evaivation for the on-site
sewage disposal syscem for the above described property. I agree that the con�ents 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 sha11 become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the propercy to the Health Dept. I understand thac in the event I have not
deIivered a survey plat of the property to the Health Dept. within 60 DAYS aftec the date oE the evaluation of
the site by the Health Dept., this appl' tion shall become void and all fees paid forfeited.
� Signcc� �wner or Authorized Agent
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T��x M�� � � P�rce1 �
S�u�hcilivi�s�ion �e r
Fh��s�e Section.Lot # :
Applicant: � n /�/Vl.l� � ► n ��-f�
Location: A ,� � /i r. ,� ,� „ �
Permit Valid for � Five Ye
Type of Facility:
# of Occupants Q # o
Proposed Wastewater System:
Proposed Repair: _��vT�/
Permit Conditions:
Owner or Lega1 Representative
Authorized State Agent:
Improvement Permit
No Ezpiration
i. New � Addition Water Supply Li/�'e �
�ooms • Projected Daily Flow�� g.p.d.
tv�v � . Type: �
� Type:
.�
� G� s�
� �� Date: � � � ��S
Date: — S'
The issuance of this permit by the �Iealth Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met This
Improvement 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 af the North Carolina `Laws and
Rules for Sewage Treatment and Duposal Systems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Healtlb
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
�Autho.rization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_).
Proposed Wastewater Syst •1,/tL(q,'�'U2 ��", ��`"i��e � Wastewater Flow �� g.p.d.
New � Repair Expansion Soil LTAR: • 3� g.p.d./ ft 2
Type of Facility: �� . Basement _ Yes � No
Wastewater System Requirements
Tank Size: Septic Tank: lZ��� gal Pump Tank: gal Grease Trap:
Drainfield: Tota1 Area: �� sq ft Total Length Dc7 ft Mazimum Trench Depth a0
Trench Width � ft Minimum Soil Cover: �P in Minimum Trench Separation: �
�C Distribution Box
��'�' U! � '�Z, �
Authorized State Agent: � ' ��
Pernut Exn� tion Date:
Serial Distribution
�
Pressure Manifold
g�
in
ftd•C•
Date: ��� `D�
The type of system permitted is Conventional '� Innovative Alternative. I accept the specifications of
the permit: `�—�-�
Owner/Legal Representative: � �. ��J�J�/��'�= Date: �'( ' � � "� C?�
PCHD7/30/2002
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SITE SKETCI�
Name � Tax Map # � �� Pa.rcel # 3 � �
Subdi �s' n � �n-. Section/Lot#
�
1'�uthorized State Agent � Date
System components represent approximate �contours only. The contractor must, flag the system prior to
beginning the installation to insure that pro�bergrade is maintained
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Applicant:`
Location:_
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T�x M�p � F�rcel # ►
Su�bciivision ��,
Pha�se Sect,ion: Lot # �
# of B�drooms G �
- perat�on Perm it c�a �
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System Type ((n Accordance With Tabie Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GEtdERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE 1MPROVEMENT PERMIT AiVD CONSTRUCTION
AUTHORI A ION. .
�� ����5�
� uthorized State Agent Date .
Instailed By: f'►'��� V'��5. Date: ,--��`"Cr7'�S
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PCHD, rev. 07129/Q4
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SEPTIC TANK INSPEC't'10R1 C6iECKL1ST (Type 11 - I!n
Tax Map #� Parce! #� YZ System Type (Table Va)
OwnerlApplicant Subdivision
Address/Location Sec/Phase Lot #
� Septic Tank nitia Date itr� icai�on mes _ ne ia ate
State lD/date , �� Sj
Capacity � n gal.
Tee a.nd Filter
Baffle
Sealant
Riser (ifi applicabie)
Tank Outlet Seal
Permanent Marker
Pump Tank
Water roof /Sealant
Riser
Water Ti ht
Pump �
Check Valve/Gate Valve
Anti-si o� o e
Floats/Switches
Alarm visable and audible
Electrical Com onents
� Rate m
A roved Pum Model
Block Under Pum
Pum Removal Ro e/Chain
��Distribution. System
� Serial Distribution
ressure ani o
Low Pressure Pi e
Appr. Pipe Material. and Grade
f
Width � ft. -S✓
Depth a� in.
LenQth �lo �� ft. _
Trench Grade �
Trench Spacing
Rock Deptti and Quali
Dams/Stepdowns etc.
Pressure Laterais
Hole Spacinq
Pipe. Sleeve
Turn-ups/P.rotectors
Required Setbacks
From Wells
From Property �lines
Structures/Basements
itc es rainage ays
Surface Waters
Public Water.Supplies
Vertical Cuts (>2 ft.)
Water Lines
Vehicle Traffic
Ad acent 5 stems
� Easements/Ri hf of Wa�
Other
; . Easements Recorded
erti ie erator on r
Tri-Partate Acareement
. Corraments
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pchd rev. 3/13/01
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL STTE LAYOUT
Tax Map �
Applicant: fibA
Subdivision:
Location:
,� ._1 j
Parcel #��,� - Township: ��� V l.° �� 1
Type of Water Supply:
Requirements:
� Individual
Lot #
Community Public
Site Appraved By: C 5
Grouting Appr�ed By: ' '�s
Well Log: ✓
Pump Tag: �
Well Tag:
Air Vent: t/�
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller: I��✓��'�
Well Approved by: Y`� � �''��
****See Attached Site Sketch****
Liner:
Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
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: �r � �� �
PCHD rev O1/27/04
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Grout Log
p� , / (��� Tax 1VIap Parcel # �
Location: -
Subdivision: Lot #
Well Cop�trnction
Distance From nearest Property Line (Minimum 10 feet) �
Distance from Sgptic System (Minimum 60 feet) is�.0
Total Depth: �`� � � ft Yield: c�� GPM � Static Water Level: ft
Water Bearing Zones: Depth a7s ft ft ft ft
Casing:
Depth: From .� to ��� ft. Diameter: in
Type: Galvanized Steel � /�
Weight: Thiclrness: ��J � Height above Ground: �� in
Drive Shoe: _� Yes No Any problems encountered while setting casing`? _Yes �'�No
If "yes" give reason:
Grout: -
Neat: Sand/Cement Concrete GraveUCement �
�. Annulaz Space Width inches Water in Annular Space Yes � No
Method of Grout: Pumped Pressure Poured Depth to Ft.
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) – Ratio to
ID plates: �Yes _ No 4 x 4 slab �Yes _ No
Liner:
Depth:
'. �v
Date Installed: Grout:
Drilling Log
Installed by:
Location Drawing
From To Formation ;�
c.,,�,_.� � ��'
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I hereby certify that the above inforn�arion is
by the Person County Health D�e art�e�—
Signature of
that this well was constructed in accordance with regulations set forth
ID#ay�� Date c� ' � S'� c�
Pump Installment
��
Pump Installation Contractor: �� State Registration Number: � �
pump Depth: DU ft �tati , Water Level: ft
Pump Make & Model: � l'� ` Pump Size and Rating: �hp � gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of this record has been provi d to the well owner.
Pump Installer Sig � O/J � Date: S" 1�'Q 5 PCHD rev O1/27/04