A27 343Amount paid ��`� 1�� " ��
Receipt l� � �] D � ti
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. / r7
Date
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Improvements Permit-(Fstablished/Recorded L,ot) I_ Reinspection of Existing System (Loan Ctosing)
Imn:ovements Permit (Unrecorded Lot)
Impcovements Permit (Mobile Home Replace)
Improvements Permit (Addition)
ReoaidReplace existing Septic System
Permit for New l�iell
_ Replace Existinj Well
I. Permi[ requested by: . � 7. Dimensions or Pro�osed Struc[ure:
�wner/prospective owne:la�ent:� r� �a G `�idth: 30
Address: • 5 � Deocn: �O
�
,
�
�
� �Iome Phone r: ��'7�=L/�0 �,
� usiness Phone r: s� �� SS S�
8. Wha[ type (if any, additions, expansions, or
replacement is anticioated to the structure or facilicy
that this sewa�e dispesat system is intended to serve?
) o �1 c
ame a d address, of current owner: 9. Water supply t�pe:
� r.f � ��lC. • private �j . public ❑ community ❑ spring ❑
Are any wells on adjoining propecty?Yes ❑ No �.
If so, idencify location:
Description: Lo[ size:
. Tax Mapu:�� / % �
Parcel�: � �
, , Township: ' �t
�
� 5. Directions [o propercy: State Road n& Road
� ames,�tc.
� rJor
H
I0. Type of structureliacility: Proposed: �Existing: Q;
Tyge of dwelling: �
House:�I Mobile Home: Q Business: ❑ �
Tyge of bustness: •
Number of Employe:s: '� �
Number of bedrooms: _.�_ � '
Garbage Disposal? Yes ❑ No �l .;
Basement? Yes ❑ No Q If so, � of basement fixtures: �
I6. Number of occupants or people to be served: � �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY Ai�ID THE CORNERS OF ALL
PR�POSED STRUCTURES.
I hereby make application to the Pet'SOII COUItiy Health Department for a site evaluation for the on-site
sewage disposaI syscem for the above described property. I agree that the con�ents of this application are true
and represent the maximum faeilities to be plaeed on the pcopecty. I understand if the site is� altered or the
intended use changes, the permit shail become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the propeccy to the Health Dept. I understand that in the even[ I have not
deliveced a survey plat of the property to the Health Dept. within 60 DAYS afte� 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
!�
PE�SOM COUNTV E�1VlRONME�ITAL HEx1LTF!
Tax Map #: panxl #�� Towhship V1 i Y'� ��� I PIN
apPucar� C�0.r'Yl ;I-2 s�ba�or� D�i'V`�TON� a�s�uo�
L.ocatlon: �L11��
Improvement Permit
New �Addition Type of Strudure � � � � �
��yV�.
# of Occuparrts�-�� # of Bedrooms 3 Other
Projected Daily Fiow: j`�(..D g.p.d.
Proposed Wastewater S�rstem: �
Proposed Repair. �7a l�riuu
i�%;�""
�
i•7//i1S+ • /
�� �
Water Supply � J a-'E-�
Permit Valid For. �.E+ae Years ❑ No Expiration
Permit Conditions: � S�- ( I C'a rl �� (� 'ia �.i '
�Owner or Legal
Authorized State
System Type�
Date: /l ����
Date: /%d� Z'� �
The issuance of this permit by the Heaith Department in no way guaraMees the issuance of other permits. The permit holder is
responsible for cheGting with appropriate goveming bodies in meeting their raquirements. This site is subject to revocation if
the site plan, plat, or the irrtended use changes. The Improvemerrt Permit shall not be affected by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and
Disposal Systems of the North Carolina Administrative Code.
Authorization To Construet Wastewater Svstem 1Reauired for Buildinq Pertnitl
WastewaterSystem Description: ��(�����i Q/1GL% Wastewate�Flow: ��.d �a.p.d. Type:�
Faality Description: ��i�- S't�J New a� Repair 4 Expansion ❑
Basement? 0 Yes �,Ado Basement Fixtures? ❑ Yes �Ndo
Wastewater Svstem Requirements
Tankage: Septic Tank size I�C�CJ gal. Pump Tank size (" .4- gal. Grease Trap size �_� gal.
Trenches: Tota{ length � ii. Trench Width � ft. Total Area ��6L� � sq. ft.
Max. Trench Depth: __��_, in. Aggregate Depth:� in. Soii Cover. � in. Trench Separation ,�ft. on center
Permit Expiration Date: —� �� V�O
Authorized State Agent � Date: l�—V�D'
'Ses attached site plan and addendum pages for additional permit conditions.
The type of system permitted � does 0 does r� m e. type specfied on the application. 1 accept the
specifications of this pertnit r
� D%OwnedLegal Represerttative Signature• Date: �
Ooerafion Permit
System Type (in accardance with Table Va)
This sysbem has been installed in compliance with applicable North Carolu�a General Stahrtes,laws and Rules for Sewage Treatment
and Dtsposal, a� all conditions of the Improvemerrt Permit and Construction Autharizatioa tssuance of this permit implies no
guara�e fhat the system installed will iunction propetly for any given period of time.
Authorized State Agent Date
PCND, rev. 03/07l01
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'�' naana-��naa�0aad�n.� I���.Il��a
Name I—t�Gl.�'Yl �� � �i-�..-
Subdivision � /-�-/U - 7'� N1
� cti
Authorized S te Agent
SiTE SKETCH
Tax Map # Parcel # 34'�
Section/Lot#
/l — D ��—DI
Date
System components represent approa�imute �contours only. The contractor must, flag the system prior to
-��- ,j -_be�inning the installation to insure thatpropergrade is maintained
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Location: �'1a ' ' C� �
t� eraii�n Permit �
. System �ype (In Accordance With Table Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEINAGE TREATMEiVT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTiON
AUTI�ORIZATION. -
� � �,,ve,� . � '��f c�Z
Autho ed S#ate Agent Date
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: a1 Parcel #�_ Township � �� ��- �% ( �
Applicant• /�(�� � � n'�
Subdivision• � �l " �� /v, Section• Lot• -1
Location: �J�N T�� L-o �:5 5f-� �'- � �i�- MQ��� ,Y� 1:2�'iiP,/S � �lK.
�ok b111eo�oi.J TI � C�01 � ln �r �/�2�,r- e.-�a' �►'�. �
Ty�e of Water Sunulv:
Rec�uirements•
�ndividual
Site Approved by �� 3�� �� a
GroutingApprovedby S�" 3�b-�a
Well Log `T' t{ 3 a(� -�a, _
Well T ✓
Air Vent ✓ �}- �j0-o2
Hose Bib ✓
Concrete Slab ✓
, , i
�'� - � ,�j,I� h��.
Community Public
Well Approved By:,i'���� Date: �i � � �Z
'�°5ee Attached Site Sketch'�°k
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PC�ID, rev. 09/07/01
���,�,s� ���.� ��
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IE �� a- o � �. � � ��.Il 7E� � �. IL �1�
D� �D � 3�.�y
� WC�lUI� l�'Gtil �/ 'T� f1�'`�! _�.�G
op�p- u � o ?,—,�-0�
Well Log
Owner; _�^G7���v j�t,,: � Tax Map �,2 7Parce1 #��
Location:
Subdivision: O 1� ;� �> Lot # �'i
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Se tic System (Mini.mum 60 feet)
Total Depth: i�4 ft Yield: GPM Static Water Level: �� ft
Water Bearing Zones: Depth ./f _ ft/ ,._ ft/���„" ft ft
Casing:
Depth: From ' to efZ ft. Diameter: (�Y in
Type: Galvanized Steel �c
Weight: Thicl�ess: •�_ Height above Ground: %�/ in
Drive Shoe: Yes No Any problems encountered while setting casing? Yes �-�To
If "yes" give reason:
Grout:
Neat: Sand/Cement Concrete GraveUCement
Annular 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
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: Yes No 4 x 4 slab _ Yes _ No
Drilling Log
Location Drawing
From To Formation j�
U� � f ` /
��' . C� �' � � �
! � '
v Z. � �� � � � Z �
'�O`t I i ` �.
M�,�' �o-����S
�_ �
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d� •
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 ��� ID#, J, 1 Date .3'� ���91„__
PCHD rev O1/16/02