A27 344Amount paid
Receipt !�
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Date
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Improvements Permit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
ImnFovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Rc
_ Improvements Peczni[ (Addi[ion)
Repair/Replace existing Septic System
_ Pecmit for New ixi el I
_ Replace Exis[in� Well
1. Permit requested by: . � 7. Dimensions or Pro�osed Structure:
�wner/prospective owne:/agent: t� r► �a G Width: 3o
Address: � S � DeotF�: SD
;
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� Fiome Phone �:i
� usiness Phone �:
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ame
. Prop
8. What type (if any, adc�itions, expansions, or
replacement is anticipated to the structure or facility
that this sewa;e dis�csal system is intended to serve?
_ ) 0 n) C
addreSs� f curren[ owner: 9. Water supply type:
,-.� ��C. • private �j . public ❑ community ❑ sprin� ❑
Are any wells on adjoinin; propecty?Yes ❑ No (�
If so, identify location:
Description: Lot size:
. Tax Maptt:_,o'L / '�
Parcel�:
Township: ' �
�
� 5. Directions to propercy: State Road n& Road
� ames,ytc.
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Number of occupants or people to be served:
10. Type of structureliaciliry: Proposed: (�Existing: Q
Type of dwelling:
House:�]] Mobite Home: � Business: ❑
Tyge of bus�ness:
Number of Employe:s: �
Number of bedrooms: �_ �
Garbage Disposal? Yes ❑ No �1
Basement? Yes ❑ NoQ If so, n of basement fixtures:
CLEARLY STA� ALL CORNERS OF THE PROPERTY AI�ID THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make apptication to the Pet'soil COun�y �ealth Departmen� for a site evaluation for the on-site
sewage disposal syscem 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 propercy. I understand if the site is altered or the
intended use changes, the permit sha11 become invalid. I understand tha[ before an Impcovements Permi[ can be
issued, I must present a survey plat of the propecty to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Heaith Dept. wichin 60 DAYS after the date of the evaluation of
the site by the Health Dept., this appl�tion shall become void and all fees paid forfeiced.
Signcc� �wner or Authorized Agent
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERNIIT
3167
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map #��`2 � Parcel #_
Zoning Township
Owner/Contractor `
Location/Address�
�1"�, ]%_ G,./ n A n„ .�I
Subdivision Name
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3�y
/� �e 1�; i�
Date 7 -
� . S.R.#
Lot# , (�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ���{`1 � Size of Tank��
SFD �/ Mobile Home Size of Pump Tank
Business # of Bedrooms_ � Nitrification Line
Max Depth Trenches_
Permits may be voided if site
Well and Septic L�yout by
Date
or
.
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• �� • -� � �;7�.�.
Well Permit Paid � WELL SYSTEM SPECIFICATIONS
Individual �Semi-Public Required Slab
Public Replacement Air Vent �
Site Approved Required Well Log
Well Head Approved ✓ � Well Tag �
Grouting Approved �,�1, _,��n �� ,
Comments:
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Date �-( �'U� Installed by Approved by �r !
—Gl
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warraots that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amiprolpermit.sam O1/95 rev.l.l
PLOT PLAN FOR
J.D. WALLACE BUILDER
SCALE: 1 INCH = 60 FEET
I
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� LOT 9
I I DANTOM I
i SUBDIVISION
i �
I I I
�SO' ACCESS EASEMENT fRESERVED FOR FUTURE DEVELOPMENT) I
t-- __ __ __ __ -_ -_�
S86°39'32"E �
356.64'
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N ��P�-� �-1 . 4 7
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--- 130.0' 3s� D NTOM
� � �UBD VISION
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1 356.tg'
� N86°39'32"W
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LOT 11
DANTOM
SUBDIVISION
Tax Map #: f'�b� �
Zoning:
Subdivisic
Appiicant;
Location:
Person County Health Departme�t
Environmentai Heaith Section , ,
Parcel #• ���
Township: � � i� R+ �'
tion• Lot: � �
Operation Perm it
. �
System Type (In Accordance With Table Va): ��
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATI N
J � V I
Authorized State gent Date
Tax Map #: � Parcel #: 3�'y
PCHD, rev. 10i1?199
a �
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: �-t�-o I '
Owner. _,o�r�'� ��'��
Location/Directions: —.�
�
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Subdivision Name: o � �� Lot #
Drilling Contractor: � � ��
WELL CONSTRUCTION
Distance from Nearest Properry Line ! v Distance from Source of
�..
Pollution t G a
Total.Dep.th: 0 F� Yield: GPM Static Water Level �Z.S� Ft.
Water Bearing Zones: Depth 1i�1Ft. � Ft � Ft� Ft.
Casing: Dcpth: From � t��_Ft. �iameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Y�s No
� � Weighc: � Thickness:� '� Height� Above Ground: /�/ Inches
Drive Shoe: Yes ✓ No . � �
Were Problems Encountered in Setting the Casing? Yes No � �
If "yes" gi� e reason:
Gxout: Type: Neat Sand/Cement / Concrete
Annular Space Width � Inches . � � .
Water in ATmular Space: Yes No
_ .. Method: Pumped - Pr�ssure � � Poured � � - � � �
Depth: From O to a C� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � � No � � � �
- 4 x 4 slab Yes i No
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�ui1TY HEALTH DEPARTM
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� Signature of C ractor Dat�
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