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A27 351
� ` . �-23-ba i �aHon oats �S . �- �� 60� � � � � a �-.�. °° -. � jLG� ��s� . cK 9�Sa�a _� . � �:�ei y-111 � r -Y t rr1 • - � • � ^• - ' ������ Tax Maa � �°2 � �� � � � 3 7 P�rmit reque�sd bY (Owneda oMm : w H�K c�� HomePhon� 597�322y �• A,dd�eas f198 �oH� n 1NSPF..A��Pr1 . e�sPtan� C97-osco - �ox�� �.e. � Fe.�Cr� � Na� attd addcnss at csure�t awnar:. Fiu�H _ t� �1�ri' d- ye f I o� —r22�z �w,, o� �1 ��s�A ,ed +a �e � ud� c�-e. ,� h,c�2� n�c _ P r° P• ����' �s P�o�rty �eac�iPtlo� I.at �x I�I Z T�cwa�ipc TAxE pir�ens ta the prope�ty (Ir�tg road tmme.� and tuu�ersx I S S Cv �S T R{�'2. Lo m ��S ou vF G - 1 �� '1' kE r v� � A L�I�N -,o �'d. � . A?PQ. a m1 t_F_.S O �J �R 1 f H T�, n R 1 i)�e�A Y• dJ� //g R So� D ee1 /a c T�� ,� � � Pcopos�i Uae and Shu�eue De�acriptio� anaw�e� e� af thn foi�n9 que�ona: � ProPosed �6�q � b� s�e�a, �e. s�wiaoo. �w�mi 3 d Nu�nber ot ea�oort�x 3 � Nucnber af oaz�sNs�oc pa�a m be secva� e) 8a�n� Yes 4 Nc 8'ff Yea. # of 6�tent �durex • t� Ga�baqe dfaposa� `les q No 6� , �- �- a l�o� f1� � Q�.or � sa� w�:a g o� �' o �1 � �PPh► � Ptivate �ne�► t8�ar eoda�g �. Pub{ic 4 �Y �Q 0 . Aro atry weMs � a�oin�ng p�opai�t Yes 0 No �yes, {� � P1�asa Indicab Daaii�ad Syatism 1�IAe: (�yaiea�a can 1� �udosd Itt oe+d� of Youc �j ✓Caaven�ot�l Mo�d Camr�tttlonai ,Ai�w _jnnovd�te Ouar {a�l�yj: �' � CLEARLY STAKE ALL t�lER3 AI�10 UNE3 OF THE PROP�RiY. • STAtCE THE CORNERS OF ALL PROPOSED STRUC7URP8. PI.EA9E ATTACH SURVEY PLAT OR SITE Pl.AN TO THIS APPl1CAT[CN ' I heteby meica � to the Pe� Caimiy Healtl� Dep�tr� ibr a s�s e+rai�on i� ths ct�eibe senia�ga d�t sY� i� • tlta above-d�ssc�ad propedy. t agcee that �e �tts of this appYcatlon ate tn� and raprosant tt� nre�dmum � to t ptaced on ihe �ty. 1�nd �the �e is altered acthe �ended uss ct�an�aa. ihs pem� st�aB bemns i�nra�d. l� that as ap�rt. i am tes�ca�e for 1da�ii�in9 ��9 P�'�Y �, �s �d � tl�s �e aa�e ficc U pecsannel af thn Peraon Co�uriy Heailh Departrnent te cac�dud itu�r svaNmiloc�s.1 t�nd lttak 1 am teapa� ��9 � Hea� D�artrnart !i mY Pro4�f � �Y � � � bY � �1l � � �eecs- � � G a23-6G� c�+.� � � � a�. �- .09/20/2000 09:0B Tu M�p I� ��� 3365975B22 P�Ni^ 1'7 ! Yawn�hlp FREEDOM 449 ��,: �.�: ��awn: ��ry � ��VA�i1r„� 9r �Rt1�t s ue w 1 att m o rr1 q i in t nn �a, , Ty�,e or S'l�uature j� wsce� 3uPP�Y�I,%v_ �,�'e New � Repelr „_. � TGC.( � of Occupants .� � oi Bad�nome � pthar �� . BaaBment?.�- B�emerd FhduresT y,,/� prFlve Years ❑ No Expirel�on ProJocted amly Fbvr .uy�.9�p.d. Pe1�nit Vaud For: � a Proposed Wa�watar sYster" TY�o . � �QR�j�q� Yai__�/N _ ..__I�i.,_L.....,n�n C'�IIPI?�1 � �'.•JJ�J`� Pe�mN PAGE 04 l�� t�Ut c . fec�f �� ����� � � t� w� � �ll��C1� � . f Parmlt �` T ' �� ' � � , �': ' pate: ' pwner or Lagal Represet►taUve Slgnal� � - Dala: Authodzed SIeM p►Benr te. ThQ Pe�t b tha H�9�h pepatlmaM In no waY gua�'nteas ihe 184uanCe of alh8� P� 4ft� ts Ths Irwemce o� thts P� y nRts vem1�D bo�ee In mesbng mel� reap�kemer�. TNts hdder ia reepor►efhle tor Ch°dd�a �� °�rOP . � s. The lmplrovwn°M Pe1'mit shsll not be 1a pr 1lte (niand�d uts sub�� � complfanc� wttt� fhs Pr�vi�lorw of the aflecfi�d by o ahpn8 In �1O��p °t ths alts. Tht� pecridt �Ws �nd Rulee tor Ssw�ao T���pnt and p�op�t Sysbms of the Narlh Cerolfn� !'►dm►nlstrativo Code• - ' --- �w__..i�ael �Ar 8111�i�ifl0 P6 �t wu � � �. .... - - , �■ ef WaatewRtet $yule �artewatsr F►ow: .p.d. F�cUf�r Type; o 9asam�ntT C] Yas SeP� Tank SItA: ,�(��.- �orp Total Trench Lenpth; �_ feet I VI I iE11A s tf'V�over: � inches NeW C�ReD� ��ansloA O 8�sement Fbdures? 0 YeR �a Pump Tank 6ize: ��— 9���6 �v��0 ix�f! � Y �C!_ _ Inchas Ag9��Ltetn Dep�h;j� in. Ma�dmum Trnnch Oep1h:1((� . Ttench Separnt[on: � Feet on Center i � � %��./.I�/J� r � �� �► � �'" -��. � �� � �r - - ;r r � � � � � : - %t/J��� , 'r � putf�orized b'teta pan Itbd O doe� O doee nat diffvr hom �e typa specllled an tha �pPllaptlon• 1 accBpt TiN [ype of 4ystom M� e1'illt� the speclHcations of ih�s P • •�Q �, • DatB' p�,ynerlLeqat Roprssanbstlw S19na�: `�' � • ' PGHD, rev110l12198 `� � . � • . Parcil �: _ _ _ _ __i . � . �� (�'fd/j#: 27 � . � Person County Health Dep�rtment � � S.� `�e(j Environmentai Health Section . � � � yl j.„ . � • � � � p�'�'� � � � 1� S �� I �� 31TE SKETCH . . � . � . . _ . �� . . . Q�,,� �n� (.�nln�n (AIQ,� ,I� � � _ . �7�i1 tlL' 1�[�Y1�5�''e� �L (���� .ifl�lUl���f r�r Appllcant's Name � � Sub�n/Section/Lot# � I'l ��/ � VJC51� f��'I ysb � . ' ; �ni►��� . 'I,�. f� 2f1v1 . �- ��1- � ' .�.�.�. � A�ed 8tat Agent Data, � Sysesm co►hponatifs represent approxlmo�e co�tours only. Tht.contraclor mustJl'ag the system . � rlar lo be Jnnin tlre ins�allallon to lnsure that ro er rade !s nralntatned p . . , � �1 Z � • . . b • � � � � . � � . � � , � , � I . � ' � � � . � � '. ..� , . �, . � y �o � Q : � . �o � m i . : 7. 4' �� � � - _ , __ � � �i . Q� �� . � � � � � \� � �m , \ .� � — � i � .•,, a: . fN �J•„ cJ a � � ) f..r'a� O ' N _ .', . � �Tl � � Scale: }'1,� �D S��'.�.P . ; � � . � � . . � � PCHD, rey. 10/12/99 . • � � � . . , Person County Health Department . Environmental Heaith Section Tax Map #: ,� Z7 Parcei #: ��% Zoning: Subdivision: Applicant: ��/� �/,l;t 1�.� Location• �7� � �� Township: � Section• Lot• Operation Permit System Type (In Accordance Wth Tabie Va): /'�j[���1 �713Y1� THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPLICABLE NORTH ���' "/`" CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION AUTHORIZATION. ` � �Q-� t�� uthorized State Age t Date Tax Map #: � �� . � W • f�1i(�i1� IL j���-�- ,� ��g�� 4,5�� 3�I i �la" 3 ` �' 3� G��F�Di,�"� - . Parcel #•. i ?J-1 q�sya�� ,J� �,���� PCHD, rev. 10/12/99 � PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE �LAYOUT Tax Map #: �� � Parcel # � � � Zooing Township AQplkanC �o�n \ ����•. Loptlon: �Q� �� I � l��,�1 � v" 1�'S' i U✓� �.' Subdiviston: � ` SeWon: N � �---L—= Tvue of Water Suvplv: Reauirements: Weil Permit ✓individual Communiiy Public Site Approved by �� Grouting Approved by �' 0 1� l6v WeU Log � iz-S' !c� �>> e a Well Tag — � Air Vent � � Hose Bib � Concrete Siab -� Well Driller: ��'ti �� Wei1 Approved By: J • ������ Date: ���L�� **See Attached Site Sketch** � Wells must be 10 feet from praperty lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: � � PCHD, rev. 11l29199 Date: /C�-�o . Owner. � Location/Di � � Subdivision N e: Drilling Contractor: PERSON COUNTY ENVIRONMENTAL HEALTH � � � WELL LOG SR# Lot # _ �� f �J C� I � WELT. CONSTRUCTTON � Distance from Nearest Property Line i v Distance from Source of Pollution ( G a Total.Dep.th: C� Ft. Yield: GPM Static Water Level a.r'" Ft. Water Bearing Zones: Depth �_Ft. /dc� F�, LF� Ft. Casing: Depth: From 6 to ,3 Ft. Diameter: Inches TYPE: Steel � Galvanized Steel If Steel, does owner approve: Y�s No � Weigh[: Thickness:� '� Height�At�ove Ground: 1�/ Inches Drive Shoe: Yes ✓ No _ Were Problems Encountered in Setting the Casing? Yes No � If "yes" give reason: Grout: Type: Neat Sand/Cement / Concrete Annular Space Width � Inches . Water in Aruiular Space: Yes No _ .. Method: Pumped � - Pressure � Roured � - � - - Depth: Fr�m O to �� Ft. Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs. If mixture (sand, gravel; cuttinas) - Ratio: to ID Plates: Yes � No � � � � 4 x 4 slab Yes i� No T�RTi .I .TNG i .CX'r � I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY-THE PERSO�t COUi1TY HEALTH DEPARTMENT. � /D /��� - Signatur of Concr tor Dat� � .;-,__._.. North Car4lis�a Dtpartim+at�t oiEnvtro�t au�i Natur�l Reso�acea Dtvi�doa of wates �s�lity C�t+ot�ndvvattr Sec�n P.�. 8wt 2987$ - A8l�'i. N.G Z762�,0578 t z � �l � 2V►�'��� � � b0.�l�ti,hiCrl �.� V �L��, cl-� S � ptoad. v.oib• 3abdtvisb�. Lot lYo.1 u aa�,1s °' �h �`t�4 �p��1 K-�-PL, WLLL DIAGR!►M: Dtiw A de�ed elcecch af 2. OWNLR: , ' e�!I stio�iA� to�l daPch. depch ae� dia- trteta� of ecc�ee�s c� tn t�se w�ell� g�Rvd 3. ADORE86: � lae�ttral. � oi as�� pertu�tions. and �. 't'�POCR!►PKY : �raw. sl . hilbt►�p. valley. flu d�P� � ��' � �1 ma�slals uaed, . �� 5. C1Sr C�F tiAIEI.l.: �►�= ----��-� � 6. TOR'.�1�. DEt�'rH: 2O DWrlS7�R: ' 2� �. u*SINa AE.riOVF.�. _ �� � � Z �� rrr����' 8. JWAW�,� 1�f1�• � S�� � ',��f t7( CClilKit ,.,�� I3�i Ot CC1RG4: ��� ��1�. �t water i. yds. of sx.�d ._._�.. g,�is. of wat.� ,�, LL�.`�ct 'c'yp# mAtertal .�ouru 9. EXPbAt� M�I'HGD E�S�L'�CF•MFNT O�'KA'��p � j�ie� y.. I do b�eraby ca'r1tY thac tb�s well c reoad is e a�ad r�acG � �� 3 � st�cure ut ccna��wr «Ag� W r l.E. �.00A'lI�N: Dsavt a lacatlAt�t sketrh ou tha xa9etse of #bis sfseeL. si►awh'$ che . tfcc, �d msnaee of tee•reli oo at :east cvao C�! naryy sefceaa pos�4 s u C h a s t 0 a d+ t. v� s e� a� 1 i Q Y d �� m d. s d e t l t t l j► t o� t 3 s oetth $tate I� .aa�r road tdm�Ac� � submic a�gl�at eo ths Orvisson oPwauar Ow�i1tY. one caa5► to etse DnuQ. �d wne copy to t�e owoer. GW-3Q R�vi�ed 1 /98 .,�r�plica4ton Date• � a -� ( Amount Paid• �ec2ipt #: _ �'ax �ao �: Pares! #: Psrson Caun Heaith �e artment � "�- � � �� C Environmeniai Health Section �, APPl.ICATIOPI FOR SERVICES IF THE INFORMATION IN THE APPLlCAT10N FOR API IiU1PROVE9UlEiVT PERMIT IS F,4LSIFIED. C9iANGED. OR THE SITE IS ALTERED, THEA� THE IMPROVE�1flEP1T PERMIT AND AUTHORIZATiON TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: (Owner/agentlprospect3ve owner): 2 �t _ L� !� �'� Home Phone: Address: Business Phone�. .�eS'� Cl•� 2) Name and address of current owner. ��� Y��- f ���( / "oZC�t> .t vh� Uu, t�.sri�cia� /.�. 3) Property Description: �ot size: Township: Directions to the prope (Including road na es aad bers): S� w'T L �o � L � jd..v0 4) Proposed Us�nd Structure Description: answer each of the following questions: a) Proposed , Existing ❑ b) SGck Built �, Modular ❑, Single Wide �, Double �de 0� c) Number af Bedrooms: d) Number of occupants or people to be served: e) Basement: Yes �, No I�f yes, # of basement fixtures: � fl Garbage Disposal: Yes O, No 8' g) Dimensions of Proposed Structure: Width: Depth: 5� 1�/ater Supply Type: Private �new � orexisting 0), Public �, Community �, Spring ❑ Are any wells on adjoining property't Yes �No � If yes, location 6) Piease Indlcate Desired System i ype: (systems can be ranked in order ofi your preferenc�) Conventional _Madifled Conventlonal _ Altemative Innovative Other (specify): CL�4RLY STAKE ALL CORNERS AND UNES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLE�SE ATTACH SURVEY PL4T OR SITE PLAPI TO THIS APPLlCATION I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal sys#em for the above-described property. i agree that the contents of this applicatian are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the irrtended use changes, the permit shall become invalid. I understand that as appiicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the personnel of the Person Caurity Health Department to conduct their evaluations. I understand that I am responsibfe for notifying the Health Department if my prope ontains any wetlands as designated by the Army Corps of Engineers. a- a-o I - Owner o gal Representative Date PCHD, rev. 10/12/99 PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG Date: �'�y �/ ' Owner. ��� GJ����rr Location%Directions: ���� Subdivision Name: Drilling Contractor: SR# Lot # � WELL CONSTRUCTION � Distance from Nearest Property Line ! v Distance from Source of Pollution ( G a Total.Dep.th: Lfop Ft. Yield: GPM Static Water Level U?.r" Ft. Water Bearing Zones: Depth�'�'�l��,[.F[. F� Ft� Ft. Casing: Depch: From 6 to�_Ft. Diameter: Inches TYPE: Steel � Galvanized Steel If Steel, does owner approve: Y�s No � � Weighc: Thickness:�, '� Height�Atiove Ground: I�i Inches Drive Shoe: Yes ✓ No Were Problems Encountered in Setting the` Casing? Yes No � If "yes" give r�ason: Grout: Type: Neat Sand/Cement / �. Coricrete A_ruiular Space Width � Inches -- � � Water in Annular Space: Yes No _ .. Method: Pumped � - �Pressure � Poured � � - � � � � Depth: Fr�m O to � 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 DRILLING LOG � From To � 7 �� y0 D Formation Description I HEREBY CERTTFY THAT THE ABOVE TNFORM�TION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE�PERS0�1 CO`vi1TX HEALTH �EPARTM . CU 25� �/ . _-- ` ignature of ntractor Dzt� ID 159-005 � � JAN-26-01 1l:17 �01 14:40 �25 CO3/P02/H20 � ' �' � . !A! � " � :'� - �'� �.'�:�' � �. � F Y, � � � . . ' , ...� •. � j ;, ►�%�' 4� ' a � � ������ :��±y t��. . . .��+ ' ' - LAF '�s�, ��• ,. �� �,i ,� � a", ,�'�. Y!�a , 4 �, . r � � �'-J , --y'- " �1�l` • �a ' ' c,, '� 6 . r:'> _ t1' �i/►` �fl�—�''^'�Y� 9 �►. . 9 ^�' 7� � : r . . , . ,..� y . � . --T� q 1 . �. * � '' '� - ' `�- ' 1�f � � ` rY � � _ � s .Y' +F�� f j, �� 11L '!`�� 1��7i�� ' � � r � �.� 1�-' . i , � . 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