A27 353Ap�lication Date: � � D r
Amount Paid: . � p
Receipt #: �'3�
Person Countv Nealth Department
Environmental Health Section
APPLICATION FOR SERVICES
Tax Ma #: - � (
Parc21 #: �3 �
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IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CFIANGED OR THE SITE 1S
ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Owner/age � rospective owner): fl � �„ ���
Home Phone: ,��� d Address: e o t l' �
Business P hone: �� 7- �'� `j y o 2? S � 3
2) Name and address of current owner: i`�' .-�� l�� � b�M,Y W+ �c1S �� G
S ,r ,p�
�,,�o -� �l3 .�- 225�73 "
3) Propertyr Description: �ot size:lj� Township: ��%`!
Directions to the propert,�r (Includ'ng road n mes and numbers :
� n., : ��S , � t 1` ..) % i= �-�
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4) Proposed Use a�n tructure Description: answer each of the following questions:
a) Proposed C4!Existing ❑
b) Stick Built ❑, Modular �n I t� r�. p�ble Wide ❑
c) Number of Bedroom • / d W d) Number of upants or people to be served: �,
e) Basement: Yes , o�7 !f yes, o s�ment fixtures:� - --
� Garbage Disposal: Yes 0, No � -- __ -- »_. _. _ .
g) Dimensions of Proposed Structure: Width:� Depth:,�
5) Water Supply Type: Private ew 0 or existing �), Public �, Community �, S'ng 0
Are any wells on adjoining property? Yes 0 No es, location
6) Piease Indicate Desired System Type: (systems can be ranked in order of your preference)
_l/ onventional _Modified Conventional _Alternative _Innovative /�! �.,5 �1��
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Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
I hereby make application to the Person County Heaith Department for a site evaluation for the on-site sewage disposal system 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 property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand
that pplicant, t am responsible for identifying and marking property lines, comers and making the site accessibfe for the
pe o ei the Pers County Health Department to conduct their evaluations. I unde�stand that am resp nsible for notifying the
al D artment ifi m roperty co ains an we lands as designated by the Army Corps of Eng' ers.
s a�Owner or Legal Representative Date
PCHD, rev.10/12/99
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Tax Map !k ►yr� 1 Parcel #.�.� "`'To�i�ship l=J l� VT . 1'1 � 1 1 P1N
APP�ca� �' i Subdivision Phase/Secnon Lot�
�e��: �� � �l,� L r � 110; � :I� ��� c�-,n ('� L��Ab� � ��'8 rr� �cKS�n o -�a.�-�. �
lm�roaemeni Permit
New '` Addifion Type of Strudure ���� 1''� Water Supply ��Cx-f�
# of Ocxup�M�s!� of Bedrooms � Other � System Type�
Projected Daily Fiow: `-�� g.p.d. Permit Vaiid For. l7l�iare Years ❑ No Expiration
Proposed Wastewater System: ��fl V�'1�� �rv�.�
Proposed Repair. ' ' "
Permit
Owner or Legal
Authorized S#ate
Date: L �
Date: ��r��''�)
Tha issuance of this permit �r the Health Departmerrt in no way guarantees the issuance of other permits. The peRnit holde� is
re�ponsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if
the sibe plan, plat, or the i�rtended use changes. The Improvemerrt Permit shall not be afFected by a change in ownership
of the site. This permit is subject to campliance with ihe provisions of the Laws and Rules for Sewage Treatmerrt and
Disposal Systems of the North Carolina Administrative Code.
Wastewater System Descxiption: �:.f���i�i �nC3 � Wastewater Flow: �'�� Q.p.d. Type: �
Facility Description: `"1 �� � t'"._L� New ti� Repair ❑ Expansion ❑
Basement? C�l'4'es ❑ No Basement Fixhires? 4 Yes'�ldo
Wastewater Svstem Requir+Ements
Tankage: Septic Tank size I�L� gal. Pump Tank size J�'� � gal. Grease Trap siz�� 9a1.
Trenches: Total tength J�_Z ft. Trencti wdth �ft. Totai Area �J" sq. ft
Max. Trench Depth: � in. Aggregaie Depth:�� in. Soil Cover. 1� in. Trench Separation �R. on center
Permit Expiration Date: "� "�� � '"V �
Authorized State Agen� � Date: �J �`J`�'`� � �
*See attached site plan a d addendum pages for additional permit condil3ons.
The type of sysLem permitted � does 0 nai differ fivm ttte type s ec91'ied on the application. t accept the
specfications of this permit
OwneNLegal Represe�rtative Si natu . � te: �� 0,�
Ooerafion Permit
System Type �n accardance with Table Va) �_
This has been installed in compliance wifh applicable North Carnlina General Stafutes, Laws and Ruies for Sewage TreatrneM
D posal, and all co itions of the improveme�rt Permit and Construc3ion Autfiorization Issuanca of this pemut implies no
9 t�t'� sys�instafled will iunc�ion properiy inr �ry given period of titne.
�c,�� � 1 a-� � � �
State Agent Date
PCiiD, rev. 03/07/Q1
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Tax Map #: � a� . Parcei #: 353
Zoning: Township: � f �vQ � �l !
Subdivision: � Section: Lot:
Applicant: ���-�, �, f�'�e� _ ,
Location: � � av �� � c.,�•,��sa-.re 2z �, � o.c�rs �. 's���1 �a^^^ �
v��-
�peration Permit
System Type (In Accordance With Table Va): ��
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE (dORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
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PERSON COUNTY E�IVIRONMENTAL HEALTH
PL�ASE SEE ATTACHED PLAN FOR WELL SiTE LAYOUT
Tax Map #: �� 1 Parcel # �� � � �
Zonin ` _ Tovmship � ,�„e �d'G �` � 4� �
9
APPUcant
Locatlon:
Su6dtvision• Sectlan- �
� Well Permit
Tvae of Water Suaalv: dividual Community � Pu�lic
Reauirements•
Siie Approved by ���` �)
Grouting Approved y ,
Well Log ��
Weli Tag - -�
Air Vent C5� r 2-y-or
Hose Bib C�-SS ►2-�/-v�
Concrete Siab C,.�S ► 2-�r-��
Weli Driller
Well �Appro
Date: � � � "T �� �
**See Attached Site Sketch�""
Wells must be 10 feet from property lines.
Weils must be 100 feet from septic systems.
Wells must be at least 25 feet from any buiiding foundation.
Other conditions: __
PCHD, rev.11/29/99
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date:� - � (
Owner:
Location/Directio s:
Subdivision Name:
Drilling Contractor:
SR#
Lot #
Dis tance from Neares t Properry Line __ - A vJ .
__J.�1L.�-� Distance from Source of
Pollution_ /v �
Total.Dep.th: Ft. Yield: v GPM Static Water Level_ d' �
Water Bearing Zones: Depth ��_Ft, , — . F�-
? y F�-�_Fc. Ft.
Casing: Depth: From_(�_to t��-,,�t. Diameter: Inches .
TYPE: Steel � Galvanized Steel �---
If Sceel, does owner approve: Yes No
Weight:�_'r}u���s:�� Height Above Ground:_T Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No `...
If "yes" give reason: —
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Grout: Type: Neat Sand/Cement � Concrete �
Annular Space Wid[h______�_�ches
Water in Annular Space: Yes �c No
_ .. Method: PumPed _ .Pr:ssure Poured v . . . . _
Depth: From_- �o_ r) 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 � No �
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTEI� Ilv ACCORDANCE WITH REGULATIONS SET
FORTH �3Y�THE PERSON COUiJTY HEALTH DEPARTMENT.
Signature of � ontractor Datc