A41 143 (2). d
�alication Date ����` V� � d Tax Maa #:
Amount �aid• P 3 �% � ', 3 �3
Rec�iot #: � � �arca! �:
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APP�1CA710N Ft3R SEiZVIC�S �
•IF'THE INFORMATIOM IN i'HE APP��CATION F�R AN IIUFPRa�/EIVIENT PERMR IS INCORREC:T, FALSIFIED.
Ca-IANGED. OR THE SiTE IS ALT'ERED. THE3N iHE il{APROVEiNENT PEi�MIT ATID AUTHORIZp1'�IOPI TO .
CONSTRUCT SHALL BECOME INVALlD. -
1) Permit requested by: (Ownedagent/prospective owner): ��Ss�lt G• t-1o�on
Hame Phone: 3(��t-�i25 Address: �z3�3 N�<ci�e mc��s �a .
Business Phone: �/A� N�uc��e mi 1t4,, �1G
2) Name and �ddress of ca�rrerit owner. 1�u55e11 G� I�or�cm
' '72��3 �-i��clte N��115 'Rc�.
N�rclle. ►''ni1�s, niG-z'15�l)
3} Property Des�si�tian: Lot size: rn•a�c�c.Townshlp: ��.+'Qi�e<
Directions to the properly (lnduding road names�and numbers): _
�ot #� /
4) Proposed Use and Structure Description: answer eacii of the following questions:
a) Proposed � Existing , Type of Structure: r�s��ar�u� Width: � Depth:
b) Number of edrooms: _,� Number of occupants or peopie to be served: �_ �
c) Basement Yes�, No Will there be plumbing in the�baseme�t? N o
d) 6arbage Disposal: Yes No �C .
5) Water Supply Type: Private C� (new � or existing�, Public . Communiiy� . Spring _
Are any welis on adjoining property? Yes_ No ,�, tF yes, piease indicate approximate locatiori on the
'site pian.
6) Does your property carrtain_previously identified �urisc�ic�ional wetlands? Yes No�,
PLFASE NOTE THE FOLLOWING:
➢ A Pl�T OF THE PROPEl2TY OR S1TE PLAPI �AAUST 8E SUBMITT�'ED WITH �"9-11S APPLiCATiON.
➢ PROPERTY LlNES .�ND CORldERS MUST BE CLEARLY MARL�QcD. -,
9 THE PROPOSF� LOC�TION OF ALL STRUCTURES MUST BE STA%D OR FlAGGED.
9 THE SITE MUST BE RE�►DILY A�CESSIBI.� F�R AN EVALUATION BY THE l�EALTH DEPAR'TNIENi'
STAFF. �
I hereby make application ta the Person County Heatth Department for a site evaluation for the on-siie sewage disposal
system for the above-described property. i agree that ttie contents of this application are true and represent the maximum
facili�es to be plac�d on the progerty. I understand if the s�te is altered or the irrtended use ct�anges, the permii shall
become irnalid.
V `�-u�'�e.ee ,�. [� .a� �I -a6-a�
Cwner or Legal Representa�ve Qate
PCFiD, �ev. 06J27/UZ
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Applicant:
Location:
�
Permit Valid for �
Type of Facility: �
# of Occuvantsi/t1�J(
Proposed Wastew
Proposed Repair:
�-i
sx-11 e v �.�CuJ S--
Tax M�� E� P�:rcel �
S�u�hcliivi�s�ion ,� ' �(� �
Ph�se Section Lot #
J a�-a�,. Fle
Improveflnent Permit
_ No Ezpiration
New � Addition Water Supply ���� �
Projected Daily Flow 3� @ g.p.d.
Type: �
'I'ype; �a
Date:
Date: ` ;
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicanbproperty 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 of the North Carolina `Laws and
Rules for Sewa�e Treatment and Disposal 5vstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorilX in the future or that the water supply will remain
potable.
•Authorization to Construct V6�astewater System �Required for Building Permit)
* See site plan and additional attachments (�.
Prop ed Wastewater System: �:�'�f,� '�1�1i1G�� Type ,��t Wastewater Flow 3�0 g.p.d.
New� Re air pansion Soil LTAIt: � d g.p.d.l ft 2
Type of Facility: ��` �� Ul�a.��r►'► �n/� Basement � Yes 1Vo
Wastewater System Requirements
Tank Size: Septic Tank: � fiv gal Pump Tank: gal Grease Trap: gal
Drainfield: Tota1 Area: �� V sq ft Total Length 6� ft Mazimum Trench Depth o�3 in '
Trench Width � ft Minimum Soil Cover: _� in Minimum Trench Separation: l ft
Distri6ution: � Distribution Box � Serial Distribution Pressure Manifold �
Specifications• � bp1C f1'r ��1�(��
Authorized State Agent: . fi�
Permit Expuation Date:
Date: �� J�� �
�
The type of system permitted is � Conv tional nnovati e Alternative. I accept the specifications of
the permit.
Owner/Legal Representative: Date: `` � —��
PCHD7/30/2002
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'I'ax Map #: � g'azc� # � �' 3 ']Cownship
�PPlican�
5..1� 1 e.y_ Law �
Subdivisi�ri: iCys� � Y�v1 Seetion: Y.o� 1
�
✓�,�t ls
�'y�e of Wate� Su��ljr_., � Individual Community Public
Requireanents•
Site Approved by ✓� N' G a-03
Grou�ting Approved bp �� N � "a �3
Well Log �/� � � d-�3
Well T L �' - O
Air Vent �
Hose Bib
Concrete Slab /�/�
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Well 1�pprovec� �y: Date: � `�o �a �
'�See Attachetl Site Sketch�
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be ax least 25 feet from anp building foundation.
O�er conditions• --
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PC�ID, rev. 09/07/Ol
V
��� S� ���� �� DD �� � oD � '?07
�'_. , ^^ CC � �ILLT�T� � ` ° [� a�o N < < n�,c��.� �,ti L LL
���s��.,m-„ ��.��.� ���.��� D�o Dr��[loc� � � �-Q3
Well Log ��l ��
Owner: ;�5�'1 �P[/ _� t,�S Tax Map �� Pazcel # 1�3
Location: '
Subdivision:
Lot # �
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (l�finimum 60 feet)
Total Depth: � ft Yield: �_ GPM Static ater Level: ft
Water Bearing Zones: Depth /�.3�LJ ft ft ft ft
Casing: �' 3
Depth: From �' � to � a ft. Diameter: Zp ` in
Type: Galvanized Steel ✓
Weight: . O l$� Thickness: m 01 Height above Ground: �� in
Drive Shoe: Yes No Any problems encountered while setting casuig? Yes ✓No
If "yes" give reason:
Grout:
Neat: Sand/Cement �Concrete GraveUCement
Annular Space Width inches Water in Annula�Space Yes No
Method of Grout: Pumped Pressure Poured I/ Depth to Ft.
Materials Used:
No. Bags Portland cement 3� Weight of 1 Bag %`%� Pounds
If mixture (sand, gravel, cuttings) — Ratio _� to
ID plates: _ Yes _ No 4 x 4 slab _ es �
Drilling Log L,ocation Drawing
From To Formation
�
10 � �
D
Cd,2Qi�c� �
�
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.
`� � 5 - o� �-0 3
Signature of Contractor � Q�J2,U b'�1�-tJ(fl ID # �2 Datc
PCHD rev O1/16/02
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I I �, I � � ��� \ �. .����p�, �, - , ,
� ��� � � � � Subd� s o � ,
i, , . , , �.. , , , ,., .- , , � ._, i i .- .., i , i., Ph�s�e Sec�t�ion Lot �
Applicani
Location:
Operation Permit
� � 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
AUTHORIZATION.
_ �'��'4�
uthorized State nt Date
Installed By:�/ � l y�.5 � Date: Lo - 3d - D 3.
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PCHD, rev. 07/29/02
SE�ZIC TA aC INSPECTION CtiE�CB{LIS7 (Type 11-11/)
Tax Map #�� Parcel #__/��_?� System Type (Table Va) �4
Owner/Appficant � Subdivision �
Address/Location SecJPhase Lot #
sept�c i anK
State ID/date r'� Q`�ao �-'
�aNa�i�y. /000
Tee and Fiiter
Baffle
Sealant
Riser (if applicable)
Tank Outlet.Seal
Permanent Marker
Pump Tank
/Sealant
Riser
Water
Pump
. _ Check Valve/Gate Valve
Anti-sip on o e
�. � : Floats/Switches
Alarm visable and audible
Electrical Components
Rate (Qpm)
Approved Pump Modei
Blocic Under Pump
Pump Removal Rope/Chain
Distribution System
Serial Distribution '
ressure an o
Low Pressure Pipe �
Appr. Pipe Materiai and Grade
Valves
�-�o Trench Width
Trench. Depth
Trench Length
Trench Grade
Trench Saacina
_� _
nes
Rock Depth and Quali
Dams/Stepdowns etc.
Pressure Laterais
Hole Saacina
Pipe Sleeve
Tum-ups/Protectors
Required Setbacks
From Welis �.
From Property lines
Structures/Basements
- Ditc es rainage ays
_ . Surface Waters
Public Water Supplies
Vertical Cuts >2 ft.
Water Lines
Vehicle Traffic �
`� Easements/Right of W<
Other
� � Easements Recorded
Tri-Partate Actreement
Comments
pct�d rev. 3J13/01