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A31 124._ � 1 � � _ o V�reA�"''e.� /� d'� � `a .�.� �Y°e�e� � y3 Apalication Date: oZ'"�3� `7 � 1� � � � Tax Map #: � 3� Amount Paid: � � �� . Receipt #: � Parce! #: I a �' � # � '�,�� - _'-- � � �� aavaa-oa�a�--•-�' .Daa-�mI1 g-�o�.71.�IZa APPLICATION FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFiED, CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. � 1) Permit requested by: (Owner/agent/prospective owner): O�CD Home Phone: 59 - S/ Address: �i,[,� /p / Business Phone: 99- S�70D 2) Name and address of current owner. �/�u C D tc ��tct�� 3) Property Description: Lot size: %•� Township: [s u Directions to the property (Including road names nd numbers): /!/��zi,l�., /.n�� n��/_ 4Q ..� 4) P�roposed Use and Structure Description: answer each of the following questions: a) Proposed �, Existing , Type of Structure: %Yte�fl�- /PRNC.fc.. Width:� Depth: 2!�_ b) Number of Bedrooms: ,�_ Number of occupants or people to be served: �_ c) Basement: Yes , No � Will there be plumbing in the basement? d) Garbage Disposal: Yes No �— 5) Water Supply Type: Private V(new or existing�, PublicJ Community_, Spring _ Are any weils on adjoi property? Yes_ No _ If yes, please indicate approximate location on the 'site plan. 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPL1CATlON. ➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKEDr� , ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health 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 -a or Legal Representative �-/3 -b � Date PCND, rev. 06127/02 ��.s� ��.�� 7.��a-��.-�•� ��¢�.]L 1�1I��.]1�Il�. Applicani Location: T��x M�;aF� G - Pa�rce�l # S�uhci'ivi•s�iota . .. Ph•��s�e Sect�iom Lot � Improvement Permit Permit Valid for Five Years No Ezpiralion Type of Facility: 1; New `� Addition Water Supply be.�e . # of Occupants # of Be oom Projected Daily Flow �C O g.p.d. � Proposerl Wastewater System: �� g�Q av�n �m.�-+,�. � g�.--�r Type: Pmposed Repair:��,.�,,� C�'3% r2�.��'�a� � TYPe� %%Q_ Permit Conditions: Owner or Legal Represe Authorized State Agent: 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 applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are me�. This Improvement Permit is subject to revocahon 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 Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewater System �Required for Building Permit) * See site plan and additional attachments (_�. ____ '�n�� Propose Wastewater System: � �,.,o Type � Wastewater Flow 3�ag.p.d. New � R air Ex ansion Soil LTAR::3�j'.i�' %J g.p.d./ ft 2 Type of Facility: �� ' Basement Yes _ No Wastewater System Requirements ��,�u� Tank Size: Septic Tank:/Oc�c7 gal Pump Tank: /t`�ck7 gal Grease Trap: '— gal Drainfield: Tota1 Area: ��sq ft Total Length�� Mazimum Trench Depth �_ in Trench Width � ft Minimum Soil Cover: �9 in Minimum Trench Sepazation: �_ ft Distribution: Distribution Box Serial Distribution � Pressure Manifold Specifications: Authorized State Agent: �,ap� Peanit Expiration Date: The type of system permitted is the permit. ' Owner/Legal Representative: � � Innovative Date: ��--p� f Alternative. I ccept the specifications of Date: PCHD7/30/2002 . � 7 � �� ` 1 .y .� �`. _ �/ � � � � � —�� g�n.�:n"i.�am�-,.-.t-n a�an_�Lam.� g-�L��n...�.�� SITE SKETCH � Name ' Tax Map # �31 Parcel #�_ Su ivision .:. ��n �'e l�{' Section/Lot# � � .�—at5 z�� Authaiiz d Sta.t Agent Date Syste»a cotnpo�aents 'repr�esent approximate contours only. The contractor must flag the system prior to beginning the installation to insure that �iso,Fiergrade ts maintained. ! �� C�� t ��a� � cS�l� �tc� . --- �� , c�c�;lQ �� X C�QI-n � ss;r ��v us�� 5 � %Gc '— � � ��` �- J �� .,�-�. P�i � . ase 0 ; � s,� �. ,�� , 3 �s' �' cr� 3� � �' �� . ,�, � �� . � �� V �� p . _ �� (�� C��-2f�v�+�2 SD�'Ilt G�.�S �+�.n!-.i� � �- �O C� �-2 � _. C.� � v � � c��- � O� �2,�h L _ �,�v� ,� � � � --�-z.� i�-,�� c.��1� . � � � ��'�.QQ,,I-- C� �1� Cl'1S��e . �r' � � � ��f �� Z � Sc;�te. ,� , � � ~� � \ _. y �� / 0 �� E�3� q� �.o �� 3 ,i- �' , Q �� —� T 1 ��2 � �� 1 u� '�'' � o-� � � �;�.. \ o�- � �'s p►� � �� -- ��0.�- 5�2. �o.�- I�Si � �'� 21`r"",a-- �� ; �s cr'c, C/'22 , � " 2 C�r2 � �/� t�C�S �-G�\ � � . � � P.J�C1� i�� — �- c..�A'`�--�- � '� , � � � �'c.u��,� „ r�?�� a�-sr, ��-,w ` � � ��' � �es�c.Q � l oa� C��n��. �'� � �k o��' ,�erc.�. C�2,� c ln.o�c�� , ��,v:� � g-a �� `�� . . PCHD, rev: 09/12/01 . _ _ _ . . �� .:. .��,�,+� � �j"� �\� �.�':�J l:�l ��;. , �'..ra�a�u.�r�an.�n.�aaca�.�.�. �o�:Il.��a.:: .. . . . ..: WELL PERNIIT . PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map A�. � Parcel # Townslup: � ��w �c.. Applicant: �a,�1�., ��. Subdivision: (�,`►�t •�Qds Lot # ?, Location: c.t4 S -a (1�_l�Lnrlre. -1,c�� 'RZ. -� � �.. �,,,��,r� �has fZ� -a 4�.L lo�. 0..(7 Type of Water Supply: � Individual _ Community Public Requirements: Site Approved By: Grouting A roved By: �'o? � �� Well Log: - �S� � Pump Tag: We11 Tag: ✓ Air Vent: �p--� �y Hose Bib: ,� Casing Height: �G("�S Concrete Slab: �/ C' Q Well Driller: �'��1�'t�.- Liner: Installed by: Depth set: _ Grouted• Date: Water Sample: Well Approved by: Date:� n- i��'/ ****See Attached Site Sketch**** Wells must be 10 feet &om property lines. tl Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: PCHD rev O1/27/04 BarnetYe Well Drilling Inc �36 598 9275 08131104 04:42P P.001 . �� .S f �� 0� OD � 3 � � ��7 `� �... . (�'(�'''� o a a�o (,��r�e�a-e We11 i�r;)1�' o � `L._J!•� �.J � � � �,�,�,�,� L ]�.ra�-mri�a�-�o►xa�rp-aar��ca�.�� .adn.�.tC.�a. L°JWIY� UIIWRIl9�W �! � 7 M � , Grout Log Owner: I�a 1 i�ce �} � IC� n Ta�c Map �_ Parcel �k 1 a: �/ iocation: �••: l� Sara N b Prry F';,� I� Subdzvision: In/ � I G�[�a.nr b cr� �;�1 c� s Lvt #,. �_� Well CpAstracdpII Distancc Frozx� nearest �roperty Line (Minimum 10 feet) 3 O Distance from Septic System (Minimum 60 feet) � 4 O Total Aepth: J�� ft�SCield: J� .C'�+�M Static 'W ater Level: �� Watcr Bearxng Zones: Depth �1 � ft ft 1! O ft ft ol,gal �3 9a I ft Cit5lrig: Y7cpth: From �_ to �,I �3 - ft. Diameter: % in Type: Galvanized Steel � Wcight: Thiclmess: �/� 8 Heigl�►t abave Cnound: � ir� Drive Shoe: J� Yts No Aay pcoblems eneounttrul wiule sett�ng casing? Y'es _�/'�10 If "yes" give reason• Grout: ' Ncat: Sar,d/Cement Concrctc _ _. ___ _. _ . GravcUCement . Annular Spacc Widlla � inches Water in Annul Space Yes �No Nlethod of Grout: Pumped Pressure Pot�ed � Depth _Q�, to 4 3 Ft� 1Vlsttcrials Used: No. B�gs Portland eement ' Weight of 1 Bas �I 7' Pottnds If rnucture {sand, gravel, euttings) -Itatio to m platcs: �Ycs _ No 4 x 4 slab c�Yes ^, No Liner: . Depth: T7ate Tnstallcd: Grout: nrilling Log Installcd by: _ �ocation Arawing From To Formatiou � ,�,.L �r v v o°`� � � �� V r � , `r�f � �� '� s,� � � r� w6� I htreby certify that the above information is correct and that this well was constructed in accord,attce with regulatrons set forth by the Pcrson County FIenith Departmcnt. ' � �! Sigaaiure of Contrsttor iD # a.. �v '7 Date �- a Pump Iast�ll�ueut Pump installation Contraotor: i3c� � n e�-fc _L✓ e� I n�:_I_� ��c Staie Registration Nwnbcr: i 6(�j Pump Depth: _ f� o ft Static Water L' evel: 7, S ft Pump Mako & Model: ,_l� e� �'a ��'��- Pump Size and Rating: �t�p I O gpm I hereby certify that this pump was installed and thc rve11 head completed aecording to the Pctson Co�mty Well Rules in cffect on thts date and th�t a copy of this record has be�n provided to the w�11 oWntr. . Pump InstaIler Si�nature ,.1� 'i��+^! Date: �-� 7-[� c.� PCFID rev O I/27/04 ��1: � �� .. � �1^ � � � � � � ��rnvra�r-��n�n.c��n��.� ��n.��n ��-t'� Qt�17dv� Appiicant: Location: Tax M�p � P�rcel # Subciivision , � � ' ' � �Fhase Sect�ion Lot # # of Bed�rooms O eration P�errnit System Type (ln Accordance With Table Va): ,:�J�'iG 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 � AUTHORIZATIO � � a-� --�� Authorized State A ent �� Date Installed By: � � Date: �� D n CI-E�tKe�;� �`'r t�� SYS� Loi- � i 4.��i •��l' � �s� Pb�� cl►��>>�� r ,�. � ��2 �� r� ��,p l ($� � � u 51'� `�t�i ru S� � R -z�(-�'Y �S t (1 tr�(�,r �u��PS �r - '(o cc��-o�r- �L � S`�PP � l��e ��in QC�S.erti��- -.�:i T*_'£-.�! s �:��'l�C��i _r�sji � ..., t1�- . .�_,-v• 1-T % -�� s ••� R. �1 '�- _=r�� C-� �.'�T�;ri� —�sTi ��ii�.tl-_'i!�!C-�;qr;.��i :fti.r..rvll�r*i� � a� .. c - _It�: - ti:_ •: - ,• _ is7s - � ;. : _i;_: �t iy•��.= s��..� ��E��-� ��c�- u �. -� �.r_ !r ie� c- •t• -;�_' � _-- ��V��.L=� �.11l!� i '�,�_: _ ':�.._ -111• ►-' lt�si:.: �Iti�• ��i-=,� y�_'t��i:=. �� icilt:��r ��• a, .lM�r-1�� -��c�:_.�l._:+�ti.�<{,�� •: '.l.._-�� J�. �.r'.:� -..�- 1ic•:_ r_1 � :;fc t• �n� �� r�:;j=�ff'�=.��` =��r�iL".- �.�.� 1( �^'-�l�I�IL�1� ��tif-i�i�Tr[=1'�� ! . �r_�� !sc �1 •�= S !_:�=1tF=1t_ � �tE=_=?tH' ct��r_ �•�t�ii��-;�i.; w � , . `> ('� ��) 1 . ��\ �� T��x fvl�� F�:rc�El = . S�uhci'ivi�5�ion �Zs,_ _`.. ( . t�) l \ . ( . � . . �. i ,., - � , ,.. ,., ,_,., . ,., � i i t .- i , i_, F'h:��se Sec�tiora`Lot +� Applicar� � . . . Locafion: � � � O�perati�n: Permet System Type (In Accordance With Table Va): � � THIS . SYSTEM HAS BE�N INS.TALLED � IN �OMPLIAPICE WITH APPUCABLE NORTH ' CAROLlN�► GENERAL S'fATUI'�S, RULE$ .FOI� .SEWAG��TREATMENT ANQ �DISP�SAL., - AND- ALL CONDITIONS OF THE IMPROVEMENT � PERMIT . AND CQNSTRUCTiON . O TI .. .. . . . . _ . . � . � -. :. . . . �5�.�,�c. .. ( W' � -�. . _ . . . . .. , � � A . o Sta �Agenfi � � � . . - .. � ' : ' : � Date � - . . . Installed By. � d- � . Date: . �� . . . . . . � � � � . ��-. oF �"�� 1 � �,a- -�,t�,- � �. .. � .. � .. . �. . . -.. ��.� .by� .. . . - �" � . • . � . " ... � .. . . . . � . : C� ' \ p � cl,'�<-I � ' ._. � -_ . - • - � • ... . � sl�.�.�. � .wa?�^� 'PV C. � . � �. . . -�� 0 PCHQ, rev. 07/29IO2 , ' . ' .' � �i . __ " 5:..... �,F