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A35 127, r � • i Application Date: 3 -�4 -oa Amount Paid• 3 �a Receipt #• � � Improvemen4s Permit (Re+ Person Cauntv Heaith Deaartment Environmental Health Section . APPLICATION FOR SERVICES :��`.:::::: ::::�.::::ServicesReques •.:..� i:.. ed Lot) - 5150.00 � Well Pertnd (New/Replace� arded Lot) - 3150.00 ❑ Existing Sysiem inspectior Improvements Pecmft - 3100.00 0 RepairlReplace Exi (Mobile Home ReplacemenUAddition) Construction Authorization -;100.00 0 Redraw Site Plan - Tax Map #: J�� Parcel #: �z � - 5125.00 1) Permit requested by: (Ownerla ent/prospective owner): �TCUE/� �A �i0it/ Home Phone: -�( 9?� 53� � Address: _3� �S ,�i�B �' Business Phone: 33�-s �-_34aa .s��2� G d �57 2) Name and address of curt�ent owner: �L�i91��. �S ��JI/� 3) Propert}� Description: Lot size: �' �� Township: Q� t$o� � ta� �� Dire�tions to the property (including road names and numbers): �/ 8 �� '4%1"� �`� nM�(�s ,al. �.c. 2c� . � �'T t�ssel� �'��a.•��,✓ x�' /33'7 �o 13f'o 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed d, Exisbng � b) Stick Built �, Modular (P�Single Wde �i, Double Wide G c) Number of Bedrooms: � � Number of occupants or people to be served: a e) Basement: Yes �, No C�"(f yes, #p f basement fixtures: � Garbage Disposal: Yes 0, No B' g) Dimensions of Proposed Structure: Width: �a� Depth: �8 � � Water Supply Type: Prnrate Lsi(new [�or e�asting �), Public q Commun'ity �, Spring ❑ Are any wells on adjoining propertyi Yes � No � If yes, loca6on 6) Please indicate Desired System Type: (systems can be ranked in order of your preference) ✓Conve�tional _Modified Conventional _ Altemative Innovative Other (specify): CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR S1TE PLAN TO THIS APPUCATION 1 hereby make applicatio� 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 repcesent the maximum faaGties to be placed on the propecty. 1 understand if the site is altered or the irrtended use changes, the peRnit shall become invalid. I understand that as applicant, I am �esponsible for identifying and marking property lines, comers and making the site accessible foc the personne! of the Person County Heafth Department to condud their evaluations. l understand that I am responsible for notifying the Health Departrnent if my perty coniains any wetlands as designated by the Army Corps of Engineers. �- � �� Owner or L epresentative Date w��n `.. �I�I��fMfl PLEASE SEE Tax Map #: � Zoning Applica Locatio Subdivision: ED PLAN FOR SOIL AREA AND SYSTEM LA Parcel # � 2 � Townsh(p I't�X��/ V Section: Lot: ��u��, ,�. z%/D ��.�%�� Improvement Permit A buildinq permit cannot be issued with oniv an Improvement Permit New �Repair _ Addition _ Type of Structure/Yi� Water Supply�Qrl [tL�� # of Occupants 2 # of Bedrooms � Other Basement? ��Basement Fixtures? Projected Daily Flow: ✓��g.p.d. Permit Valid For: ive Years ❑ No Expiration Proposed Wastewater System Ty�De:,.,�'/'� lf�E IIP,�.�,/��.(Z��r��/ ! i �)) Pump Required? Yes ✓ No L .J Permit jNl'jViL Owner or Authorized State Agent: C� '+C Date`: �� Date: J � � The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. Thts site is subject to revocation if the site plan, plat, or the lntended use changes. The Improvement Permit shall not be affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. � Authorization To Construct Wastewater Svstem (Required for Buildinq Permit) C�, vlu�r,{,t;E-t ov�,P Type of Wastewater System ��astewater Flow: �g.p.d. jre�i,�1� = �U C�� Facility Type: �� VL�/�Q_ New 6?�Repair OExpansion� ❑�� 1/� Y�� r� Basement? 0 Yes o Basement Fixtures? O Yes q�Vo ��y��UCe.�V� Wastewater System Requirements Septic Tank Size: t ODD gallons Pump Tank Size: �� gallons Total Trench Length: qOD feet Maximum Trench Depth: �,� inches Aggregate Depth: ��in. Maximum Soil Cover: � inches Trench Separation: �, Feet on Center • - / / J I .i/VLII . . • �. - � � / • - • � � - �,�� /� �I ./ .�1�� _ - � � �� • The type of system permitted 0 does Q does not differ from the type specified on the application. I accept the specifications of this permit. Owner/Legal Representative Signature: �,� `�' Date: �%�_a� PCHD, rev/ 10/12/99 ., recs�'�D�" 2128(� Applicatidn #: Tax Map #: Parcel #: �27 Person County Health Department Environmentai Health Section SITE SKETCH i��(h°i� G��'�l (�fa,� 5 �,(.a� Appiicant Name Subdivisio ection/Lot# _,�� ,��' � uthorized State Age Date System components represent �►p.proxinrate contoirrs onlv. Tlie contractor must flag the systen: nrior to beeinnin� the installation to insure that proper grade is maintai�re� �V �G�� 0� �G Scale: I � � = J� � � � ! C � �1�C�-.� a �-- I I / �� , � _ r _ �Q a� . � 8 _ �. _ .: �i � � �. � � �i �� / ��1�,� p�'o�oa� g� / o� ��''.,� � � ��I .; PCHD, rev. 10/12/99 / Person County Health Department Environmental Health Section Tax Map #: �35 Parcel #: i27 Zoning: Subdivision: •.. � :1� I i /..'� Lil/ �� , � 1 . . u . • :�,/ _ ,I.l ,/ Section• Lot• O eration 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. t!i I�.1►. ' w,� ,/.ilJ/ II�/ � I,I (/ . ._ - . -. - �.- Tax Map #: iq�� Parcel #: (2% PCHD, rev. 10/12/99 Person County Health Department Environmentai Health Section Zoning: Township: ��OrQ Subdivision: Sectfon: Lot: Appiicant I �+ � C � � , �� j G j � < < < � Location• 2�� WIL�� ' Operation Permit 1. LOCATION AND SEPARATION DISTANCES A} System meets .1950 setback requirements,�,__ B) Distance from system to any wel(s C) Distance from septic tank to foundation D) Distance from system to property lines z/ �� 2. SEPTIC TANK A) Visuaily inspect the exterior walls and top of the tank _L� B) Visually inspect the interior wails, baffle, tee, filter, riser, lids, air vent, bottom, and water tight outlet ✓ C) Date of tank manufacture ,�— D) Tank seriai number — — �z E) Liquid capacity of tank 1�_ gallons 3. SUPPLY L1NE TO TRENCHES A) Grade ' 1/8 inch per foot minimum) B) Material supply line ' constructed from cY,G'1 48 �IiG C) Diameter � ►� D) Length (D' � E) Distance from tank to drainfield/distribution device ,�_, 4. DISTRIBUTION DEVICE(S) A) Type B) Is Device water tight C) Distance from the distribution device(s) to the trenches A� I j(� D) is the device on a level foundation �\1 �� E) Does the device pertorm according to its design specifications F) Reco�d the inlet and outlet elevations 5. NITRIFICATION FIELD A) Trench depth inches B) Trench width inches � C) Distance between trenches � t ,f/I_ ��/1.�� _ D) Number of trenches E) Length(s) of trenches F) Aggregate depth �2 inches G) Aggregate material and size ' O H) Record septic tank outlet elevation I} Trench grade�SYP �1�[�,I.VIVI�It_ (< 1/4" pe 0') . J) Step downs a. Minimum of 2' of undisturbed earth ✓ b. Proper rise over step down �_ c. Solid pipe used ✓ d. Elevations of step downs (R�ecord elevations and show on as built) V'q,W ! l��a� See "as built" plan oti attached sheet. PCHD, rev. 90/12/99 PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT • Tax Map #: � � � Parcel tF � v � Zoning Township '`D/�f��D Appticant: LocaUon: � Subdivision: TVpe of Water SupplY: Requirements• Site Approved by � Grouting Ap ro�ed by / Well Log _� Well Tag Air Vent Hose Bib Concrete Slab Section: Well Permit Lot: � � �� _ �� '`-�. ✓ �ndividual Community Public 0 Well Driller: ��i �� l�/��atyr Son -�C •_ Well Approved By: Date: �' 21-� 0 **See Attached Site Sketch** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: PCHD, rev. 11/29/99 / � . . . P:RSON COJNTY ENVIRONtt�NTAL H�ALTH � - •_ � . w�LL Loa . D � ~ _ —t� , T0�1 SR# _ � � ate.:�. � �. � 01N � • � � a ' - ne,.._____-- Loca�io�%Directions: . , Jr.�t �E Sub lv� �sd on I�Tamc: �� Cbntractor: - �a Drilling . �� ,zT Y rnt�T�'t'Rt7CTI�N , . � - D�st;u�cc from Sourca of Dist�ncc from Nc��t Properry Lir►c �� Poilution g _ Gp� Static Water Leve� F� Total �eP�ll: F� Yield:.,_ ' F� F�..._. �� F�' / Inches Wac�r $earin.g Zones: �Depth �t. Diamet�r: � Casing: D�pth: From___Q.__co � - : ' . E: Stcel ' Galvanized Stecl . r�rn o��: Y�$ N� � . Yf ��teel, docs owner appr � Height Above Ground: __ Inch�•s 1�Icight. ThicknPss: • . -,. ' Drivc Shoe Y�S�---No • � blems Encouritercd ir► Setting thc Casing? Ycs_ No_,._____ _ Wexc Pro : ;f "ycs" givc rca.�on: SandjCement �Coricrete�— — . Cr�uc: Type: Neat — ches . : � Annular. Spac� Width 12__._.�1 ; `�ater in ,�uliilar Spac�: Yes_ No,,.____- � �'tessure._..._, �ourcd •�._..._ � . Niathod: Pumped�. 0 � � Depth: From_ -�� _— L0 • �' l�s. . : No. Ba Portland Cement------- Weight of 1 bag._..,....._ Matenals Used &S . Ra�o:____— co� Yf mi�cture (sarid, gravcl; cuttimgs) . . XD Platcs: �cs '� No---- . . . ., _,_` v„� � I�10 . . � F RTIFY THAZ' THE ABOVE 1NFORMA`1'ION iS CORREG"r Ai�ID TY�:A'T' Y HEREBY CE S,r,RUCTED � ACCORDANCE WITH REGULATIONS SET THIS WELL WAS CON �OR�'H BY �T�I� P��ON COLTN'I'Y HBALTH DEPARTMENT. ; , . . . . °�: � �j��dp Signarirc of Conuact • Datc �