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A35 140The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PER�T No. Date ?� ' .�> Owner: �� ��. - / � Location: � �� !( � .� Contractor: ^ � Water Supply: Private lic Sewage Disposal Facilities: No. bedrooms "`– Dishwasher, Disposal, washin _� 1i�, other automatic appliances r ` � " � ''�"-- Size of tank: �� �' Nitrific�ation/ _lrine: - / /��%f.lf7t I l Gvt, � tirr lY,c�. Other disposal facility: .a��X�_ _ ���x�� Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INS�A LATION IS COV- ERED ANB PUT INTO USE. `/ /� ^� ' � f � � Date approved: — Signed � ����'^-r'�' � Well: , rf Sanitarian Sewage Disposal: I Counter- $Y: signed (Owner or his representative) CerlificaYe of CompleYion ��L� Date Approved: J~ 2�- � By � f anitarian 1 (OVER) ' � Location of well and sewage disposal facilities sketched on back. NOTE: Make sketch vf installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located at later date. Note location of water supplies on adjacent lots. S'�� �33� Applicatton Date: • � �' �� "� �}' Amourrt Paid• Rec�i . ���_ � I�'EII�IC�� �� - - _� � � ���-�- ���o� � ��� ���� r� �n� #- � 3 -� . PareEl �: � � � AFPL]CA7iOP1 FOR SHiVIC� • CaNASTRUCT SHALL BE�aME IN�/ALID. 1) Pernut recN�ted bY� (��a9�P�� ��� � S�c�t�- fT"G,D.e�s Home Phone: 3°$ -3'97-o�/b.J ,a��s; o eus�ness Pt�on� 3 r�lo ��9� 9�3,3 x�Qo no �t/G o'i 7 z) Name and.adar�ss of c�rrent owe�,- I���-�i�J /?� �t% r aC Z3 ,c40/?.O /t! o?'1S %'�3 3) Pro�erty Description: Lot size:. Dir�tio�s ta the prop�r qndudi aj 5) ��k � o � tMN`'I , ���� � Tawnshlp: C��l� Subdiv�sio�: Lat � road names and numbers): C1tat B LA�x� .RoR.D TO rl?�C�HE� 1" T/1 �' L,EF�r 9v /� TD /ST' [.h'!Y �iu 7�iRS"�c Tia . A-r l�'iRsf L��T' e�tt,ctt is o�.�C G2ovE .R.S ��3Rd ?�n,v��lYo�v RI�ttT" praposed Use and Structure Descripdon: ans�vwer eacfi of the foilowing questlons: � a) Proposed � Existing , Type of StruetwB: Width: � Depth: • b) Number of �edcooms Numi�ef of acxupants ar peopie to be secved: �. c) Basemer�t Yes . No Will there be plumbing in the tiasemerrt? d) �bage Dispasai: Yes No . Water SuPPhf �IPe: Private // (new _ or e.�asting,_�. Pubiic_, Commwviy , Spring . . Ar� any wells on adjoining ProQerty? Yes_ No _ If yes, Pieasa indic�6e aQpraodmate lor.atiai on the ,siie pla�t. 67 D�s your property ca�ain previousty identified ju�ictic�i w�lands? Yes_ No v '�� PLEASE AIOTE THE FOLLOVYING: ➢ A P�.AT OF THE PROPE�TY OR SiTE Pt_AN NNST BE SUB�ITTE� WITH THIS ApA�.iCAT10N. ➢ PROPflZTY L1NES AND CaRiHEiZS AAUST BE CLPARLY NAR!{E�. •, � . 9 THE PROPOS� LOCATiON OF ALl. STRUCTUR .F".� MUST BE STA� OR FiAG��. ➢ THE SiTE 11AUST BE READILY AC�IBLE F�R AN EVAL1JATiON HY THE HEALTH DEi�ARTMEi�i' STAF'�. � . > ( hereby maice appiicatian to the Pecson Courtiy Health De�artrner�t iar a; siie evaivation for the on-siie sewage dis�osal system for the above-described pro�rty. I agree that the cantents af this appi'u�tion are true and represertt the maximum facliiiies to � piacrd on the properiy. I unde�sfand if the siie is altere� or the ir�eended use cf�anges, the permi� sha1� �nrner or Lega! Representative � ir .� a� Da PG-10. �r. �IU2 �`'� �L � �� S ,l) ����"�� !�o �y�y f � ���0.!'�� � ` �� � � ���� °���� 0 0 � � aa.�aa-osa�*-„-„ ��a.��.� �"��mm.���a Applicant: Location: Improvement Permit Permit Valid for X Five ears _ No Ezpiration Type of Facility: ��G New Addition _ # of Occupants �j # of Bedrooms Projected Daily Flow --- Proposed Wastewater System: �_ Proposed Repair: �d�l� �ti�iL� Permit Conditions: Owner or Lega1 Representative Authorized State Agent: ` Water Supply VI��.Q g.p.d. Type: Type: �g Date: �a' � '� `� Date: � 6 The issuance of this permit by the Health Department in�d'oes no�suarantee the issuance of other permits. It is the responsibility of the applicant/propezty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met This Improvement Permit is subject to revacation 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 Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Euvironmental 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 Construci Wastewater System (Required for Building Permit) * See site plan and additional attachments (�. Proposed Wastewater Sys : .�p�j�F�/'�-t�it/�iL(r Type _�c Wastewater Flow _g.p.d. New Repair Exp ion _ Soil LTAR: ^ g.p.d./ ft 2 Type of Facility: v Basement Yes _ No , Wastewater System Requirements Tank Size: Septic Tank: /Q�gal Pump Tank: �--- gal Grease Trap: gal Drainfield: Tota1 Area �000 sq ft Total Lengt�?oo ft Mazimum'�'rench Depths;;� in Trench Width _� ft Minimum Soil Cover: --� in Mini.mum Trench Separation: � ft Distribution: Distribution Box � Serial Distribution Pressure Manifold Specifications: �'�it�i� T�i✓,P�� D�,�Jv �> Authorized State Agent: ��i Permit EXpiration Date: Date: The type of system permitted is � Conventional Innovative Alternative. I accept the specificarions of the permit. � c� Owner/Legal Representative: �J !� Date: ��� � �� / PCHD7/30/2002 :����.�� I��I���� �•' �"i�_ /� ��\ " �C. �J ��N�C� ����� � ��� ���� S�'�'�� S�7C� -. � �'� � ��. . ,.�-- ...- a �' i � •• ' - .. • .. - «... . t- .� ��, � // i . � s.•. �. u�- • •w i. System cnm�bonen�s ae�fi�r�rzs�t a�blbsaxranate�co�orsrs ouly. T ite c�v�rctor stsrcrt�Tirg �lie� sysTe•m�rior rt� beginnis�g the �on fo i�sur� i��ergmde ia ��ed . s�: �(�'� /i��� � �v� �,�� �,=T o� . ._. ���' ��1� ��;�ri >� r�'r,� , � �` �J�z�ws;C;%� iV � � .. 0 4A+� �� / f � r (✓a� ��i . �{�"�'��3�%foL •Q�c�// . `' /��c%� .�'�q/ ��� . ��� � �:1�'�,�� �'��y�c'� ���t 7 �' �°� Q����"�'��� �c;��✓'�� ���� ��P� � �. �' ��1���. .� e . d �,� G��',� �, . -� %�� ��'�'� ������ � .�� ��� % T� � Y, ���r / �/Y�%/Y'-J •� v���( r� f�.d�%—� � . 4�� �� ��1��� ���������� � �� .C�G�� �N '� ��� �, � D9/32/Ol ��c<c:1 � � �.�d' - . . � H O a Amount paid loO�va .e� _��' -q� RwceaR.t �� ' ll S �� Date .t� • • �'� ��/ APPI,ICATION FOR SERVICES rovements Permit. (Established/Recorded Lot) ImpFovements Permit (Unrecorded Lot) ts Permit (Mobile Home Replace) Improvements Permit (Addition) :'.;�teinspection of Existing System (Loan Closing) Repair/Replace existing Septic System Permit for New Well _ Replace Existing Well , <:.�. y,,,:, .._.w�.. _�,.._..: __ ..._. . _. _ Bacteria Chemical Petroleum Pesticide _ Lea Permit requested by: . ���j�- �� 7. Dimensions or Proposed Structure: ner/pros ective owner/agent:f'�!i��/-�/%Pv� Width: dress: �'► L� 1- 1��nY'�.`-`' 2 ��, _ Depth: � a w ,��, Home Phone #: � ¢ usiness Phone #: a � 2. Name and a�idr � r� of,current owner: N� z,� �73 ion: Lot size: Tax Map#: Parcel#: _ 0 . Directions to property: State Road #& Road ames,�tc. Number of � � w 1'��w�a� ' x3 – 2 n �`– 2a cn or neonle to be served: 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? 9. Water su ply ty�pe: private public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No j� If so, identify location: 10. Type of structure/facility: Proposed: L'"1E Type of dwellin : House: obile Hvme: C7 Business: ❑ Type of business: Number of Employees: " umber of bedrooms: �— �arbage Disposal? Yes ❑ No C1 IBasement? Yes ❑ Noi�'If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND TIiE CORNERS OF ALL PROPOSED STRUCTiJ-RES. I hereby make application to the PerSOn COunty Health Depal'tment for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the conten[s 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 before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this applic�on shall become void and all fees paid forfeited. Signcc� Owner or Authorized Agent Permit Issued ❑ Permit Denied ❑ Plat Observed ❑ Signature Date i _ - � . ' ,, • �{, r''`ra �..r< .., s. ,:�,FAcroxssTreEVN.vnnoN, ...:::' . .'�AxeAt:aM` z p�12 �RF�3 � NtF�a .: . .. . .:: .. s , ;:�: ;s.... t..;� . .;?.;:���:, ._� �� ... ,. . .. _: � � � � . i. S1APE ( b) S S S S PS PS PS PS U U U � U 2. SOII,TIXTURE(12•36IN.) S S S S (SANDY. LOAMY. CLAYEY, NOTE 2:1 CLAY) PS PS PS PS U U U U 3. SOTLS77tUCfURE(12•161N.) S S S S (CLAYEY SOiLS) PS PS PS PS u v u u. 3. SOILDEP7N(W.) S S S S PS PS PS PS U U U U S. RESTRICi7VE HORIZONS (INJ S S S S (BdPERV10LS STRATA. ROCK) PS PS PS ps U U U U 6. SOiLDRAINAGFJGROUNDWA7ER S S S S (DCIQtNAL R INTERNAL) PS PS PS PS U U U U 7. SOILPERMEABIL.ITY S S S S (PEKCOCAATION RATE� PS PS PS PS U U U U E. AVAR,ABLE SPACE 5 S S S PS PS PS PS U U U U 9. SIIECLASSiFICAT70N(SEEBELOW) SOIL SERtES S-SUITAIILE PSPROVLSIONALLYSUr1'ADLE U-UNSUiTABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, e�C.� C:NMfPRO�DOCSIAPPSEC.S�1 FUTANCE.PC CRAIG D. L�LINSKI D8 216 P 95 I__ --- --- ------_ � __._-__ --- — IF ��� t ___--- -- �� � _�___ —__ — _J--- ---�- -- 47' OS"E � � PowER N79• , � C A R 0 L I N A �8,� . 59 1 & �IGHT COMPANY iF • i � L I N E N23'43'46'E � ANSMISSION ___ ---- TR oo � R/w -�- 5,.23� __ --- --- —.-- --- _ � � � IF —__ — � � . -- � µ86•30'52'E � 36.23' 281 . 29' �N- � � �LL 30 � N J i ��� �g 3• s �'�P� 273.5' 1 � l PbRt:Fl1 I �e i : -7 �:� r I '���_ — � r�J �:; � , /�� ��— ' � ��i �;' o� � � ��,�E�- i� �" � :. � � �,Z� � � . ��POLE . � i v�� ���' , . � o� Po� � • ' : • • IF Of�E STORY DOUBLEIIIDE � �'� � •30�52"M ����� CONTROL * � IS SERYICED � 8Y I�DERGROI�D �IF CORt�R ��, � I � ROBERT T. RA�ISEY � � 83 —E— 103 ��, � �h �o I "� N � . � � O w u � IF� i � 4.00 ACRES DEED BOOK 160 PAGE 123 PLAT CABINET 5 PAGE 137A JOMI A. HARRIS DB 163 P 421 u • J � �1� o� IF JOHN l� DB 1 E Person County Health Department Existing Sewage System Report For: �Mobile Home Replacement Addition . ,I � , � i � • ,.,� ��� � �/ / � � 1 � cation/Directions: rt V Original Yermit Located Home Phone# �Jl Business# �� //� 'Pax Map# � �� 7 (� i��oe M i-. 2; on/ �l`P l.� , % �i�Yl n Septic System Uesigned r'or: � Kesidential Business Other (speciiy) # f3edrooms �_ # Employees Other _ Uate lnstalled , J—�"g� Water supply Type of System i� v�'�� �Y1Q J�(a ,►� d�` �'�-�� Nitritication Line ��, �� � � a� � i��0 � `Pank 5ize / v� �� �" Certified Operator Required On site wasL•ewater disposal system showes no visually apparent malfunction on �/�a��u Yermission is granted to: �����, II�!� According to the attached site plan. Comments :�i�Us-�. m L�.s�-C�� a,,� a,,� �-e�.�-�- 5_-�._ ��- � as t` ��. - Environmental Health .$�C..