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Appiication Date: �-
Amount Paid: �DO •U�
FZecei�t #: �_ 7.�.Q 2
d �° 3
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Tax Map #: � 3 �
�arce! #: � � I
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APPLICATION FOR SERVICES ��v�
IF THE INFORMATfON iN THE APPLICATION FOR AN IMPROVEMElVT PERMIT IS IiVCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTEF2ED THEN THE IMPROVEIVIEWT PEiaMIT /�ND AUTHORIZATION TO
CONSTi�UCT SHALL BECOME I(VVALID.
�o,.�o,ld � . �"hoMa s , S�
1) Permit requested by: (Ownerlagen4/prospective owner): C�.J �
Home Phone: � `�� �-.5 S7 ��.3 � D �•�o Address: 0 � , �a M �� •
Business Phone: 3;-6'97 ;E,23� c�. �r0�y,,f oa ha��v .t/�7S 7`/ -
P
2) Name and address of.current owner: S�r��1 P
3) Property Description: Lot size: y3 �'l�r. Township: Subdivision: }ot #
Directions to the property (Including road names and numbers): �/�G �Nl�r.�� ��>11.�..-r .��/. �
�) Proposed Use�Structure Description: answer each of the following questions:
a) Proposed ! Existing _, Type of Structure: ��i �•, � �e w�� P� Width: a�' . Depth:�_
b) Number of Bedrooms: �L Number of occupants or people�to be served: -3
c) Basement: Yes� No ✓Will there be plumbing in the basement?
d) Garbage Disposal: Yes . No ✓
5) lNater Supply Type: Private _(new _ or existing� , Public , Community , Spring _
_ Are any wells on adjoining property? Yes ✓ No _ If yes, please indicate a�proximate location on the
site plan. .
6) Does your property coniain previously identified juriscfictional wetlands? Ves_ ido ✓
PLEASE NOTE THE FOLLOVllIP1G:
➢ A PLAT OF THE PROPERTY OR SITE PLAN IIAUST BE SLtBMITTED WITH THIS APPLICATIOM.
➢� PROPERTY L(FVES AND CORNERS MUST BE CLEARLY MARFCED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE ST�4KED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE F012 AN EVALUATION BY THE HEI�LTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Deparfinent 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.
or Legai
��-a�-a �
Date
PCHD, rev. 06127/02
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Applicant:
Location:
T��x MaE� i � P�rcel #
S��nhc1'ivi�s�ion '
IPrfp�a�s_etSect�ioii�Lolt #
o r-tnn (�u. I I itc m f�d (�Z.) &�
�rnc.r d. drivc Gt,lonti S��c_
./ Improvement Permit � To,54.arc. w�u wl
Permit Valid for V Five Years _ No Ezpiradon � / °t��a�'`�'� t°t �`
Type of Facility: i c, c�m i 1 c� 1 i New V Addition Water Supply �_
# of Occupants (omax. # of Bedrooms 3 Projected Daily Flow,, (00 g.p.d.
Proposed Wastewater System: Convtn -E� ��a 1 G �avi t�r . Type:
Proposed Repair: .�n/IOV�-Ei VG (a5% r'e d u-c,t��c�✓i,� Type: .Z�1 (�
Permit Conditions:
Tn Stu I f 1' c.� �
Owner or Legal Represe
Authorized State Agent:
t�.l ( S vSEcm On Con tc�u� G5 Ffc�a9 �
�c`sio.� di'tc-h G,b shoc�n Sy.Stcm �,•
CvUcr to bc. addcd at-uc, fo 5(c
've Si�atur�e: %��%�,�,� �,.,2 ,�,� �.
" oF
Date: � /7- o,�
Date: � !�-�3
The issuance of this permit by the �iealth Deparlment in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are me� This
Improvement Permit 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 j'or Sewage 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 (�.
Propos Wastewater System: '�nV�n�iona ��Zr'a�� ty Type � Wastewater Flow �Qg.p.d.
New � Repair Expansion _ Soil LTAR: • oZS .p.d./ ft 2
Type of Facility: i Fa ' c, f I i.� Basement _ Yes �No
Wastewater 5ystem Requirements
Size: Septic Tank:1� gal Pump Tank: NI i� gal Grease Trap: �� � a uP s �oP�
field: Total Area: � 4�} D sq ft Total Length �� ft Mazimum Trench Depth �_ in S� 1 c
ch Width � ft Minimum Soil Cover: �_ in Mini.mum Trench Separation: Q ft
Specifications:
� ` �i C t0 l,
Distribution Box
D SyS�M � �
a�i" C� �ru�a-�-
Authorized State Agent:
Pernut Ext
� Serial Distribution Pressure Manifold
aPP�o��cl� So i LS �
n'...� i`4.n1� c f.n r�
Date: 'I � t (a - U $
r�
bc. f `w �
Date: ��) �C-Q'3
cr
v
The type of system pernutted is � Conventional Innovative Alternative. I accept the specifications of
the permit. '/�
Owner/Legal Representative: �v� �..,�„� /�,��a Date: 7/7- d 3
PCHD7/30/2002
MENT
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S 'vision
Authorized Sta.te Agent
SITE SKETCH
Tax Map #�� P�cel # � �
Section/Lot#
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Date
Systern co�nponents represe�zt a�iproxisnate contours only. Tlze contrnctor must, flag the systern prior to
beginning the i�istallation to insure thatpropergrade is maintained
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THIS IS A PRELIMINARY PLAT, NOT FOR
RECORDATION, SALES OR CONVEYANCES.
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T�x Nl��� i . P�:rc�el �
Suhei!ivi�s�ioi�
Ph�s�e Sec�t�ion`Lot �
Applicant: ��a�ht I h�m�`-5 �
Location: �
C�peration: Permit
System Type (In Accordance With Table Va): ./Z�� �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES .FOR SEWAGE �TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF TkiE IMPROYEMENT PERMIT . AND CONSTRUCTION
AUTHORIZATION. � .
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Authorized State Agenfi � � . � � �Date � -
Installed By: i,���r %/Lc����..� . Date: fs-�i-.O�
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PCHD, rev. 07/29/02
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S���IC YANE� �NS�ECTiON �9iE��CLIST (Type IH - IV�
Tax MaQ # 3(o Parcel # � � System Type (Table Va) T
Owner/Appiicant �,►�ayn� �T"hom�.s Subdivision
Address/Location Sec/Phase Lot #
State ID/date STB 14a
Tee and Fifer
Baffle
� Sealarrt
Riser if ap licable
Tank Outlet�.Seal
Permanent Marker
Pump Tank
tate ate
Capacifii .
/Sealant
Riser �
Water Ti
. Pump
Check Valve/Gate Vaive
- nti-si on�lo e -
Floats/Switches � �
Alarm visabte and audible
Electrical Components
Rate (aom)
ApProved Pump Model
Bloc� Under Pump
PumQ Removal Rope/Chair
Distribution System
Serial Distribution '
t�3 Trench Width ft.
�-c� Trencf�. Depth fn.
Trench Lenqth �. f�� ft.
�'{� $- ,�3 Trench Grade .�
3'� Trench S acin '�
3H Rock De th and Quality ✓
3't� Dams/Ste downs etc. � �
�tf Pressure Laterals
� Hole Soacina
���
���
���
Low Pressure Pipe •
Appr. Pipe Material and Grade
Valves
f lU1G �71LG .. . . . .
Pipe Sleeve . -
Tum-upsiProtectors
� �Required Setbacks
From Wells �.
From Properiy lines
Structures/Basements :: ° .
Surface` Waters - � -
Public Water Supplies
Vertical Cuts (>2 ft).
Water Lines �'
Vehicle Traffic
Easements/Right of W�
Other
Easements Recorded .
Cornments
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pchd rev. 3113101