A39 3464/�4/2007 14:42 3365977808 PERSON COUNTY ENVIRO PAGE 02
Apqlication Da� � � 07
AmQunt Pald _,
Recel #: _
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Improvemec►ta Pertnft
Imprcvemsrxs Pfrmlt-S150A�
(EAoblla Home Repleo3ment1�4ddlNon)
�0[V�RTRUC,' $HALL BECOM� 1NVALID�
AP�LICJ�j10N FOR 9�RVIC�S
�.an�wcuan autnorkatlon for
5150.DOJS200.0�
PertnR Ravtelun F� - #75.00
1) Pertnit requested b : (OKmedage�tlprc9pective uvuner): � ) ,.,, , �� � �.� �
Hame Phone• - S$ Address: �o8'Q' ,f�,-/. � „
Business Phane- - D i3 ���/��e c� 9 r� �i
2) Idame and addr�s af curtent ovmer. � ,� �
. � �
' red ,t��.�rd yi � 2�`I,�L_..
3) Praperty Desc�ptir-- � -• -•-- � - - - -.� . _ /,I .t - - —
Direcffons �o the pro
4)
P'roposed Use and 3tructu�ro�a rlption: anstinrer sach af the folla}nring questions: � �
a) Proposed � Existing V� Typ�e af Strucfure: /1�,��•,� f«� Width: � Depth: ;
b) Number of Bedraoms: �_� Number of occupants or peopie to be sesved: _� �
c) Baseme�t: Ye�_, No �1 the be plumbing In fhe basement7 -
d) 6arbage Olsposal: Yes • . No � . .
5) Wat�r 3uppiy. Typa: Private (new , or existing�, Publlc,�✓ Community , Spring ,
� Are any we�ls on adjoining p�operty? Yes,_ No , If yes, please indicate approxlmate loc�ttion on the
'slte plan. � ., . .. ' , .
6) Doea your property corrtatn p�sviously idarrtffiad ��irledpctlonal wetlands? Yes4 No�
PLEASE NOTE THE F�LLUWING• �
� A PLAT OF 7HE PROPF,�tTY OR SITE pLqN MU9T 86 3U8MIi7ED WiTH�'TO�i19 APP�ICATION.
� PROPERTY L1NES AND�CORNER9 MUST BE CLEAR�Y MIIRKED, .
➢ THE PRQPOSED LOCATION OF AL.L 9TRUCTURE8 MUST BE STA�D OR ELAGGED. � �
➢ THE 3fTE MU$T BE READILY ACCESSIBLI� �OR AN EVALUATION BY THE HEALTH DEi'ARTMIENT
STAFF: ' �
I hefeby make app{icatlon to the Person County Health Department fo� a sit�: evaluatiort for the on-site sewage dispoeal
system for the above-described prapecty, 1 agree that the cont�nts of this applicatlon are true aod represent the maximum
facilfties to be placed on the property. I undet^stand rf the site i� altered or the int�ended use changes, the pem�it shall
become invalid. r,
�
Owner or Legal f�p'resentative
---�7�=-,�-�� �
Date
PC1dD� mv. 08/27102
Applicatton Date: �°Z� � v Tax Ma /�' J f
Amount Paid: 3
Recetpt #: Parcei �1:
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��_ �/'� C'` �� � � / Z APPLICATION FOR SERVICES � �'�5�� � � � 1
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Improvements
- $200.00 I ❑ Well Permit
ments Pertnit - $150.00
Home ReplacementlAdditlon)
teolace Existlna Svstem Permit
Construction Authorizatian for Septic Systems-
$150.00/$200.00
Permit Revisfon Fee - $75.00
IF THE INFORI1flATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFIED
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERIIAIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. �
1) Permit reque ted b:(Ownedagent/prospective owner):
Home Phone: °'�''� �\S" O�C`�� Address:
Business Phone:(�C�� '1 GS— 4d� �
--� � �
2) Name and address of current owner: � 0�(`��e �,��a_
3) Property Description: Lot size: ��rc- Township: Subdivision: Lot #
Directions to the property (Including road names and numbers): 3�� y.,/. ;�..��� 2��
4) proposed Use and $tructure Description: answer eacKof the following questions:
a) Proposed _, Existing , Type of Structure: Width: Depth:
b) Number of Bedrooms: �� Number of occupants or people to be served:
c) Basement: Yes_, No Will t}�(ere be plumbing in the basement?
d) �arbage Disposal: Yes � , No'►/ .
5) Water Supply Type: Private (new _ or existing�, Pub�li _-, Community� Spring _
Are any wells on adjoining property? Yes_ No vlf yes, piease indicate approximate locatiori on the
'site plan. '
6) Does your property contaln previously identified jurisdlctional wetlands? Yes_ Nq�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �,
➢ THE PROPOSED LOCATIQN OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED.
➢ THE S.ITE 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
hr�r.nmP invaliri .
�
�n.�l
Owner or
Representative
� ��r ` �
Date
PCHD, rev. O6/27/02
� �•) � � � � . J \�/ \ •� ►f T�x M�p : ' P�,rcei �
�•� t \ - I - � - Su,bdivision
I , . , , ., � , � ,., � � , i I I , . , I � I., Ph�se Sect�ion ot �
Applicant: . �n.y;�Q. � ��nn�-t'�f- kia�k�n�
Location:
Improveme�t �ermit
Permit Valid for _�'ive Years _ No �gpiration
Type of Facility: New Addition Water Supply
# of Occupants ma� (L # of Bedrooms �� Projected Daily Flow 3!� � g.p.d.
Proposed Wastewater System: Type:
Proposed Repair: �sP., � Type:
Permit Conditions:
Owner or Legal Representative Signature:
Authorized State Agent:
Date:
The issuance of this pemut by the Health Department 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 met. 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
`iaws and Ru[es for Sewa,ee Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmental �ealth Specialist warrants that the septic tank system will continue to function sadsfactorily in the future or that
the water supply will remain potable. �
Author�zation to Construct Wastewater Systean (Iiequired %r �uilding Permit)
* See site plan and additional attachments (_).
Proposed Wastewater Sy�,tem: _a,r�Pd l�Z -��aw er C�iQw,d er� Type�T�R: Wastewater Flow �g.p.d.
New Repa �i/ Expansion _ Soil L • 3� g.p.d./ ft 2
Type of Facility: �r, .n �e �P.,�� Basement _ Yes _ o
Wastewater System It.equireffients
�x�'s?�'n
Tank Size: Septic Tank: .�al Pump Tank---�Lal Grease Tra . 1
Ilrainfield: iotal Area: �DD sq ft Total Length ,�Q�_ ft Maximnm Trench Depth �_ in�
Trench Width 3 ft 1Vlinimum Soil Cover: �_ in Minimum Trench Separation: q�' �
Distribution: Distribution Sox Seraal Distribution �Pressure Pvlanifold
Spec�ca�ions:
�,
Authorized State Agent• �� Date: S 22�d�
Permit Expirario Date: 5—ZZ /3
The type of system pernutted is Conventional �Accepted Alternative. I accept the specifications of the
permit.
�wner/I.egal Representative: Date:
PCHD rev. 11/10/OS
: ������ ���� ��
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IE��y-�,r„ ,�,,.,, ���.11 IHL,a�.fl�
SITE S�'�C�I .
Name _ n�,'�� �� �2►,nH-gr �aw�i� Ta,g Ma.p #�.Pa:tcel # 3_�_
Subdivision � _ � Section/Lot#
— -��-2Z --aR' - .
Autho�ized State Agent . � Date .
System cnmponents nepresent a�i�inoximate�contours only: The contractor naust, flag the syste9nlbrtor to ,
beginning the imstallution ta irasure that�iro�bergr�ade ss maintained
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Applicant: -�J
Location:
T�x M�p : Fa�rcel �
Subdivision
Ph�se Se,ct,ion Lot #
Improveme�t �ermit
Permit Valid for _�ive Years _ No Eapiration
Type of Facility: New Addition
# of Occupants # of Bedrooms Projected Daily Flow _
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Owner or Legal Representative Signature:
Authorized State Agent:
Water Supply
g.p.d.
Type: _
Type: _
Date:
Date:
The issuance of this permit by the Health Department in does not guarantee the issuance of other pemuts. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affe�ted 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
�nvironmental �ealth Specialist �varrants that the septic tank system will continue to function saasfactorily in the future or that
the water supply will remain potable. �
Authorizat�on to Construct Waste�ater Systean (�2equired �or �uildi�ng Permit)
* See site plan and additional attachments (_�.
�
Proposed Wastewater Sy em: Type Wastewater Flow g.p.d.
New Repair�Expansion _ Soil LTAR: g.p.d./ ft 2
Type of Facility: Basement _ Yes _ No
�^Vastewater Sg�stem Requirements
Tank Size: Septic Tank: �j�Q_ gal Pump Tank:--�--gal Grease Trap: `---gal
I)rainfield: Total Area: sq ft Total Length ft Maximnm Trench Depth
Trench Width ft 1Vlinimum Soi� Cover: in Minimum Trench Separation:
1V
Distribution: Distribution Box Serial Distribution Pressure 1VIanifold _ ,
Authorized State A�
Pernut
Date:
The type of system permitted is Conventional Accepted
permit.
flwner/I..egal Repr�sentative:
in
#t
Date: �Q "/� � �
Alternative. I accept the specifications of the
Date:
PCHD rev. 11/10/OS
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�]m�'YY����r�-e�..7m�.�ffi.JL JLJL�B.�.JI.��m
SITE S�'�`��-I
Name , a, i� � ��er,n' r ttaw�'r�, Ta$ Ma.p #�.Q3q Pa:tcel # 3�_
Subdivision � Secti�n/Lot#
�-- � S-?,Z —DR' - .
Authorized State A.gent . � Date .
System compmnents r��eseni �ir�ximrate�contouzs oraly.� 33ae cora�r�attor srsust, flag tBae s�yste��irimr to ,
8egir:ning t3ae instalJ�atiora to iarsBcre thsctprvpergrtt�e is n�airstained
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Applicant: _,e � � �t�y�`v�. i �?S
Location: ����_T_ � n
e
i.
�x M�p ��rc I .
Subciivision
I'h.�se Section ot #
# of Bedrooms
� .- � � _
�'� � .; �:: -
. System .Type (In Accordance With Table Va): .
THIS SYSTEIUI Hl�S �EEiV INS7'ALLED 111! COMPLIAIVCE 1tVITH APPLICABLE . NORTH
C'AROLINA GENERAL STATUTES, RU�ES FOR SEUVAGE TREATMENT AND DISPOSAL,
AND - ALL CONDITiOiVS OF � THE IIViPROVElUlE9VT PERMIT AND C�NSTRUCTION
AUTHOR[ Otd. � .
. I�!� Cc . � 2.CJ fl � �
uthorized State Agent Date
1ns#alled. By: �` �' l�� � Date: � � Z� � ?f _ � �
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PCHD, rev. 07/29/01
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���'�i1C T�K iN�PE�T3�� �I�E+��LlS�' �'YPe �➢ � I�
Tax Map # 3 Rarcel #� Sys�em Type (Tabie Va)
OwnerlApplicant Subdivision
AddresslLocation Sec/Phase Lofi # � �
S�?�7�9C. ��8�� 8691�9� /�3$� 1$�"6 iC��OPi lP1�3 63@�@� �'�
State �lD/date 5� S�2 � � t/' Trench �dth� � ft.
Ca aci ai. � Trench De th in.
Tee a.nd Filter - • T,rench Len h fi.
Baffie �' Trencli Gi~ade � �
Sealant Trencf� S acin
Riser ifi a licabie � � Rock De th and Qual'
�'ank Outlet Seal ✓� DamslS#e downs e#c. �
Permanent Marker Pressure Laterals � �
PurnD Tank � �, � e, Hole Spacinq �
v�a« ivfac�v
� - Ca acit g
Wate roof /Sealant
Riser
Water Ti ht �
Pump
Chec� ValvelGate Valve
Alarm visabie and audibie
Electrical Com onents
� Rate m ..
A roved Pum iViodel
Biock U�der Pum �
Pum Removal Ro e/Cnai
. �Dis�a�ibutivn;Sy�ien
� Serial Distribution
ressure Man o
Low Fressure Pi e
A r. Pi e I�aterial and Gi
Pipe. Sleeve
Tum-ups/P.rotectors
Required� Setba�ks
From� Wells '
From Praperty lines
Surface Waters
Public 1Nater Suppi
Verticai Cuts (>2 ft.
Water Lines
Ve�iicle �Traffic
Easements/Righf of
Othe�`
Easements Recorde
Co�aments
ree�nent
.
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pc�d rev. 3I13/01
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