A40 186Apqlication Date: �a a� ao
�Amount Paid: 1��
Receipt #: � 2 I 60
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Person Countv Health Department
Environmental Health Section
APPLICATION FOR SERVICES
Tax Map #: �'�4
Parcel #: � o �
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS 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): ��nxm�9x I/ia�v,a��� ���c��
Home Phone: Address:
Business Phone: _�3�SD? g08 � •
2) Name and address of current owner: �
3) Property Description: �ot size'a ,' Township:
Directions to the property (Including road names and numbers): /���I� �� �%c�lc�w
4) Proposed U e and Structure Description: answer each of the following questions:
a) Proposed Existing ❑
b) Stick Bui t, Modular �, Single Wide 0, Double Wid�
c) Number of Bedrooms: � d) Number of occupants or people to be served: .�
e) Basement: Yes ❑, No�lf yes, # of basement fixtures:
� Garbage Disposal: Yes �, N�
g) Dimensions of Proposed Structure: Wdth: �1 Depth: �
5) Water Supply Type: Private�(new�6r existing 0), Public ❑, Community ❑, Spring ❑
Are any wells on adjoining property? Yes�' No ❑ If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
�Conventional _Modified Conventional _ Alternative _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
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 underst nd if the e is al red or the intended use changes, the permit shall become invalid. I understand
that as applicant, I am resp ible fo entifyi and marking property lines, comers and making the site accessible for the
personnel of the Person Co Heal epart t to conduct their evaluations. I understand that I am responsible for notifying the
Health DepartmenJt,i�f�ii perty tains� tlands as designated by the Army Corps of Engineers.
or Legal
�a a� ov
Date
PCHD, rev. 10/12/99
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Appllcation #i � • r
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Parael #:
� Peraon County Hsalth Dapartrner�t . �
Envlronmental Health 8ectlon
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Subdivielon/Be�tlonlL.ot#
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Date . � �
n� r�epreaQn� appruztmat� conloura on�(y. Ths coalraclor mt�l flag tbe syats�n
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R7,�!1-�If1 rnui_ '111/'12/9a
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V�o�u - l,o'�- On Corx.er w �' an'rh��o� �;r��e
Subdlvhto� ��� n�ver ��w'�a`�w� 3�tla� IaC �
� improvemen# Pennit � ,
A buildincqpermit cannot be issued with aniv an imarovement Psnnit
New `� Rep�air Add�ioa Type of S4uc#�ue S� �
# of occupaNs 3 �•af Bednooms 3 Otl�er
Basement? �iQ_ BasemeM Fodunes?�
Projeded Da7Y �� �Z 9-i�.d. Permit Valid Fat: i
FroposedVlfas�ratetsSrstem'ty�: �.�nvc?v���rn,�
Pump Required?' Yes � � No
ProQosed Re{�2i� : C.a K� u� i o�'lA (
Pemnit Cond�ions: �'r�n su s 1-Pr� � 5�w�, .. _�o,-,�
rc,�e .�v ��� ��
Owrter or Legal Repr�ve
AuthotQed State Agert�
waterSupply W��l
Y�rs 0 No ExpiraUon
Ca�
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oate: � - o� — 0 (
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The issuance of this perRut 6y tha H�h Departrne� In no way guarar�ess the issuanca of ather pgrm�s. Tt� perrnit
hotdec is respons�la for checldng with app�opdate goveming bodies tn meeling the�c reqt�emeMs. This sita is
subject to revocation if the sib� plan, plat, or the intaedad' ttse ci�angea. The ImQnovemeM Permit shall �rot be
affecied hy a cfr�nge in ownerahlp of the ait�. This permit Is subjed bo complianca wittt tha provisions of ttte
Laws arid Rules fcr Sewage Tr�tttferlt artd Oisposai Syabems of the North Carolina Administrative Code.
Authorization To Construci Wastewater Svsterr� (Revuir�ed for Building Pertnit)
-ryPe o�w�� sygc� �'oh �QT� i w� �r_ 36b_9.�.a.
r-�, TyP�: 3�r: ��sc de�,-t�� r,$w��a� ❑
8asemert? 0 Yes o Hasen�nt �atiu�es? Q Yea�o
Wastewater Svstem RecuiremeMs
. Sep�c Ta�c Size: %�D gagans Pump T�ic Size: �'�%' gailans
Tatal Tc'ertdt Length: � fie� Ma�dmum Trench De�tk �� A� Depth �� in.
Maximum Soil Cover: �_ ind�es Tr�et�tt SeparaUOn: � Feet ort C�rtt�
�ther: �uC "f"o S��llec✓ F-�e-� s��t �`" �fof he%� u�c�pe�- ��vr�,dp,-t �/,H.e�Se.e So�e Ske'�c�.�
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Permit Exp�-ation Date: � - `� ��
Authorized State Age� CJate: Z- 2�(� ,
The type ai systsm permitted 0 does 0 does nat. diRer from specified on the apQUcatian. 1 ac.�apt
the specificattaas of this panait
flwnerlLegat f�re.ser►lative Sigrtat�tne. � - pz���'��I .
PC�-1D, reu.11/18199
. � Person County Heaith Departrnent
Environmental Heaith Section
Tax Map #: � �D Paresl #: .I �b
Zoning: Townahip: �t�X�Or'�
Subdivision: �laf ✓��1t�1' �/Gih��'(�v�, Secticn:_ Lo� �
AppiicarrC �1�f0 �� �����
<: '� S ` �� � �J�1� � a nla�c Ul�. �� r �
Locatlon: _ � 7 � F�/ I h�`� �'�a r�i ` �
� � Q�, C�r13 �r ��-
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Qperat�on P�erm�t
�� System Type (In Accordance W�th Table Va): �� � �
THIS SYSTEM HAS BEEN lNSTALLED lN COMPLlANCE WITH APPUCABLE N�RTH
CAROUNA GENERAL STATUTES, RULES FOR SEWAGE TREATAAENT AND DISPOSAL,
-AND ALL CONDITIONS OF THE IMPR01fEilAENT PERMIT �AND CONSTRUCTtON
AUTHO N. �
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. Person Couniy Health Department
Environmental Health Section
Zoning: Township: �X �o ►�v
Subdivision: t-�0.'� 1\���+" P�ah�af�e-�, . Seatlon: Lot: �,_
Applicant: C 0 r�5 ��� � . �
J�% � Ah, A�io'►� C 1 � � r t+�� C►1 h 5� V� ��/(� o;.
Locat%n: � S � e S- o-� Cv �..G !o �
Operation Permit
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1. LOCATlON AND SEPARATION DISTANCES
A} System meets .1950 setback requirements � S �
S) Distance from system to any welis no h' lecf �
C) Distance from septic tank to founda6on
D) Distance from system to property lines > �D
2. 3EPTIC TANK QS
A) Visually inspect the exterior w�lls and top of the tank
_ B) Visualiy inspect the interiar wails, �ffle, tee, filter, rise , lids, air vent,
bottom, and water #ight outlet " �� -
C) Date of tank manufacture -��d •
D) Tank serial number �
E) Liquid capacity of tank � /oo o gailons •
3. SUPPLY LINE TO TR�NCHES �
A) Grade SP,� d cJi 1/8 Uch per foot mini um)
D) Material suppiy lir�e �s constructed from e U �-
C) Diameter .�
D) Length � '� _�� 3 f
E) Distance from tank to d infie stribution device
4. DISTRIBUTION DEVICE(S) �
A) Type N` �
B) Is Device water tight �(�,
C) Distance from the distribution device(s) to the trenches �/�
D) is the device on a(evei foundation N A-
� E) �oes the device.perForrn according to its design specifications �
� Record the inlet and ou�et elevations /� �
5. NITRIFICATION FlELD
A) Trench depth inches
B) Trench width inches q �,
. C) Distance between trenches r I B� l�.��ler
D) Number of trenches 3
E� Length(s) of trenches g��T�GS �� ����
� Aggregate depth �a inches � 57
G) Aggregate material. and size
H) Record septic tank outte elevation S-S
I) Trench grade � SZe ��crw, ti-g L �/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth ue�s ,
b. Proper rise over step down 2� 5_
c..Solid pipe used yeTS
d. Elevations of step downss '+�� (Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 90/12/99
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� PE�SON COUNTY E3�IVIRONME3rITA`L HEALTH
t pL.FASE SE� ATTACHED PlAN F�R WE�-L SITE tAYOUT
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I J� I O f'�t S� �j�%C'S ��_ .
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� �$�7 3 � C�n�a 1 ` o�r+ ' e - I�C�G�r �. `tL�YK �
�, ('.� rr3 �n �. er 1n1� � (' CQ� oi
�a-f- I`'��/2Y P'A„1a�0�
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� � Weil Petmit ' '
Tvae of Water Suaalv: �, tnd'nridual Co�nR►uniiY • Pubtic
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Reauiremer�:
Site Approved by � fZs ��(- � i
Grouti69 p►PProved by�1� 5 3� (' b(
WeA Log � - l -6 �
iNell T 3'�3 � -�� �
Air Vent 3 3 �-o /
Hose e�b -� ��3n o1
Conctete Slab � .�-30��
' Well Driller
. Wel[ Appro
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'`�See I�tEached Site Siaefi�cti*'
� Welts must be 10 feet from property �tnes• � ,
Weils musf be �t from sepiic systems. �o ��e�_
Welis must be at least 25 feet from arry build'mg foundation.
Other conditions: �
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PCHO, rev. 1 �/29l99