A28 135A�Qiication Date: -9 -U %
Amount Paid: 0 ,00
RecEipt #: k 3 � -71
��i-
a66�1 _
�����5� ���.� ��
- _� � � �1�T��Y
��vaa-�aa�--� �caa��.Il. ���o.IL-�Ik-k.,•
APPLlCATION FOR SERVIC�S
Tax Ma #• �
ParcEl #• / 35�
IF THE I(dFOR11flATION IN THE APPLlCATION FOR Ald IMPROVEME�IT PERMIT 1S II�lCORRECT. FALSiF1ED,
CHAIVGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZdlT10M TO
CONISTRUCT SHALL BECOME INVALID. �
1) Permit requested by: (Ownedagent/prospective owner): Q/v� � �/a
� Home Phone: ��� - � ��� Address: 2a'G � Ch � /, 1c,� ,Qrri'
• Business Phone: .�'9z -/,�"�3 �o� bo �a n� G 2�.���
2) Name and address of currerrt owner. �na /7:���
/!/ i7r;c- n�� Rd
� �o,c bo�v !J L 2 �57�
3) PropertyDescription: Lotsize: �.�$ Township: � ' Subdivision: ��s-i�e�i �nc Lot# °2
Directions to the property (Including road names and.numbers): /// 0���'y A�d Rd, pa+ 1��'S :
4) F�roposed Use and Structure Description: answer e�ch of the following questions: � z�
a) Proposed �� Existing ___, Type of Structure: <_�ac-� Width: .�� Depth: `�
b) Number of 6edrooms: Number of occupants o people to be served: ;
c) Basement Ye� , No _ Wiil there be plumbing in the basement?
d) �arbage Disposal: Yes , No _
5) Water Supply� Type: Private _(new _ or existing�, Public_, Community , Spring _
� are any wells on adjoining property? Yes_ No _ If yes, piease indicate approximate location on the
'site plan. . �
6) Does your property cantain previously identified jurisdtctional wetlands? Yes_ No�
PLEASE NlOTE THE FOLLOWING:
9�► PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLIC�►T10M.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. �•,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAF�D OR FLAGGED.
9 THE SITE MUST BE READILY ACCESSiBLE FOR AN EVALUATIOPI BY THE HEALTH DEPARTflAEiVT
STAF�: �
I hereby make appFication to the Person County Health Department for a site evaluation for the on-siie sewage disposal
system for the above-described property. I agree that the cantents of this application are true and represent the maximum
facilities to be piaced on th property. I understand if the site is aitered or the intended use changes, the permit shall
become in alid. � ,
C�!�� � a �?
:.�
or Legal Representative
ate
PCHD, rev. 06127102
PERSOR! COUNTV ENVIROIVME�ITAL HEALTH
i�LEASE SE� AiiAC�lE� P�AfV F�R S�IL AREA .�ND SYSTEiVI LAYOUi "�
Tax Map #: �� Parcel #� Townsitip 1 1� i� e- ('� � � I PIN
ApPQcant� '� ri Subdipision� w�Phase�5ectton ��' Lott� .C_,
�..ocanore �aC.k a t' '' `� Q�
�'�''`�`�J�"'`� ��''��'`L� Imt�rovement Permit
New �ddition Type of Structure44�L� � i�. �' Water Supp ��
�� c,�
# of Occupam� # B�dreCom � Other System Type��
Projected Daily Flow: ��.p.d. Perm' Valid For. 4.Fiv�Years ❑ No Expiration
Proposed Wast e� System:
Proposed Repair. _
Permit Condition . `�'
�
Owner or Legal Represe� \_
Authorized State Agenfi
Date: / v1 Vr Q/
Date: - o�o v
The issuance of this permit by the Health Department in no way guararrtees the issuance of other permits. The permit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if .
the site plan, plat, or the irrtended use changes. The Improvemerrt Pertnit shall not be affected by a change in ownership
of the site. This permit is subject to complianae with the provisions of the Laws and Rules for Sewage Treatment and
Disposal Systems of the North Carolina Administrative Code.
Wastewater System Description: ,
Flow:
Facility Description: `�� �-- � ��� ( V � M _ _ New �'- Repair ❑ Expansion ❑
Basement? O Yes �Ytd�'— � Basement Fixtures? � Yes �lo�
Wastewater Svstem Repuirements
Tankage: Septic Tank size� gal. Pump Tank size . gal. Grease Trap size �� gal.
Trenches: Tota{ tength� ft. Trench �dth � _ft. Total Area � � sq. ft.
Max. Trench Depth: �_ in. Aggregate Depth.�in. Soil Cover. � in. Trench Separation �ft. on center
Permit Expiration Date•
O�f ��l-� - a Cn �'`r`°�;v�.
Authorized State Agent Date:
*See attached site plan and a dendum pages for additional permit conditions.
The type of sysEem permitted ❑ doe oes not differ trom the. type specfied on the application. 1 accept the
specifications of this permit
Ownedl.egal Represerrtative Signatu Date: ��=g���%
Onerafion Permit
System Type rn accordance with Table Va)
This sysbem has been installed in compliance with applicable North Carclina Generai Stahites, Laws and Rules for Sewage Treatrnent
and Disposal, and all conditions of the Improvement Permit and Construction Autl�orization. {ssuance af this permit implies no
guara�rtee thatthe system installed will function properiy for arry given period oi time.
Authorized State Agent
Date
PCHD, rev. 03/07/Q1
Appiication #:
Tax Map #: a
Parcel #: 1 3�—
• Person County Health Department
Environinental Health Section
SiTE SKETCH ��,���(��,/ - -
� l� `n �-e��
pplicant's Name Subdivisio ctioNLot#
Authorized State ent Date
Svstem components represent approximate cvntours only. The contrartv� must flag the system
�
the installation to insure that
proper grade is matntaine[�
�-o $la;t o��� Pd .
���; ,� �- �r �
�ii � vL �l:n�\.�
G �
. �� ��` � \
_ - � . =� L \
, �bu.5� �
! �,r,: +-�Q.t 5���e�,
C� Kee.p �o� �'ro�, �ro4��y �� ne.
Q =,ns-�►.�i o n 'C���x,�.�;
� �cHyo P�C '^�( Cle�no�-a�.G�e.(of,
� M�� �-f s o n-S�i�. 4,L1`�`;�o
�Q.�(��-,�o,n t
��Z
Scale: ( ���- � C�'
�� ��{���C.
.�
PCHD, �ev.10/12199
Person County Health Department
Environmental Health Section
Ta�c Map #: �� � Parcel #: �.�
Zoning: Township: �� � v� 1-1 � �`
Subdivision: �ti� 41S�t_a_r,i . T�t G. Section: Lot: �_
•�• v•�.� . . i�
. . �. . _ .� �. ��.
Operation Permit
System Type (In Accordance With Tabie 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
THORIZATION.
� 6 ��
Authorized Sta Aaent ate
3v►Sc.N yoF'''C
��p � cie,•.nCv.�
Tax Map #: � � $
Parcel #: ��..5
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section
Tax Map #: ��� . Parcel #: � �
Zoning: Township: � � � � P t-1 � � � _
Subdivision: ,� �� ► �S��r.� �i G. Section: Lot: �_
. ..�-
• Applicant: �,c`�n��,n�� �;�'1�� [.1� .. ._
Location• L 1
Operation Permit
System Type (In Accordance With Tabie Va): ��.
TH1S 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
THORIZATION.
V �j ���'
Authorized Sta Aaent ate
�_ �
. - — �
�,��
,�,�
A�G tt�..
� 3a' s c.f-� `1 �• ,c�►'' C
+1� � c��G,,�
Tax Map #• � � �
� �
� .--�I
C�Y �.�r�1
Parcel #: � �.5
PCHD, rev. 10/12/99
� �� .� ������ ��� �G��
\_1 � d � � � �
` `� �� � � ��� � . �
� �.�T38� " G� �� ZYlA�7L � �-��3� � � C� �� � �.1�Sii
'I'ax Nlap #�� I'arc�l # �_
�xisting Sewage System Re�ort For. Mob�e I�ome Replac�snent a'-�� x 3��
� Addition Type• 1 �T�GH �
-�-
Requester. G' Pr�.-VSN Cl fl�?""� IZNA K9�ome 1'hone# S`�`� "' �`1�S
�8� I ��_��_�� � - Business # �� a - � ��► 3
2�� ° o �c_ a�l S� �4 __
�oCatiori: l � � �itiT�Z ��►� �-`'�
�riginal Permit Frocated: 5 Water Su�ply: W��—
Septic System Designed For. �Residential Busi�ess Othes
# �edrooms� # Employees��_ Other
�
System Type•�_ �C>'�'� Size:��_ Nitrifdcation I.ine: �tE'� K_3
l�ate Installed: _,QC S� 1 Certified Opearator htequired: tv 1 A
i�n-site wastewater disposal system shows no visual si.gns of malfunction on 5�� �.nn� ��5�
IDermission is grantesi to: ��-�--�0 C`-1�L1-Q_ `�� ,,t�s S�i�IiS�Y� QrtJ+� �� •
Conlment5: ��E r�'�I��A L Z►J��P��T�.�.t�1 �F �'�/�� �"� �LJ ��
��� P� ��K� :; � L��A-i�L1T �1-i�A-S �T� � �� �i4 CiT=1(J �S-cv �J
'�f �`2��� �`? TH-� �N�tZ-E:N ME1J'ift C_ �-�A �-(' tt- ��T •
�s C� �TI�-C-(� �,Y> SZ SV,E�-(�+�
�nvironnaental �ealth Specialis I�ate: �-1-
�
A
�
��� )' •� �1l:ii�� ``.l �
�� �1LjJ� //�/1�� /�(\�� �\ �T
� - -�w � -^ ' 'iJ V1� • �n� "i��, � V�' '1L' �.
'r -]T3."�33L ��eT -mrn 1Pr7L'11G.�{, �L 1LIl:r��3 . .
� �7� �7�.i. ""1..�1Y. � '
N�me ^Tzc., r� `�`�no�l Ta � 1'�Sap #�o`�R Pa:rc� #�
Sub ' � n • Se�tio�/Lo
. Q . . . .
Ant�a�ed St� � . . • D
, _ . �
'� Syst�s�a cmaaa�iaraear�r re�a�sE� �rm...�isr�a#��msa�o�ars os�y. 7'he c�aai�ac�r �a�t fl�ag t3ae sy.s�te�a�iri�� �ri
�� b��a9ag � s�as�cadl�ss to �esaa�e 33a��'�r�ergr�e is sasaintuzned
� r����t �� a
. . � _
�,� ,. _ .
. . , �.
_=-=---�� L��
`� a�.o�� a�' 1
��`l� I • �
IC �
Sca.le: i�l o—C �� S�PrI�E-
� �T� �-� T �1-.� �1� � '�
�(�5��'Tc�B� ��
L-ti.Q.��`�c �`�- N t�
�o�� J l'3�..�-K�N .
�L�A-Ev�� Mu��' `�E
��L.-L J �Y�
til-E�2z.F� E� � ��? • i �E
- �w�-�rt ��P�2TN��T:
r •
� C��!-�L� C-R�'fJT 13� (�N`�'
�05�- 1 }-t-AN � �' -��2oM
, C.l_�AN�l.ST 0��-- �U2A�N I..ZN�S.
��''',-��� rev. ��/L/�1
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: / `-1' � � Parcel # � ` ) �
ZoNng TorvnahlP _,�1�1' � V� � t�
Appliwnt
Locatlon:
Subdivision:� Sectton- � �
� i n�'1���ZY1C _ Well Permit
Tvae of Water Supplv:
Reauirements•
��dividual Community � Public
Site Approved by �
Grouting Approved by .5 ��a��°�
Well Log C
Well Tag �
Air Vent
Hose Bib
Concrete Slab
Well Driller: � ��'Q
Well �Approved - �
Date: lJ ` �—� I
**See Attached Site Sketch**
ells must be 10 feet from property lines.
Wells must be 100 feet fram septic systems.
Wells must be at least 25 feet from any buiiding foundation.
Other conditions:
PCHD, rev. 11/29/99
�
��i:i;:;c,r•, c:�,��,�,�r}- ,:rvv,.,cc,rrr;::rv�,•<<i. iu:n�.�•t�
,
iri:i.i. t.uc
�
� �a (�: �� • .
O wn ei-: .� -;---.._..
z.oca[ion/,D��-cc[��`=�=d.. z� � .
,�
�
,
1):';vls��j.��---_.__.___ .._. ���! ��� d j�. ........ .... _._�_! s��' ---__
�IiI1.i1� r .N:���i�:: _..
b Con��act ` --...
O.I'.��/.�/J....�.,. , j...�_r....,j_.... ...•• •- .._.._ ._�,L�� ��
� �...G.
,D�st:zl�cc lrom IVc > >�!I: l .f .�.,���N�_l , 1.�--�..g .. � �
Pollution `u c.�t � �-�j�cr�y L,i��c: � �I� 11C1�•((�N
To[aI vcpth: � � � .-��.��..�1.��..s_._.rllist:ir,cc .(i-om Sou �
rce of '
�w���r �:� r�. � ;�a��: � .
C�� aring:Lones. U��[li � ..--r�-.S.__... ... C��1'!vI .Strili
�: beptli: � j= , --.. �-. 1'r..._�� � w�zeer Lev
�'�PE: Stce] roin� �_..ic>_.. ....��y � `������.��.--Fc. . el �
X.�__�"— � C.• .3-�'" .Ut;,nictcl: `' ; -�[.
S[cc;1 � ��. ---�_...._._.. �:�Iv:,r�iiccl ' • , n � � � Inches
1 O(,,, O 1�l� c. S I c.c. �_ L/ .
1Ve�.g}it: --� , 1' �11���r�v�:; a'c.� —�--• . .
,
�ii v .I 1ti cIv � css: �`–'----Nc�---�_ .
� 5110 C: �� S �--rL-��. .�-,�C1 h(' �O V � '
��lc� � �`�' Grour�d: ,
Wcrc .��toblcros .Ciicotzitt�rccl il:�-.._, ••--L�.'Zi1�he;s
., —.
,.
Grout: ��' y�s �iv� i•�,isc�u: _.. -• __. i,�ctU�i1; clic C;IS�l1�1''� Xcs �' .-----.
YP�' Ncat ` -- .� • ``_ No
_`_-----_._. ,S:tt -�" '�_.--
wuiular.:Spacc Wi�lth lc.1/Cc:,ncnc �i `'_ C, �`__„'
,`� ` ------- •n�rcte • . •:.��
�l[CI" � �.12I111�:1C � ):ICL �..._...... . ._•--.111Ci1(,S • r
McUtod:� � 1 � c::- '',j;;
I� tu�ilx;c��;� , �- .. . . ---�_. No. `---- .
llcp[1,: I=rom _�....... ...._ 1 r�c.:.:;:urc; �, � . .
11'Ia ie�•i ajS "'_' . .. .. . t u _ � �-----_.... _.___. 1 c � u rCCI_ L,� . . . '
USCCl: NU. �j•� , � • ••-- I'l. -'----_. . ••j. .,r
.
Xf in�;;[tu-c (s.Zt�d, Lr:i��c:l cu� c�r�l;u�d C��i�cn� � . .
Z.I� � � [tir „ ) _ �,i . -_ Wc � r .
`� � ��1:11 iS• �'cs"-- _..._ IVo. �:,� I . �i��:__ _.�`� ��1Lt�t ° ,I'bag-�lbs:
� � � �s v _._ � . �:,
� --- --_.. Nc� • .. • '�
. .
�– � �----�.__._.._ ..._ _ ...»h I.I _f .1NC� l .0 � .. : ,.
�_ � _.. _ _)C' •
�- ►
r�m _ _ �,o — -- �-- -- - .. ._... �-`---
- _ .... _ .. �;c�l-J.1, � �n ..._.:..�_
-�-CG �.. . .__ _ .1��.:��rl [lOn
._-��..t_ �-r�._..���
_ �____� �_
--�,r='4--.ir , / �`� '==�5-._.
7' �__.�
' �- ��`�'� _ . �.. ..... . __ '-,.....�. ... -�-_r
- . . x��R��x ��1zT�r-a� �'F� ' --_...__.. •_ • •.�,-_•``-._.__'-'�-----� . .•;:
H7S 1��LL W!�S CONS 1�, 1l�IL A.X� c") VL �N1=UIZ���. .. �•; ;.
� UC �,�I.) [N ��.CCOI�ll � 1,(ON ZS CORRECI' A.ND �:,.:
' . S�RT�I � Y�T� I� P�IZSpN �-. . , ' ' �A.ly ;'%`�
,
.. .. nIJ.N�j � (��1:/11..7'(-I pL•:P�11 -�-w���Ii IZEGU�,A��NS:�-�
j. �
M �N • • . �-,Y,�
,Sil;r�r,cui�c i�l'C�onr�,;,:tc,;....__.�_ --_
�
--�.-
• Dacc •�'�
;,�,' •� ;
'•��
.•.•'~�:
•'t