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A28 162Application Date: 0�-8 � 6 Amount Paid: �2 U. D O Receipt #: ,29� � # ��q3 � � �0 '�31 �� �(� �,°2� ���,s� I�I�I�..� �� � - —_ � � �T1� �C" �Y ���.a-������ma ��.�.a��-a. APPLICATION FOR SERVICES Tax Map #: � Parcel #: % �2 � ,��� a day i� a.dvo.x�� i-o N�ee'� � ���� 3 36"3 30 pq60 IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED, CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEDIIEN7. PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. � � 1) Permit requested by:((Ow� agent/prospective owner): �Jv�n 5' ���� Home Phone: 336 �-�33o c�'-r6o Address;; 38� �D�>-c- K.,►1 �� Business Phone: SSR� 5 3a� I�.-� b�� 9.�. c. 2) Name and address of current owner: 3) Property Description: Lot size: ?1_�Township: Subdivision: Lot # Directions to the property (Including road names and numbers): 158 w-Lsi- ,o�.s-f- � N�(�/i YLc� , �. -�e a, i �- �� a �.�. y� � �..,k �,-� y .v. � 4 -n�ah�. � 4) P'roposed Use and Structure Description: answer each of the following questions: , ��) Proposed � Existing , Type of Structure: t�.Y�- Width: Yo � b) Number of Bedrooms: � l Number of occupants or people to be served: a- �) Basement: Yes , No ✓- Will there be plumbing in the basement? ti a d) 6a.rbage Disposal: Yes , No � � �ea v e �„� cSS�` � Depth: �o 5) Water Supply Type; Private �new %r existing�, Public� Community_, Spring _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the 'site plan. 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No_ 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 LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED. ➢ THE SITE MUS�' BE REi4DILY 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 become invalid. _ S� or Legal a � ��o (� Date PCHD, rev. 06I27/02 ___-__-...------- . �.i Y� .... "f �` } \ '; r^'"'� �` _ ...-...: _� _�1�.� ' •4� � _ � ���-� i ��� / ��j �.J4..lQ �� �� ��v > J� . -� C����T� � ���a-�� � ��.�.m.11 IL33L�.�.Il Applicant � N iQ`f-t� T�x h�1a� /� � �rc�el � ' Serbd!ivi�s�io��� h�s�e Sechian'Lat � /-� a l � - - improvement Yermit ��rmit Valid for �ve �eaa�s No �apiration Type of Facility: r.�r w • New �Addition �ater 5nppip W�« # of Occupants M a� # of ooms 2 Projected Daily Flow 2� g.p.d. �� Proposed Wastewater System: ��1 '�-c--n � TYPe: Proposed Repair: �u v��- �r Type: Permit Conditions: �aP S � S�'e �'�'� Owner or Legal Representa.tive i iure: Date: Authorized State Agent: � r""l Date: Q The issuance of this permit by the Health Department in does not guarantes the issuance of other permits. It is the responsibility of the applicant/property owner to in sure tha# all Person County Planaing and Zoiring and Building Inspections requiremenb aze met This �lmprovement Permit is subjecf to revocation if the site plan, plat or the intended use changes. The Improveuient Rermit is not affecterl by a change in ownership of the property. This permit was issued in compliance witii the provisions of the North Carolina `Laws and Rules far Sewage Treatment and Disposal Svstems' (15A NCAC 18A .19Q0). Neither Person County nor the Environmental IIealth Specialist warrants that tf�e septic tank system wi71 continue to function satisfactonly in the future or'that the water supply will remain�potable. � Authorization to Constra¢t Wastewater System (Reqnired for Building Permit) * See site plan and additional attachments (_). Propo ed Wastewater System: ��"` ��'`� ( Type �� W�ewater Flow �.p.d. New � Repair Expansi n Soil LTAR: . 3 g.p.dJ ft 2 Type of Facility: �Yn j �i'�� Basement _ Yes ?� No . �Vastewatea� System ]L�ecyuirements • '�ank Size: Septic Tank: (� D U gai Pnmp Tank: gal Grease Trap: gal �rainfield: Total Area: ��� sq ft Total Length ��� ft 1Vla�mnm Trench Depth � in Trench Width � ft Minimnm Sail Cover. � in Minimnm Trench Separation: �#t l�' C� �istribation: ��3istribntion Bog Serial Distribntion Pressnre Manifold Specifications• �-'e .S �d� ��t��''� Authorizesi State AgQnt: t'� � �� Date: � 2} Permit Expiration Date: � �7 Z `7 ( ' The type of system permittetl is � Conventional Acce�ted ` Alternative. I accept the specifications of the P�t Owne�/€�egal �epresentalive: S - � Date: �s " � — a � ' PCHD rev. 11/10/OS A `���, f �Jl.d�� �� . . - - "' �.����� 1E��so� � m��m.Il � IE-�m.m.Il�71a STTE PLAN Name � �l (� c���� Taz Map # t� r� o Parcrl #� v 2 Sub ' ' ' Secrion/Lor# D Authorized State Ageat Da e � System aomponents irpiesmt spptnzrm�te roamuts aalp. The coauacta�rmuat9sg tlre sysaem pdot m begianiag �e iasral/adoa to ;nQ,,.� �tP�P��de ia maiattiaed � �7 s���� �� �'�„� � «� . � �( ��— l'7 �o. D-Bo� � -� S�,c( �_ bo x W ���'� . °3� 4� � r� �S . � � Ul�t.2vt C��P�crr1� CY�i��,°�C� G�v�, (�P°b�cr� � 4�,'� 1�s f�'�e �s � ss� b�- � � �_/j �� u� i� 5.1.�ct s� s�r�-, c�uu�►� w�-� C��'�°� s- sa1� `( � � � � C7 K�`� '-��C{ r ", (�� i ✓1 �� � �C 0� 1��Q �� � �14 S �tr� • rcxD, �,•. o�/�z/oi � . �._,�� � � l��.�' � �� �� y11�� `_`' ----�- c� � �Tl�� ��� � ��s.��,*-� -**r++ �za.tE�.�. ����.�.��i � . . ..s •r_1• I.� 8 �� � � • ��x M ' arc # Swhdliv�i_ion � ��"�l-�i�r1: o � a.' edraoms �� t: t- -� �` '' �� � System Type (tn Acr�rdanca W�h Tabie Va): —�- a � THIS SYSTEI�! i-tAS BE�i�d It�ST��►LLFi� 1N COMP!_!�►NC� Wi'i'H APPLlCABLE NORT�-i � c�►RouAd�, G�i�E�tAL. sTA�i'UTE�, RUL.�S Ft�R S�IAGE TRE�'i�VlEAlT AND D1S�E�SAL, A1+1D AL•L CflNDlTit7NS � OF ' THE 1HIIPROVE3ViEiV'T PE�NIIT A�dD COi�STRUGTIO�f . �,u�r�-ro � � o�u. . � � . � ` � f��-�� - � - � utt�orized State Agerrk � � , Daie � lnstalteti By: . � l � �� rCHD, r�v. G71=?la� 0 � ���� �'��lB� 9A��r°���� �e'yE�''�S � ��� �l - � Ta� Ni�� � P�c�� # : Sys�m Typ� (i'a�le Va) Owned��piir�# Subciiivis9on Addi�slLD�ion SeclPfi2se �# � � � - � - � .��e - 0 �cl�d reu. 3/�k^JO�i � ... <..; ;: ::.'., . ;:�.�:�:''� . �. . .. �. ..:� . �.'�::�::..•.,;:. :." ...... :::; :�. t�•:�::};••�i�J:: .� .:�'J=i-LC �� : '.�r�.+!.�ti„~.:: ''";;.� :..�.... ..:�.v.. "''� �� �� .. 2:�:i_/�:�.'�'...�"..•' �� � �'•+. �. . � ���•�•� ... ........:,,. ::.:.:......: •.v.,;,.:.:::.�..;..,,....::••. . .. , , � . �:. .. . : .;.,. . : ; .. . ... . . : :.. . ..; .. . ; ,.:.:... ., . •::. .;. •..�tT'.�y:71•.'1L!49`11.7L� �„r-n;+n�> . .:.: �. � �7. /'j�� •. • . .. . .: ..�::n �n. ..�. ,R"i-,.s �.:'�'..�tiz`A:�.':�:•: ,.;, � ,... ... . .Y..;;,••:.•::. � . .,... . ....:.:,.•.. .. ��'rtII.�L:.�'1L�rn�.'' VY �LJ�1U �'�L' S3.lVJl.Y Y � �JL�1'�►7Y:r �9:�� Y3JL 3 t+1��3Y K A' N1 1��i �bA Y9' L' JI�.B� �H 9..' 'U '1.�� 3� 9J 3 Tax Map q�i _ Parcel #�p �, To�wnship: _'2.,X bo.+� Applicant• i.,,,_ 1C�Q �� 5ubdivision. Lot # Location: 1 SR c�r�t- sxas� l2a�r+ h�o�ri� �-�i i� a�. i,� 1 o a�. � �a ��) r-� x.ss �� b,.... �� ao -b �^a a,-,,� Type of'DVa$ea- S�apply: ✓ Individual �teqnar�a�en#�: Cammunity Public Site Approved By: �Z, ► � 3. p(p _ Grouting Approved By: � � Well Log: ✓ Pump Tag: ' � Well Tag: Air Vent: � � l �lose Bib:— l Z/.�oi4 Casing Height: � Concrete S1ab: � Liner: �Installed by: Depth set: _ Grouted: Date: Water Sample: Well Driller: � Well Approved by; � �� � Date:, J Z s d �***�ee �.ttache� Site Sfl�etch*y*� . � Wells must be 10 feet fram property lines. � ,� Wells must be 100 feet from septic systems, Wells must be at least 25 feet from auy buiiding foundation. Other conditions: �o� � o„o PC�ID rev 01!27/04 ...��� �.�Y � �,.��:.����:--: - � o� � � _ � Y � .� - i-{ �c� � �� � � ::�=-;� .. � a _ :;�::�:����::::����i:. : . .:� - . � :. ..--_.� ----= ..: .�: ��=�,m�.:����,.;�:�::: � �u€���:a.�: D� C�1 G . .. Grout Log �Q - ! Owner. ��l� �i � Tax Ma� Parcel #�l� Z Location. L7 _ , Subdivision: � Lot # � - Wed Constrac.tion , Distance From nearest Property L'me (l4tinimum LO feet�G� Distance from Septic System (M'mimu�n 60 feet) Total Depth: _l�/� . ft Yeld: ZU GPM - Static Water I,eveL• �� ft - - Water Bearing Zanes: Depth 1% ti ft/ L�% ft ft ft - Casiag. ' . Degth: Fmm .� toG��_ ft. Diam+eter: � in - Type: Galwanized Steel . - � Weig� ThicI�ess: j�� Height above Graund: in � , Drive Shoe: �� Any problems encoimtered wh�e setting casing? Yes �#� If `�es" give reason. • - Gront: ' Nea� Sand/Cement �/Concrete GraveUCemeni . -•. Aimular Space Width • mches Water m Annular Space Yes ' No Method of Grau� Pumq�ed PressUre Poured � Depth " to Ft Materials IIsed: - . No. Bags Portiand cem,ent ' Weight o€1 Bag Pounds . If mixhue (sand, gravel, cuttings) —Ratio to ID plat,es: _ Yes _, No 4 x 4 slab _ Yes _ No Liner_ - - -�. Depth: Aate Installed: DriIling Log Grout Installed by.- Location Drawing l�rom To Rorn�on . 2.. � 2 � - `' � � . �s`�� _ � � � . - � �oX��y. - s I hereby ceatify that �e above� informativu is coirect and t�at i�is well was cons� in accordance wii� regulations set forth by the Persan CountyHeatth�ar�t _ ' � Sigaatare of Coairxc�aor ID # � Daie Pamp Instaitment Pump Installation Co r_ (�J�'�!'�I;�%�liUf i.�� � State Registxation Number: Z. �� g� P�P �Pih �� ft 'c Water Level: $ Pumip Make & Mode1• �vll ��, P� Size and Ratin�. �Z.. hP gpm I hereby certify ti�at ti�is pwmp was msmlled and t3�e well head completed accordmg to the Petsan Coimiy Well Rnles in effect an this date and t�rat a copy of ' o� vided to well owner. . �P ��' �'e � Date- 7i � PG'AD rev Ol/27/04 �z s�ac� S��, �� ��, 7', � l`?J� —b t ������� �1G�� C��ed irt .�. /lC'GJ l.�!(_',�� c�r�`lec� °f�' qV'occ� on �J ( - 3a - 07. ��fs�iz. �'�o �C r,�;q� ,� / e � : �i ���. G��� ��a,Cy �,r yf �, �✓.� ��-C �� • �� ' �v� �i f-��rr/i�/ T- �/.�/� ,✓�� �'i , �� � � � � �,�� � ��