A28 167. . 3 � � '.� -
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Person County Health Department �
Sewa e System �mprovements Permit
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Date: �I'h�s Permit Void After 5 Years
Owner: � � _ fl SR# / 1�
Subdivision N ! Lot #
Lot Size: ' �' Type of Dwelling:
Water Supply: Private: Public: Community:
Bedrooms: Z Garbage Disposal
Basement Basement Fixtures
INFORM N R��D BY r ��t,?"�..f?�AZ� .
REPAIR: � � REEVALUATION:
Size of Sepdc Tank: ���G�„�— gallons Size of Pump Tank: ----I
NitrifcationLine: �f�10��� �
(
Depth of Stone: 12 inches
Max Depth of Trenches: ,
AltemaUve System: Conv. Pump LPP P�mp
Remarks:
,�
D e Well :�'� Well should be 100 ft� from any sewer system
B Sanitarian � �
e ewa S pproved: `3-- 1
B Sanitarian
' . CERTIFI ATE OfF COMPLETION
Contractor. � �+ww-/
------------------------- �
Sewage System location, installation, and protection must meet state and local '�
reguladons. Septic tank should be pumped out every 3 to 5 years and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and'd
nitrif'ication line must be inspected and approved by a member of the Person Counry �
Health Depaztment before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemut is subject to revocation.
(G.S. 130 A-335F) �
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Location of sewage disposal sewage system sketched on back. �
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7
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date: Note location of water supplies on adjacent lots.
(1)
(2)
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Apalication Date: _3/1/07 Tax Map #: A28_
Amount Paid: �0
Receipt #: 1 Parcel #: 167
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APPLICATION FOR SERVICES
Permit (Recorded Lot) -
❑ ImprovementsPermit-3150.00
(Mobile Home ReplacemenUAddition)
O RepaidReplace F�dsting System Pem
Construction Autl
$150.00!$200.00
Pertnit Revision i
for
- $75.00
3) Property Description: Lot size: Township: Olive Hill_ Subdivision: Lot #
Directions to the property (Including road names and numbers): 49 South, Turn Right on Blalock Dairy Road,
approximately 2 miles on the right after 1509 and before 1360. A log house in the woods.
� 4) Proposed Use and Structure Description: answer each of the following questions:
� a) Proposed _, Existing X_, Type of Structure: Width: Depth:
b) Number of Bedrooms: _2_ Number of occupants or people to be served:
c) Basement: Yes_, No X,_ Will there be plumbing in the basement?
d) Garbage Disposal: Yes _, No X_
5) Water Supply Type: Private X (new X_ or existing�, Public , Community�, Spring _
Are any wells on adjoining property? Yes X No _ If yes, please indicate approximate location on ihe
site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No X_
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 STAKED OR FLAGGED.
➢ THE SITE 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
become invalid.
Owner or Legal Representative
<3')-� 7
Date
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PCHD, rev. 06/27/02
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STTE PLAN
Name ��Cd� yl��r•,'r�+t�.il Tax Map # �g Parcel # iro7
Su%div' ' Seuion/I.ot#
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A orized Stabe Ageat Date
Syatrm campaamtv neprescat appca�are contaras mly. The co�uacormusrflag the system pdar to be�Ounmg �einsraO�oa to
�no..... t6atpmPergrade Is mmiam�aed
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+awner. � c.d �p a Well Log
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Location: !-� 5-� � o T� MaP � P�rcel #/ 6 7
Stxbdivi�iur.: !�1q--�s-K F�t2v Rd —� L it--�.^L..�
Lot �
Well Ca�utr�ctioa
Distance Fr�r.� nearest Prupezty Liae (Miai�mum 10 fc�t) ► c� �
Distance from �aptic System (Mu�imum 60 f�et} �. a
T°� �P�: , 2,,.a5 ft Yield:� l��� GPM S ctati 'Water I,evel: a.s ft
Watet Hearing Zar�es: Depth 1' 7 0'�' f� ao o'� t} „�_____ fi f} —'
� F-�er 7'SO �
Cs�la�: 8 4
Dept�: From �_I to _�3 ft. Diametes :����{ in
Type: GaJvaaizod Stetl ✓ `�"'
WesBht. _. o�'I'�ickaess: - p� Height �bave Ground: 1�. in
!?riv� Sho�: _✓ Y+as I�� Any prablems cxcc:ountered while $etting" uicas g? �Yes !✓No
i�' "y�" give t�e�san•
, �
Grout: '
iVr,�t: SandlC�meat �Cancretc GraveUC�mcat
Annuiar S�sacc Width ,_ inc��s Water ia Att�ul�Space � Yes No
'4iCihc�i of Groui: Ptuz�pcti .__....._ r Pz�ess�u+e _ Poured � I3epth to ^ 2� F�
'_b�dxirr�ia�s Uxed: .�
No. Bags� Portlend cmieat Weig6t of 1 Bag �� Pound�
Iz mixture �sa�d, grav�l, cuttings} — Ratio to
ID plaus: � Yc� ____ No 4 x 4 sl�b ,� �e� � No
Drlllin� Lc►g Lacation Drawiauu�
I hereby c�rtir'y th�t th� above informution ig eorr�ct and that this weil wa.a constructed in accorclance w�ith regulations
set farth by *he Pe'rson County Health Degartment.
Si�a,�ture af l'.untrsctor _� n,c., "��%¢it�-_�� IIy i� � Dste ��% — 6 7__
PcxD n� ui�i �.�e: