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�PP�.lCATIOfd FOR SE3iVIC��
�F TH� 16VFd�f�hflA�'1�N �� ��IE �►P�L9C,4T30R! F�DR ��I IE1�P44��fE�IENT ff���illAl�' !S IPdCaRRE�'i' ��LS6F�E�3
CN�►6VG�i3. O6� T�9E S9T� !S �1LTE�E�. �i�Ei� T'➢-9E !6i(Iff'ROb'E�iE�I?' ���f�i9T �ND �U��RtZ�i'i'l�� 7'i�
CL3�l9S'�!!CT SFIALl. �E�OflAE IAIV.4LlD. . -
� Pea�avei� re u�ted B� : �vue9�r/a �n4! ros ective �wner • �� c� � (� � � .`� +� e
) ve � Y la 3. p &� �� c�
Home Phone: 3 3C� �g �j�� �� 9(�, Address: :� / ��� / r5 C
eusiness Phone: 3�(c� Sv�f / 7S'� o v .�' 'G � 75"7' �
�)
N�e anc9 address of c�arrent owiener: �uC � T. � l�,'Aa� SA e.
3 /, ' e� es� �s� �
. n o G tX��ir
37�F �t Sck� ,��,° . . _. >i � i
3� Pro�erty Des�sti9
Directions to the
4�) �P0�30S�C� 4�S£ �I9f� S�YiBL'$SBPL �3@S�fip9#➢�P9: answer eacf� of the foilowing questions:
a) Proposed ✓, Existing , Type of Structure: �-Io t.�s C Width: 'ri�� '�f Depth: 3��'f`
b) Number of Bedrooms: 3 Number of occupants or people to be served: 2
c) Basemen� Yes , N� Wiil there be plumbing in the basement?
d) 6arbage Disposal: Yes , No ✓ �
5) �/ater Suppiy Type: Private �(new ✓ or existing�, Public� Communiiy� , Spring _
Are any wells on adjoining property? Yes ✓ No _ If yes, please indicate approximate focation on the
`siie pisn. �
+�) �oes your pro�ert� c�ntaan pe�viousiy ac�e�#efaes� �u�6sc�i�ional wei9ae9cis? Y�_ R!o �
F'��SE �07'E TF9E �OLLOVVING:
9� Pl�T O� THE l�R�P�3ZT`t OR Si'� FLAi� i1�1lSi �E SUBNi1�TEi31fVl'i'7� THBS �P��.�C�►3'ION.
➢ �640P��Z'T'l L1RlES .�AlD C�RRIE3�ZS nAIIST �IE CL.�►RLY NIAR�GED. � , •
9 i'�lE PROP�S�D LOC.�TiOM OF.4L�. STRUC'�UF�ES NiUS'i BE ST.4FfE� OR �i,.�GGE�.
9 T9-!E SITE iV1UST �E �aDILV e�C��S51�L� rOFZ �►i�l EVALU�lTi�EN $°f TT�IiE 3-i�►L�r$ �3E�AR'i'i�llEt1�T
S?�►�iF.
I hereby make application to the Person County Health Department for a siie evaluation for the on-si�e szwage disposal
system for tfie above-describ�d property. I agree that th� cantents of this appiication are true and rapresent the ma:timum
faciiiiies to be placed on the property. I understand ifi the site is altered ar the intended usa changes, the permii st�ai!
becom�vaiic�, � CL�V�=Li2�
�e � /t � �c� �- C��
Owner or ! �al Representative
Da►e
PCHD, rev. a6127J02
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Applicant
�
T�x (�ba� � , i ��rc-el � , i
Sllb(�'IVI�S�I011
Fh�s�e5ect�ian`Lot �
h �e S�,r (.e'�►��C ( c.rC'ro �s � ►�-, '
` C, �Kir�, e �r� �'
Improvement Permit
�ermit Valid for ��ve e No Ezpiration �� C
Type ofFacility: g� � New %� Addition i�ater 5nppiy
# of Occupan 2 # o Berirooms Projecteri Daily Flow 3� g.p.d.
Proposed Wastewater System: V L�« � � Type: -�``�
Proposed Repair: vi.v�e+.� ?.�w Type: ��i
P81�llt COIIC�1t101LS: '� I%� cl ln� S`l�
-��— .
Owner or Legal Representative
Authorized State Agent:
Date:
�
The issuance of this peimit by the Health Department in does not guarantes the issuance of other pezmits. 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 Caralina
`Laws and Rules for Sewo.�e Treatment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmeutal Health Specialist warrants that the septic tank system will continue to function satisfactonly in the future or'that
the water supply will remain�potable. � �
Authorization to �onstract Wastewater System (Reqnired for Building Permit)
* See site plan and additional attachments (_�.
Propo d Wastewater System:�� U.l,�.�,'�tU-t�. � Type, � Wastewater Flow �.p.d.
New � Repair Expansion _ Soil LTAR: r'?�- o g.p.dJ ft 2
Type of Faciliiy: � �� ��P �'. Basement _ Yes _ No
�a�Vastewatea� System Rea�uireuaents
'Tank Size: Septic Tank: (�C'l�ai Pamp Tank: gal Grease Trap: gal
�rainfield: '�otal Area: �� sq ft Total Length T� ft Ma�mum Trench Depth 2� in
Trench Width ,� ft Minimnm Soii Cover. `P in 1VIinimnm Trench Separation: � ft d � C•
Distribntion: � IDistribntion Bog Serial Distribntion Pressnre Manifold
Specifications: � �P s< �� 56.�'�-'r^ �
Authorizesi State A.gent:
Permit Exp�
Date:
The type of system pemutted is �, Conventional Accepted Alternative. I accept the spe�ifications of the
O e�/i,eg�l �epresentative: Date: � `� �''� %
' PCHD rev. 11/10/OS
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Ant�o� State Agent Date �� '
System eompcm� �mt apprco�rmsoe caamua c�cly. Thr ma�aarmustSsg �e sysirm pdar m begm�g ffie ms�saaa tv
fn,a„,. �rPa'Pagadeism�o�ed _ _ , —
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Applicant:
Location:
�x M�p II � � �rc I ; i ,
Subciivision
Ph�se Section, ot #
# of Bedraoms
—� --
- �r�#ian er it cZ,��
System.Type (In Accordance Wiih Table Va): �v
THIS SYSTEM H.4S �EEiV INSTALLED IN COMPLIANCE WIiH APPLlCABLE . NORTH
GAROLINA GENERAL STATUTES, RUtES FOR SEWAGE TR�TMENT AND DISPOSAL,
AND - ALL CONDIT1�iVS �F ' THE IIViPROVEME9�T PERMIT AfVD CONSTRUCTI�N
AllTHORf R!. � .
. � � Vl/'e� _:J 7 "d$� � .
A th rized State Agent Date
lnstalled By: �' � � �' � Date: � �1��� � �
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PCHD, rev. 07/29/04
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���'-r�C �°�� ���������� ��i�+�c"�b.�s� �'��� �� � �
Tax Map # �� Farce! #�(o Sys�err� Type (Tabie Va)
Owner/Appiicant Subdivision
Address/Loca�ion SeclPhase Lot # '
Se��c.'Tank I�ataa 1Da� atra ac��aora ines n��a a� �
State�ID/date S��C�e�, �/ Trencfi �dth� 3 ft. ,�4-s�
Ca aci !9 8�. al. �`�' � Trench De th in.
Tee and Fiiter - • +/ T,rench Len h 3oa ft.
Baff1e � ✓' Trencf� Grade � �
Sealant Trench S ac9n .✓
Riser ifi a licable � � Rock De th and Qual' �-
Tank Outlet Seal Dams/Ste dovms etc. `-°-
Permanent Marker Pressure Laterals � �
Purna Tank � � � Hole Spacing � . ~
v�a« �viwc«
- Ca acity gal.
� Wa#e roof ISealant
Riser
Water Ti ht �
Pum@�
Check ValvelGate Valve
� nt�-si on o e
Floa#s/Swiiches
A(arm visable and audibie
Electricai Com onents �
� Rate m ..
A roved Pum 1Viodel
Block Under Pum �
� Pum Removal Ro elCnain
. �Dis�ribu�on;Sy��rn
� Serial Distribution
� Pressure ani o
Low Pressure Pi e �
A r. Pi e I�iateriai and Grad� �
Valves `
O e iZG'
Pip�. Sieeve
F2equired� Se�acks
From Wells
From Propertv fines
Surtace Waters
Public INater Suppi
Verticai Cuts (>2 ft.
Water Lines
Vehicle�Traific
Easements/Right of
O#tte�'
Easements Recorde
Co�raim�n�
reem�nt
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pct�d rev. 3/13/01
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IC�aia�n.���.yu�sr..����.71 IE-IC�,�.3L�ILa .
WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �� 0 arc # a� � Township:
Applicant-�� -�
Subdivision: Lot #
Type of Water Supply: � Individual
Requirements:
Site Approved By: S 13 � 09 -�����
Grouting Approved By:
Well Log: , n
Pump Tag: � , . H l�f•
Well Tag: , /
Air Vent: �/
Hose Bib: ✓
Casing Height: �
Concrete Slab:
Community Public
Liner:
Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
Well Driller: � `� `�^5 W p � ( � r`� �� � �
Well Approved by: �nn Date: �� 3 f�
****See Attached Site Sketch****
Wells must be 10 feet from property lines.
Wells must be 100 feet from sepric systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD rev O1/27/04
�_ �.
12i05/2287 113:17 =365977508
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O�m�r:
TaxMtp�� Puas1 #
Looadon: �
9ubdiYi�an:
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' � Wdl Cy�u�! roe�Os
Distauo� Frvm a� Prap�atY Line (��3t�um� 10 fbctl- --
D�umc� from tio Sys�a� (Miaieatmt 60 fa�t) ,_.r.,_,_.�._ .
Taesi L�e9eb�: !t Yidd: �iPM $LetiO Wd� Latt�l: � s �
. Watar � Zae�s: Death t� !� - it . R
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i
Dep�h: Fra�n ,^„Q,�,,,_ ta � !1. Oi�rtwbeir. �_ !n
��►pc: WCiv�wa�e�d�iwl �� Heigbt above arotmd: ..1,�_ i�
Deiye 91we: ,_,,,__ Ya No Atty prabt� �pva�tutt�esd wkil� � oatm�t ,Yea
If "yrs" �ve sM►wn: �
G'i��ot�tt:
Neat SaudrC�trr�nt ✓ Conote�e ,_,_,,,,_ Qnvr1K'�eeaent
A:mul�r Spaae Widtb taeb� Watsr ia Mo�Lr BPace _._Yw _..
Macbod af Cirout: �Pxqwre �% Pouaed � Deptb to
Mat�rf�tM U�i:
No. Bap portl�d c�t � Wei�t af 1 Bs� �,�potmda
If miut�e �pw�d,.grave2� �uttlngi) - � �;,,�,'�b �
Q? plaaet: ��rea .,,r No 4: 4 �lab et � No
L�o:r: �
Lkpth: Dibe ia�tsikd: _____�._,__� Cito�t� . ._...
�� �
I.Ct��Oi
I hareby certSfy that thr tbove tufarmatian is oo:sett aad tl�at tlt� walt '*n! cavstruobed in
by the PRsott Co�mty I3a11k Dep�Vs�t ,
s� �tcorwao:
1D 1t ��� _� D�t�
Trn� InK�i�t '
Pva� Isubatl�uon Contraci�r: Stfte R�istr»tion Nta�s
Put�p Dop�i ft Stadc 1�V�ter Levsl: !t
Putt�p lisats � Model: Pu�p Size u:d Rr��:
[ hereby cer�ty tb�t this pu�np wu instalted �sd tbe �asil hwQ acmtplited tczoedinf ro the
on thie date md th�t a aapy of thi�e rrcocd hu bcea provided to e'!w w►d1 oveaa.
Puetp �wtailawr 5i�tatara Dste:
Itt.
by: ____
�cc with re�ulstiasaaa sac fcatb
,�� . ��, �
�tr:
�P . �
C�ty i+vs1l Itula ia effect
__ PC�iD nv Ol/i7n04