A28 59•Amount paid ����---
Receipt.� ' Q
z4�_ �'y� - ���}I�
Person Couniy Health Dept
325 S. Mof�an Str��t
Aoxboro, N.C. 275?v
Gour�er'�2•��-15 �
�) / � �
Date
� mprovements Permit. (Established/Recorded Lot) ._ Reinspection of Existing System (Loan Closing)
_ Impxovements Permit (Unrecorded Lot) _. Repair/Replace existing Septic System
�. Improvements Permit (Mobile Home Replace)
II_ Improvements Permi[ (Addi[ion)
�
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� ' 3� �� $ � i-,.,F..�t .z.i � %..`•Y.av;.�x;;',. .-Yt""'+r r� ���5! yr.K
pv�e.`.bi .�1: de.::, F a,X'.x `....`S,..van:.� c,'s 3;.
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Bacteria Chemical
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�1'ecmi[ for New Well
_ Replace Existing Well
_ Petroleum I _. Pesticide � _ Lead
l. Permit requested by: . 7. Dimensiot�s or� Proposed Structure:
owner/prospective owner/agent: �.AroA �E���%�s Width: �4 � �
ar�rirP�t� . R y(A d �o.STO�J t�o A-/� _ Depth: 3�
�
�
ome Phone #:�,36 - S � y' ��o �
usiness Phone #:3.!� � �g7" ��s0
Name and addre�s of,current owner:
r�
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
9. Water su�ply ty pe:
private �public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes �.�'No �.
If so, identify location:
. Property Description: Lot size: �� 7d /�C I
. Tax Map#: o �d- � 10. Type of structure/facility: Proposed: xisting: Q�
Parcei#: � ,Pcpu�°"` Type of dwelli g:
Township: D/� v�. /.�;//. ��" • House: obile Home: C7 Business: ❑
. Directions to property: State Road #& Road Tyge of business:
tames,�tc. wc.s T Number of Employees:
�i /SS3- .L��/�S �1h'q Number of bedrooms: .�_
� ��� ����N�� d� Garbage Disposal? Yes ❑ No �
��n iao Brz��✓csf Sue_ T,z�, ;�ro sK�- Basemen[? Yes ❑ Nofl�o, # of basement fixtures:
Lc�� . �� ,
6 Number of occupants or people to be served• .�_
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'Son COunty He3lth 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. I understand tha[ before an Improvements Permit can be
issued, I must present a survey plat of the propercy to the Health Dept. I understand chat in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
z v J Signc� Owner or Authorized Agent
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Taz Map #: ��iJ Parcel # l- I
Zoning Township /� � � —
/I4R/(�S/,�'/IUY/ll9/. /f i'It74/%/%rJ
�
I' �I � � �/�
.I�/ /, �� /.L.%
Lot: �_
Improvement Permit
A buildinq permit cannot be issued with onlv an Improvement Permit
New � Repair _ Addition _ Type of Structur�� Water Supplyj�UP,�.�
# of Occupants 2 # of Bedrooms � Other •
Basement? � Basement Fixtures? _�'j�
Projected Daify Flow: � g.p.d. Permit Valid For. GYFive Years ❑ No Expiration
Proposed Wastewater System Tyge:���(-f�1�]._(1 �/�i� � Q���>' �"/ J
Pump Required? Yes ��No ' u
Permit
Representafive
/
Date: � � " ��
Authorized State Agent: ����. � la/1 �3'//I,( � �/% Date: � � � �
The issuance of this pennit by the Health Department in no way guarantees 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 intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance wiEh the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Type of Wastewater System(��
Faci(ity Type: (5
Basement? 0 Yes o
for
P��(�1�CLUi�jNastewater Flow: �g.p.d.
T-/ �
New G�' Repair DExpansion ❑
Basement Fixtures? O Yes !o
Wastewater Svstem Requirements
Septic Tank Size: 1�� gallons Pump Tank Size: � 9atlons
Total Trench Length:q�feet Maximum Trench Depth: �1 inches Aggregate Depth: �7in.
1U.��rwtc�c�Y1
imu Soil Cover: � inches Trench Separation: � Feet on Center
• - `' .I _.I /__� iI_
Permit Expiration Date: s �—���
Authorized State Agent: o�x���/, . � � �����e���ate:��,�d1
The type of system permitted ❑ does Q does not differ from t pe specified on the application. I accept
the specifications ot this permit. _
Owner/Legal Representative ignature: - � �– Date� � � �d
?CHD, rev/ 10/12/99
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Person County Health D.epartment
/� Environmental Health Section
Tax Map #: r) 2� Parcel #: 5�
Zoning: Township: '
Subdivision: �f���1� I'�Vt".C�/_1-�V � Section: _ Lot: �
Applicant: Lll/�LIG� �
Location: V� D l5 � ��l�/1'�w �
O eration Permit
System Type (In Accordance With Table 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
AUTHORIZATION.
, • �'/ � `l�
uthorized State Ag nt Date
Tax Map #: ,� Z� Parcel #: ��
PCHD, rev. 10/12/99
• ' Person County Heatth Department
Environmental Health Sect�
Zoning: �2� Township:
Subdivtsion: ,� CX� i'o/ Section: Lot: �
Applicant:
Locatiom ���
Operation Permit
1. LOCATION AND SEPARAT(ON DISTANCES
A) System meets .1950 setback requiremey�ts ✓
B) Distance from system to any welis r '
C) Distance from septic tank to foundation �
D) Distance from system to property lines �/t��
Z. SEPTIC TANK
A) Visually inspect the exterior walis and top of the tank ��_
B) Visuaily inspect the interior wails, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet ✓
C) Date of tank manufacture �, l�-�
D) Tank seriai number,�1� -1��0 STf�-l4Z
E) Liquid capacity of tank _1f�00 gallons
3. SUPPLY LINE TO RENCHES
A) Grade (1/8 inch per foot min�� �)'nUG
B) Material su ply lin s constructed from ,S' ��
C) Diameter ��
D) Length � �
E) Distance from tank to drainfietd/distribution device ? •
4. DISTRIBUTION DEVICE(S)
A) Type -
B) Is Device water tight
�l � C) Distance from the distribution device(s) to the trenches
I D) Is the device on a level foundation
E) ❑oes the device pertorm according to its design specifications
F) Reco�d the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth inches
6) Trench width inches
C) Distance between trenches �q � Ob'I (.��i1�'
D) Number of t�enches .
E) Length(s) of trenches
F) Aggregate depth j�_ inches
G) Aggregate material and size
H) Record septic tank utlet elevation
I} Trench grade 1 G1 (< 1/4" er 10')
_ J) Step downs
a. Minimum of 2' of undisturbed earth ✓
b. Proper rise over step down _��
c. Solid pipe used �_
d. Elevations of step downs �(Record elevations and show on as built)
See "as buil plan�n attached sheet.
PCHD, rev. 10/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: �" " Parcet # � �
ZoNng Township ��� �/� " ` "''
ppplicant
Location:
S �Section: Lot: �
Subdivlslon: �� r _
j��
Well Permit
�pe of Water Suaalv: ,� Individual Community Public
Reauirements•
Site Approved by ✓
Grouting Ap ro ed b�
Well Log 'I
Well Tag
Air Vent
Hose Bib
Concrete Slab
• . rt : r.1i1 ►
/'
. . . . - . �,.. �:!� l�%i
Date: 7 � ���
**See Attached Site Sketch**
Wells must be 10 feet from property lines. �� ��Ov,� ���
Wells must be 100 feet from septic systems.�l(�G�GLG�(!�!G� � C,� �
Wells must be at least 25 feet from any building foundatidn.
Other conditions:
PCHD, rev. 11/29/99
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