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A28 88' A�oltc�qo_n na�r • 1- aa2-o ( •�,�' � aa.� r � �' Dv o �. . . r� d o . _ �_ ='�a����,� . ��= . �_ - . �, I_ -. �� -. _-.. _ . . �a��3 . Person Caunh� Hea�h Dso�rhnartt Epviroemrntai Heaith_�� �'r:i _i.-' • i i�l. _ =i11�'_ r� �.o � � a �g �� �R _ 1) Asnnitr�qu�bd by: { �; -KeY. T� en �:.h ��ders H�Pl�oeec 33�- 59�i-�tc`I C3'i�� Add�aa� �5 ��•, iu� a P,�, Bt�i� Pfio�: 33 t� 5�iq • LI I? o ro '1 -r� �el�ta� �o.p#:�i- �c. � Z) Nte� and addnn ot t�a�nt a�nse: tZev. �i{e,n Ch; I ders , c� '15 ' OY$oeA rtic ' �.'15'13 '� �P��I � �� �.�� • � ( I�rt.. �i���H�,,'`( Dl�ions io ihe pr�eriy � rced nan� aM nwnhas� l 5 i� V� Gt> r'r•e r . p �'►-,eG NQstec' i2d • . 4) Prcp�d t� a�1d 36vdttna Desc�ip�an: an� �d7 of ths iDBoadr�g 4� � a) P+�'�. 6d�t�p � b) Stidc Bu�'A. No�r 0.� Wlds q Daubie.lNlds ❑ c) � of �n�x . . � Numher of aas�perria a' peo�s bo be se�va� e) Basemenr Yas Q No�(!t �ta�s� n ��,ra.� � . � �� No 6'a�b��, gj p6�u�ions of proposed 7� pa�h; '�' j ��'s�PPhi'rYP�: Prlvatel�i (naw � or eod�9 �. Pub�c 0.�1f 4 s� ❑ • � IUa anyweBs on ac�o�drp pro�lyy? YasO No � Ityes. locafion ��� D�d 9ya� TjIP�� is71� cast be �u�iaed M ardsr ofY� P�'�l v Ca�n� _llo�lt�d Comr�tlaav! _ A�r�w �enanrati+� . -, . �� t�!►I� 1►�� � oE4"ice. �ersor�„¢t co�w,; ttee� I o-tv l5 �!s�os.� ' tX.PA►R�.Y STAl� ALL CORNEi�B J11iD � OF THE Pli�PERTY. 9TAKE THE tARME�iS OF ALL PROPOSE� S'iR�JCT!lRE9. P�.FIhSE ATTACt! �t1RVEY PLAT OR 31TE PLAN TO TH18 APi�LlCATIGN 1 heneby maim �t tfl ths Peia�on� Cciarty Haailh. Departrne�rt ior a s�s sva� fi� the on-e�e aewaAe �posai aya�n for the aba+�e�desQibed pcope�ty. �i agree tl� tha co�s af tt�is app�n a�e tn�e and rept�etrt the maod�uun ia�s to be pi�ced an 1he p�stly. I under�nd if the s�e is ai6e�ed arthe ir�ded uae � ihs pen�it � become i�n�fd. i u�tdersCand' that as a�rt, 1 am r�or�fe i�Cr' ide�9 �+�g ProP�Y �. c�mers aRd msidng the s� a�e iOr the R�ttnd af ihe Persa� Caeudy He�th D� fe. conduc3 iluair aueiva�ons. I entde�nd thet i a�n raspona�s to�r nai�a►9 the }iea�h �epertment tT mY ProP�fi ��na anY w�attds as � bll tha AtnN CanAs of �a�a. . . t, , . 0�—��-�� . • , . �vmer or t.egel Re�ueaen�i[ve . Da� - . Pa �e.. � o -� � PERSON �UNTY ENVIRONMENTAL HEALTH Tax Map #: � Parcel #� Township ���P ��r f� PIN � 6eulah %3apflsf C tizh AppUcar�C Ke n Ch lc��P SS Subdivision Phase/Sectton LotS t.ocanon• l5� (,t) S� � lniP�l (�/ i h L��7'�r � Improvement Permit � _� GIJP� New �ddition Type of Structure %5 X y5 � G�1 N/'c�i Wafer Supply # of Occupants # of Bedrooms Other o� eM,O%vPe 5 d/Oo //7���e�5 System Type_�G�. Projected Daily Flow: 5S0 g.p.d. Permit Valid Fo� ❑ ive ears ❑ No F�cpiration Proposed Wastewater System: G�r1 �>� n�� or�a Proposed Repair. Permit Owner or Legai Representative Signature: Date: Authorized State Agent: Date:�L � The issuance of this permit by 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 Improvemerrt Permit shall not be affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Wastewater System Desaiption: Wastewater Flow: �r`- "�S'O a.p.d. Type: � � Facility Description: �G New� Repair ❑ Expansion ❑ Basement? ❑ Yes�] No Basement Fixtures? � Yes No ~ I� Wastewater Svstem Requirements Tankage: Septic Tank size 5� gal. Pump Tank size ��I gal. Grease Trap size �� gal. Trenches: Total length �_ it. Trench Width �_ft. Total Area O-� sq. ft. Max. Trench Depth: ��1 in. Aggregate Depth:1� in. Soil Cover. � in. Trench Separation ,�ft. on center Permit Expiration Date: �/ � l�i � Authorized State Agent Date: i / � � *Ses attached site plan and ddendum pages for additional permit conditions. The type of system pertnitted ❑ does 0 does not differ from the type spec�ed on the application. 1 accept the specifications of this pertnit Owner/Legal Represerrtative Signature: Date: Operation Permit System Type (in accordance with Table Va) This system has been installed in compliance with applicable North Carolina General Statutes, Laws and Rules for Sewage Treatrnent and Dispasal, and aU conditions of the Improvemerrt Pertnit and Construction Autl�orization. Issuance of this permit implies no guararrtee that the system installed will tunction proper(y fo� arry giveo period of time. Authorized State Agent Date PCHD, rev. 03/07/01 u � � -._a_ . � -� _ � .. _ . . �s�ea �� i�eaitDa �e�ar�r,eni � �ae��raener��ai �ealih S�ci�ors ,. , ; . ,� r� . o r . .r:� :� ��� - . �a� g � c � s� s�-rc� . -- . . . . . _ --�--�{��. ��.����h;/ A� � . ,4p�itc�s Name s�diviaicNS�cNLc� S y� , o . . . �d s�te,�t � - � � �►������m�ao� The�m�r,1��� . p�do� m� die i� �v m�e �tp�+�� �S �ami�r+sd '7 � 1" G��'� s`��� �Y �� r� �,n j�a e. 5 �e.e_��� �� t� G���LTi (ti- � ro (1 Oi' ��,T qr��A.� Gu��Qr'�-� � J � �/ . � Q� a� ' � � �-�- , �• - P __ 0 � . ,6�, , ;-r � :� , .'� j�'�;,: ��% � Q ' � ,�;-� v° , � ,� y.� ;��5, �, �rj�¢iG. �t��1�1 �'�Qf! /Ytq�/lt�ni/t S, 5ef�c•c►� ��om �'J u,'�cf;n� . �. su,�pry �;��, ��,� -�an�� +o C�ra�n���e�t� 5�ict�� �2�. S�P�.U�d , b�C�tuS� 'c�ri V� Wa� i 5" " ���.f4X O /1 1 �� • � Sww� �f �•�n� �a �. n, ��;d� �I� �.h � s �ll h �, i n5-�A �%� A, b o U�2 C� rc�; ��; �c( , y. � �i' d��;,�1� �� � � + � - a�'' ��en�� �,� h s �i� �� ;,,$�At�� a,, • Gon-�-pc,�� � � � _ _ � \-��. � �;�:Zt � � a (� � ��G�1 -- �,.� Sc�e; � . `` PERSON COUNTY ENVIRONMENTAL HE:4LTH ' PLEASE SE� AT�ACHE� Pl..AN F�R WEi.L SIT1E LAYOUT r r Parcal � � D � � Tax Map � t� T�1p bIl �_�l� ll Zon 9 , �°_ / : a�u,�o� �p f;5 . L u ��-� �►P� Ken Gh � I �r� �s . : . . ��: -- _ � �: �- Subdlvhioa• - . Weil Permit ' yae of Water Suapiv: Individual Community Pubiic Reauirements• Site Approved by Grouting Approved by Weli Log Well Tag Air Vent Hose Bib Concrete Slab _ Weil Driller: Well Approved By: � Date: � **See Attached Site Sketch** Welis must be 10. feet from property lines. Welis must be 100 feet from septic systems. Welis must be �at least 25 feet from any building foundation. Other condiiions: p� �,So�'S / � � PCHD, rev.11/29/99