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�el�ta� �o.p#:�i- �c. �
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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+�
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� oE4"ice. �ersor�„¢t
co�w,; ttee� I o-tv l5
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' 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. . .
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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
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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 ��-�
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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
/ �
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PCHD, rev.11/29/99