A29 115Applir.atton Date: � � 5–j� �.
Amourrt Paid:
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Tax flAa #: / �c�
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APPtJCAT10N FOR SHZVIC� �
IF TNE INFaRMAT1aN IN THE APPtICATION FOR AN IMPROVE�AAENT P�RMIT 13 INCDRRE�I' FALSiF�E�
CNANGE�. OR THE SITE IS ALTEREi�. THEiV THE IMPROVE�UIENT P�MlT AND Alli'HORIZATION TO
CaPioSTRUCT SHALL BECOME IN�I/ALID.. -
. —_
1) Permit rsquested by: (Ownedagentlprospe�ive ownerj: (� M. �w�s
Hcme Phone• Address: S' S
Business Pt�one:s� - 5��� 5
2) Na�e aud .address of ciment ovmec C,„ �,L(�
��-T T' `\
3) Properly Description; L�t size; Twvruhlp:
Di�ections to the property (Induding ro�d�mes and numbers): __
Lat #
4) praposed Usa and Struciure Descriptlon: answer eacfi of the fdiowing questions:
� a) Proposed „�Existing ✓ i"ype of Struchu�e: � Width:� Z Depth: �J•�.
h) Number Of �edrooms �� Number of oc�upants or people to be served: �'
c) Basemer� Yes . No �il there be plumbing in the basement?
. d) 6ar�?9e Disposal: Yes . No �� . ,
5) Wafier SupQiy Type: Private �new _ or existin��/ , Pubiic_, Community� . Spring
Are any wells on adjoining property? Yes_ No _ if yes, piease indicate apQroximate locatiori cn the
'siie pian.
6) D�s your proQerty ca�ain previousiy identifi�i jurisdiGtio�i w�lands? Yes_ Na�� .
" PIEASE NOTE THE FaLLOWING•
➢ A Pl.AT OF THE PROPEi2TY OR SiTE PLAN lI�UST BE SUBMTfTE� WITH THIS APQLICATION.
➢ PROP�iZTY L1NES AND CORlNEiZS MUST BE CLPARLY AiARl�D. •,
9 THE PROPOSE� LOCATiON OF ALL STRUCTURE3 MUST BE STAi�� OR FiAGG�.
➢ THE S1TE MUST BE RFADILY ACL'ESSiBLE FflR AN EVALIlAT10N BY THE HEALTH DEi�ARTMEid'i
STAF�. �
! hereby make aQpiication to the Person Caur�ty� Hesith Departrnent fn� a siie evaivatio� for the on-site se�wage disp.osai
system for the above-described properiy. i agree that the cantents af this appiication are true and represent the maximum
faciiiiies to he placVd on ��erty. i understand if the siie is aitere� ar the irrtended us� ct�anges, the permii shail
became irnraiid.
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Qate
PCI;D. tev. OGiZ7102
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Tax Map # � �� Parcel� # �
Existing Sewage System Report For. �obile Home Replacement a '
✓Addition Type:��,��� � �nnn� J/�O�
Requester. ( �
-� 39 �{ � �
Home Phone#
Business # _� %" �
�
Original Permit Lacated: Water Supply: � JV�
�
Septic System Designed For: . esidential Business Other
# Bedrooms � # Employees Other
System Type:
UJ/��{VM�C�,� Tank Size: Nitrification Line:�� 3�
Date Installed: lo I a'3 ��_ � Certified Operator Required: / V I/�
On-site wastewater disposal system shows no visual signs of malfunction on ��I �[D`� .
Pemussion is granted to: �. ),(1 �� �� l�UC�t c�G'1.,�.C� 1✓�.t-+ �c
�nmmPnta� �e�� V `�- • �irYl � h )T� � • � ,� � `
Environmental Health Spe ' t Date: �� 5�
Person County Health Department
Environmental Health Sect�oCn� ��
Zoning: Township: UL -
Subdivision• 1 � ��t fa IK-t_ �, Section: Lot: �
Applicant: ��1/V���{,�
Location• �C� �7 ��� _l���T 5 ����' L'! !� I �l � V �
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements ��_
B) Distance from system to any welis / �
C) Distance from septic tank to foundation
D) Distance from system to property lines
Z. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank _�
B) Visually inspect the interior wails, baffle, tee, �iter, riser, lids, air vent,
bottom, and water tight outlet
C) Date of tank manufa ure —
D) Tank seriai number —
E) Liquid capacity of tank _� n� 9allons
3. SUPPLY LINE TO T ENCHES
A) Grade [ 1/8 inch per foot minimum) uG
B) Material supply line i constructed from �
C) Diameter � �
D) Length �
E) Distance from tank to drainfield/distribution device �
4. DISTRIBUTION DEVICE(S)
A) Type �
B) Is Device water tight
�`j�/ C) Distance from the distribution device(s) to the trenches
��.1� D) ls the device on a level foundation
,�� � E) Does the device perform according to its design specifications
u let elevations
F) Record the �nlet and o t
5. NITRIFICATION FIELD
A) Trench depth inches
B) Tre�ch width inches �
C) Distance between trenches Z���/1 ��,(i%1 �i�
D) Number of trenches �
E) Length(s) of trenche ���
F} Aggregate depth � inch s
G) Aggregate material and size �
H) Record septic tank utlet elevation 6�
I) Trench grade /� (<_ 1/4" per 1'
J) Step downs J
a. Minimum of 2' of undisturbed earth �
b. Proper rise over step down
c. Solid pipe used �
d. Elevations of step down$yz�� (Record elevations and show on as built)
� See "as built" plan`dn attached sheet.
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section
Tax Map #: �"7� Parcel #: � I �
'Zoning• Township: ci%�/1,� TTI�V'
Subdivision: vi � �P. �QI /�� Section: Lot: r
Applicant: ���iw�-� �
�ocation: �gS �l� tl��-er►�st��e �;��1�► �Dt D�/I i��.
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.
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PCHD, rev. 10/12/99
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � Parcel #
Zonin� Township
Owner/Contractor
Location/Address
Subdivision Name
Date � —1
> �'P� l� .�'`�
S.R.#
Lot# ' j
SEWAGE SYSTEM SPECIFICATIONS
Lot Area �,��� Size ofTank � '
�/ Mobile Home Size of Pump Tank
:ss # of Bedrooms ,� Nitrification Line � il'3 �
Permits may be voided if
Well and Septic�ayout by_
Date
Installed by.
Max Depth Trenches �'�
�f �� �� �
is altered Qr ir��ded use changed� (� ��
by
�" �."" 1�-�29-9 v �
Well Permit Paid W L SYSTEM SPECIFICATIONS
[ndividual 1� Semi-Public Required Slab ,/
Public Repl ment Air Vent �/
Site Approved � Required Well Log �
Well Head Approved Well Tag
Grouting Approved 1
-��........,,.,�... M ,n I��I�- �.m�v� �n.r�. � /�1� ���'� � l _ � i�i✓►�
Approved by_
This report is based in part on i�formation provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental nealth specialist is also not
responsible for co�cealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l