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Receipt 1� '��j�j��^� � G � Date
��— l���• A nnT TrATT(1N F(1R CFRVT�FS
- - - �"�
Improvements Pemit-("r,stablishec+/Recorded Lot) I_ Reinsceccion ot �xisting System (Loan CIosing)
ImG:cvemencs Perrnic (Unrecorded Lot) I_ Repair/FZeplace existing SeNtic System
Imoroveme�ts Perr,ii[ (Mobile Home RepIace) �_ Pe„nic for New �iJetl
Impravements Permic (Addition) Reptace Existin� Well
_ B acteria � _. Chemical
t. Pecr:�i[ reques:ed by: . �
�wne:/grospective owne:,'a;e:�t:�
Addcess: � � i_� �� ��.'�
:ome Pr.one �:
usiness Phone n. ���� .-L�C�7�
_ Petroieum � _ Pesticide ! _ Lead
7. Dinensions or P:oposed St,�:cture:
Width: —
De�th:
8. Wnat tyce (if any, addicions, expansions, or
re�lacemeZt is anticipated to the structure or faciIity
that chis sewa;e disucsal system is inteaded co serve?
Name and address oc:c:.�rrent owner. 9. Water sugoly cS•pe:
' private j. pubiic Q communiry ❑ sprin� ❑
Are any weIls on aajoining prooerty?Yes ❑ No (�.
__ If so, identiiy tocation:
. Property Description: Lot size:
Tax MaF
Parcel�:
5. ' Directions to property: Scate Road #& Road
Names,y �
6. Number of occuoants or people to be served:
10. Type of structurelfaciliry: Proposed: �Existing: C
Type of dwelling:
House: ❑ Mobiie Home: Q Business: ❑
Type of business:
Number of Employees:
Number of bedroomr. _______. �
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ No� If so, � of basement fixtur�s
CLEARLY STAI� ALL CORNERS OF THE PROPERTY AND THE CORI`IERS OF ALL
PROPOSED STRUCTURES•
. I heceby make appIieation to the PeL'SOn COunty He3lth Depar�ment for a site evalua[ion for the an-sic:
sewage disposal syscem for the above described propeccy. I agree that the con�ents af tfiis application are true
and represent the maximum faciIities to be placed on the propeRy. I understand if the site is� altere3 or the
intended use changes, the germit shaIt become invaIid. I understand that before an Improvements Permit can b
_ issued, I must present a survey plat of the property to the Health Dept. I understand tha[ in the event I have not
deiivered a survey plat of [he property to the Health Dept. within 60 DAYS after the date oF che evaluativn of
the site by [he Health Dep�, [his application shall become void and all fees paid focfeited.
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ignec� Owcy�r or Authorized Agent
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Applican��
Location:
1
Ta�x Ma'� P�rc�el �
Se�hci'ivis�ion � r.' ' a►� �,'
.
Ph���s�e Sect�ion Lot �
Improvement Permit
Permit Valid for _ Five Years _ No Ezpiration
Type of Facility:
# of Occupants # of Bedrooms
Proposed Wastewater System:
Proposed Repair:
New Addition _ Water Supply
Projected Daily Flow g.p.d.
Type:
Type:
Owner or Legal Representative Signature: Date:
Authorized State Agent: Date:
The issuance of this permit by the Health Department in does not guarantee the issuance of other perniits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit Ia aubject to revocation if the slte 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 provlsions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900).
�' Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (�. C-� ���`'�
Proposed Wastewater System:�� ' �� Type �c� Wastewater Flow �.p.d.
New . �/ Repair Ex ansion Soil LTAR: + 7 S g.p.d./ ft 2
Type of Facility: , �L ��(7 Basement _ Yes �
,. —
Wastewater System Requirem@nts
c'`�
Tank Size: Septic Tank:�� gal Pump Tanki�l� gal Grease Trap: � gal
Drainfield: Total Area: ��� sq ft Total Length �1 �(� ft Maximum Trench Depth . in
Trench Width 3 ft Minimum Soil Cover: �P in
Distribution: Distribution Box ✓�erial Distribution
Specifications:
Authorized 5tate Agent: — l�� L�
Permit Exnirat n Date: h 3--� 7
The type of system permitted is Conventional
the permit.
Owner/Legal Representative:
Minimum Trench Separation: � ft
Pressure Manifold
Date: 7— 7��Z,
Innovative Altemative. I accept the specifications of
Operation Permit
Date:
System Type (in accordance with Table Va) •
The system has been installed in compliance with applicable North Carolina General Statute, Laws and Rules for Sewage Treatment and
Disposal, and all conditions of the Improvement Permit and Construction Authorization. Issuance of this peimit does not guarantee that the
wastewater system will function properly for any given period of time.
Authorized State Agent: Date:
PCHD rev. O1/23/02
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT 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
Subdivision Name
Lot
��
Date ,� �
S.R.# //lpG
Lot# '-J
SEWAGE SYSTEM SPECIFICATIONS
Size of Tank
) � Mobile Home Size of Pump Tank1C
iness # of Bedroom� Nitrification Line
Max Depth Trenches
Permits may be voided if
Well and Septic Layout by!
�
Installed
is altered g.�,i,ntenc�ed use changed.
ell Perinit Paid �� WELL SYSTEM SPECIFICATIONS
dividual �mi-Public
�blic Replacement
te Approved ?�I i I-a I-o�
ell Head Approved �/`� �t. �-� -r.�3
-outing Approved �3 �-I � �-a � - �
Date
�
Required Slab �,%S�k '���I�n�
Air Vent \� �'+t �-�i-�3
Required Well Log �/�Y N 1 I�a 1-�
Well Tag �� 1� I-�i -0'3
IaoSc 6�b c/J �t 1-� -a3 _
Installed by C` UZI.� W� Approved by,
This report is based in part on information provided the ha
representative in the application submitted for this permit.
or his/her
The environmeotal
�
� health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
� responsible for concealed conditions on the property or for statements in this
� report that may have resulted from false or misleading statements provided to
E-' 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
�
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�sa.�ns��,rn,*-„-,�a��n.�.a�.1L ����.�.��
Appiican
Location
T��x M�p i�', ' F�rc�el �
S�ubd�ivis�ion ', � - - -
Ph��s�e Sec�tion Lo�t �
Operation Permit
System Type (In Accordance With Table Va): .
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NQRTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
�ALL CONDITIONS OF T}iE IMPROVEMENT PERMIT AND CONSTRUCTION
AU ORIZATION. �
� �� � ��� ���
Authorized State Agent
ed By: T Lew;.s
�
�
Date
Date: �� � 8"� � �
s �To�e �'�.�
, ` ", \
- �,
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,��
� �,�
� � v (
PCHD, rev. 07/29/02
SE�i1C 3'ANaC INS�E�CTiO(V CiiE�9t1.lS7 (i'ype il - IV�
Tax MaQ #,��-T Parcel #� System Type (Tabie Va)
Owner/Appiicant Subdivision
Address/Location � Sec/Phase Lot #
�ept�c i anK
State ID/date STS� ��I-a- ��11
Tee and Filter�
Ba#fle /
Sealant
Riser (ifi applicable) ,i
Tank Outlet.Seal ✓
Permanent Maricer �/ �
Pump Tank
tate ate G. � 1_ � 2 G
Capacity i �
Waterproof /Sealant
Riser ,/
Pump
Check Vaive/Gate Valve
nitnncat�on L�nes In
Trench Width ,3 ft,
Trench. Depth in.
Trench Length �-9 y� � ft.
Trench Grade �
Trench S acin ✓
Rock Depth and Quality �
Dams7Stepdowns etc. / ,
Pressure Laterals
Hole Spacing
Pipe Sleeve
�� Required Setbacks
From Wells �:
From Property lines
Strvctures/easements
Fioats/Switches � . . _ . _ . . _ .
Alarm visable and audible
Electrical Components
Rate (aam)
Approved Pump Model :�
Blocic Under Pump
Pump Removal Rope/Chain r
Distribution System
Serial Distribution ' ,/
ressure an'�of-d
Low Pressure Pipe •
Appr. Pipe Material and Grade
Valves
SurFace Waters
Public Water Suppl
Vertical Cuts (>2 ft.
Water Lines
Vehicie Traffic
_ Easements/Right of W�
Other
�$-o Easements Recorded .
Tri-Partate
i
Comments�
�
pct�d rev. 3/13/01
11/21/2002 10:19 336-388-5940
���. ss ��I�.� �:��
` � �O 1�J' 1r�_� "�i[`' �
�1Cnvr]i�L �nA�t9ta•Ux�.�i.:.n.IL JA. 1�•t�..n.���l:�-n.
�wner. ��
Location:
Subdivision:�
EV�P�S WELL DRILLIPJ6
D� OD �
C cvn�p��.n y N�<�,m �.�
O���t�e Ori'I!leci
Wcll .Log
Tax Map
Lot # r7
Wcll Const�uction
Distance From nearest I'ruperty Linc (Mininuum 10 feet) `—"
Distanee from Septic System (Minimum 60 fect) �-- �`
Total Aepth: �� �i yield: �� G�M Static W�ter Lcvct:
W�zter Beaziitg Zoncs: Deptli 7c� _ ft_2„� � i� R
Casiug:
Depih: From _ D to S`6 fl. Diacnet�r: G�_ in
Ty,pe: Galvanized Steei Cr- ""q`""
Weight: �_� �i `�_ Y����lt abovc Ground:
Drive ShoC: �`Yes ivo Any prob�cm� encountercd whiIc se�tinb
If `�►es" give reason•
�--
PAGE 02
_�CL_.IZ�:"I/=.� g
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,.,—� � �Vo
Grout:
Neat: Sand/Cemcnt �� Concrcte GzaveUCcmc t
Annulaz Space Width �` inches Watcr i,n Aiuiular S�aec
Method af Gcout: Pumpcd Pressure �oured Dc tb,
Materu�L+ Uscd:
No. Bags Po�tland ccmcnt Wcibht of 1 i3av _�� Pc�u ds
t.`.�i�turc (�ranrl, Lruvcl, culcirlbs) �-- �taiio Z. �o f
ID plates; `-'�'ey � No 4 x 4 slab �Xcs _ No
Drillin�; Log
1G'rom To _ Fori�xatiou
u
I hcreby certify that the abovc uifotmation is correct :iud th:at this well was constructe in
set fortb by tl�e person County Heaith Deparrmen
�
Si�natuxc af Confractor Ill � -� _�, , rC
-s�-�-
'—%io
_ to Ft
win�
with regulaTions
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n�+rsr. �........�