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A29 123Per,s�;r� Courny hv:lit� C�r: a �6 ,a6 3�25 5. �ior�an S�re�# o���t�a - , � IU — I�-9q �2 e c e p., l�. ' a(� � Roxeoro, N.C. 2� rJ%.r � �;(?t�fiBf'�n2.?�i$ D a t e � i�, � �'`�' a � �-2- � APPLiCATION �OR SERVICES � , l i�� t " j'�" `4:t R� !. i . 1�1 k k t 7'� Rw ivP' '� "tlMii �' i 1 / MQ' i � s' %"r .6 .�'^� 3 b Si..:' A� =.% �v',�4y.� � .- i �I ` ; �r"`��` ry �•<r n ' .. r �;'` `� " :� °t ��'"�L .�Serv�ces=Requesfed �. ��:o �x ..�::�s,z �» � . :z �d,�.�}�:�.�.�r�w.,8� �;?a,.,e�.�.....-.<i-.t.. �.,...:..,f.,x....re,�.....,. ...:�n. e- , ...�;�;� �.. ....,>..>:xz_.. .: >>.,.....,..:,.:.,.,,., ..-.-�....,,.. . :.��... .�> ��:� .. �Impr ements Permit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing) pFovemen[s Permit (Unrecorded Lot) _ Repair/Reptace existing Septic System Improvements Permit (Mobile Home Replace) _. Permi[ for New Well Improvements Permit (Addition) _ Replace Existing Well � � \!D'i4 ]. �. Y'�K `C �f K r? YA -::/'S r$Y � t S:. R'Cx M�' \ yrh% .. . � S. .. t i: �.� A r �4 � � g = � _ � < } Water Sam le to be`Collec�e� a � �' {� t .t '[ a F a^ 3 r,{� ? v^ri:� ��<.`�"��� � Y, Lt�t "af xt �,�. � .'' .- ^ -s.i>w�� s; aa. .,."".�.� �.w.�.wY,��CI ;o'� ,..� re:.o- .,��..... ......w....<�..-, . ..-e.'*.. � . . ro T � ..+-.... _ Bacteria � _ Chemical , Petroleum _ Pesticide � � w U � a � a ¢ � ¢ H W ¢ z 1. Permit requested by: . ownedprospective owner/agent: �:M e ���. ' Address: i� > (�oX � -] I (� 1 `1 - n.�rl„�,,.� . Nr.C. 2�7�7� �_ ome Phone #: y �I - 8�C � 8 usiness Phone #: LI � 1- �� � 8 7. Dimensions or Proposed Structure: Wrdth: �i 0 � Depth: 30 � _ Lead 8. �Ihat type' (if any, addi[ions, expansions, or replacement is anticipated to the structure or facility that ttiis sewage disposal system is intended to serve? Name and address of current ownec: 1�9. Water sugply t}•pe: T� S+ C, H-s sc, c �� c private � public ❑ community ❑ spring ❑ Are any wells en adjoining property?Yes ❑ No �. ' If so, identify location: n I<now n - Description: Lot size: . Tax Map#: A -.a q Parcel#: � � � Townsh�ip: OL �.v�. 1� �.1 �_ . Directions to property: State Road #& Road � Number of occupants or people [o be served: 10. Type of structurelfacility: Proposed: C�Existing: Q�' Type of dwell'ng: House: �Mobile Home: C� Business: ❑ Type of business: Number of Employees: Number of bedroorns: �_ Garbage Disposal? Yes, �❑� o � Basement? Yes ❑ Nol�ilf so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PeI'SOn COUIIty Health Department for a site evaluation for the on-site sewage disposal system for the above described property. I agree that,the con[ents 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 that before an Improvements Permit can be issued, I must present a survey plat of ihe propercy to the Health Dept. I understand tha[ in the event I have not deIivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evalua[ion of the site by the Health Dept., this application shall become void and all fees paid forfeited. �. Si�ncc� Owner or Authorized Agent --. - ..�_�� PLEASE SEE ATTACHED PLAP! FOR SOIL AREA AND SYSTEM LAYOUT Tax Map #: l�' 2. � Parcal # 12 � Zoning Townshfp �L�JE rilL�' Applicant: ��m�s ��\L�- LocaUon: �l S T I� t-Ce��-�°f' `S �'�O ��� r �- �^'`� s�j Subdivision:��SL��LLE R��G� SecUon: �ot: � 3 Improvement Permit A building permit cannot be issued with onlv an Improvement Permit New � Repair _ Addition _ Type of Structure j�l� Water Supply 111�1L # of Occupants Y1�1X �# of Bedrooms 3 Other Basement? �10 BasementFixtures? ^�U Projected Daily Flow: 3�0 g.p.d. Permit Valid For: O Five Years ❑ No Expiration Proposed Wastewater System Type: On1� E►�ii IOIV�L _ Pump Required? Yes _�No Permit Condi#ions: \n1Si'���- �1 CC��TOu� S�AU ON�" 0� ��tl 1,(,I�< — � Owner or Legal Representative Signature: , Date: I I '� Z � �� C Authorized State Agent: s Date: � �'2 �"�iq The issuance of this permit 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 mee6ng 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 with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Authorization To Construct Wastewater Svstem (Required for Buildinq Permit) Type of Wastewater System �,oN'��T'[OY�i}� Wastewater Flow: 3�o g.p.d. Facility Type: �� New�epair DExpansion ❑ Basement? O Yes No Basement Fixtures? O Yes �fNo Wastewater Svstem Requirements Septic Tank Size: I Oeb gallons Pump Tank Size: f�l 1� gallons Total Trench Length: a►�o feet Maximum Trench Depth: �_ inches Aggregate Depth: 4a in. Maximum Soil Cover: � inches Trench Separation: � Feet on Center Other: i�:S�At,�. ON COn1T0�1(� PermitExpiration Date: �`'2O-�`� AuthorizedStateAgent: Date: ��'?0'Ci� The type of system permitted O does does not differ from the type specified on the application. I accept the specifications of this permit. I I��n �l < <`2Z'� � Owner/Legal Representative Sfgnature: Date: PCHD, rev/ 10/12/99 Application #: Tax Map #: (�-2� Parcei #: 1'23 Person County Health Department Environmental Health Section SITE SKETCH �HmEs � t t �. �osG�1 ��� -, R� �6� , �oi' 13 Applicant's Name Subdivision/Section/Lot# Jb� Y� � �t�� 1LK�S 1�-20-Q.�1 Authorized State Agent Date System components represent approximate contours only. Tlie contractor must flag tlie system ( (,D! 23)SEPT<<- Scale: 1 �� = bo �_ PCHD, rev. 10/12/99 PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT T���#: �nz� P�,� i2� Zoning Township R/' ��/�- " t` I .�� � � -.�. APPifcant � )Q�D�� _ � �/� LocaBon:�✓_J S Subdivtslon• ection• Lot Well Permit yae of Water Suaalv: � Individual Community Public Reauirements- Site Approved by ✓ Grouting Ap rov by Well Log �1 6-a Well Tag Air Vent Hose Bib Concrete Slab IDI � � � �'( �-rl-a ( �9'� � Weil Driller• Well Approved By: � �'J V Date: � �� ' � � - **See Attached Site Sketch** Weils must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be �at least 25 feet from any building foundation. Other conditions: PCHD, rev. 11/29/99 �l � ' �i�i:t;suri �:uuri i��� i;ii�� i iiuiiru� irrni, ur.ni.•rii � ������:_�.�.�� 1.� i c:)wii�r:._.. � -�al�'Ya�.s- �=��- ---.�, . __...._ .. .._... 51�11 __. _.. .. �--......_ - . - �------ . 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S�R-�►�. � � . . . ---�s . � - � eration P�e�mit � � :' System Type (in Ac�ordanc� W�h Tabie Va): � . T}HIS SYSTE3� HAS BE�V iNSTALLE� 1N GOMP�_lANCiE WIT�i� APPUCABLE NOi�tDi� CAFtOL1NA G�+IEi'i�4L STATUTES, RULES FaR SElNAGE TREATII�IT AND D15POSAL, -AND 'ALL CaNE31T10NS OF THE UAPROV�IAE3�iT PEi�Nlff �•AND CaNSTRUCTiO�I AUTHORIZATi � ' . At�hor�ed Sta�e P+garst � �e � . . V . . � ��� �n l, �� � Y . � _ � . � � �,�, . -�-22-o r _ �� ��. � �T� ��� � . . r�►�zu, � cd. � u112�99 .