A29 125Amount paid
ritec�eipt l�
O� .`�FfS�:('i (�OU(Tt}/ i�c3:1ltf� �.c�;:� � �i� �
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_ �;q�tr;er'�?2-?�is �1� D a t e
C�� a p.52
Improvements Permit. (Established/Recorded Lot) l,_ Reinspection of Existing System (Loan Clos
Imp.Fovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
RepaidReplace existing Septic System
_ Permit foc New Well
Replace Existing Well
�i ' I N` . 4 i Y A. .d ' �1 \ �iF �, � / �a, : fa Li N'f' � i^' '3� 3wfw.r "q« �. b _„�"'' i f � � ) L'� - ���.
e�?�'��a;E k� ��r' y.i .t imx f.'>`'£ * �i�,� e s:. R' o.t� Y i.�. �. *X� s:�„(� i�x 3 a. „�u_ s�<z <+* .x x:!'.
'
p „;�t =£6r � �� ,x, . L ,::�, ��`� r:���`k ��Water:Sample to be Collected ,�y ;�;�,_.� �a„ ,,.��,F,�
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a ,. .�s
_ ..:4, ,...:: r�,� > N .:
_ Bacteria _ Chemical N, Petroleum N� _ Pesticide _ Lead
1. PeRnit requested by: . 7. Dimensions or Proposed Struc[ure:
ownedprospective owner/agent: � n� e� I-�, �, ' Wtdth: �� � —
Address: i� � (3oX -J I(� I 4 _ Depth: 30 �
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w
� Home Phone #: y�I - S(o � 8
a
usiness Phone #: L( � I-�� � s
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8. �Nhat type' (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
. Name and address of current ownec: t 9. Water sugply ty'pe:
�' f3 S+ C. f�i-s sc, c Z� � _ private � public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
' If so, identify location: n 1<now n -
. Property Description: Lot size:
. Tax Map#: A. -.a q
Parcei#: 1 a5
Townshlp: OL �.�� .1� �.1 j
. Directions to property: State Road #& Road
iames,�tc.
r ,� , � . , ,,,> �i a G.. ,-�1,. .. o . ��..-�- ,�,
0
. Number of occupants or people to be served:
10. Type of structure/facility: Proposed: �Existing: Q
Type of dwell'ng:
House: �Mobiie Home: L7 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: .�_
Garbage Disposal? Yes, �❑�o L�
B a s e m e n t? Y e s ❑ N o l� d' I f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AI�ID THE CORI�IERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PeI'SOn COunty Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the concents 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 Pecmit can be
issued, I must present a survey plat of the propeccy to the Health Dept. I understand that in the even[ I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Sig O ner or Authorized Agent
PERSON COUNTY ENVIRONMENTAL HEALTH
��EASE �EE ATTACHED PLl�1N FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: t'�'oGq Parcel # � �5
Zoning _
Applicant:
Location:
� Ll.
Subdivisior.: �O�GJ1L�.� R1DGE Sectfon:
Township dL�y� �LL�'
Lot: ,�_
Improvement �ermit
A bUilding aermit cannot t�e issuz� with only an improvement Permit
New � Repair Addition Type of Structure i O�rC Water Suppllr WtLI,
# of Occupants �� # of Bedrooms 3 Other
Basement? No Basement Fixtures? ►Jn
Projected Daily Flow: 31r0 g.p.d. Permit Valid For: �e Years ❑ No Expiration \
Proposed Wastewater System Type: 'a5°lo �fDC7��lON SUS�� ��-� �p" Sb1 L CbVGR CC�ROLIP ���021.�L )
Pump Required? Yes / No /
Proposed Repair : �t,lr�1Q CoN�F,NT�oNA'L �
Permit Conditions: Ir�S�IL onl �-c^�T'py(Z , n1�INTA1►J �o �M PoN� .
Owner or Legal Representative S
Authorized State Agent:
�P �vu �RA�n�A�� ��.T o F
Date: �` 'Z—�c-�t � SOl l�
l� R�S
Date: 1 a ��,�7
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 meeting 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 System (Required for Building Permit�
Type of Wastewater System RE TItYJ , Wastewat�r Flow: 3i�0 q.p.dr,
tY YP ,� S�S'� W l'T1� �0 S�tl. C.OVE.(Z W�DWP S� (�21� S(�Lt�s�
Facili T e: New.O'Repair DExpansion ❑
Basement? O Yes ❑-I�o Basement Fixtures? O Yes C��
Wastewater System Requirements
Septic Tank Size: 1 O�U gallons Pump Tank Size: �� gallons
Total Trench Length: ��� feet Maximum Trench Depth: � o� inches Aggregate Depth: � a in.
Maximum Soil Cover. � C� inches Trench Separation: 9 Feet on Center
Other. �� �C�1Q�Cv'E(Yi�.N� 1''E��T
Permit Expiration Date: ��-y -0
Autr�orized State Agent: � Date: �a.a-gq
The type of system permitted �oe ❑ does not differ from the type specified on the application. I accept
the specifications of this permit.
� ` 2-' � �
Owner/Legal Representative Signature• Date: � � �
PCHD, rev. 11/18/99
Application #: �
Tax Map #: �-29
Parcel #: �'��
Person County Health Department
Environmental Health Section
SITE SKETCH
�RmEs l�,�� �astivtiu.� �,�. Lor !s
Applicant's Name Subdivision/Se ion/Lot#
Jat�l k_ �ov��KES , �.S t 2`�-4ci
Authorized State Agent Date
System components represent approximate contours only. The contractor must flag tl:e system
to beeinnins tl:e installation to insure tfiat proper graue rs ma�nralnea
CatvtiRT
i
Scale: i'� = �00
PCHD, rev. 10/12/99
_�l ; , S� ���� ��
�. � � � � � � � 1!.
IC �.d-a �- � �. �. � � ¢.m.Il IHL � .�. ]1 �1�
Appiican
-Location
Tax Map '� � F�rcel # �
Suhc1'ivision _�_ • •�:
1
Ph��se Section Lot #
# of Bed!rooms
Operat�on Perm �t
System Type (In Aecordance With Table Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE RTH
CAROUNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTIOIV
AUTHORIZATION.
� )a, - 2-v�( �
Authorized State gent Date
Insfalled By: �`c�s�Q ���s Date: I � - �-c7-f
. .�
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4—��„�Z S�;\ cc�aar �3 i .�-
�
-�v b2 �'�0.cs�.Z �s^-.T��c
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PCHD, rev. 07/29/04
S��'fYC �Ta41VE� d�S�E�TIOM CNE��ISZ' (T� Q- f�j
Tax MaQ #,�_ Parc�! # la � � Systern Type (Tabie Va) .
OumedApQiicarrt � Subdivision -�-rQ�a 1 �a I�sZ
Addressll.ocation � SeclPt�ase _________ Lot # I � �
. r � .
. Septie ae�ic on e� r� .
. St�te ID/date �-a� -oy � S�r T�ench Wtdth 3 ft �
Ca I Oc� 9a�. �� Trenc�. De .� in. v '. �
Tee and Fiiter � �✓ �� Trenct� Len ft.
Baffle � " .� Trench Grade �
� Sealarit � " Trenct� S acin �
� Riser rF a� licab�e Roc�c D and Qual'
Tank Outlet:Seai � DaEns/Ste owns etc. � �
Pertnaner�t Marker Pressure- Laterals � � �
. - - - Pump Tank � Hole S�adng . . .
e• � o ... . .• ,. .
. Ca al. . Pt s Sleeve . . . � � . . - � �
W roaf /Se�lant � Tum-u rotec�ors � • - � �
� � . Riser � ' � �Requ.ired Setbac�s . . �
Water-�Ti trt � • � From Wells •. � � • - �}. " 1 � ,
. . PumQ- . � From Propert� lines � � .
� �edc Valve/Gate Va1ve . � � . . Structures/Basemetrts.:: � '.� . � �
. . i on o e . . � . � es ra� � e � a s• �f .� . . .
F%atslSwitc�ies.�: . � � . • . . s . _ : . S�xrface`Waters -� - � :/ � - • � � � .. -
. Alarm visable and audible
• E�ec.�tical Com nerrts
Rate m
roved Pum Mode!
Btodc Under Pwn
Pu Rerr�val Ro e1Ct�ain
�Dtstribution Sys�em
Seriai Distr�utlon ' � a�
ressure an'
Law Ptessure Pi e �
,4ppr. Pipe Materia� and� Grade •
Pubiic Water SuppGes
Vertical Cuts � F>2 f�.).
Wa�r Lines �
Veh�ie Traffic
Ad�acent�Systems
EasementslRight af �l1/�
� dt�er
Easemer�fis Recorded .
0
. pd�c! tev. 3113ID1
0