A29 198�
A�alication Date: � �-��'��
Amount Paid: , d .0
Receiat #• �.l 2 • Q �
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Perso� CauntY Health Department
Environmental Health Section
Tax MaQ #• � °�' f
Parcel #• � � 6
. APPIICATION FOR SERVIC�S -
IF THE 1NFORMATiON IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED, CHANGED, OR THE S17E IS
ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORiZAT(ON TO CONSTRUCT SHALL BECOME 1NVAUD.
1) Permit requested by: (Ownerlagent/prospective owner): ���'�+'�w ��� ��-
Home Phone: �Iq-5G 3�f/7'�' Address: o td . �^. ' .
Business Phone: 9/9• 3�-zz�{y vn �, v,_Q.� y�i �...
2) Name and addcess of current owner �✓wr-er� A�''i/�`$-
.30�. l.rs• t3��zl�a,.., �.
rn,•P�AGt..,.4, t� � �'7 � __�
�
3) Property Description: �otsize: l�d � Townshtp: ��_�%11
Direciions to the property (Induding road names and numbe�s);
�• �...
��� �
4) Proposed Use and Structure Description: answe� ead� afthe follawing questions:
a} Proposed 0!Existing 0 ,
b) S6ck Built �, Modular �ingte Wde �. Double Wde �
c) Number of Bed�ooms: � d) Number of oax�pants ac people to be served:
e) Basemen� Yes �� No A'Ifi'yes, # of basement fixtures:
fl Garbage Disposal: Yes 0� No �'
g) Dimensians of Proposed Structuce: Width: ,� Depth: �
� Water Supply Type: Private�'(new � ur e�dsting �), Public q Commun'rty �, Spring ❑
Are a�ry wells on adjoinirig propertyrt Yes � No �-ifyes, loca6on
6) Ptease tndicate Desired System Type: (systems can be ranked in order of your preference)
, /Conventional Modified Conventional _ Altemative Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND L1NES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPUCATiON
1 hereby make application to the Perso� County Heaith Department for a site evatuation fcr the on-site sewage disposal system for
the above-described property. i agcea that the coMents of this appGcation are true artd represent the ma�timum faa'Gties to be
placed on the property. 1 understand if the site is altered or the i�rtended use changes, the permit shall become irnalid. i understand
that as applicarrt. I am responsible tor identifying and mariring property. Gnes. comers and making the site access�ble for the
persortnel of the Person CouMy Health Departmerrt to condud their evaluations. l understand that I am responsible fo� notifying the
Health Department if my property coMains any wetiands as designated by the Army Corps of Engineers.
�:�.� /,��.. ,� 3 �'�� o�
. Ovmer or Legat Representative Date
PCND, rev.10li2i9
��
- PLEA�
Tax Map #:
Zoning
Applta
Locatic
PERSON COUNTY ENVIRONMENTAL MEALTH
Pareel �
r�.:tit..
i � � , ., � i
a� . I '/If�!///�I��AI,/� �
.J�,/�►'•,
• . �
''/
New � Repair � Addition Type of Strudur�� Water Supply ���! J��°
r�s• � w�
# of Occupants � #•of Bedrooms � Other
8asemenYt _j�Q__. Basement Fndures? � .
Projeded Daify Flow: �-,�. g.p,d. Pertnit Valid For:
Proposed Wastewater System T .�' Gf�VI �Iti�
Pump Required?' Yes�o
Proposed Repai� :
Permit Conditions: �,IS I. ;1. Vl i` ir ��
1a� bu,fi
Owner or Legal Rep�esentative
Authorized State Agerrt: �
a 1Ya�r� �Y laz�� D�coY
�
Date: �- 3-0 /
Date• �i- 7 Z -O C`�
The issuance of this pertnit by the Healih Department in no way guarantees the issuance of other p�rmits. The permit
hoider is responsi6te for chedting with appropriate goveming bodies in meeUng their requirements. This sifie is
subject to revocation if the slte plan� plat, or the intended use cl�anges. The Improvemant Permit shail not be
affected by a change in ownership of the site. This pertnit is subJect to comptiance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Caroiina Administrative Code.
Type of Wastewater System
Faality Typ
easement?
Wastewater Svstem Requireme�ts
Septic Tank Size: i,�Q� gaAons
Wastewater Flaw: �g.p.d.
New CY' Repair �Expansio� 0
Basement Fbdures? 0 Yes ¢��
Pump Tank Size: �_ gallons
Total Trench Length: � feet Maximum Trenc�► Depth:1� inches Aggregate Depth: l2 in.
�,tl Vl I V��.l,{.yl'l � —
Maxirtmm-Soil Cover. � inches Tr+ench Separation: Feet oa Center
Othei: �{��Ul� �1�1�(.�wl �rf%��C/��(%t�Y����e
Permit Expiration Date: �J �2�-" (� � � � �
Authorized Stata Agen� . �Date: C 2_-�
S( l ����i� (.(�_
0��1 VI ���1 l�l'I �
The type of system pertn�tted 0 does 0 does not differ from the type specifled on the application. i accept
the speciflcations of this pertnit
Owne�/Legal Representative Signature: _ Date: �- �� �
PCHD, rev.11/18i99
,�
IT'��T 2� +�..._.'.�.'�'
Parcel : (�.�.�.
Person County Health Department
�nvironmental Health Section
SITE SK�TCH .
-`�;U�l�--�CAA1 l5 . ;.�o�� ������lo
A licant's Name � Subdivision/Section/Lot#
PP . . .
.. .. - � � �-15_�D� .
. ..
" � Authorized State Agent �,Y'(�i}` Date,
Systeen components represent approximate cotttours ottly. The.contractar must ft'ag the system
prlor to beginnin� the i�stallc�tion to insure ihat proper grade is malntaine�
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PGHD, rev. �10/�i2/99 �'
���St�R9 �C319N�'( ��9°���O�nflE�1TAL �l�,L�'3-�
3����,5� ��� .a��'a���31E� ��►� �t3R '�E�i. ���E �'l'D�3�!'
Taz 9BaP � � `� ` Parcail� � l �ii '
���vt[��
Zoning Towmhip . . . .
AQpUcanC ��I ��/� (�i�� d �(.1�,� � �i ---r.
�a�:a�',P� �Q � � —
� �o�-c) � l,�e ►��,(.�.«b�: �. r o
S�„�:,
Well Permit '
Tv�e of Water Suapiv: ,,,�Individual Community Pubiic
Reauirements:
S�te Approved by
Grouting Approved by " �
Weil Log �
Weil Tag
Air Veni •
Hose Bib
Concrete Slab
Well Driller
Well Appro
,a�.,�,
Date: � �
*'"See Attached Site Sketch'"""
Wells must be 10 feet from property lines.
y�elts must be 100 feet from septic systems.
Weils must be �at least 25 feet from any building foundation.
Other canditions: � �
PCHD, rev.11/29/99
01/�8/1995 �6:3� 8�a45a78a3
ll�t�:: '. �8- �
C)�r•ner:
I..cx:�liuri/I)irectian5:
`;u � t :����on �7' m..=�
Uriliinb C�t�tractur: .
BEPJtdETT WELLDRILLING
YERS�N COUNTt' £Kt'IAO!t!lf�+i�i, NE.L�.r�
xE[.� �U;;
PAGE �2
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Slt�t�
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Lc�I r1_ /O �
1_�Ei.�i. CO�i`j �K��'tQ� � ---_ --�--�,
Uist:utcc fioR► �le�test F'io�:try Li�1c._..____�___�,_ Dis�xr���; frur�� S�,�,rr.�: c�f
�'ollutio�t
--_.� . .....
'ius�1 D�m�]r:�_ F�. Yield: 3 CaPM StBtic: Wa�er !_,cve)�.�,�,��Ft.
lVatcr Dearing Zoncs: Depth _Ft. �t. 1=t. •�.
C'�sing: !)epth: ��ro�� t Diame�sr: /
TY�'E: S�cei �
.�l_3_.___ .Fc. U�c.hcs
_ _,_,�Gelvanizr.ci Scr,zl,�� .
If Stal, does ov►+�a approy�: Yes Nc, � •�`''�'
Weighl:l���,'Ihiclrneas:. �'�`..—. _—_---.
DriYe Shoe: Yes ��• l�ei�h� At�o•�e (��otu�d:�� 1�ches
✓ � No__ _
Wer� NroW�ms Encountered in Settirg th� t'as;�i�;? }•rs,,,,,,,,___ r� i✓
II� ..).�s.' g�t'� i:ason:
�.;t�u�: �'yp�; Neal ✓ SanJlCcmcnc i • .
_........._...._. – , a; �c r t tc.
�ui� sPa�� w;��,��._ _. �.�����5 .
Water in Aiv�ular Space: Yes_. _.. Tlo ✓
Mclhpd; �P��� _ I�tr�ssurt Noiu t�i
Dcpth: E�rom � _� 10.�_ ,��c_ �~--._._`_
Materirls Uscd: No. Bags Poniand Cema�i -,Z,�, �ti'eigt�t ui I hag .,��it,,.
tt n�uture (sand, gt�►vel, cuitings} - Ra�io:���_ :�
lU Pl�tes: Yes,.�_ No -
4 x a S�sb Y�.�. � xo ,y
t I�E:REBY CkR'1'tFYTHA'I"1'!�E ABt�YEIN�OKA1:� i'l�►N l:� (:c�ftict:c'��' nr�l� ��tl�►�i�'
T»�$ �'ELk, Vi/AS CONSTRUCTEI� tT1 AC�.:OKU:��•JCF: �Yj"fii REC;�)LA'l�lc �N� SE.T.
Ft)k'!'H RY TNE PERSd,�t COI,��T}' �iEA1.:T�� I}EP�RTAt�;N"f.
, '� - -..2�• aae�
� ,S�gnatuic p f t'�Tr.t� �ct�,�• [),i;�:
Person County Health Department
Environmental Health Section
Tax Map #: � Parcel #: ��
Zoning:
Subdivision: - P � � • � r� ! ��
Applicant: ���� �1G22l� S
Location: �� i�i'�� tti� � �����
Township: �%V�°f�.��
Section: Lot: �v
Operation Perm it
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.
� v / U �-��
Authorized State Age Date
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, ,�i�r� � � � 1
1 �
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Tax Map #: �� Parcel #: ��
w
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PCHD, rev. 10/12/99