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A29 198� A�alication Date: � �-��'�� Amount Paid: , d .0 Receiat #• �.l 2 • Q � ��s � � •� � D��Q� G�� t��U�`-'" - - �� � 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� , ti� � � � �� . , I� ��.�2 � •��'f.' F � � i�3�' 1 �3' � l"W '�� �� � �' � �iob ��(� � ( Di' � �{'( G� , � 9 �..�� m , � ^ � ` � �vi7- '=J 7 � � � � � � � Z _ ; � �p� G� , _ � � �. � � . . . G�� ' � . , `�' _ � � � � �� ��� � � � .� � � , I ��., �o � �`' � - .i, �,�: �`��c�� ������ .� _ / ��° c���° , �`'� '� �'�� � � I� �4�.v� �.Y� � . � �� c� . w �.�. . .Q� , �. . _.�. �.,__..__.. _.�= - � �� . _ ,, � � . -,--� o � ��-�'� ��' ��c�,� .� � - � � _ _ - . ''� - C�'��.�.� �- � � ��%� � � .,..-._.._.� �..���.,�,,� �� ��-QtI����.� _.---� � 3 4 . 86 ' � �'��,'';� �� � �z�=% � �` � �, � , ����,��"� ���i, ' • � } g �� ylj � 16 4 C-�c�i.s � �ti c ����, . � N32 56 �. � �!'� C,���,� �� . � ._ _ --_____._ ����. . �� _, _ _ _-�.-- . � : _ � ,�1, - c� � % .� 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 �,�°�� .%� �- Slt�t� _... .._ 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 �'L � ` ��-c� - , ,�i�r� � � � 1 1 � � ' r' _ G ;� � z Tax Map #: �� Parcel #: �� w � � PCHD, rev. 10/12/99