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A29 220
Aoaltcatla D• - ���D � 7ax Mao #• �qnount �aid: � ' . Recai� #: _ � ��'i � 2d fCp �arcal��: e�.� ��� . .-�` ���� � �I�IE�..� �1� - - . � � -��-�-- ��.-�.�.�..__,.....,._... m�,.�.m.�. ���-.� CON9TRU�1' SHALL BE��1�E IA�11jAL1D. '• 1j Permik requ�d b•(Ownerlagerttlpms�re 4wner):� </� Home Phone: –/� v Address• � . ' c Busineas Phone• � 7 i '� �� 2a Name aad alddress af cwment o�retee: d P L . ' � `�, � � o / . �' , � 3} Peop�erty Destcription: Lat size: �� Tcwnshlp: S�} bdi on: • Dir�ctions to the propertY Anduc�ing r�ad names•and nu�b�): /��ro"��: ��,�,�[ c n�!�S Lot 4) Pro{�os�d U�e and Stru�tur� D�ripN�n: answer aact� of the following ques�ons: � a) Proposed � Existing Ty}� vf Structure: �0��>G— � Width: '%�L Depth: ��r� b) Numher of �edrooms: �„� Number of accupants or people ta be� served: _Z • c) 8asemen� Yes . No l�Wil1 there 6e plumbing in #he•t�asemenYl . d) Sarbage �fsposal: Ye� � . IVa �" $J w� �PP�IF �: Privabe �ew' �cSr exlsiing_,.j, PuWic^, Commw�itY_..� SP�9 ' Are any wella on adjoining property? Yes Na _ If yes, pl�ase indtcate approxtmate loratiori on th� .sife pi�n. � 6j Does your propeety contalri_p�vioasiy ld�ntiiied JwrissdicHonai w�tlands? Yes No; � � !it_ i. _ . . ➢ A PL�►T OF TWE PROPEitTY t�R SRE PLAN 1NUS'T BE SUBM[TTE� WRH T6�llIS APP4.1CJ�1TiON. ➢ PltOPEiZTY UNES AND CORNERS 141UST 8E Cl.EARLY MAR�. •, ➢ THE PROP08ED LOC/�T10N OF ALI. 9TRUCTURES MIJ9T BE 3TAfCE� OR FIAGGEiJ. 9 THE 9fTE MUST BE RE�DILY ACCESSI�I.E FOR AN EVAUTATiOAI BY THE HEl1LTH DEPARTOflEiNT STAFF. � • � I hereby make appi3c�#ian to the Person Caunty Health Departrnent for a site evaivation fior the on-siie sewaga �18posai. system far the a6ave-described property. i agree that the cor�tents of this appiicatlon are true and re�Oresent the maximu�. f�ciiiiies to be plac�d on the pro�erty. I undetstand if the site is altered ar the intended use changes, ttte permit shaq became I atld. i�.�G-�/% G-C/�//G Cwner ar Z,s� ��� Date p�;�p, �ev. D6127102 ; ��� s ; ���.� �� ��. � � ��� � � �J � � � I���aa-���. ����.I1 IE-ZI��.Il�� Applicant: lill E Location: . T��x M�p � � P�rcel # - � � s�Uh����s��o►, Ph�s�e Sect+ion Lot # Improvement Permit Permit Valid for � Five Years No Ezpiration /� Type of Facility: . New � Addition Water Supply �,i/ �� # of Occupants y�(a �( (�, of Bedrooms Projected Daily Flow 3(oa g.p.d. � Proposed Wastewat System: v�, `�� Type: A Proposed Repair: _��v� �>v ,� Type: c�A Permit Conditions: Owner or Legal Represe� Authorized State Agent: S� �S Date: Date: —D 3 The issuance of this permit by the Health Deparhnent in does not guarantee the issuance of other permits. It is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site 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 provisions of the North Carolina `Laws and Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Heaith Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewater System (Required for Building Permit) * See site plan and additional attachments (_). Propose Wastewater System: ��/�;� �,-�� l Type� Wastewater Flow ��� d g.p.d. New � Repair Expansion _ So il L T A R: � � g.p. d./ ft 2 Type of Facility: � j� �P�� Basement _ Yes �No Wastewater System Requirements Tank Size: Septic Tank: �j�Uc� gal Pump Tank: gal Grease Trap: gal Drainfield: Total Area: � sq ft Total Length � ft Maximum Trench Depth 1g in Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: � ft Distribution: � DistributionBox �1 Serial Distribution Pressure Manifold Specifications: ,�--�78 j� QY- �,rj (�i' Authorized State Agent: � Permit Expirat�on The type of system permitted is �Conventional the permit. Owner/Legal Representative: VV��' Date: �" �`�`� 3 - �- - Inriovative Alternative. I accept the specifications of Date: PCHD 1/17/2003 !S ,,, ^46� 3�, J-� °` ' i i .r�-- — — — � (6 r � ___ ��� + 2a _ ��� n �- -�-����- �nD o .� `^�I,t��`�" d� � ��a o � ���� : � � . �_'.. �.:.. . . .. � . . A , —I O � A /� ,^ r��(� tM � � .�Y ` O �jV�j y�i � �Vl �" '" � O � � fTl < J /�/ e • w . d u' -a' �3 � _ > 3�` a�� , � � b� L.�(f.� ; ns� � 1 � N� ��:� - o , �Z � � D �� � �3� � ����1 � �� t1 ,. f��' ` i $ ��, �n� � . � �e,� �= � � � � �., _____ j� / -- ��-�' C���.�� �rl���� r __ o — s _ _._- - . _�-- o _ ____ .� CT � s O � y� ..iQ �/ u� � Y K�^;•.. � o �1 'y,� . - ti fiDx�oro _ — s _-- _—.- _-- . . . . � . �-_- ��� ^ - � _ � � �g ,� �� � 1V � 545 p g. 113, P' 553 & 54 �. p.B• 118' P. � � �a'�l � �� = l�� . ���.�� ���.� �� -, �- �����{��- ���"71.�KDr-n "'r-n �7L^1��.�t 1L Jl�a7�..1i�� VY 91S.+L S�H�1Wb9. A . �1.�C9J�+ J��' lS1 313�i3�r� �n ,� lV Y"�8l 'dYS'.a •a • Jli�, ���V S '�ax Map #: �'2 � Pazce� # a °2 � 'I'ownship �PPlican� WC Subdivisiori: Section: Y.ot• � 'I'�e of Water Su��le: Res�,uireffient�• / �I1ldividuaJ. Site Approved by � � ����� Grouting Ap roved by ��' S-'I �tZ. 3 Well Log �'�� - �a-o We11 Ta.� ►/`�tt 8'(a�a3 � v�nt � �✓ 3 �t B- �a-"� Hose Bib ✓ �N �-1a-�3 Concrete Slab ✓3� a"la �D3 Well We1l l�pproved. �p:, , �1 Communitp Public �� J � ��.Q,f� ` �''�/ �Lt /I;� air�cJl „v�► (n�--e � I)ate: �"Iq ��3 '�°5ee Attacflied Site Sk�tc4i�` Wells must be 10 feet from propertp lines. WeDs must be 100 feet from septic systems. Wells must be at least 25 feet from anp building foundation. Odier conditions• �-� 2-�3 ��� �� � C1��" 3 �3�N , � � q -� � .tQ.��..�c� �+ o�► ��d�Q �.,d � , PC�ID, rev. 09/07/01 n �� � ���� �� � Li.� � �' _ '�-- � � ��� � �-'�am.-�s�-�-n �*m* ��n.vC�,.�i ���Bs.7I.. _-. � _ � n. . AQpiicant: Location: c�1}( �'�r���3 � ' �,I"C�) ,- � S'l'�:b'C�;I'11:S�I+Q tl ;. h:�seh�e��iat��.��L,o�t r �r����r� � �r° � it . � � System Type (In Ac�ordance With `Table Va): �°� TIrI1S SYSTE�fl HAS • BEE�t! IlalSTl�LI.�i? dN C�IUIP�.L�iCF. :1�VITH APPLIC�►BL� N�R'�F� CAROUId�► GEjlIEF�AL STATUTES, �FtIJL.ES F�&� SE�AGE "TRE�ii�iE�T �1D I�iSPOS�, . �1D A1.9_ CO[dDiTiOi�lS ..OF 'Y'HE IMPFa�VE9ViE�"6" PIE€2M1? AND. �C�IdS�UCTi�N - ��aurH� o�. . � � � . � . : . .�.. ..� � . : . rV� . . _. - .��. -�,�$=�3. .-. . .. .. : � . � uthoRzed State Agent � • - . � � � . .� � � ' � Date . ' Instalied H�r: �.J �- ���!%�(�. � • � Date: . %�� S�'0� . . _ . — �nal� (l. U J J Q � _ N_ 50 .___-__. � rt _ 5 �5 t � `s K--.� � .P%L N22' _ —� — . �;�, �. �.o �D��� 10 D� � � 1 � 0' l � �' - �o t� � � � ..�� ��� �`�t Pci-iD: r�v. a7�2fl/i2 � ���������'��N �i���l� s �'�� al - � . Ta: l�a�a � � �arc�! # � Syste�rt Type (Ta�ie Va) Own�rfAppIic�arit Si�bdivision - Address�Location Ser�li°hase L�i # . St�t� IDldate � � c� Trenci�t VV1�id#h �, fr. t/' .. Capaciiy, p p�0 . gai. - Trencf�. Depth _- in. ' �. Tee and Flier � ��� Trench Length .,8�, ft . Baftte � Trenct� Grade Seatant ' Trenct� Spac9ng • • Riser ifi applicabie) Rocic Depth and Qualiiy � Tan�C Ouffei:�Seal . � � � Dams/Stepdo�nms �etc. Permanertt Marker � � - � .._., . � Pressiue Lateeais . � � Puarap Taeak . ._ . . Hole �Spacing . .� tate ate � . o e ize � . . . G��acity. ' . . . ' gai. . . : . Pipe Sleeve . � . . - Waierproof lSeaiar� : � . .. . � � Tum-upslProtectors � . . . R9ser . � � . " . Ree�t,tin� S�ac�ss: . . . Wai�r Tighfi . �rom Weils •: - �ump � From Prope�iy lines � . _ Chec� Vaht�IGate Va�e : � ��� : S�-uctures/8asem�rrts . . . ._. . � � � . � �� . �fi=s�pt�mn o e . � . - � �. : . � � . ... �i es rainage ays _ :... �.�. €=ioats/Swific��s =' . . ..�- . .._ . .: . �. _ . � . _ . - - �Surfa�e�iNaters �� Alarrn� visai3le acsd audibie Public Water Su�piies E3ecficai Componec�ts Vertecal Cuts �>2 ft Rate gpm � Wat�r Lines A proved Pum Modei Vehicle Traffic Bloc���lnder Pump Adgacerrt•Systems Pump Removal RopelC9�ain. Easement�/Righ# rnF iNays � �Distributaon S�ffitn ' �er � S�riai Distribution ' E3semec�rts Recorded . .. ressure an d � peratar or�trad Low Pressure Pipe � Tr9-Part�e Agreem�nt Appr. Pi�e Nla�riaa and. Grade � Valves • ' � C�manerats. . , . �� � r��. 3f�31c1 ��� � 1l-� � ��{ � .��.�' �U.�� ��v��� :. �- �: ��� _ - � - - , `,- ��,a„a�,�,� G�� ����, «_� i�,f� �� ����;1: � c� c0 ZU:�`�C ��� n�,�,� 5 �x�n.�r7in—�m�cT.�iT:n.�v—�i-n.tt:..:,�.11. �.��.��c�.:.n.���l:�J:n. �`� �l�Ul1�7L"1 �_��_�03 Owner: ' �l•:�� �vt.,l��� ��:����1 ir a a- o Location: � �,L� /S � d.�-� �.� .i��.t�/���a-�-^ ^— Subdivision: �,ot !F i l�l�cll Cozx�ct'ixctic�a� Distancc From ncarest 1'r�p��•ty Linc (Nlinimum 1() �teet) _�''_.�____..._,_ Distancc from Scplic System (Ivlii�imum 60 fcct) � Total Dcptl�: ��v R Yield: �__ GPM Slalie W:iter L�vel: �_ 1S_____ li Water IIcarinb Zoncs: Dcp[h T�� ic � fl _ �t _ It ~ Casinb: Depth: From _�_ lo �� tt. lliamctcr: _� ill Type: Galvanized Stcel '� `� Weight: ��_ ".�l�ickness: � I-Iei�;l�t abovc G�-ound: __,L� in Drive Shoc: ./ Ycs No �1ny problcros c►ic�uulcrccl wliilc sctlia��; c:isin�'? __ Ycs �--�No (f `�es" bive reason: _.__ Grout: Neat: Sartd/Cement �� Concrcic Gr�1V�lICC111Cl1t Annular Space Widtli �_ inches Watcr in �.z�nular S_ace Yes `— No Mcthod of Grout: Pumpcd I'rc:ssure: ' 1'oured Dcpch � to �t. iY�atcz-ials Uscd: No. Bags Portland ccmcnt Wci�;l�l c��l' l 13a� ^___._ ['ounds It mixtz.u-e (sand, �ravcl� CUlC1Il�L;J) - Ratio _� co ( ID platc�: �I'cs No 4 x�E slab �-�.'cs _� No �iI'Sllillb Z,Qb l,c�c:ilioi� lli•awiixb I'rom ���0 Z� UI'Ill:ltlUil � _� � � v � /^o � it , ., � 3-Gr ��- • B /-� .-,_,_,qs.,.--t., ( hereby certiiy that clle aUovc intonnaciot�. is conect and that tl�is wcll tivas c:onstructcd in accordancc with regulations sct forth by thc Pcrson County J-1cal •parhnent. Signaturc of Coutracto�- I1) !� _ 2 a,3 I_ �:itc �- � a.. o �3 ncl� fCV ol�tbioi