A29 45A09-30-1998 11�3$AM FROM
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: � ,.,�,Improvements Petmit(Estat
;
PERSON COUNTY HEALTH DEPA
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� '• ImpFoverr�cnls Pernnit {Unr+Ccoided :}
� °K1 ;_ tmprovenients permit (Mobale Home :�
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� Improvetncnts Pcnnit{Addition) ;
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i ; , '�dv�rnship �� ���} �.
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: i: , 5. Direc�ioczs fo property: St�
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TO 9194798336 P.01
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; \ Date
�.ot) _ Reinspeccion of Exi$�
.,, RepairlReplace exis�i
�) Pcrmit for New Wcll
- ,..,_ Rcplaco Existing Vvic
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_ Petroleum � P i
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7. Dimensions or Pro�c
� � � Width: � 0� �
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� �P�� � �
$. �18t tjIPC �!f S[1�1� AI
repiac�ment is anticip��
�� at this sewagc dispo��
owner: � 9. Water �uPP1Y �}P�=
s � _ private � put�lic D
� Are �y welts on adjc
If so� idencify locatio�
Road � 8� Road
� �e
., , -
�;: �: I creby .tnake ap�lication tv th� Pers n
': �i .� se gt d�sprosaP system for thc above d:;
� and r�en't th� maacimuc� facilicies c t
; :'; . , a
�<:: � in4en uiss:changes. the per;m'st shall e
' issu I� must pr+Cscnt a sucv�y plat of t►�
;; i deliv_ a�u�vey ptat oE iho property a
. the s� c by t�ie Hcaith Ikpc:. �his applic it
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10. Type of stcuctura
Type of dwelling:
�iouse: �..Mobilc
Type of busuitss:._._
I�iumber of Emgloya
I�iumbec o€ brdroom:
Garbaga Disposal? �
Sascmcn[? Yes � I'
���
;RS OF THTs PROPEB'X'I' AND
Ro�osEn �r�vc��.s.
Cou�ty �ealih Department
:ribed property. I agru that the cor
; placed oa the property. I undcrst
:omt invalid. I undcrstatid that bef
property to thc Hcalth I?ept. I und
:he Health DepL within 60 DAY9 �
on shall becomc void and all fees 4
pwncr o� Auchocizcd Agcnt ;
� f�� Closin�
S}�stem
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1t10I1S, CX'�t1S10I1S, OC
i to the strr;x�cur� or facility
sysf�m is �ntchded to scrvc?
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unity C�� sgrin [a . q-
P�tt���cs � No . :
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Eacili • Pro � �sicng: Q
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Home: Q �ine�s: CJ
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esD Na��.
o�If so;.# af bascment fixtures:
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QF AL�.►
a site ava�ua�ion fvr the pn-site
ts of [his a�PP�i<�tion ace trtse
if the site�.s alEcred or the
an Imgr+��e�ents.Pccnut can bc
anc� that' in ttie �vent I have not
r the datc o'f the evaluation of
forfcited. � `:
TOTAL P.01
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' PLEASE SEE ATTACHED PLAPI FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: ff ' Z 9 Parcei # �s�
Zoning �� /D��l_ Township 0�/�� ���
Applicant: V/7/'ICS G• ��LL
�ocauon: LoT 23 �dS�/o/LGG R/DE� S'�% 0�"� OF S/2 //�
Subdivision:
/Qds�(//�E rf �'�t�I�Section: Lot: 23
Improvement Permit
A buildinq permit cannot be issued with oniv an Improvement Permit
New �Repair_ Addition _ Type of Structure�� Water SupplyP(�l��r� w��-
# of Occupantsb /�'X. # of Bedrooms 3 Other
Basement? � Basement Fixtures?�
Projected Daily Flow: �04 g.p.ci. Permit Valid For: �e Years ❑ No Expiration
Proposed Wastewater System Type: CO/'�V�1�dh�� �J
Pump Required? Yes _�No
Permit Conditions: �I�S�'I.I.- D� C�A/71�,t�2 MI�X tVl/�u Y^ ��V�GN U�n-1 2[ 1NGH� •
�"� S � 'Fo�L S ST�m Lo .9TToit/• � .ee�ucno,v ,�F r�i,c
Owner or Legal Representative Signature: \ oate: ��- 9- 9`(
Authorized State Agent: �—' Date: � �
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 governing 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.
CO
Type of Wastewater
Facility Type: �us �
Basement? ❑ es o
A� Wastewater Flow:c� g.p.d.
New �Kepair OExpansion ❑
Basement Fixtures? O Yes �Pdo
Wastewater Svstem Reauirements
Septic Tank Size: � �� � gallo s Pump Tank Size: � gallons
�/0
Total Trench Length: � fee Maximum Trench Depth: 2 � inches Aggregate Depth:,� in.
M�/dmum Soil Cover: �_ inches Trench Separation: � Feet on Center
INS�-c. oN GfiN1���. �% ��croN 2��R. .
Other:
Permit Expiration Date:
Authorized State Agent:
Gi!
v � �
The type of system permitted �'does ❑ does
the specifications of this permit.
i
Owr�erlLegal Representative Signature:�
Date: �/ � �1%
differ from the type specified on the application. I accept
I I - R -`� �
PCHD, rev/ 10/12/99
Application #: 0?0 7dt6
Tax Map #: f�-2q
Parcel #: �/SA�
_ Person County Health Department
Environmental Health Section
SITE SKETCH
l�� �-• %jILL �QO.S�I//GCE iPI,U�� GoT 23
Applicant's Name Subdivision/Section/Lot#
, » 6 9�
Authori St e ent ate
System components represent approximate contocrrs only. Tlie contractor must flag tlte system
rior to be innin t/ie installation to insure that ro er rade is maintained
�" KE� ,��l�OM
Nous� �:o�n►an,-wN
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PCHD, rev. 10/12/99
, . Person County Health Department
� . � �,c� �Environmental Health Section
Tax`Map #: � Parcel #: �5�
Zoning: Township: i� �-�� �E � J l�
Subdivision: RoSev�ii-c 2�d�c Section: Lot: �3
Applicant: �u �s �"i (I
Location: ��S��S ��D�� 2 �
Operation Perm it
S stem Type (In Accordance With Table Va): �
Y
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
AU ORIZATION.
��� q-��-o �
Authorized State Agent Date
Tax Map #: � �� Parcel #: � 5 �
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section �
Zonin Township: �1 i V�- �-{ r 1�
9� ?
Subdivision: �DSCU►` (�t 2i d`i � - Section: Lot: av
Appiicant: J��s H � r �
Locatlon: �-S'��� s��� 2`�
Operation Permit
1. LOCATION AND SEPARATION DISTANCES -/
A) System meets .1950 setback requirements "
B) Distance from system to any wells ���
C) Distance from septic tank to foundation 14'
D) Distance from system to property lines 1 S�
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank ✓
B) VisuaUy inspect the interior wails, e, tee, filter, riser, lids, air vent,
bottom, and water tight outlet
C) Date of tank manufacture t� a�9
D) Tank serial number � T(3 /`�a
E) Liquid capacity of tank ►000 gallons
3. SUPPLY LINE TO TRE,D�tCHES
A) Grade �� (1/8 inch per foot minimum)
B) Material supply line is constructed from v�� 40 �U�'
C) Diameter 3 "
D) Length s'
E) Distance from tank to drainfield/distribution device N�� .
4. DISTRIBUTION DE�/���(S)
A) Type r� f� .
B) Is Device water tight
C) Distance from the distribution device(s) to the trenches
D) is the device on a levet foundation
E) Does the device pertorm according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth � �� inches
B) Trench width v�. —inches R�
C) Distance between trenches
D) Number of trenches
E) Length(s) of trenches 5� I) 0 j I(0 8�
F) Aggregate depth Ja inches
G) Aggregate material and size J�7 �
H) Record septic tank outlet elevation
I) Trench grade ✓ (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed eartf� ✓
b. Proper rise over step dowy ��
c. Solid pipe used c� /
d. Elevations of step downs ✓(Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
ITax Map #: / 1 � �� Parcel # ��
Zoning Township (! � I vI
Applicant: � ��' �f .
LocaUon•
; �p�il�� 2
Subdlvislon: Secdon: Lot: _�_
Well Permit
Tvpe of Water Supplv: �dividual Community Public
Requirements•
Site Approved by
Grouting Approved b,y `f��"G�
Well Log i/
Well Tag
Air Vent � /
Hose Bib
Concrete S ab
Well Driller: �' "(N��;/
Well Approved By:
Date• �`� �����
.—,
**See Attached Site Sketch**
Wells 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
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