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A30 150Application Date: /' � Zz= 8 q Amount Paid: �qQ ,DO Receipt#: 3 7 � ���� � � ���� ��� ---�= - ==�- � � ����- 1 -�� �za-s �ii u �ci. s�..••-„-„ <c3 ar^� �L ,�. � 1� � <e�-an.. � ti:�a TasNlap: ��30 Parcel #: J S — Applica�ion �or Serv3c�� (Septic Systems and Wells) Services Re uested mprovement Permit (Site Evaluation) � Construction Authorization $200.00/$300.00 (if> 600 g d) (Fee is de endent on the ty e of s s ❑ li�obile Home Replacement or Building Addition f� Permit Revision $150.00 (if site visit re uired) $75.00 ❑�i'ell Permit (New/Replac�ment/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 No Char�e � �,0.� ���� � � ` i � •� A` 1� � , � f.J�i%�� � .�,�," �1) Services Re uested by: � , Name: � �, c� • ��tt � �' �d Phone # (home): S9 �'�gQ � Address: 3 (work/cell): — 7 � ��¢ �-2Q„ /r!� . 2 qj`�Fi 2)1\Tame and address of cuprent owner (ii dif%re�t t9nan applicant): Name: 5 �,��n F Address: 3) Property �escription: Lot Size: � g� �e � 2- •�ubdivision: Address and/or direct�i�on� to Property: _��,� � q�' 7' ; n � . e Lot #: as �- Hcn � 4) Proposerl Use and Type of Structure: Residential Business/Type: Other Number of bedrooms � / Number of people served (seats/employees): Basement: Yes N� (with plumbing: Yes No � Garbage disposal: Yes No _� �j'��ater Supply: / Private Well �(Proposed Existing _) Community Weli: Public Water System: . Are there wells on the adjoining properties? No Yes �please show location on site plan) liiate: A conapteted at��lication must also include: :� A�lat/site plan of 1/te property tliat sliows proper#y dimensions and the �ize and location of all proposed struclures. 9 A signerl copy �.,�'tlze `.�ot �'reparation' form verifying that the property i� ready �o be evaluate� � ami submitting ihis application to request services frona the Person Couni� �eai#h �epartmeut. I aanderstand that �i the im%r�aiion pravnded is incarr��f or i�f the site is 5ubsequently alter�d, or f�' #�e int�nded use c�anges, all per�nits �nd approvals shall become invalid. . � � , _�� � �ignaiu�-� (Owner/Legal Representative): � /C � �ate : 10/08 Person County Environmental Health, 325 S. Nlorgan St., Suite C, RoYboro, NC ?75 i 3(336-597-1790) ��� ) �.�.. ���� �� � - � �--�' � � � � � � J � � •7T']1'ti�71.77� cfD 7t7L7L7Y71 <C�=` Sta �..�1L ll Jl Jl � �:R. � �� Applicanl Location: Tax Ma�p � � Parcel # • Subdivision Pha - Sect�ion Lot # � Improvement Permit Permit Valid for ^�Five Years No Expiration , / Type of Facility: �r i Va�2 �QS;� �ce. New Addition _ Water Supply W e 11 # of Occupants �x � # of Bedrooms ,3 Projected Daily Flow ��_ g.p.d. Proposed Wastewat r System: �,on� ` aq — Type: Proposed Repair: —� Type: � /' Permit Conditions: � Atn a�v► A SQ Q .S Owner or Legal Represe Authorized State Agent: Date: Date: Z � 3-- 0'3 The issuance of this pernut by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspecrions 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 Serva�e Treatmei:t and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health 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 �'asiewater System (Itequi�ed for Building Permit) * See site plan and additional attachments (_). Propose astewater System: COhVeh%1��n� Type �a( Wastewater Flow 3f�0 g.p.d. New � Repair Expansion Soil LTAR: . 3 g.p.d./ ft 2 Type of Facility: �r iJ�i' PSi c�evlCe Basement _ Yes _ No Wastewater System Requirements Tank Size: Septic Tank: 000 gal Pump Tank: gal Grease Trap: ---gal Drainfield: Total Area: 20o sq ft Total Length � ft Maximum Trench Depth ��in o•G• Trench Width �_ ft Minimum Soil Cover: �_ in Minimum Trench Separation: � ft Distribution• Distribution Box 'V Serial Distribution Pressure Manifold Specifications: a �,�q� Q[� SCl1�C�S Authorized State A� Permit The type of system permitted is pennit. Owner/Legal Representative: � Date: �G � � T `�Conventional Accepted Date• — �e — c.Zoo�-�o� � 2�L�1`3 Alternative. I accept the specifications of the Date: PCHD rev. 11/10/OS -L"'��,,;,,�� ���� �J'�_ �l , � � ' `�`` � `lJ� `v 1V �� 1�E�-�y-������.�.11 ]H[�.ffi.11�. � . �I'I'� �I�'I'Cff� : Ivlanne _�u___ d�e, w�i�-h'�e,�d Ta.g Map #�.,� �.Pa:��el � 5- a- .�.�____ Sub ' ' ' n . � Section/Lo1:# " �2-�-�9 . . .t�uthorized Stat� Agent . � Date .4'yst�sr� cvm, ponerais r�}►ir�sent a,�i�►ir�oxin� �ca�:torsrs os�ly.' ihe cosa�rictor r��st fiag the sys�tes�a ps�or t� b�gir�raYrsg th� installu�ioss to ��sure that pm�i�s�gmd� u�aYv�tained � i(,"�� r �f� �61.;1?(? S: i?r_At o� ;i �() �7`C ���,'�:15,()4�� R'j� , �}� , _,. ��r�'tr?C��1������ ro .4�,1.�},J ..._�,. � ,� _ �._ •��a l,� if �``"�'<,.. _ _ . _ - 1 � � ~ -.�%1��0 � o 3 S� � '�.`�,C I .1� � l'1�Ji� '`..``74t.. �r � ��S ° � `,.-i, i•c' t / rJ �```�,,..�� 4� �_ •� � .. r 6 � ``•.,, `^.� � `"`•,�. C�� i' � e.. � : ,. 7�-` `�:=� i� � � ' (� ,' / � r :, �,. t � h , ' � S�m r, � 't ��h a �/ _ � , - 3c�o' c Pd l 3��a ,' ,i s cc rn� , l O f?, :t " �T �� �tn� �� c,, .;;- r�ir�y�:_ /1 I �-�r,, �, ��t.e� ` �'�d' l�b►1✓�nT�DhIL J • ,3 "w � f � Ser �'a ��►�S� �' h dn ; l • / / ��,. � �:;5'�:�; � �, ,. t ���'��st���r��� �c;��r°� f{�s �,�r�w � �.,; N� f• t�;;" a�� , �?�•�:t�� �z>�>�i•r � �f�S(�� C, Gf;;��p«, a � r�y�, ,e,�. �!, � �• ,ti{�,�.���f� 11�;1 ,q6�.; .�C ��..ns.��,� �5'f{:,z, � hi)(i�F. ''��t� ;��R,j ,. � Re;{;�,,�; � , ," '" ��,j W ?-���,1r�. „ �. „ iP� �. �,k.>K:y•rr, � fy� 1.�, ���� �'����o� .'` :. ; -;� 1�,:., �1 ::• i�� ` :��-. • i t: ``;:� r~. :�,i,�'; ';i� �.�:`: ,`; ; i,, `�;:: .. � _ � .9 N)`ty . .. . �q�;���y� A l � ��ac�S a ••.� `' ,. ` �s ;' :.i ` . �� �� � '�p �. . � � + + j:� cc� \4� _, ,. .. � �,� �; ,c , � . � I 4l (0 � � � � I � I.���e Pa� �� /_ - �_ �- �._� - i � � � . � r�� _ � -(,t:t°�:'1�.. ��;" �.. - — ,.'r� ' � � �'\ �,} - �� � 3; .N - , . � ._.� .. ' 6 k e� _ � �, y. �t: �,, i . • ., i.,';"�� t , ', ����+ �� : 11 ��" �.a� `�J 1:. � � `"' � ^-; �C' � �J���� J.L.rJ.R��ST'�.Z�:�ZCS.�T� �'J'I.�.Ar<C�iL�l. ��CL'<'S1..JL��LJL �1�'%��� P���l�� �9�YV �d� ��&' � — s°� �i �'�g ���: 30 ������• 5 Su�div�s�oa�: �s�g: A��Sfla��m��� t�a��: Clu�e {,�'��el� l��ai�g Adc���s�: ��aon� i�1aa��e�§: ��c��o�a o�f ��m���:�� S 7 �e��ndi �'onditaoras: I� See attached site plan for proposed well location. 2) All czpplicable State and County reaulatians governing construction and setbacks capply.� 3� Permits expire � years from the date of isszre. ��3a�r Cmrada�Yon�/�'ommen�: a� a� n a s Q� s „ �'���aa� ��sa�er� �g�: .;� ��ie: � -Z ' 09 ���'�'�'��F�`�� ��' ��1��.�+ ���I�t 1��� �I�fl� �������n�ffi: EHS/Date Location: Grouting: Well Log: iNell Tag: Pump Tag: Air Vent: Hose Bib: Casing Hei .,,�iit: Concrete Slab: 'b���1 �����er• Pump Installer: 'Y'��� A��rm��s� �y�: Date Sample Collected: PP:son Counry Eavironmental Health 3�� S. Vtor�an ST., Suiie C Ro::boro, �iC 275 � 3 �.,n�ne� ��5�e���an: EHS/Date Installer: Depth: Grout: ��� A���s���n����: EHS/Date �ompleted: MethodMlaterial(s): _ 3�a���a�� #: License#: ��t�: Date Results Mailed: Phone: 336-�97-1?90 F�: 330-597-7808 8/lr'08