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A30 68The District Health Department CASWELL - CHATHAIvI - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PERMIT No. � Da e ��.' �' Owner: - ' � Location:--� �-'-�— '�7-!"-� <_ !"7 �.1�'- I � � - .~y Cnntrartnre __.�%% �A ) �s Water Supplp: Private � blic Sewage Disposal Faciliiies: No. bedrooms washing machine� qther,autor�atic appliances Size of tank: Other disposal facility: Dishwasher, Disposal, � s�ssa �� i7�C Water supply and sewage disposal facilities location, installation anS°u"� protection must meet state and local regulations. Septic tank.should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF TH� DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE I ALLATION IS COV- ERED AND PUT INTO USE. / � - / Date approved: 5igne ' anit rian Well: Sewage Disposal: Counter- signed By� (Owner or h' epresentative) Certificate of Complelion Date Approved: � By Sanitarian..- (OVER) Location of well and sewage disposal facilities sketched on back. Aaalication Date: 7 � � "�0 Amount Paid: lOtj� (r0 Receiat #: �3 � ��—� �� Person Countv Health Department Environmental Health Section APPLICATION FOR SERVICES Tax Ma � #: 30 Parcel #: �� ht �. � KSe� s��•-a��-3� �� .�,1 or P��-� �`� '�` �"► in�..-�,� sys�.- IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CHANGED OR THE SITE IS ALTER_ED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permitrequested by: (Owner/agent/prospectiveowner): Gi�L�K1 � � `�v'S�" Home Phone: S``JS- 0 �S l Address: Z Q-�y�� '� lCs �/��^-�i Business Phone: �"�S -Zz-� �C�I �J I ��►_� G-� �y� l�� — 2) Name and address of current owner: �� '�'-'�- ��Z-� �� ( /O o v�v C -L Ghv2 c-� �d, oY� 2�0 1�. � , 3) Property Description: �ot size? � Directions to the property (In�luc{ing rc Township: T3 v-S %1 y /�O/2 �. S 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed,� Existing 0 b) Stick Built � Modular �, Single Wide ❑, Double Wide ❑ c) Number of Bedrooms: d) Number of occupants or people to be served: e) Basement: Yes � No � If yes, # of basement fixtures: � Garbage Disposa�`. Yes �, No ❑ �/ � g) Dimensions of Proposed Structure: Width � b Depth: � 5) Water Supply Type: Privat�l(new �/or existing ❑), Public �, Community 0, Spring ❑ Are any wells on adjoining property? Yes ❑ No � If yes, location 6) Please Indicate Desired System Type: (systems can be ranked in order of your preference) ,_Conventional _Modified Conventional _ Alternative _Innovative Other (specify): CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION • I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invatid. I understand that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the He artment i y roperty contains any wetlands as designated by the Army Corps of Engineers. � ''J-,? �f -D U Owner or Legal Representative Date PCHD, rev. 10/12/99 r", ,: � Person County Health Oepartment E:xisting SeWage System Report For: Hobile Home Keplacement �ddition Requestee: �Q U�° �+I� I i�r►1.�,i Home Phone# ��"i%f� � 8'�'� t�I�lhs�S ��P.� � susinessx ��'��3� . 'Pax Mapx u� (DO . , . _. � _, -•- Location/Uirections: _ � �b`f� �a�� Y� ��. C! ��/2wa� S _ {�► vv�se Original Permit Located s Septic System Uesigned For: ltesidentiai � Business 0 (,cv�� %1,�� I� • {�, -- �ea �— � c� Gi,i Q�i� d.� �ri ✓'�.. � � Other (specifyj � 8edrooms � # Employees llate Tnstalled vr ^ 3��5� Water supply Tvpe or system �DU� �' 3� Conv?�•-�io�. Nitrification Line Tank 5ize ��0 0 ��p� 02-�� , Other � e il Certified Operator Required 1�� , On site wastewate dispnsal syste�a showes no visually apQarent malfunction on g a 3 D� Ou� �a-�o�7 JDp Yermission is granted to: u!`!;'� �Co��T�an � �� -e �- � �use..— �1,� ;�.� ek, s�ih �Q.�!'�o,�. ex ��1 ��'� Accordinq to the att ched site plan. C o m m e n t s: ��'� q � r�a 1��l 4t,i�A��! eA' ��— ��r. `,�i-, G�cc.�c � fi �h �'d Environmental Health $�G.• �l _S.�Qf i �►��-s � �� 3 ✓r• � DATE � / PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT Tax Map #: ff 3� Parcrcat # Zoning Township V lJ�-S t'4G APPUcant: �2,fVhC�� nV4S� _ . I�{ _ 1 I.ocatlon: (0�'7 �Ouh0.S vhatx� .�.u�l,. Subdivision: SeWon: �C Improvement Permit � A buiiding permit cannot be issued with onlY an Imarovement Permit New _ Repair ^ Addition ✓ Type of Structure ,_ Water Supply �G �� # of Occupants # of Bedrooms ''1' Other • Basement? �2i Basement F'uctures? �6la- I Projected Daily Flow: � g.p.d. Permit Valid For. �Five Years ❑ No Expiration Proposed Wastewater �ystem 7ype: Pump Required? �� Yes No Permit Conditions: �PP �.ou5� �•��o^ �S,��` Se, �';c -�an� AK� 0�1� �; t�� ►, 5��w ri-- � � um� �n�c Owner or Legal Representative Signature: Date: Authorized State Agen� Date: Z? b 4 The issuance of this permit by the Health Departme in no way guarantees the issuance of other permits. The permft . holder fs respansible for checking with appropriate goveming bodies in meeting their requirements. 7hts site is . subJect to revocation if the site plan, plat, or the intended use changes. The Improvement Pertnit shali nat be affected by a change in ownership of the site. This permtt is subject to comptiance with the provislons of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Authorization To Construct Wastewater Svstem IRequired for Buildin� Permit) Type of Wastewater System V �fii lona � Wastewate� Flow: �g.p.d. � Facility Type: Vr 2S �peK�i New � Repair OExpansfon ❑ Basement? Yes ❑ No Basement F'uctures? 0 Yes �No Wastewater Svstem Reauirements Septic Tank Size: �o gallons Pump Tank Slze: 4 Q � gallons �e�'`�� Total Trench Length: �4o feet Maxlmum Trench Depth: �� inches Aggregate Depth:L in. {/�►�n�Y�n,bV►� , . ea� Soit Cover. � inches Trench Separation: � Feet on Center t� , , �- a� ex�� ' � �y°'`� Other.T Di' Ver (/l S lt b2 $��p�'Pa� O1/�2 /�ie� `f 1�`2✓iGheS� Pertnit Expiration Oate: � 4'3 Q �V��$ aY\ R.� � Cji�� Authorized State Agent: Date: a'� a 6 The type of system pertnitted ❑ does Q s not differ from the type specified on the application: I accept � the specifications of this permit � Owner/Legal Representative Slgnature: �- Date: PCHO, rev/ 10/12/99 ,,._,. ..._., . � � _._. . . . / l� � �D � . �ale: or_Nn rav_ 9(1/12199 • , AppllcaUon #: � Tax Map #: �3� Parcel #: (o!I' Pereon County Health Department Environmental Health Section SI7E SKETCH .. � �.�`� �N ��5� .Applicant's Name • 3ubdivision/SectioNLot# � a-3 a � Authorized Agent ate . � � Syatem con�ponenl� represent approxlmate contours anly. The contractor must flag the sysfen� rlor to be lnnln !he ln$taUatlon to lnsan t�iat ro er rade �S mnlntained. i�Ei7o-� � '� �a � C ` / � \ i^� N (�(',Q,� �'�� \ � Q� �� r o \ m ,� � �e. c�ld,`F-�on t � � �` Gu,u$e lS'-�'rnw► �i- � i�2P.�� 'j�`n � � 1 , }�ee� 9°'� fQ `s' � � �Ur�4T�0v� S � I 2 11,,�� t YrlinjNvmuNt d�5�l•.�w rj� � o � > .-1�(0►w ��ri.�►nA s �C' S,� �� .�-G�n�C. �' — Z, �,dd c�. pu�p� I , � ��^e 5 ► �. fl��on ls�- � 1 �►,e;�a�p r�x • l ` � 9 �' o� b'n �) . 1 ��, ��o� °�' ne`� . 1 �rne mkS� � � ir s-fa l�e�o � � ��cn neC�O� � . a �i�e o� `t� .QX I`S'�'i�n Q S l Y��'n ..� use' �c re�a, � ; J 3� y' ��,� rax• , . 1 a,��: 6 7 �1 / q � 0 M , _f a 11 �new�� 3�' -lr��e�.�lay�Q� �h P�Pert l�� P� 1 � . . , p y ..� ,�,�;+� � aihl2ci w� �r`, 9 b�� ,�P�,— � r; �.