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A31 144
r � . r J �►paiicatton DatB• �� � � Amouet Paid• � ' Recei t �k �. I �d'S� G�� d za� =�a � .�,��. Persa� Countv Health Det�artrnent Environmer�t�i Heaith Section Tax Maa �k !'t'� � �arcel #: � � '� � . APPUCA'RON FOR SEitVICF�S . IF THE INFORMATION IN THE APPt1CATION FOR•AN IMPROVEMENT PERMIT 1S PAISIFiED. CHANGID. OR THE S1TE tS ALTE}�� THEN'THE IMPROVEiIAEi�11T PEi�MR ANO AUTHORIZA'itON TO CONSTRUCT SHALL BECOME iNVALID. 1) Perntit by: (Ovmerlagen rospecttve ovme Home Pho�e: u-� 38 - . Bttsiness Phone: S9 t 9� 6Q 6-�3 by� - ti�., s�t I�s Q J�x.� � 1 t-�t �a: �� PSS e � ?c.�s��+;�t � Name and address ofi curretrt owner: L y N �� . W;(5o iJ . —�' 1yy rfl���Qi�� �1,���I� .�:d �c. �75y� �s 3) Property DescriQtion: Lotsiz� .0 Tov� 0"aedions ta tfie ProP�Y n�8 road name� and aumbers): e� ►�•� G1na r I: P �o r�cj ��' d t e��t �-_ Lor ',1� SOcnv�� Iat ON K:(iN ��:�! ��reS�T �c�r�ss NG � % S �'at � I�o-r # �. o,v m��tle, � ,e; � . �) �Qse St z- h�.�ked M��, .. �� i-wcN I01 � f� ��- %t�,• 'S rr"v r(/ � , �e ��� s/.o 4) Prapoaed Use and 3truct�sre Desasiption: anawer eact� af the fodowing ques�ons: a? ProPosed�f. E�ln9 CI b} Stidc Bw'it 0. Moduiac� Single Wide Q Dauble Wide Q . � Number of Bedtoams: �,_ � Number of o�nts or PeoPle to be seivec� e) 8asament Yes j�. No � lf yes. # of basement �ducax � fl Garbage D�tp�a� Yes �, No 1� � OLnensia� of Proposed Struc�u�e_ Width: � DepfK �„� �� � Watec SuPPhf Tj�pe: Privata� (ttew � o� e�dsNn9 �I. p� 4�lf 0. Sp�+9 �. Are any weUs � a�oinin9 ProP� Yes [I No'�li yes, iocation 6j Pleaae lndicata Desii�ed Syatem Type: (sys�na can be ru� In erder of yauc pteta�) , �ConveMio�ral Moditled Conv�ntional _ Aliarnatwe �nnovativa Other (sp«�iyj: �Q�� �2 A�y�tS �C},.tdre►� CLEARLY. 3�T.�A,,�CKE ALL CORNERwS, ,AN�D U�NESC }O�F �TpHE PROPERTY. �� l fIG ��6�iW OF Aii �7WrW W�7, ii�� PLEASE ATTAC�i SURVEY PU1T OR SRE PUW TO THIS APPUCATION I heroby make apQB�t ta the Pecsos� Ca�mly Health Oe�rartr� icc a sde evaluation far the on-aibe sawage diaPo�l sya� �a the a6ove-desaibed property. l agtee tl�at the cantania of this �on are true and rep�t the ma�dmum � to � ptaced on the propaty. !�es�and �the si�e is alteced acthe ir�nded use d�tangea. the pnan� �itail become invaqd- i� that as app6cant, 1 am tespon�ie. for idec�ifying and rtmririn9 P�'�Y �, � and mald�ug the s�e a�e for t� pesso�nel of 1ha Pessot� Cou�jl Heailh Depattrnent to candud the� g+ralusitoaa. l t�stacid ihat 1 am �� �°�9 � Healthh De�actrnectit If rtnf ProP�Y �Y �� �� blf � A�Y �� ��- e�U .�,_ �� a�� S� - I`!" - OC� Owner or Legal R�ve . Oat�e ��'� . �.� :� � �� .� ;�'� . .e�:_. th z1t `u�a i � er}; % f �s •-- - � . � . e�; ; . 7 - �0 sn d f91.�. � !�3� R �� ��ry 7t stered y nnd nt. � doy e - JQ�IC �. / %,� �� � Q�'%� - � � �� "�-� � , � � 3_ 1�5 � z Lot 23 L" - � � Lt � . �� . P ;� t? � ' /��J '��/ � � '� �! ` ` �N �` \ ����- 'C� � , � �-?; ) � �` � � >. , �� -� � �.. '\ .� � � '�'� � � ; � , 1 \ ` { ��"� * � ,�� L,�� ,�� , Pe99Y Y. Porl�rfiekd . k ,�".,.� _,Lb' - D . 6 , f�# 7 - 6�� �� .� y `�, , ' , � � j� � T n' �OX' , r, \ �, .� � C��-� , '.� ;� �,�, �.�. ��, � � � � � ,. `{� . - :�' �1 � . � � � � . r � �� + ���. . O � S a� " �'o.b' � i � �� d � �- � �� � � � o ,,� ! ' � ��'�? � � s�; `�: ��- - ,` ��_ � � �.'�'� aG. �� � / ��� `S� ' p�' ',� b� � ��� $ . � . � �3� � . -� � � �p . ., � / �. � �' � �-_-ti._._ , F� . . . �O � � � o�r k- � D _ L . yJhitfield - . ,. • L � . AC Tax Map #: Zoning _ �o�t+o�: Sectlon: )IL Parcei # �� Township �y � Lot: � � D� ! v�• �'�( �� b��1 l�• �� Improvement Permit A buildinq permit cannot-be issued with oniv an Improvement Permit New � Repair _ Addition _ Type of StructureS��Water Supply Qr I V�� # of Occupants �# of Bedrooms Other •` Basement? � Baseme�t F'ixtures? � Projected Daily Flow: � g-p.d. Permit Valid For: �ve Years ❑ No Expiration Proposed Wastewater System Tyy e: VI Ut°i� !�(%1 �rf�,(��(.d �d�L Pump Required? Yes ✓ No J � Authorized State Agent: �� Date: Date:���J '— � The issuance of this permit by the Heaith Department in no way guarantees the issuance of other permits. The permit holder is responsible for chedcing with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if the s'fie plan, plat, or the intended use changes. The Improvement Perm(t shall not be affected by a change in ownership of the site. This permit is subJect to compliance wiih the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Authorization To Construct Wastewater Svsiem (Reauired for Buiidina Permit) Type of Wastewater System �IVastewater Flow: �g.p.d. ���']�,�� ���j� j�'j��' ' ��.. - - Facility Type: New CY�tepair DExpansion ❑ �Y���� Basemsnt? es ❑ No Basement Fixtures? �s O No Wastewater Svstem RequirEments Septic Tank Size: �� 9allons Pump Tank Size: �� gallons Total Trench Length: � feet Maximum Trench Depth: �"7 inches Aggregate Depth:� in. i�I,lL1 t 6'Vl(,(-!M �Pdlaximtrnr Soil Cover: � inches Trench Separation: � Feet on Center Other: �D�I�iVI�1%�� �s ���"""'�`'" _ - �.i� . _ _ lG 5� Ol�YI D(�5� � � �5�/�Y��l�It Authorized State AgentL_!�r�k-l�-�� � Y�Y ��� �'.t� Date: — U � The type of system permitted 0 does . Q does �ot differ from the type specified on the application. I accept the specifications of this permit � Owner/Legal Representative Signature: Date: � S VU PCHD, rev/ 10/12/99 ��` � � . . � Parce : ,jQ�______��_ � Person Couniy Health Department � � . Environmental Health Secfion . � SITE SK�TCH . � �� � � � � l�t�f� ��1 ot 2z �n�,�-� vi . . . � Applicant's Mame � Subdivision/Secti n/Lat# - � �_� �� � Authorized Sta e Agent Dete, ._ .cU�:am �nri�„enents renresent �arpproximate coniours. only. The. contractor must flag.ihe system rlor lo be innln the installntion to lnsure that '-1 i• N v�,: : . . ,. . �: , ,�. ,. ,,,� , . ... � �:� ,�°!r,� ,� �.,�4. ,� �. . . . � grade is malntaraec� � y 1 � . A . 1 i . } .�, ;f• • r :�„�;• � , , � . Scale: I ��� ��.�.-- � : h . � � . , � PCHD, rev. 70/�i2/99 � , . . � � Person County Heaith Deparimant . Environmen#al Heaith Section � . Tax Map #: ` Parce;l �: Zoning: � Tovmship: ' Subdhtision: �� Sedton: Lc� r� �C ' AppUca� _ �,�, � ? �f�'�% ��►��� . Locatlon: s � / 4 e�ration �Perm it � S stem T e(In Accocdance Wtth Table Va): ���� . „ Y YP TH1S SYSTEM HAS BEEN INSTALLED IN COMPUANCE WtTH APPLICABLE NORTH CAROLINA GENERAL. STATUTES, RULES FflR SEINAGE TFtEATMENT AND DISPOSAL; .AND ALL CONDfTIONS OF T}�E IMPROYE�AENT PERMiT AND CONSTRUCTION AUTHORIZATION. s �- � ��a �� ��o Autho State Agent Date i�. ��o. �_ `�_�_ ,,, � � . K3'��' ° 3 �GII'% r, � �D S l ��� ST ��J L/ ' �/� ��,, /%� � �' ' � � PCHD, rev.10l12/99 Person �ounty' Health Deparkment Environmental Health Section Zoning: Township: Subdivision: �iJ� �CX, �� ��-;-�'Y/ Section: Lot: �� a Applicant: /1 ocation: � ' Fl c v�–d� �../ � /'�/-'2— ,�/�lv� �� L � y � O era#ion Permit �0�0" �'` 1. LOCATtON AND SEPARATION DISTANCES A} System meets .1950 setback requirements � B) Distance from system to any welis C) Distance from septic tank to foundation c� ti���� D) Distance from system t�'r��erty lines 1 r� � 2. SEPTIC TANK A) Visualiy inspect the exterior walis and top of the tank � B} Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent, bottom, and water tight outlet �_� C) Date of tank manufacture tD �� D) Tank serial number E) Liquid capacity of tank � gallons 3. SUPPLY LINE TO TRE S A} Grade (1/8 inch per foot minimum Q u� B) Material suppl i is constructed from C) Diameter � D} Length E) Distance from tank to drainfield/distribution device � 4. DISTRIBUTION DEVICE(S) A) Type � B) Is Device water tight C) Distance from the distribution device(s) to the trenches D) Is the device on a level foundation E) Does the device perform according to its design specifications F) Record the inlet and outlet elevations 5. NITRIFICATION FIELD rf A) Trench depth �"1 inches � B) Trench width inches f � C) Distance between renches D D) Number of trenches � �/ E) Length(s) of trenches � ! ' j �=- / 1 F) Aggregate depth �� inches � � G) Aggregate material and size H) Record septic tank outlet e evation 3. 9" I) Trench grade S (< 1/4" per 10') J) Step downs a. Minimum of 2' of undisturbed earth b. Proper rise over step down c. Solid pipe used�� � ' d. Elevations of step tlowns s4� � eco d elevations and show on as built) � � See "�s built' plan on attached sheet. ,� PCHD, rev. 10/12/99 '., PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: f I'11 Parcel # /� � Zoninq Township APPlicant �JVI I� 1 Y" Ilil.t� I l�! . �eo�: Subdivision: �,% //� .�A �l'.(iir'f ectlon- �,oC �� � T ��� Well Permit Tvpe of Water SupplV: Requirements• � Individual Community Public Site Approved by ✓,��� C����D Grouting Approved by 7'nl t� -��v-�� Well Log 3�1 '1 a�-� Well Tag � Air Vent � Hose Bib � Concrete Slab Well Driller• � li�r�' Well �Approved By: Date: � � �� **See Attached Site Sketch** Wells must be 10 feet ftom property lines. �Velis must be 100 feet from septic systems. �1Nells must be at le st 25 feet fro an buii in fo dation. w`��y w�u� �e � l��"���-��ot� ���1�1� Other conditions: __ PCHD, rev. 11/29I99 � � � .,�..�...� � i. �.���� ,� i�.ivv�.�cc�rrr:r�:r�r�•ni. . •i �� ', � �c7IC;.`�_ � / . . , IJI:I.I. 1.(!(: i �1V1�C;�-_ '�;•�a o � � �� �101]/�' . —�~�,�. 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' .. �", �� tl� -_ ... ... ... .. ... ...�?1� 11.1.1 iV(�' � �. � � ' ' � :� ��Glll �`: _' . ` ' • .���� �_... _ � —y_ � ' ---�_� 7 r� • • ...... ... . ... -, . -•--- •--• ...._.. 1"�irri_ 1`tIjU1� ��.�C .. ``��.�.�( . �� ` ` ��l��../�6P_��_ � • - ... .��..�-. /1' ..%�----- � ' - . r � L n r �----t.`_"r'---_.�...,,,_.------ y ... • .... 4 ,_- Y . .y �`-- .-.... • �T�S���a c,��zrzr����,f.��. _" _.., � ���-�- �'ti'AS CO�S. ,� � �'I� �1,13(:)V ; � _ 11� UC�• - � lN!-UlZM,1'l :[p �oRr�-r � y.T�-1::. Pz:,�so r � �:c.� .lrv ncco �z, ., � .. r•nU.N�•1� I.11:�1T,�-l1,n��C�; /11� "f'� : ,.. ; .._`.` . �C.l «�-� �1��11 1�I1 . 1)����()Illi.i�:� � �s �o.�n�cr Ar r.IT1-f 1Z.�G U,�,A�( t;tv-t�. . ,