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A31 153S�s�Y�G ��lK 1NS��C'i�d�fd ��iE��lS'i' ('�ype 9� - I� Ta; MaQ #� P !# 1� System Type (Tabie Va) Owner/Applicant� . ."'2e `' Subdivision � Address/Location SeclPhase Lot # St�ate ID/date ��fi� Capacity. . g� Tee and Fiter Baffle Seatarrt Riser ifi applicable) Tank Ou�et�. Seal . � Permanent Marker � � - Pt�mp Tarak � vvdt�i . � Riser /5ealarr� Trench V1lidth 3, ft. � Trenci�. Depth ._ in. � Trench Length 3 � ft Trench Grade Trench Spacing • Rocic Depth and Qualiiy DamslSte owns etc. Pressure Laterals . . Hole �Spacinq � Sleeve = � �� um-ups�rrotec�ors •— . , R.equirecD Setbac4cs. . . � . From Welis �: �ump . From Property lines � ✓ . _ Cbeck Valve/Gate Vaive : � �� : Structures/Basemerrts . � � �� . Anti=s�phon o e . - � � � �� it es rainage ays _ :... :.. Fioats/Swiict�es �: . . ..-� ... . � . , - - � . _ . - - Surface iNaters . Alarm� visable and audible Public Water Suppiies Electrical Components Vertical Cuts �>2 ft �e gpm Water Lines � ✓' Appruved Pump Model Vehicle Traffic Bloc� �lnder Pump Pump Removal Rope/Ct�ain. � Distribu#ion Sys#ern � Serial Disttibution ' ressure an Low Press�are Pipe � Appr. Pipe Materiai and Grade EasementslRight of W� Other Easements Recorded . Conai�en�ss pc�d rev. 3I131�1 i �.}� �►x Nl•� a:r�c��l T i ` �.� � !�i ` ip r i � � S�ubd;ivi:s�ion �( (�} t � l� � ha:s�Sec�tio�a:� ot r i,., . � , ... �_, - ,., , _, i i i - i , t_ � , .�� r��0i� � ��'°' � It � � > Sys#em Type (In Accordance With Tabie Va): �1` THIS SYSTENi HAS BEEM IIdSTALLEi3 IN COtUlPLI�►NCE� WITFi APPLICi�BL� NOR'TF9 CAR�LlNA GENEi�L STATUTES, I�ULES FOR SE�VAGE �TREA%1AENT AND I�iSPOSAL, . AND ALL COIVDIT10IdS OF i'HE tMPF�OVE�l1E�T PEF�MIT �►�D. COMS"�RUCTI�R9 �AUTHO 1 TION. . . . . . . . . .. '. _ .. . . . � ��a.�� . � . , .. thorized State gent � � . � • � Date . . �. . l" � . . . . . . . . - � • . � . Installed B.y: � • �if � � . Date: �� `'d � X�� PCHD, rev. 07/29/�2 Receipt �1 �•� � � v� Da te I� � . . 1 a � � 0 . �j�'c:� � • �� AP��xcA�cx�� rR s�cRvx� � �.: �w . er- ' es ues ed: �'�`��` Improvements Permi�(Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing) Im�ovemencs Permi[ (Unrecorded Lot) _ RepaidReplace existing Septic Syscem Improvements Permit (Mobile Home Replace3 _ Permit for New Well — Replace Existing Well ____ Improvements Permit (Addition) — � , �., „ , � � ,� o � , . . �� ..:�..: � . . Bac[eria Chemical 1, permit requested by: . -�-� � �� owner/prospective owner/agent: �1d�-E Ad ress:� � a ��rt�`^ �%`�d� ��.. �� _ ./� `��h �Z 2 � � w U � _._.- --_ ........._ _ I Petroleum Pescicide _ Lead 7. Dimensio�s or Proposed Scructure: � -�.' W idch: z � ' Depth: �Z � T �� — 8. What type (if any, additions, expans�ons, — replacement is anticipated to the structure or facility — that this sewage disposal system is�-intended co serve? Home Phone #: `i/� 3�`f' �7 � 2 ' usiness Phone ��i� 5�s - 3� � 1 �� 2. Name and address of current owner: 9. W ater su ly t} pe: Q � ` private public❑ community ❑ spring❑ � Are any wells on adjoining property?Yes ❑ No [� If so, ,identify location: Property Descri Tax Map#: Parcel#: _� Township: =� � : L.ot size: � �"<-� � . Directions to property: State Road #& Road ,�tc. (/,3 � S� f��„ ,,��.,/ �40� � � � F ,',wa 7- r,.s� s. 10. Type of structurelfacility: Proposed: C]Exis[ing: Q j Type of dwelling: , House: ❑ Mobile Home: C�usiness: ❑ �� ; �T of business: .� N mber of Employees: a �� y"/ Number of bedrooms: � � ( ��, `., Garbage Disposal? Yes � No � Basement? Yes❑ No��so, # of basement fixtures: : 6 Number of occupants or people to be served' %� � CLEART�Y STAKE ALL CORNERS OF TT3E PROPER'I`Y AND THE CORI`IE12S OF ALL PROPOSED STRUCX'U�tES• I hereb make a lication to the Person COunty �ealth Depaxtment for a site evaluacion for ahe o�ei�� Y PP sewage disposal system for the above described ptoperty• I agcee tha[ the concents of this application �. 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 invalid. I understand that before an Improvemencs Permit can t-� iSsued, I must present a survey plat of the property to the Health Depc. I understand tha[ in the event I have n�` delivered a survey plat of the property lo-the Heallh Dept. wi�in 60 DAYS after the date of the evaluation of the site by the Health Dept., this ap�lication shall become vott3 and all fees paid forfeited. W ¢ z Si�nc�i Owner or Authorizcd Agent e�nic Issued ❑ �errnit Denied D : .:,;- =; •lat Observedl� Signature , Date � � e . • . . . � . . . .. . : . . . 1- '�.Y' � . 6 •�-�:�.vmm�tviuA�rIONSICOMMENTS: - � SITE CLASSIFICATION DIAGRAM.(Include: Soil areas properly lines, roads. streams, gullies, wet areas, �ill areas, wells, water bodies, slope patterns, etc.) ' • C.1/1MfPRUDOCMPPSEC.S1�s �ANCEPC � VJ � a w � a � . g �840 PERSON COU�TY HEALTH DEPARTMENT WELL AND SEWAGE SI 'E, I�CATION IMPROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # tt � � Parcel #_ Zoning Township Owner/Contractor J Q m 5 I-I ,(.Jh ; t� Location/Address H W U �5`7 S f- t� � 1► � Subdivision Name Lot# � S.R.# ) / 3 y � � Permits may be voided if Well and Septic Layout by_ Comments: si�e,�s altered o�intended use changed. � � � �� Date _ - � Installed by� ell Permit Paid ❑ WELL ind� idual Se '-Public Site App`�o Well Head Grouting A Comments: Date by Approved by. ECIFICATIONS equired Slab _ Vent Req red Well Log Well � by. X►�s�,� +� This report is based in art on inform 'on provided th�homeowner or hi er representative in the app 'cation submi d for this perm�: The environme ta health specialist is not resp sible for false r misleading information contained in the application. he environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. 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. c:\amipro\permit.sam O1/95 rev.l.l � � • . PLOT PLAN . JAMES H. �WHITE --�_ DELORES G. WHITE �-- ` �--� SCALE 1 " = 50' � '-� ��-� S.R ��--__ _ . � � ___ 6 � 3 �,__ NF N��,s35�' NS�_ � 60 / �-__ _ 5g „w � R _ _ \W — —�-_ � S�� ; �_ ---- _ _ 59 „e � � � �ss IS `v� _ 4g� _ �NF� EOP __ __ J � _ rn �� ' � , CONTROL _ ' � _`� r� ' � � CORNER EOp • � ' � � � � -__ � v� �n _ - 2 '� �A' - _ N � JAMES H. WHITE DB.152, P.385 PC.8, P.20-1 IS N27"22'S4"W 41.32' IS IS ,�o PROPOSED MANUFACTURED HOME , �u b�y� �� .� S �'y� �� , -► � ' „ �� N ..�� ,�� N09°36'S4"E 42.50' C �N�1 er1�'��a" � z 0 5y�� °' � a� � � � ��.�� s �� 135 15' 1 S87 ` 34 � � 1�� W I F IF �./L,r� �`-�-' �TS- I �o �'�t3-1�(Z �� 4 �aq��7 � o o � � � � rn , �^ . ��n JI R. BRADSHER , l�_�_q� . �. Apulication Date: a�d'�63 Tax Map #: �� Amount Paid: 1 G� G Receipt #: 2-70 6 Parcei #: ��3 �� .�� I��I�.� �� 3t � _ — —� c� � �T�'I��1�YT� �a'a� RS�Oa'a.�^^� eBa3�L��Y ��LL�JL�iC� APPLICATION FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED, CHANGED OR THE SITE IS ALTERED THEiV THE IMPROVEMEMT PERMIT AND AUTHORIZQ.TION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: (Owner/agent/prospective owner): �... �s `r�l��'�t Home Phone: 3�� _ ?/2- ��t�-rfqi,3 Address: iiZ s,.r-�� .��/ /{•-/ Business Phone: v�9 9- 3/ 7/ �0�.�•r,e�,.�:F�) u-�-r/ ��'�/s , �tY�- i� ��` � 2) hlame and address of current owner: -�..�� Y'�- ��.� s d 77 �� 'o.l../ .B .....� / r �l �!/s /�c �- r%J��f � 3) Property Description: Lot size: /�� Township: �� t� Subdivision: � Lot # Directions to the property (Including road names and numbers� h�^-, �Y�✓>� !S7 Sg¢� �,�,P� ,... � ,-.. ��, �f o �. -r� S�. �-.� _<�../'�.C./� � .�/ ws � ��. � 2Z. z- �' 4) Proposed Use an Structure Description: answer each of the follow' g questions: � / a) Proposed �Existing _, Type of Structure: ��v.p %.... �� - Width: 28� Depth: �C b) Number of Bedroom�: � Number of occupanis or people to be senred: S c) Basement: YesJ No Will there be�plumbing in the basement? No d) Garbage Disposal: Yes � No yc� 5) Water Supply Type: Private ✓(new _ or existing�, Public_, Community_, Spring _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the site plan. 6) Does your property contain previously identifiec! jurisdictional wetlands? Yes_ No � PLEASE NOTE THE FOLLOWING: �➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPl.ICATION. `�➢ PROPERTY LIPlES AND CORNERS MUST BE CLEARLY MARKED. '�➢ THE PROPOSED LOCATIOIV OF ALL STRUCTURES MUST BE STAlCED OR FLAGGED. ✓➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATIOIV BY THE HEALTH DEPARTMENT STAFF. 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 facilitie to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall beco�invalid. � Owner or Legal Representative z� zo-z��3 Date PCHD, rev. 06/27/02 ��.'�,�� — � � �� .�a-�� .��,Il I�1L��.IL�I� T�x M��p � P rc I# S�ubdlivision Ph�s�e Secti�on`Lot # Applicant: �u''"'1�� ,,f Il�r `r'� � Location: `2 � Z � � � � Permat Valid for � Type of Facility: # of Occupants �� Proposed Wastewat� Proposed Repair: Permit Conditions: ear� � #`of System: Owner or Legal�Represe� Authorized State Agent: � �proveffient Per�t No Ezp�ation New � Additi Water Supply�_ k� `5i� s Projected Daily Flow � g.p.d. '��i Type: _ - Type: _�•� � S'^ Date: Date: Z,�'�7'y The issuance of this permit by the Health Department in does not guarantee the issuance of other permits.'It is the responsibility of the applicant/property owner to in sure thax all Person County Planning and Zoning and Building Inspeciions 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 %r Sewage Treatr�ent and Disposal Systems' (15A NCAC 1�A .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 suppiy will remain potable. . �iit�Od'&aa$lOI1 t0 COgLSi7Ci1C$ �S�t��$�i S�S$��31 (Required for �uilding Permit) * See site plan and additional attachments (_�. Proposed Wastewater System: New � Repair Exp Type of Facility: � �vt.er � Type �� Wastewater Flow �g.p.d. Soil LT'�t: r 3c.� g.p.d./ ft 2 ; Dlu,�,i i3�vt� � V'1 b/k"��-f Basement �Yes _ No Wastewater �ystem Itequirements Tank Size: Septic Tank: `��' � g�l Puanp '��kk: gal Grease Trap: gal Drainfield: Total Area: �� 5� sq ft Total Y.,eng�a l 3� ft 1��Iaxiffium Trench Depth � in Trench Width �� ft li�inianuffi Soil Cover: _?� in Minimum Trench Separation: �_ ft I)istribu4�on: Distribution Box � Serial Distribution Pressure Manifold Specifications• �� ( f'�7�J�i � �� C D''C- ��Y� � r �l� �� ,�� uthornzed State Agent: � Permit Exniration Date: The type of system permitted is '`.�-Gonventional the permit. �wner/�egal Re�srese�tatnve: Innovative Date: t—f� � Altemative. I ac;.ept the specifications of Date: PC�-ID 1/17/2003 PLOT PLAN � JAMES H. WHITE ---_ DEL ORES G. WH I TE ___ ` �--� SCALE 1 " = 50' � '-�_ _�_`_ S. R � --`__ �3 � 4 � �_,_ NF N�� 5351�'�NS�; �O � -``__�_- __ s9W �_ R�w �_ ` �__�_ � s, 5 ;59�_ -� N•` 155. 4g, E �-�NF� EOP IS -__ _� � J � � o, �� ' - � _ CONTROL ' i JAMES H. WHITE DB.152, P.385 PC.B, P.20-1 N27'22'S4"W 41.32' � �;rS� �t �t'� � �� P� Y� S � ��. �� IS . IS a' � ' � � CORNER EOp ^ � � � �' -. _ __ 2 N 9�_ � / ! _ �� IS �i / "O�o� �= o � oC�.� l,� � z� � 2'��tra�� .L, e��s-��.^/,, n 5�- �?% ��,{/i WL. / i� �� .� ��'/L� I�R . BRADSHER � �.�`i� 1 � - (��- 4'� 135.15' S87°34'11"W