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A31 162r Apoiicallon Date: . � ��0� Amoutrt Paid• __�� Re�iQt �: z � 7_ � � �''� '� � �� ����_ � I��II�.� �1� - - � � ���-�- ��.���. -_....,. ���. ���.� APPUCA710N FOR SH�VIC� Tax Mao �: Parcgl #: IF THE INFaRMAT10N IN THE APPL3CAT10N F�R AN IMPROV�E31lT P�iZMIT 131NCaRR�T. FALSiFiEi]. CNANGm. OR THE S1TE IS ALTEiiED. THE3N THE IMPROVE�VIENT P�AAlT AND ALTi'H�RfZd1TiON TO CaPISTRUCT SHALL BECDME INa/AL1D._ • I 1) Pern»i requestad b.{Owneri�entlprospe�ive ownerj:= l—e ro C � O� Home Phone: � -.3' Address: `1 I� U u �� ro � �• Business Pt�on� .�`i 7-6174 _ �y rd l e �;11 � 1J C� 7�4 � 2) Name aad � of currer�t owner: ,� �!f��p ���- � ��45 y2r�n 6�-ta , ,�; � �2 7 .S'7�_ 3) Pcoperty Descriptian; Lot s�e: L� Tawr�sf�ip: Di�ons to the property {Induding road n�mes and sio�_ Lot f'1.t.•11s I`�i' 7 x��- l�r�c s;�. . �c.fri' �vrs�'� 5 �� 4) PmQosed Uss a�Struciure DescriQtlon: an.swer eac,f� of the failawin� questions: .• a Pro osed / Existing , Type of Structure: I�}o� te- ��} �Ck 6�'�- Width: � De�th: • '� b) Number �f �edraoms Z Number of acs�pants oc people t,o be served: .- c) Baseme.nt Yes . No �/ Will there be plumbing i� the basement? � d) t5arbage DLs{�osal: Yes ✓, No _ . 5) Water SuPQhI �51Pe: Private �(new _ ar ex�stin�. Pubiic_, Commun�y , Spring -, Are any wells on adjoining properly? Yes No _!f yes, Pi�ase indic�te ap�aodmate lac�tiai an the 'sifia pisrt. � o�s you�r pro�rty c�nta�n �re�ous�y i��� jur��ona� w�tands� ves_ No ✓ �- Pl.FASE NOTE THE Fa1101MNG: ➢ A Pl.AT OF THE PROP�ii?Y OR S1TE PI..AN MUST BE SUBMTfTE� WITH THIS APnL1CAT10M. ➢ PROP�TY LiNES AND CaRNEiZS MUST BE Ci.F.ARLY NARl�. •, � 9 THE PROPQSm LflGAT10N OF ALi. STRUCTUR� MUST BE STAi� OR FiAG��. ➢ THE StTE 11AUST BE READILY AC�ESSIBLE FOR AN EVAL1fATtON flY THE HE�ILTH DEi�ARTME�Ii' STAFf. � ! hereby maka appiicatian to the Person Caur�ty Heaith De�artment fnr a siie evaivatiort for the on-siie sewage disp.osa! system for the above-descrii�ed pro�. i agree that the car�,ents of ihis agpiicatian are true and repr�.seavt the maximum faciiiiie.s to he placrd on the pcoperty. I undersfand ff the siie is alt� ar the irrtended use cf�anges, the permii sf3ail hecame inva�td. � � Owner or j�a! Repre�tative - l � -CS S a� PCliD. tev. 061ZT102 .:,<;. ������ �� � � n � �� �� \� ~ � � �lJ � J�. 1L • �sa�as-o..,.,, ,,.,,�^ oaa��.�% ��ae.�.���a. T��x �:i�aE� ' � -:}rc :>.I -, S�u!f�.cl i�v i•�i nai F bk:i_��C%5��� t1011:� La t� �j1C� �L� ��i � . , Location: I ot n4ac+ �v- �v a I ts ��„� �•u�.. G. Ri �p��effi�t �'�t , Fermi� Valid #�r ��+i�� Yeaa�. Riq �g�r�at�n -. . � -'I�ype ofFacs�it�: �,v�a(. '�cr��u � �9-Q.�•:� �� New ?C Addition_ �T�#er �uppr9� f�i�o�c # of Oc�ant� �# of Bedroams 3.. � e,cted Dat7y Flow 3C�� g P.d. Proposed Wastewater S�st�m: �ntiucQ . _ . �PraposedRepair: (�•or�� ' ' ' Type: J�Q Type: � Peani# Conditions: �-0\1� �� Slc.e�. ���•� � ��� b-c w� Fk.� +�+�•I c � (�- � �'la�sc ' asLt i� ff.��,,.�,�� • _ ' � QWIIE�Y 021.� �e Authorized State Agent: m D�: DStE: tv-�S%OS 'I7�,a isauanco of ifiis permit hy 1� Heaith Departmc� in does not gu�e tho issaanca of other pe�ita: l[t is i�e nsponsb�lity of the aPP��P�P�S' owner to in sare that all Pettsoa Cou�y I'la�ng and� ZoniaS and Bwldmg IusPectinns requiremeats are met �his Improvement P.ermit is subject to revoeatioa if ta�e �ite Plaa�, P�t or the iuteucied use eiaauges. The improveaneae# fl'ermit is not affected bp a'change ffi nw�mer�hip oi the propert�. �'his permit was i�sueai in complianc� with the jprovisions of the N�rtie Cmrolina `laws and a or S Tiremlrnes�t anri D�is�wsul S`v�teras' (15A leTCAC.IBA .1900). NeitLer Person ("o�ntp nnr the Enr»�ro�ental Healtli Speciai�i warrants tl�at tlee sepiac t� system w�71 contLt� to fancdflon satisfactor3l�* in the futare mr that tLe wa#er �uppty w�71 remam potahle. � " ' �An�o�taon #o �o�ta a�'�a�t�w�ter� S��teni (Requ� �mr �a�t� �ermit) . * See site plan and additlonal uttatc3Q»ents (_). � . Pmpos� VVasteWa� SYg�m: C, �•,.,. _�.�, :J Type �� Wastewater Flow � o. g.p.d. New �C Itegair Eapansion � Soil L'TA�2: . a�s g.p.d.! $ 2 Typo of Facility:. `c�� ��,�aL�. '�-.1�. �c_Q�� � � � Basemeut _ Yes�c No — - - ��stewa#er System Requiremeats � . Size: Sepiic Tamk: I(� gal . P�amp Ta� �� gal' . Grease Trap: -- gal fie1d: 'Total Area: � 3�� sq $ Total Lengtl� `�°�� ft l�ia�mana'irene3a 13epth �� � C�L ���91 .g � � So91 i�'Vea: � ' C � M�nimrnn �I`reIIC31 SreQ3iat10II: �_ $ � t •►..���.� :.: specaficatio�: Se�xi�l Distribution �Pressure Ma�old Aa�ho�aed 3t�te Agea�: � ' � Date: Peunit �xpiration Date: � The type of syste,m: persuitte3 is Conventional Innovative Alteffiative. I acc�pt tlie specifications of the pesmit ' 1 ��e�lg.��g� �pa�se�i�ie: � � � � .. Date: � � � PC�D7/3�/2002 �-�26-20E i�:� 6= 26A�1 FROM E ►-� . ,s.�.r,,, :�. �.;,w.�.r�}'{_: <' , . • , f ;r : f3. :.:: ��: . 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I.o f '�i'� �STi3� C.Gi� Qf �@t3; ' / � . _...— � ` . _ I� . Fd' tl �1i1:� t ,� . _. . .- _ '�� - � � :.: i 1 . -� }� ,-`-;-�,..J' -- .� ' � v,�.� i= _ --_._._---> C£���ERY �Y � �. �.2 %1 v _ �•• �r � . ..-•r � . �, ��� � - L � �t� `^ .�oc •n� � x e - - ��C$6.00` � �� 3 �Pc�} � f ; ; vy -,+, f� _ 1` _. / �� . �. , � ; F �}/ � � � J�d 7g O 8 �' � 4 � ' "-� _ _ � � �5-�i - .�__ -`� - - � � ��� � r- � ; ;_ � - �l � � ��A�� 2 �- --- ---��—! —��; ----�, � 4 � : t-� � �� ' � . � . � ����� •• . * �� / -�,-�(.- - �"`� _ ' N � � . 0 � u � _ � �, � � rv f ` � j `� D ; ��. �� � _ -o �� . . � . -� _ . �; �, o . � :� � . V : m . � e � . � r _ � .. . � �S D �: 6 _ 4 5 ' _"\ D �J Z , ,f � /'�� n r.,i � ;- � ,: � , _, •-,,,�-� �� .� > :: `� d<:; u; � 1 v� �s `` . J r� m �-. � m w p N �!3 -� ` " ^ .. . -, . sc�Tr o: - -- �` N .;,;`y � `j' i> . � �. � � .' ' ~t 69 �.�=���' ` `� ;s' ��;:: � ` � � � , :;�. `�` v � � ` � 'F� •}, , . in ��:'?: �,-_'=�` (T� +�i:.- :'��.; ------� ` �=- � � ' ` _` "o ; �4` � � - � � • - 1 � � �LE/�►SE SEE �TTACHED PLAN FOR Sa_i_L AREA AND SYSTEM LAYOUT Tax Map #: �c� I Parcel ii 1 t�a . Zoning Township��;V F�rK Applicant: r� �l �o�aeon:l P r �eCl�u 2d, G"o�S;S K�vcr Znd, dri�c bn � Subdivision: SetUon: Lot: improvement Permit A buildinq permit cannot be issued with oniv an improvement Permit New� Repair_ AddiGon _ Type of Structur�� Water Supply�ri�Ci�t-(.�-�� # of Occupants � # of Bedrooms � Other . Basement? ,j�_ Basement Fixtures? �� Projected Daily Flow: �oU g.p.d. Permit Valid For: �Five Year<_ ❑ No Expiration ProposedWastewate SystemType: ��UC�'�i0r10.� �i'Gtvi'�`! 7unc,� Pump Required?,,,�Yes P;� For Rc.�ir Permit Conditions: �;C��P l�� � f 00� F�Dm Szpt►C.. �n5-fr��l C�5 Ftc���cr! on la�t vv b�_ cz s f,t ►Q' �om G rcwc�� r�1. _ Owner or Legal Represeytt�tive Signature: Authorized State Agent: Date: Date: I37 � The issuance of this permit�y the Health Department in no way guarantees the issuance of other vermits. The permit holder is responsible for checking with appropriate governing bodies in mee6ng i�,�;ir require-�•�nts. This site is subjec: to revocation if the site ptan, plat, or the intended use cha�ges. The Improvement Permit shall not be affected by a change in ownership of the site. This petmit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. NCiili�l` �'' �ftl: 1'O %Oi2�>'� l: "� �+ :�'i+:i�vi:�e:{' .S�'�ii :ti1 �i�CQUIt't : for 6uildin� �er(?11t� Type of Wastewater SystemCO�o�.11ti�rm I Czr�yi astewater Flow: �d%g.p.d. Facilit T e;J�i �, �m� I i�t�if New �' Repair DExpansion ❑ Y Y' Basement? O Ye o Basement Fixtures? 0 Yes � Wastewater Svstem Reguirements � . C. F°r (Zt(�`cr� Septic Tank Size: ���� gallons Pump Tank Size: � Oo'O gallons Total Trench ��g�fh: �feet . Maximum Trench Depth: � inches Aggregate Depth: (ain. N� LCbS-F�o�h Maximum Soil Cover. � inches Trench Separation: � Feet on Center Other: OD (�i p T O �� J G ��! � t" � t�0'�iC O r 2��a � r F}rCO� Permit Expiration Date: 0 � o�OC� _ ' Autho�ized State Agent: Date:� The type of system pe; m' d O does Q does differ from th e specified on the application. the specifications of this permit Owner/Legal Representative Signature: Date: G(/"'� '�� I accept PCHD, rev/ 10/12/99 , , . ' , � . o- � Application #: _ Tax Map #: Parcel #: / (0 2. Person County Health Depariment Environmental Heaith Section � c SITE SKETCH ;� ��J � L-c,ro C! �'� p pplicant' Name Subdivision/SectionlLot# � G a- J � ~ � �� �� + � � S � � Authorized State Agent Date �, o��� ���ZO Sysiem components represent approzimate contours only. The contractor must flag the system ��'^ ?'� rior to be innin the installation to insure that ro er rade is maintained c�' � ��� � �o .� _ � � � c ,; 3 � � � � ��s� dN _ '�� � � .,' � � 3 a v"p v �o ��o � r`D va ,� �-b ,�� �� � �� a� cj G o� �'� j '_' J9 � J ��.n I � .� �l �� $ � ' � O .nbf �P �� .na Yp'L� � �c � �bf'�bJ� � ` tA � 2 � � � s ° '�b � Pp �O � � ��� �y � J� �' v'o , a � � � T � t5'� '� �- � �� ; O � � v � ��' 'c� o � �° ,. � Scale: �--=,00� 0 � J �3 v 3 0 � � .$ �-n � � � � 2 , w �� �`s"� �M j "� j � `0 . � ° v � � C yl -�- - - - -� 1-� � d 3 < �, � � � � � � p � ` y � .� �s. � ,� -� � ; . ,.� I `p��'� Ob �, ' � Q J • � � � � � ( ..�. �, d'� O� � � � � Z .n � i'g $ �. ��, ' i .o ��) �----� � V1 � � \ � ` `"1��1 7 J � .s v PCHD� rev. 10/12/99 L � 662�/06 '�a� `aH�d �i y:# laa�ed �� I�. •# deW xel � 'G S L �1 .1-- ' ► � '�i� ��� �YI Ql/� I a�%� I �� ri �� a� � ,�Q a�ea �-Ql - s . ' -• • - •- • . TI�/�!�►ri'/�� !' �; i7/►� , , 'NOtlt/ZRIOHlfld N011�f1211SN0� aNd 11Wa3d 1N3W3A0?ldWl 3H1 �O SNOI110N0� "I�H aNd `ldSOdSla ONd 1N3W1d32l1 3Jt/M3S 2lO� S3�fla `S31fi1`d1S �V213N3J �dNl�Oad� H12iON 3"18d�t'ldd�d H11M 3�Ndt'idWO� NI 0311t/1SN1 N339 Sb�H W31SAS SIHl �i�n alQ�l u�!M a�uepao��y u�) ad�(1 wa�s�(g �i�u�ad uoi��.�a p -�,� ,,t� ���p � ��an�s ��oa� • � (/f7�f , '1/1't� �c'1 :uo�}��o� Q� :;ue���ddy :;o� :uo�;�ag :uois�n�pqng � :diysunnol :6uiuoZ � :# laaaed :# dew xel o���aS 4�I�aH I�uawuoa�nu3 �uaw}.�edaQ y��eaH I(}uno� uos�ad Person County Healih Department Environmentai Health Sec ion r, Zoning: Township: �_ Subdivision: Section• Lot• Applicant: �Uv �GI,I-� ,�,p �ocation: �5� �`�� -i'� �� �L.1��G� Ku. � GV'D� r l� , . 2��d d �l I,� � ►'°� • Operat�on Permit 1. LOCATlON AND SEPARATION DISTANCES / A} System meets .1950 setback requirements � B) Distance from system to any wells x- 6� C) Distance from septic tank to foundation ' D) Distance from system to property lines � 0' 2. SEPTIC TANK A) Visually inspect the exterior walis and top of the tank ✓ B) Visually inspect the interior walis, baffle, tee, filter, riser, lids, ai� vent, bottom, and water tight outiet ✓ � C) Date of tank manufa ure —" D) Tank seriai number " ^ 2 E) Liquid capacity of tank � _' Df�� gallons 3. SUPPLY LiNE TO TRENCHES A) Grade 1/8 inch per foot minimum) B) Material supply line ' constructed from F!/n �i pG� C) Diameter �i`� `,� D) Length ^'n D' fl � I��1� (iU'I�Y� d„r( �� E) Distance from tank to drainfieldldistribution device � _ 4. DISTRIBUTION DEVICE(S) A) Type - B) is Device water tight 'n/ C) Distance from the distribution device(s) to the trenches (� ��I�c D) Is the device on a level foundation �! V �� E) �oes the device perform according to its design specifications F) Record the inlet and outlet elevations 5, NITRIF1CATtON FIELD A) Trench depth inches __ B) Trench width inches t C) Distance between trenches ?� B1� _ D) Number of trenches E) Length(s) of trenches �� V�G�i1-Uf i�l 'F) Aggregate depth �_ inches G) Aggregate material and size � H) Record septic tank o tlet elevation 1� I) Trench grade �(<_ 1/4" per 10' . J) Step downs ✓ a. Minimum of 2' of undisturbed earth b. Proper rise over st� down �_ c. Solid pipe used d. Elevations of step downs (Record elevations and show on as built) . �l See "as built' �lan • ttache� sheet. PCHD, rev. 10/12l99 PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tex Map #: / 1 ", I Partiel # � ° � - Zoning Township ���y �O�f � APPlicanx I�e.�� �% � �"-Y .. LocaUon: �u i � rlYl ('� � Subdivtslon• Sectfon: Lo� Type of Water SuppiY: Reauirements• Well Permit �ndividual Community Pubiic Site Approved by ��1 N '2q / 00 Grouting Approved by I 0� Weil Log ' � Well Tag Air Vent Hose Bib Concrete Slab Well Driller Weil Appro �. � e"- ' � �� 1� •- / Date: � a �` � O ( **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 P�R5UN COUNTY ENVTRONH�NTAL IiCAL'1H �' wELL Loa Datc:� ���� . . � . SR# . Owne�....— � ` Location/Directions: . � � vision I�tamc: L�t �� _ Subdi ��`N W�� u� �a�m Sc�.�.; S-� � • Drilling Contractor; �,.�r Y �QNSTRU�'1'IQN Dis�ancc f�om Ncarest Properry Linc_ _ Diswncc from Sourcc of P�llution � Tota1 Dep,th: F�. Yield: l�J GPM Static Water Level Ft. . Wa�er Bearing Zones: Depth Fc. Fc. Fc._ 'Fc, Casing: Dcpth: From____�,___�o Ft. Diamctcr: � YnchcS �Galvanized Steel '� 'I'YPE: S�cel ' . If Sceel, does owner apgrove: Y�s No___._____ � l�eight: _ Thickness: • � Heigh� Above Ground: _ I:�ches Drivc S:�oe: Ycs No _ _ . —.---- Wcrc Problcros Encounccrcd in Setting th� CasinB? 1'�S -- NO------- ;; "ycs" givc rc;�sor�: Gr�uc: Type: Neat_ _ SandJCement Concrete Annular. Spacc Widch 12._—_�chcs Water in Annular Spacc; Yes _ No� _ Mathod: Pumped � Pressure___._� I�oured �„�__._ Depth: From O to O Ft. Materials Used: No, Bags Portland Cemenc______. Weight of .1 bag__lbs. Jf mix�ure (sand, g`r�avcl; cuttings) - lZatio: - �o - . - - Yr� T�1:, �c- c ---- 4 x 4 s�ab cSS---r-- -- --- I HEREBY CERTIFY THAT THE ABOVE YNFORMATION 7S CORRECT ArID THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FOR'1'x BY�THE PERSON COUNTY HEA.LTH DEPARTMENT. ' � ��' ����� 00 Signat�irc of Contract • Datc