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A31 185� °� Appiication Date: ��� �� � 'P 3'1 J' / � d� Tax Map #: Amount Paid: � �t0 RecEipt #: L 7�� � � Parc�l #: � � � •`�� ?: ��— ���� �� fid � 1 � � ' —ti— c� � iLTI�T'1� �Y �\ � � � � � aawsa-�zca,-^--^ mas�mll �E�mmI1�1�a �-� Q J�le � 0.�0.1 v�,,cA APPLICATION FOR SERVICES p. �� G � �,,�� � l t .�r;�� ba��� IF THE INFORMATION IN THE APPLlCATION FOR AN IMPROVEMEfVT PERMIT 1S INCORRECT. F�4l.SIF1E�, C9iAiVGED OR THE SITE IS ALTERED. THEN THE IMPROVEiVIENT_PERMIT AND AUTHORIZATION TO CO STRUCT SHALL BECOME 1NVALID. - ,•`t) Permit requested by: (Owner/agent/prospective owner): �c✓ti�' K�r, ��;,✓!c%.-S Home Phone: ��� -�? -S7s"� Address: �d,� R,�..��- ,���• Business Phone:3�-Sf� 3- s/� 7 T;c_�� ,� .�� .�sT�' 2) Name and address of current owne�: ���.,.� �c,'.- S � �sl �ii. f� e. �/'� /-I ✓ [- ' ' Qn �.l-y� r, � NL 2 75-7 H 3) Property Description: Lot size: T.ownship: Subdivision: Lot # Directions to the property (Including road names and numbers): {�Jr� I� m t 1 i S 2� ¢�� ��..,[. x/�. /�� , ,.��I. _ II , rt_,__ .. _.�� .,i----�_ n. . � 4) P'roposed Use and Structure Description: answer each of the following questions: a) Proposed , Existing Type flf Structure: F1o� s � Width: Depth: b) Number bf Bedrooms: � Number of occupants or people to be served: � c) Basement: Yes .�, No Will there be plumbing in the basement? d) �arbage Disposat: Yes No / 5) Water Supply Type: Private /(new _ or existing�, PublicJ Community . Spring _ Are any welis on adjoining property? Yes_ No _ If yes, piease indicate approximate location on the 'site-pian. 6) Does your property cantain previousiy identified jurisdictional wetlands? Yes_ No / PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPE3ZTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY L1NES AND CORNEI2S MUST BE CLEARLY MARI�D. �, ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAI�D OR �LAGGED. ➢ THE SITE MUST BE READILY ACCESSIBL� FOR AN EVALUATION BY THE HEALTH DEPARTME�IT STAFF. I hereby make application to the Person County Health Department fo� a site evaluation for the on-siie sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum faciiities to be plac�d on the property. I understand if the site is altered or the intended use changes, the permit shali become invalid. Owner or Legal Representative Date PCHD, rev. 06127102 .'.��;:�:;. ;.::',..' ".�.;. . . . �. ,.... :• . .�� ; ... '�"1��::x � ��. �::�.. � :.��� .. ::: ' . ::�' . .. :•.:� . .... �' ':.., •:. . � �. .... ..:. };:�•�:: _. :. .;..: . �,.,_,..� ..: ;.,:;:..:.:.:..� � �� . .,.. .... :..:: : ��, s:��:�:���.� �� .. ...........::.....::: ..:..v•:�:<::.�.;.-.,:,,;.<, ., . . .._:.........�.,:.;:.._. : ,...,,:... .. ... . . .. ..:. . ... . . .. � . . . . . .. .... . ...: . �.a�n:j.�v-u��a�TMri�� �:.'a��rn:�;�:1L'•�''�3� ... . . �• • ' ,a,; ��: : ..••:r:.....,:•.••• •.-...:.:...:-..�:.: ......•.::.. :: . : , •.,. .... ..:.....,,. •.. :...: : ., <�' � FVELL PERIYIIT . PL�AS� SEE A�A�D ]P7[�r�N F0�2 �YELL SY'� LAYOIUT Tax Map ��_ Parcel # l8� Tovvnship: Applicanf: _ vKer. ��.ak� rzs Subdivision. Lot # . Location:_�1�r�1� t��Us 2d. -�(��, �-,�� x-� � R� -�- (�t �,-. ��g6�y �� 1.'S m� � Type of'GVater 5uppiy: ,� Tndividual _ Community Public Iteqnirements: Site Approved By: }� ��2z�cs7 Grouting Approved By:'� � ,3) 2z��� Well Log. �/ � Pump Tag. ,,/ � � Well Tag ,/ � Air Vent: ✓ ln t � Hose Bib: � Casing Height:� � Concrete Slab: � � Well Driller• _ c�p;r�.� Well Approved by: �_y� � P�q �— ****See Attached Site Sketch**** Liner: Tnstalled by: _ Depth set: _ Grouted: Date; Water Sample: ' �/W��ells must be 10 feet from property lines. G;?�VVells must be 100 feet from septic systems, �- Wells must be at least 25 feet from any building founda,tion. Other conditions: Date:, Lp � I�� �—j . , PCHD rev 01!27/04 May 14 07 08:54a Keith L. Barnette 336-598-9275 p.5 YiHLG! l U� Q�c; � JJ•• �a�EQ . � -'. � � _. 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P�T� Z �P..M �S �� -.- _fr �uatua'j/Eaes.u� a�auquo� ;aa�a�/PueS �s H . . • • - ��� �� �X ���sea .�r�as a _uoseaY aa� Ksa�, �I , � �a�aa smaiqo�d. �tuy o�I s��� :aot� a,tiu� . ' II! ��- =P��J �� �?aH ��� '< :ssaus��?tTy �Ya1�1 I�S P�+1�J �L . � �'��� '� c c�7 0.� � iuoa3 , . :�'°Rse-J �}'''�� ���' 'F�. -.—._.�, � _ � $ �T '�4� }�3�,,� t�.daQ :sauu� �arseag r�e �T �',% � -la�a-I ar�e!!i ��tS - Y1TdJ at < �A. �� �t .�. � �� ��at t�.ps . ;J.v.� (�� o� �� �,c� �� �� ��u , nS �%3 Qi ���yY) amZ �a� �a m� a�u� notpa.�snoJ II?t4� _ - � y - z - - � �r�,�,r. � �c✓ �o ��%� # I�d .�deyli �.L . �; rr , �--� . ' ' �O . o�;no.t J . �. � �''— � � --- �� � .'�a �"�'`�7L"o��3E-�L • :�'�'��u,�.'vc.osa�:� ��, J�l �!-(.7/ - (� c � � .� �'i' �. � �_� .Ij�`� .. • '� G • -w '�"""�""`�' `�' �����`�� ' •�. -' ... <: :. ?i^_*.s1� `�' � 9.� �'� � aa � . � � .���� �. ,� -�� r ' �' "��: .. . . . . .. �.. . . • ...i : . .i. � 'k.:-. .. ... . . -..� . •.. ,.. �� r 1. i��� /� J� i a ia ��lJ V� �� w 1 J � . -�- C� � �.Tl�T�° � ���s�„�„ ,�-n-�► ���.�.Il I�3L ��.Il. Applican� Location: T��H 1��1�a�� .1 �rcel = r S u,b dii v i�s�i�a ia h��s�e S�ct+ion'Lat � Improvement �ermit - . P�rmi# Valid for ��ve 'i�e� PTo Eapiration Type of Faciliiy: '� �I � New � Additian �ater Suppip p�� # of Occupants � # of Bedrooms -4 . Projected Daily Flow a0 g.p.d. Proposed Wastewater System: C�`��v[h-%i� � Type: �ci Proposed Repair: _(�,,nc�`re»-Ei rnn 0 TYPe:-�1-'C�- Owner or Legal Representative Signature: Authorized State Ageut� �� i c� � Date: '� The issuance of this permit by the Heatth Departinent ia does not gvarantee the issuance of other permits. It is the responsib�ity of the applicaat/proPerty owner to in sure that all Person County Plannmg and Zomng and Building Inspectioas requircments are met This Improvement Permit is snb ject to revocation if tt�e sife plan, plat or the intended use changes. The Improvemeat Permit is not affected by a c3�.wge in ownership of the property. This permit was issued in compliance with the provisions of the Nort6 Carolina `Laws and l{ules for Sewa.�e Treabnent and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person �ounty nor the Environmeatal Health Specialist' warrants that. the septic tank system w�71 cflntinue ta function satisfactonly in the futnre or'that the water supply w�71 remain�potable. - _.. � Authorization to Constract Wastewater System (Required for Bu�ding Permit) * See site plan and additional attachments (�)• . Propose Wastewater System: V�,Ve(1�1' �Y1G�_Q � Typ�� Wastewater Flow '4� g:p.d. New � Repair Expansion _ Soil LTAR: o,2 S g.p.dJ ft 2 � Type of Facility: �-I [' , Basement Yes _ No � �astewatea� System Res�uirements 'Tank Size: Septic '�ank: lo� gai Pnmp Tank: ' gal Grease Trap: — gal �rain�eld: Total Area: 1qa o sq ft -Total L�ng#h � ft � 1V��aaimnm Trench Depth �[� in Trenc� Width � ft Minimnm Soil Cover. ,� � h� `n M'in'lmnm Trench Separation: �_ ft Distribntion: specifications: )C I9istributiox► Bo� Serial �istribntion Pressnre 1Vlanifold �I �;,�� � r���-� � . n,, ,�- ►�,n , a o ,r, � �- �, ;r, n� �-;�1 c�-,vf Anthorizerl State A.� Permit Date: -17 �I The type of system permitted is � Conventional Ace�ted Alternative. I acc�t the spe�ifications of the P�� Owne�l�,�al �tepsesentative: ��- Date: a l a� 101 ' � pCHD rev. 11/10/05 ;. . Gi- � . _ . � � � � � �c � -� u T � � + . � � � �. . � L �� �. �� �-. �-� � � _ ______ _ _ ��� SI � � � �06'9Z� � �3 � � � _ - ,�' --- � � � � .� .� � � � , - � � �� �" - bd y � ' y� -ib ino c�� � � � �.. .y��, -09, �� � � � D � s ° � -- P � - a9 � ��� �'- ,r. � � ST �T ����,�� ����1 �l.Jl � . . �----_ �—� � � ���� IE�� -as.�� � �a�a��.]L IF+��.m:]1��1-b STTE PLAN Name d�P t'� �1�� 1 YlS Tax Map *��_ Parcel #��� �ubdroision Section/Lo _ �M ��a -�—. � llo t� Authoazed State Agent Date Sysrem components represent appma�mate conrours only. The cvntracrormustflag rhe system paor m bPs++�ni ��o tl�e iasrallarioa to Insure that pmpergrade is ma{ntained >>t�;-S ! i3 al`�d ��C'�CCJI. �ugis .�,5'oi'HJ �1,u9g,Z�o �9_'6•t G� ���� �� ���� ��. V � . - -.� � � � ���� J.L� �N"�a- �D „-,+ ,r„-„ �L �. ��.� �'� � �ffi..LL �� T�x M�p , Fa,rc-�el # • Subcilivisiom Phase Sect,ion'Lot # � of Bedirooms � • • . ��\��lwL� L • • � � — \. � " `�J � �� � � . L. r ♦ � � f : � . v 9 `.. ./' �` �;I< ,'�• i � -' r�,. a � System Type (ln Accordance Wiih Table Va): �_ THIS SYSTEfliI 9-1�4S �EE� IIVSTALLED IN COMPLI�4NCE WITH APPLICABLE . NORTH GAROLINA GEiVERAL STA�UTES, RULES FOR SEWAGE TREATMEi�T AND DISPOSAL, AND ALL CONDITIONS OF � THE 1MPROVEi1HEIVT PER1VIlT AND COfVSTRUCTION AUTHORiZATiON. � �� �v. �� ��1� � l�, l �� ��1 � . Authorized State Agent Date Installed By: (��.N,y Cc�11�2 Date:. �I I�{I� � �3 �1-0-7 �s- ��o ��;,�\ �Q,- �(a � • ��� r . �� �s' _ i-�-Q� - �Z �� 1\ ,D) � ta�a � 6 l�-��' .� '. , `�' i" . 7$ , � . 5� � , �� i �, $„ � '�'�� �� . � �� . �� \ PCHD; rev. 07/29/Q4 0 ����PG �'�K �N�€'���HOBd ��iE��..l��' �Y�� ��'�'D Tax Map #-�,3� Rarce! # 14� Sys�em Type (Tabie Va) �--2 � Owner/A�piicant ��{�,,�,r� Subdivision Address/Location � Sec/Phase Lot # State�ID/date� W Ca aci S � Tee and Fiiter � � Baffle Sealant � . Riser ifi a iicable • - Tank Outlet Seal Permanent Marker Pump �'ank Waterproof /Sealant Riser Water Tight � P�mp Checfc ValvelGate Valve Ant�-sip on o e �� I. � �41arm visable and audible Electrical Com onents � Rate m A roved Pum iViodel Block Under Pum Pum Removal Ro elChain . � Distribution. System Low Pressure Pipe Appr. Pipe �lateriai and J ✓ / J 0 � Nitri#icat�on L�nes lna�a� Trencf� �dth 3 ft. � Trench De th a, in. � Trencti Len th ft. ✓ Trench Grade � Trench S acin ,/ . Rocic De th and Quali Dams/Ste downs etc. - Pressure Laterals � Ho(e Spacing � o e ize Pi e. Sieeve Tum-u s/Protectors Required� Seibac9cs From� Wells From Property lines ,/ Surface Waters / Public Vllater Supplies Vertical Cuts >2 ft. Water Lines � Vehicle�Traffic � /�d'acent stems / Easements/Ri ht of Wa � Other Easements Recorded -� Comra�en�.s pct�d rev. 3/13/01