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A32 163
�1����� ���� �� �..►� � '.'� � � �LJ � � � '■ '—�.'���-rrn r'„'^ �93."�2SI.JL ��.�.�L� - WEI�L P�1�T� I'I.EASE SE� ��'I'A�I) I'LAN FOR WELL S� LAYO'(J'I' Tax ldtap #: � Parcel # � � �J Township APPlican� Snbdivision: Section: Lnt Loc�on: � ' 4 !. ' /�!r '�.�t.����i. 1 Tvne of Water Suvulv,�-. �.. Individual Communitp Public JL�ec�wirements: Site App=oved bp ' Grouting Approved bp � Weil Lo� �Veil i a� . Air Vent � Hose Bib Concrete Slab Well Driller. Well Approved �y: Date: �°�"5ee Attaciied 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 a�ap building founda�ion. Other conditions• PCHD, nev. 09/Q7/01 A�piicaticn Date: �� �' �J ' Z .. . Tax Maa: � amourrt:Aaid: 6. O - �� . . - � �@CEIi]t:#: .$ � L� �% � . �3�CE��r'�. �� � � 7' � � � �� . ��.F� y� � ��� . � `�� �V� 1..�1• � 1L • • . �.�.����.�.�.._,..o�:¢�.Ib IE3L�m71:�l1a. � APPLlCATION FOi� SERVIC�S SHALL BECOME INVAUD. 1) Permit requestgd :(� e�lag rospective ownerr ���� ��� �� Home Phone: � —/ g(a� r�°� � Address: � tir" 1 - Business Phone: �C�9-?�7'f i r �-- 27 70 / 2) Name and address of carrent owner. r�f't"�nl� ���T�'�- ���� 3) Properly Description: Lot size: ��Tawnship: �� Subdivisio : N�- Lot#: ' Direcctions to th� prop�xty (Induding roa�,names and num bers . /> ��/F " � �t.o� �- !i -e� f'!/! �-nr dc _f'1�-e � /-� a-� � � l�m� 4 Pr000sed Use and 5tructure escri tlon: answer eacfi of� he followin questions:. � � a) Proposed _, Existin9 �TYPe of Strudure: �ir X'� � V�� 19� Width: 2 Depth: `�'� b) Number of Bedrooms: � Number of occvpar�ts or peopie to be served: c) Basemen� Yes _, No _ Wil1 ther� be plumbing in the basement? d) Garbage Disposai: Yes ,� No ^� 5) Water Supp(y Type: Private _(new _ or exist�'ng �, Pubiic_, Cammunity _, Spring _ Are wells on adjoining property? Yes -�Wo _ If yes, please indica�e approximate location an the site plan. r,,� a ;.�� �v'��r /'c�� - 6) Does the property eantain previousty identifled jurisdictional wetlands? Yes _ No � PLEASE NOTE THE FOLLOWING: ' . �➢ A PLAT OF'ii�E PROPERTY OR SiTE PtAN MUST BE SUBMIT't�D WITH THIS APPLICATION. �➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY NIARi�D. �➢ THE PROPOSED LOCATION OFALL STRUCTURES MUST BE STAKED OR Fl.AGGED. � �➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEAIT STAFF. I- hereby make application to the Person Caunty Health Department foc a site evaluation for the on-site sewage disposal system for the above-described property. 1 agree that the contents of this appl'�cation are true and represent the maximum facitiiies to be pla� on the p� p�erly`Lundersta/� �dJf-the"siie is altered er the intended use changes, the permii shall became invalid. l71 /� ; � ( if � `I' .� �_ � Owner 5 � U Date PCIiD, tev.101'17/0'1 �-.��� J� ���� �� ...�.-.. � � � � �� Jl JL I��.�n��.�..�.��.��.Il IH[ ��.lL�ll�. Applicant: Trux ��1��� i p�rccl � S'ff,f� {lVI�SI011 Ph,+ e Sect�ion Lot �' " � - d'fGrE�lre �r`�l,t S �( ',UI(�,�'l,i � ✓V(r�i��#-'I-�_C1��. 111 Q.t79' — - --_T` . , Impravement Permit �� � Pexmit Valld for Flve ears No Expiration � �� � ��� Type of Facility: � New �,�A+�idition Water Supply �_ # vf Occupants ' f Bedrdoma Proje ed Daily Fl�vc► �� g.p.d. Prvposed Wastewater ystem: u(v( � �� Type: �_ Proposed Repair: �� n p,,' ', '; ' Type: ' �wner or Legal Authorized Statf Date: � Date: ? o ' The isauarice of this permit by the Health Department in does not guerantee tho iasua�ce of oti�er permite. It ie the reaponaibility'of tha applicandproperty owner to in eure that all Pereon County Planning and Zoning and;Building Inspections requiremants ere mat Thia Improvement Permit la aubject to revocation�lf the eite plan, plat or the intended ase �hanges. The Lnprovement Permit is not affected by a change in ownerahip of the property. Thie permit was lsaued. tn compllance wlti� the provlsions of the North Cacollna 'Laws and Rules for Serva�e 1lreat»rent and Disnosal Svsten�s' (15A NCA.0 18A .1900). �■��� ' �` Authorization to Construct Wastewater System (�teqaired for Bailding Fermit) . � * See site pla�t and additional atiachme�lt,s (__�___ j. Propvs d Wastewater Syetem:_pC(,yh_p �j���� � �. Typa�� astewater Flow �.p.d. New � Repair Expansion � Soll.LT�►R: g.p.d./ ft 2 Type of Facility: �p; ��p� ,� Base�nent _ Yes p� No F� Wastewater 3ystem Requiremerite Tank Size: �eptic Tank: �� gal Pump'I'ank: i�� gaI -�� Grease Trap: gal ' ; � tI Drainfield: Total Area: � sq ft Total Length �� ft Maa��anum Trench Depth o� � ln Trench Wldth � it Minianum Soil Cover: _� in Minit��um Trench Separation: l ft Dlatribution: Distribution Bv� V� Serial Diatribution Pressure Manifold� '�peciflcatione: _ �� �9� � �- �i�^ � � � � Authorized i5tate Agent: � Pettnit Expiration Date: � nat@: '7-1�---dZ The type of system permitted is � Conveniional Innovative �ilternative. I accept the spec�cations of the pertnit. � Ow�ner/Lega�i Representa�ive: � � Date: .. . , _._ '� T'� r.=;;_ ;' � fcT � i_.J : 1 ':�iri -h ���� ' � , — , Ja�;, ' ^�+�:}'�+li';��-,�r � �� _ .�' "?`�, , ' � ?r ! Ji`�'.,,.?��._ ._ ✓_ _ '4 �d} I ; , /� � C`� �. 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