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A32 177}� , d o� �-g-�� � �� o,o"I . 3a Application Date: � I � � 3 �3 Tax Ma #. Amount Paid: , RecEiQt �: ParcEl #: � 7 � .j � �8 -� 7 ,���� �� 1�'I�I�.,� �� � - —= � � -����- �as�s-arama�a_�^^--^ �axm�mll ��m�.7L�I1a APPLlCAT10N FOR SER1/IC�S 1F Tl-iE 1f�1FOi2M.4T10iV li�l T1-19E APPLICA'T10N FOR AA1 IMIPROVEMEiVT PERHAIT IS IiNC�RRECT, F�1LSt�iE�, CH�►NGED 06� THE SR'E IS e4LTEitED. TI-BE�! THE 1MPROVE1�IEi�IT PEFtIViIT AND AUTH0621ZAT10id TO COIVSTRUCT SHALL BECOAflE INVALID. • � �'!) Permii rec�aestesi by: (O n gentlprospective owner): Home Phone: ' � Address: if/. Business Rhone: 3� c'� ��l� /�}Q� � f 5 2) IVame and addr�ss of currerrt owreer. /f ��� 3) Property Descr�ption: Lot size: ��ownship: Directions to the property (lncluding road names and numbers): Subdivision: Lot # I ►��S/�7 CEiA�NrGE-D �Fo ?v- g�A¢c�a it,.c. ` �! 4) �`roposed Use and Structure D ription:.answer each of the Ilowing uestions: �� a) Proposed �, Existing � ype of Structure: Width:_� Depth: � � b) Number of Bedrooms: �. Number of occupa or eopie to b served: c) BasemenL Ye�_, No �_Will there be plumbing in the basement? - d) �arbage Disposai:.Yes � , No _ � 5) Vilater Supply.'P'ype: 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. � . . , � 6j Does your properfij cantain previously identified Jurisdtctional we4larads? Yes_ iVo„� � PLEASE NOTE THE FOLLOIMMG: 9� PLAT O� THE PROF'E3�T1( OR S1TE PLAid ➢IAUSi' BE SUBflAI'p'TED WITH 'PHIS A►PP�9C.'�T1�N. ➢ PROPER71( LlNES AND CORNERS MUST BE CLE�LY MARKED. �, ➢ i'HE PROP�SED LOCATION OF ALL STRUCTURES MUST SE STA4CED OR Fi.AGG�D. 9�HE SITE IUIU$T HE �DILY ACC�ESSiBLE �OR AN EVALU�►TION �Y Ti�iE HEALTH DE��►RTME3VT STA��: � ! hereby make appFication to the Person County Health Department for a siie evaluation for the on-si�e sewage disposal system for the above-described progerty. I agres that the cantents of this appiication are true and represent the maximum facilities to be plac�d on the property. I under and if the site is altered or the intended use cf�anges, the permit shalf became invalid. �, - � ,�� � 7 Legal Representative Date . PC�-iD, rev. 06127l02 .. ��` . . . 4 _ '—• ' , ' ,,. . ' . . ��.. . • ' . . . � �' " .. � . .. ' • y • . .. � ^ , - t •"' - ' . , � . „ , , `+�.' . . - ' . . y . , � �� . . . . . . : -.=. �'� � -v^�� - � . . . � . �. , . . . . . o � � � �� .� � �� o :�� � . �.... .. ... .�. o �_ . . . . . . .. . �� . � r . . ' � . ; . . � : .- � �,: d� . . �� ., �_ ��- . w�C': f • .. . -- . .. . _ ' ' � A_. - E .. ' . ., : _. . � . � . .. �. � �: ( - � � � � � � . . . � '°- ` .. � : : - .. � .. � p � � � . • � " ' . � - • � .� ' � • � • � � �.�. . . . . �, �� . . ''�a � • _ " . � � . _ Q. " • � � _ . ti y . � . . I . .. � .. . • � y : . ' '. ep O. . ti / . � � , �' , ' . . - �I �� . � .� � -:. " �� . .. : � . " ��.. � � �. � _, . . : . -. � �: : � �,...� . � .. � � . . �,.�<,,:-_ � . . : . � . . . - � ��� � . � " �. - � : � � ��� ,� , . , � � . �. ��:. �� ` �`. , . : � � � � � � . . : . �t. �. ' . � . .. . . ; .. , `�. .. r: . � . r�� : � � . �� . : . � . � �. ,;:� �- . . .. . .��� �' . _ �. -. � . �� � �� �1. � .. � � ..- . :.. : � t � �.:� - . . ' , :� . r - . ' . . � . .. G ' E ,- _ . . � � .. � . . ; , ��� ��i ��1�. �q.�� ��. V . �, � � , ` �, � � ���� �.�n.-�-n.s��+-� ��a��.�.�1 ��.�.]I,EIIa � . �,pplicant n �i �t3l�17� C-�Qi' � T.ncatinn�' � —�l n�„ ���.�uCC . 7 1.0i�' ai�t t T�x Ma,� � � �rcel � S Ulb [�il V I S Ii01fl h a:s�e: S ect i�o n.`Lo�t � �prave�nt �ermit I'ermit �alid for 've �ears l�To �piration � Type of Facility: r� e S� e. New '�Additian � �ater Saag�p�y �t%� # of Occupant5 �� # of B oms -3 Projecte3 Daily Flow z� _ g.p.d. Proposed Wastewater yst : �to � � Type: 4 Proposed Repair: e • . TyPe" � Permit Conditions• � . - . � . /( � y� � `� Oavner or Legai � Authorized State Date: The i�ana*+�p of this permit by the Health Departmeut in does nat guarantee the ;��+,�*+�a of other permitv. If is the responsibility of the . aPPl�can�proPertY owner to in sure that all Person Coimty P3a�ing and Zovmg and Bwiding Inspections requsemenis are met This 3mprovement Permit is snbject to revocatlon if the site plan; �pl�ti''or� ti►e intended use changes. The Improvemeut Permit is not a$ected bg a c�ange in owner"ship of the property, This permitwas is�ued in compliance with the provisions of the North Carolina, .� `Laws aad Rules for Sewa�e Trearmeni and Disnosal Svstenis' (X5A NCAC 18A .1900). Neither Person �ounty�:por':t}ie.'' �� � Environmental Health Specialist vvarrants that the septic tank �pstem w�71 continue to fnnctian satisfactorily in the fnture�or�#baf. the-water supply will remain potable. �- • - Authorizatioa to Constrnct 4Vastewater 5ystem (Requ�ed for Building Permit) � * See site plan cmd additional attachmen�r (_). � � � ..-• Propos�astewa,ter Syst�m: CC �� lc�v r �, v� � er) "I�'pe �' Wastewater Flo w� g.p.d. New air ExQansion .� 3oi1 L'r1�rR: �.� g.p.d1 ft 2 Type of Fac�ity: �r i��P� �QS:i��►�. � � Baseme,nt _ Yes _ o �Va�t�water Syst� �uiremeats 'iank Size: Septic Tank:' �� gal Pnmp Tank:-�gai Grease Trap:--gai I�rrai�e�d: Total A�rea: �� sq fit Total Length :—o O'� ft ' 1Vta�num Trench Dept� �_ in p. C. 'Tr.enci� Width � f� NlGnimnm Soil Cov r�_ in Miniffinm 7.`rencii Separation: � ft Dista�ibution: �istr�'bntion �oa v Seriai �istnbntion ]Pressnre lbtanifold . Speciflcations• %; ' �ox � r .Se �ntlaorized State A.gen� � Permit Expi Date: The type of system permitted is Conventionai �Ac��#ed Alternative. I acc�t the spe�ifications of the P�� _ . �aee�l�ag�l ��praseutatfl9e: Date: g r3o �� � ' PC� rey. 11/10/QS- , .. . Y _ . •1����,,/� � .a �.�� �� f ��1 ' � � vy �i'7�V' ��LT �L.r]mY3]C'�v���TM�•'O]L3�.�.8 JL.�L�C��GICy SITE SB�TCH Name n r� �' �aN �n L� �k'� Taz Ma.p # 32 � Pa:r_cel #177 _ Subdivis' . � Secd.on/Lot# . --- � - �-6 7 . . utho�ized State A.gent . � Date , System cumpo�ents nepr�erent appr�oximate�cont�urs orily: The contractor must, fiag the system prior to begtinning the installai`ion i`o i�sure that prolberg�ade {s maintained o � m o O N m m � w = N � O1 - o r � �. n 0 O � m _ti ,Y �C� `fi � ~� A m � � \ �'` ' S 5-i-��� nt�1 al . ,� d 3� �'�� - �,- o � � � � P �a J�,,,.�o�� — �oo � �� bo-���� _'G�r .,'.YeY�� � • . p' � °'�` � 0 $ �o �, ` oti� N` ftiih��R I `�33��/ � �3do 5 . �p\ . � \ ?900 oc (Jre�� �N`�;i o 6; N � � ' 09 F y� � � � . K`� i ti����e � / 30 pil � L�' 9�� o.� nsd 3w � " , � i�i � \ / �3 i w l '�j � i a� io 3 — -- '� d•� �'3� i � `OddM�N �',�0 . ` � � —_� 0 ���� �eU '` � . �o�� r (�Q,A , ` �' °��' - , SC �' � �5� A Zo,�Z.N .. -05� ,.•�.b� 9' Z� � •• `.._-� �' �� r �� L' � �-ipa5e S�k� _ �`— r�� 00 �z 2 � m A � — L51 •� N 3-5Z" -LO�S a �� � ,� � % �G�� �� - ---- — - _ _ _- -- - -- ------ - -- -- - - -� v �-' _ rl,,,_--,` -- -- - - - - - - �...--''� -�'�i�`Y� �. � '` _ - .,�. _ •,; _ _- _�r" •. `�.. ' � �.--^" � y,, ; " ,,, '�.r,�,,.,- -!�yy _ . , "a ��.,...•" " _ - t � �- - ; _ - - - � �� 4s�. - 1�� � -- .-�•�, _ .__ i' +-'d - ' "' '- iy.ia:,� � r . - t ' . '; 1s:J I` . " . ' l ' �:� : J�/ � .. . - 4 i � � � � '- .Y ?1 .K.e� l +; . . �✓' .l � � � � — � . � 1 }. .j �- ._. . � � � ��� s.:: :�� = � � ' � 4; 'J�' ��-� i _ i _ � � � ,,, � ' � j ` _ --� - .._.,, �� 4 , �-, =�. G' �� . - � . ____—_----_� � = r .� --- --4 . __ � � , __.r-- ____ _ - - Q „ L �-----� ; z� , �� a� � � � �8 ,`� � � � �; 0�.._ Y ::� � � ��� �:��� � �c� ; �� ��� � � � ��� x . � � . ;, � : .� � . � � ; z� � �� � � � �,,,F -_ --- -- __ __ - - - --- .�._.._...._.._._.._.Y. _.,.�.r..�.�- ...a.�.- �,,,, r,.r......,_._.._:�--.�. _ --- - ---- .�'�y;. �.. . : \ ) .'"t / 1 e''� v . � � �"<"' ✓ •..r% . '.,1 ���� �� ���� �� `�.. � � � � � � � V li 11. �m.�.a-��-++ �►'TM� ��a��.�. �'���.Il.��n. T�x M�p � P�.rc i # Subcilivision Ph�s•e � ect�ion Lot # � of Bed�rooms Applicant: ��n�� ('anrd� � Location:_ f-�r�� N��11� f� -} C� � C�ess 2d -� I� or. ��,"cE QcroS� -�'r��n. br'��I�� �.� !;: '� ,;_ ,:� ; � .�:. ; �,�z �luw� . System Type (in Accordance Wiih Table Va): T_ r' THIS SYSTEM 0-I�4S BEEiV IIVSTALLED IN COMPLIAiVCE WITH APPLICABLE NORTH GAROLINA GEidE€iAL STATUTES, RU�ES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALl. CONDITI�NS OF THE 1MPRLIVEMEl�T PERiVItT AND COiVSTRUCTION AllTHOR(ZAT10N. � . �c��,_ e ��- . Authorizsd State Agent Installed By: c-v�e � 1a Iy l �--� . Date Date: ► a (-4- � o� C �ss P.� - � , _ �ao�+. �z = �a� � L3 = ���1- � ��� ;, 9 -ao-�-7 . ` I��'s- ��`w S�-3��1 PCHD, rev. 07/29/04 � ����C ��$� ���F'���8�� �u""0�'�"�..��Z ���� 0� - (� Tax Map #� Parce! # I�11 Sys�tem Type (Tabie Va) L a��Z F���� Owner/Applicant �ec�, � ('�a�d� Subdivision Address/Location Sec/Phase Lot # Septic Tank nita� a� �� �cafisora ines Ini�a� ate State�ID/date � 9��1� �«/yl�� Trenct��dth ft. ✓ N. i�(y Ca aci al. � � Trench De th in. ✓ Tee and Fiiter � ,/ Trencfi Len h � ft. ✓ Baffle Trench Grade � �✓ � Sealant Trench S acin ✓ . Riser ifi a licabie � Rock De th and Quali Tank Outiet Seal / Dams/Ste downs �tc. / � Permanent Marker Pressure Laterals � � Pump T�nk � N�q. Hole Spacing � tate ate o e ize Ca aci al. Pi e. Sieeve Wate roof /Sealant Tum-u s/P.rotectors Riser Re uired� Se�ac9cs Water Ti ht From� Weiis t� 1zlyl Pump ( From Praperty lines . Checic Valve/Gate Va(ve Structures/Basements ,/ An�-si on o e i c es raina e a s Fioats/Switches � � Surface W�ters ✓ �41arm visable and audible Public 1Nater Su iies ✓ � Electricai Com onents � Vertical Cuts >2 ft. Rate m Water Lines � A roved Pum Mode! Vehicle Traffic � � � Blocic Under Pum '� Ad'acent S tems .� Pum Removai Ro e/Chain � �Easements/Ri ht of Wa . � Distribuiion. System Other � Serial Distribution � izl�clo� Easements Recarded Pressure ant o e e erator ontra Low Fressure Pi e Tri-Partate A reement A r. Pi e I�llateriai and Grade � Va(ves - Commen� . . pci�d rev. 3/13/01 � ..��"'' � . .. •. t.� . �.•.�••'��•.?•�•'; • •'S •'�. '�:. ..�i� .� :"�'�.� . . . � �� �� . �^ :y:K.. �iL... 't'� . K' ?:�..: . .::::= ' . . .. ". .:.. :. " .� a. ��.,..�.:•::•�,,:.,, � . ��;��� . ........ ...M-:%:�:':��" ' • :::::. : . .�� ;�...,�:...:�. �.,� . �. � �•77a'L'o19"71i]L^47?�r''S"�r.n�n":�i3�R:.'�:.�'� � '•. 7�� T� . .:,, . . : . �'�`��. n93.1L���•.'. .v�:r--.:•:,,•.+•.•'..•.:..:::•:,.�.'^.:.^.;_ ... .. ,; � �' WYJCJ�/g! g a�.aa i7$S3 � . � 9.��JlJ �8�� �.1 3 t.'.L.�1.�'+J.Y S n't� i V�{ �� V 1' L' 1Ld.� 17H 1 J[U . e' W 3� �LJ 1 Tax Map 3� Applic�nt: ' Subdivision: Location: /S7> Parcel # /77 Tov� � i� �o,� '�� CI Type of �a��r 5upp�y: �teqmirement�: Lot # �--- � ✓fiidividual _ Community Public Site Approved By: �� Grouting APProved By: // • 07 Well Log: � Pump Tag: • Well Tag: � Air Vent: � ta �f � Aose Bib: � Gasing Heigh� � . Concrete Slab: �,� � � Well Driller: ,(3a „� e. t,�� Well Approved by;� �D -�� *�**Sce Attac�aed �ite 5ketc��*** Liner: 'Installed by: Depth set: _ Grouted: Date: Water Sample: Wells must be 10 feet from property lines. Wells muat be 100 feet from septic systems. VfTells must be at least 25 feet from any building foundation. Other conditions: Date:, la �� �v�' PC�i7 rev 01.�27104 �� � � j � '^+.r►�� , � } j r�y� � � � � V � � .li.-��/]t1L�9"]l71"'dCD��.3I�i71.K�'.]CD.��.� �tL:at�II.�L�.� �uilciing Additioas/ l0�dobile �ome iZepYacements Tax Map #: ,���_ Parcel#: I ?? Approval Requested for: Mobile Home Replac�ment - � Building Addition � ApplicantName: 2�,,,,,Ls, ��p � Address: " Phone #'s:���- �32-0� t S Permit Located: ✓ Yes No Installation Date: Design flow: 3�0 (gpd) Current Contract with Certified Opera.tor on file (if required): Water Supply: ✓Well Public or Community _ �� Wastewater system shows no visual evidence of failure on: �,�/S�/� (date) (Applicant's signature if site visit is not required) •� ,,. �„ i. �� ._ � Addition/It�placem�nt Approved Environmen ealth pecialist 11/15/OS G Da � _ - : �-._ - .._N-. ._rz.,v. �;:; _ _ � _ - .�_,_--� � �`�� o!a�� � - 3��- � .�- . ¢ =�'�..� ���- �:������� � � . ,..�,:.��_ _ . . {�� q� . �a�n� Ff-� c�� c � - - .:: - . r .; � K:`=� � :--�'� ����Y=`� � ��.�,��,�-��. �- ��s��� o�mo o�o� _l i � o -� � � � - � �: s���.: �, C la�,� �� craat r..og - - T�.� 3 z r�t #� � wen constra�ion DisFance From neaz�.st Pmpeiiy Liae (14rnimum 10 fcet) t��' Dishance fi+�m Se,ptic Syst�n QN�nu� b0 feet) ( D D Total Depth: `1 � ft Yeld �•3� GPM • Static Water I.eveL• Z� Water BeatmB Zo� Depth l l 0 ft 6 ft ft ft $ � Depfh: From � to �� ft. Diam�eber: � r%`/ m . 1`ype: Galwdni�ed Steel . - � Weigh� Thicimess: � 1�`�. Seight above Ground: .� Z in � � Drive Shoe: .� Yes No Any problems encountened wh�e se�tmg casnng9 Xes �No If `�es" give r�: " (�u� . _ ' - • Nea� SandlCe�t V Concretc GraveUCement . -'- A�u1ar Space Width • mchc.s Water in Affiular Space. Yes � No •- Met�od of Gmu� P�. Pre�tt�e Poiued ✓ � Depih _(� - to Zo Ft Materials IIsed� - . No. Bags Portland cement ' Weig�t o� 1 Bag � Po�mds . _ If m�ure (sand, gravel, cu�ngs) — Itatio to -- ID plat,e� �Yes _ No 4 x 4 siab �es No I iners � - — - -�.. �p�h: I?at,e �nstalted: Drilling Log Cmou� �nsfailed by: I.ocation Drawing I�om To Rormxii,oa � . • V � 2 �u c.l �- - . S� 1 �6 u _ �,(�: • -�s� , . - 1� �, ��� . - ; l,�,n,r� , . , [ h�reby ceatify that t�e above' iufc�iu�t is comect a�d t�at ti�is well was ca�ed in �ance wi$i regvlations �t fo� by the Person CountyH� Depar�t. - - s�t� o�caa�d�� m# 3�f 6r n�. l l��ri-- v� r� i��t ��t�u�o� co�a�: Q a��,�c i� c✓t�l ( sr� ��o� x�: � 6(� �- �P �Pt�: Gl (� � ft S`t�tic Water Level: Z� g �—, ?ump Make & ModeL• _ a.��e r� Pamp S'rr,e and Ratin�- � z. hp l� gpm ' hcneby certii'y t�at tius pump was uLstalIed a�d the well I�ead campleted accord'mg ta ti�e Person Camty Well Ruies iu effe�t xi t�is date and that a capy of t�is racord has l�eeu p�nvided to� weU owner_ . .-� ' ���� � � � .,i :. �., / � 1tr' ��1 ' � �/1 � . i � � �i�� • � � •