A32 196� , Aaolicatfon Date• � ' � �-00
'Ama�unt Paid• � 0 , 00
Recei �: _�� � �--
Person Countv Health Deaartment
Environmenta( Hesith Seation
APPLICATION FOR SERVICES
Tax Mao #:
Parcei #•
1) Permit requested by: (Owne�lagerrtlprospective owne�: • P QL
Home Phone: _33G-3�O S�-a� i9 Address; ,
Business Phone: , ,
2) Name and address of currerrt owner.
3) Property Desc�iptton: �otsrze: ��re�rownst�q,: � jY,�/(i,�c�, C��dle ��ls�
Directions to the prope�y (induding ro�d names and numbe�s): _���%lc.rG(ls E
-& .B. �( �r�� d F �� � „� �...... �.,.a � „_. �r
PI�,►s � c��►a �' wl tk� �'�"'s
�.1 t�a� s��,,,,y o.r� �I-� i10
15��// �{a�•t
I``,�k �`; Z-r�iN
4) Proposed Use and Structure Descriptlon: answe� each of the following questions: 5� �.s6aZ "��K
a) Proposed ef E�dsting O 7�<.�k5
b) Stldc Bu�7t ❑, Modular �, Single Wide q Double wde 0� �
c) Number of Bedrooms: 3 b� - d) Number of occuparrts or people to be served: �
e) 8asemer� Yes Q, No Fl�f yes, # of basement fixtures: ,
fl Garbage Disposal: Yes �, No e�
g) Dimensions of Proposed Strudure: Wldth: � Depth: � �
5� Water Supply Type: Private E3'fnew or existtng �� Public ❑, Community 0, Spring ❑
� Are arry welis on adjoining property? Yes ❑ No 0'�f yes, loca�on
6) Please Indicaie Desired System Type: (systems can be ranked in order of your preferencs)
r Comrer�tfonal �Modified Conventional � Altemative _Innovative
:Other (sPecifYl:
CLEARLY STAKE ALL CORNERS AND 1.INES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES,
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
1 hereby make application to the Person Caunty Health Department fo� a site evalua�on for the on-site sewage disposai system for
the above-described property. ! agree that the coMents of this appliqtion are true and represent the maximum faalities to be
placed on the property. I understand if the sife is aftered or the intended use ct�anges, the permit shall become invalld. ! understand
that as applicant, i am responsible for iden�fying and maricing property lines, comers and making the site accessible for the
personnel of the Person Courrty Health Department to conduct their evaluations. I understand that I am responsibie for notifying the
Health Departme� if my property contains any wetiands as designated by the Amry Corps of Engineers.
il � Y It-n% 9-//- D o
Owner or al Representative . Date
PCHD, rev.10l12/99
. .
. ` , :
� �
' : ' . , � S�60 3,SS�;E \
. , `
/ \ . ,O.p��
,�� � �
` � �
�� .Sot ��� is
t1 � �
. - �/ A�E� _,� � ,
/ �. �
4 fy .� i ADA HAW
� �: , P.C.
W `�.,. ,; J 1 1
� ' : . .�—. . , �' � 1
O � , �,..� a( / ,: 1 1
�o � �
O �: � 1
• � � : ; 1
�� 5.9 ;
z 5� - , , ,
.,
�� , ,
�: � � � � ,
A� � E�S��� - - � �
: .: . ,: ,
.:
,
. _ _- � �o ;,.
. , �
,
. o. o ; ,
,,
' � � � . � ��
� - z��.' y j 1�
' '
, .' '.: :.' '
1 � ;LI
� 1 O
CONTROL 1, ,v
1 — — CORNER �
�+
,, . 1 i
' IF_ � , , . ; ,. � . - . ' ;
. . � �..
FENCE ''601., 99, 1 �
CORNER ' N83'33!48nW .; '" i i
b STONE � �
. �.
IS _----- � �l_
. � �\��` ` — _
�
S WILLIAM,`RAINEY �HAWKI.NS,�_JR
„ . , rAND' OTHERS , ",':
: D.B. 184.�,,:P: 6'6
- ,
. . Y' _ , . .. .
� LEG �' :BEARING'""� . `DIST.- ' ,
. ' ` , �.,::' i ;a518'23!�36"E � '�126: 78' . '
. , 2 '=S16'23'36"E .��:51'' .
. . .
" : , . .
. � : .. .., . � : ..;.. . . ,. � _
. ..
, �. .. �.. . .:. .� k
f
��#�St3N GallIJTY ��11V1RflNME�lTAL O�E�aLTi-i
T��,� %� 3 � ��.
Zonia9 '� Tow�iP
ApQ+lanr I Y l i Ke � va hS
� 1 S� s��-1 AW k�
�-r^
�
:�I.I�.�i�l
, .,
.�. �
•. . .
� Improvemen# Permit � ,
:.
� A buildinq perntit cannot be issued with cnlv an imarovement P�nni#
• New � Repair Adc6Nott Type of Struchue C�� p� Water Supply �P-�� .
�
# cf Oax�pants � #•af 8edrooms � Other
Basemecrt? �9asemertt Fo�ures? �
Projeded Daly Flow: 3�Og.p,
Prnposed Vllastewater SysLem 1
Pump Required?' Yes �
Propased Repair ; co n v e n
permit Cand�ions: lCP e� Sc,
Owner or Legal Rep�ve
Autttorized Stafie Age�
Pe�m� Valtd Fac: Fnre Y�r:
C,oh vPn 1'tok� 1
�_`�` °—��. �
�h, s .�-,-o �. bk rl o�i
n n P F' A r-�D�Q ��l o
� ONoE� .
/
nT����a�� :G� tD �-o,=�Per�
wi�c, C6K"fouf . � '
�� Date: f - � • ��
.. pate: % � �- f- b �
The issuance �ef this permit hy the Heatttt Departrne.c�In no way guaranOees the issuanca of othec p�s. The �
he(det is respans�le for chedars8 � aPP�� 9overning bodtes it� meeting their r�rerner►b. This site is
subject to revoc�tion if the site plan, pla� or the itrtended use ctianges. Tha tmQrove�nent Permit sh�!! not be
affected by a cf�ange in awneeshtp af the site. This permit ts subjed bo camplianca with the provisions of the
Laws and Rules fcr Sewage Treatment arad Dtapoaal Systems af the No�th Caroiina Adminlstrative Code. .
-ryPe o�w�s� sy�m �ew� wa�wacer �r: 3�� a.�.a.
F�r,-y��: ,�3 �" . 5;.� p . � ,�,�,�#t'' �ra� o
8asemertt? Cl Yes �No Basement f�? Q Yea�No
Wastewatar Svstem Reauirements � ' - -
. Sep�c Ta�c Size: �Do v ga{tans Pwnp TaNc Stze: — g�tans
Tetal Trendi Length: � fe� Ma�num Trenct� Deptk � ind�ea Ag� Deptk /� in.
Maximum Soil Caver: � ind�es Tr+erid� Separ�ton: � Feet an CaNer
�ttter: � . .
Permii Ex{�atian Date- � ,� 0 :
Authom.ed State Agec� Date: �- � -o / •
The type cf sysbem permi 0 doe� 0 does not. dif(er fcom the type sperafted on the appiIcation. I ac�apt
the speciflcattans of thts psrmit
flwnerlLegal Represer�tive Sigr�u�e: _l �i'(�r�G✓ Date: /- S-O .
• PC�-i0, tev.11M8I99
. MVIvrlvr --- -�-'
�� S : , � � :e��ag
�
.---. . .
ura��� ay� Ba�/'�mw aol�da�uoa a y,� •Ajuo rrao�wo.� a�awJx+i►lddn �a�r�rdae r�
. � ' e��a0
i a-�-► -1
�po�/uall�e8/u�lel�iPqnB
. �
uol�ae8 u�I�aeH I�uewua�nu3
' ;t�euqasdeA tplsaH lyunoa uowed .
— — ;� I�aa�d
_____..___. .� d�� xey � � .
;� uopoo��ddb .
� , � .
wa�rA's
�
A� .
0
N
�
., , . ' . .`�����?.�JLl1���� �i.•, • , .
. � •`- •Tt t.� �-�n .
~ S �i�`j��,'�T JL. •
_• ._ •.• • . • . ' ' �1...IS.D' .Yd3�O�e i�xe �93.�.Y. .11,. 11.tC�JI� •
. . --- . ... �����;.;.�: 3� � . .. . P��� �: � R�
Zoning: Townahip: ' �
S�bdiWsion: � : ���: •;: . . Sectlon: � L.o�
Appitcatt� / "u41�'� ����� .
Locatiot�: � ���'''�s � �' .
�
. 4p�ratiora Perrnit �
. . System �ype (In Aa:ordance Wrth Table Va):
. ,. , .
THIS SYS7'EM HAS BEEN INSTALLED IN COMPL.lANCE WITH APPUCAHLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREAi'MENT AND Dl8POSAl.,
����'` � A�lD ALL CON 1'110NS OF THE IMPROVEMENT PERMIT AND CONSTRUC710N
� �;��� �u�ow�►no �
. • �r a, ���
- � Autho d State Agent � Date
.. .__...__.1. . . ��o `��. ... ......
-�
�
�
t{o �s�� �� l`l
to•3�
���d . �°'��� �((�
� �
. S� �� ���0.��
0
�
���� �� a��es
a
PE�tSON COUNTY ENVIRONMENTAL HEALTH
+� PLEASE SEE ATTACHED PLAN FflR WELL SIl'E �LAYOUT
Tax WP� � � � Pasd� I —
. � . T� �I �,`��s _
� .
.
� � � � �� ���� �
� ��, g � �C�,r �. � t� s l�oa,, h� D. C� c c a g s �rn �
�-.--r , � f-
'_ i`Yc ;� S
(N �
9�0� l.a� __.
� • -
. Weil Permit ' .
Tvne of Water Suaaiv: ind'nridual Cammunii}i • Public
,,.. , � �
Reauiremenis:
S'rte Approved by ✓
Grouting Approved by
Well Log ✓ v��,(��� ,� l
Wetl Tag �✓ ' �� u v �,
Air Vent _, �
I-}ose B�
Concrete S1ab
Welt Drilter: � l� � �L� -
Well Approved By: ���� r/�� ,�
�
Date• �✓�( —��
�
"*See kttacfied Site Skefich**
� Welis must be 10 feet from propetty lines.
Wells must be 100 feet from septic systems.
WeUs must be at least 25 feet from any building foundation.
Other condi�ons:
r�
�
�
PCHD, rev. t ifzs�ss -