A32 202,�rsoiicatton Date. �-3 6 —� � .
�l�ount Paid- � � .
� .�.r��i �:,�;2�-
�srson {:acsMv �leafth i3e artine�
�mrironmer�tal Heaith Section
APQlJCAT10PI �R SEiiViC�S
i ax t�a� �' .1`d' 3 0�
P�r�� �: � 3 �
IF THE INFflRMAT10N IN TNE APP�lCATTON FflR AN IiVIPROVE�lAE3VT PERMIT IS F,4LSIFiE�. C9�lAPIGEi3. OR THE S1TE IS
AL7E3Z�. THE�V THE iMPROVE�IAEiNT PERII�IT AND AUTHORIZAT(ON TO CONSTRUCT SHALL BECOME INVALID .
1) Permit �quea6ed by: (awrterlaget�tlpraspedive owne�: � i r �l �1 � _� �41�i � Y�i �
Home Phone: 33 i� �c„ U�'s5 0�- Address: � � 5 c_- us a� ` r� �1_ .�
Busirress Phane: ��3 c.� -�ti., y- tpz�o .�i urd I c- il�� i��,s U.r_., �i-� �i �
2) Name and address of can+ent owner. ruC�.-� V ic.k.► �1iSi�D�rYI
`l �7 5 Guc:�s `�? +� ' �
j�Y�al _ m;ti� ���, r�35�►
3) Property De�riptlon: t�t �ze: 2. N n�.Townatd� us h ro�-k.
Diredtcns to the
4)
Q j�hf-; qc� o�s �►e.i� �►, Ic�-l'
51 �.
Proposed Use d Strudure Descriptton: answer eac3� of the following questtons:
a) Proposed O,�F�isting ❑ �
b) � S�dc 8uilt t�!�Moduiar �. Single Wide q Dauble Wide �
c) Number of Bedrao s: �_ . � Num6er af o«;upants cr pecple bo be sesved .. � .
�-
., .e�.._�as�ner�: Y�3 .. ";; E1_:#,y�^.V:,, �..�f h�etnantfatu..res:. . _ •
i� Gartiag� Dispus�L• Ycg C�„ P;� � _ . .. . _. . . ,_ _ � . . -- . .. �.. -
e.
g) Dimensions of ProQosed Structure: Width: �, Depth: �,
fid' f�/
�I/a�er Supply 3ype: Private (new orewsttn9 �, Pubilc Q, Cam� undy q Sprmg-t7 \
. Are arry weUs on adjoining Aroperty? Yes d No q if yes, lacadon ��il' � 1�7��J
6)v P�a� Indicate Desir�d System . i ype: (sysiems can be raniced in order of yecir prafer�nca)
/ .
Comrernional _Modifled Comrentlonal ,_ Aitemative . lnnovative
�� isP�Y�=
CL�ARLY STAKE ALL CORNEi�S AND LiNE� OF THE PROPERTY.
ST,1KE THE CORl�IF�S OF ALL PROPOS� STRUCTURES.
PL�►SE :4'RAC3i SURVEY PWT OR 51TE Pl.AN TO THIS APQLCATION
i here5y make app�an to the Person County Hea!#h De�artrnerrt fer a sit�e evaiva�on for the an-s�e sewage disposai �system far
the above-descx�bed property. i agree that the ceMeMs of this appiication are true and represent the ma�mum fac'sTities ta be
piaced an the pro�erty. I understand if the siie is alte�ed ar the intended use c�anges, the peimit shall bemme inwalid. I understartd
that as appii� I am respansibte fo� identifijing and marking proQerty fines, camers and maldrn,� the siie accessbie for the
persanne! of the P�san Caunty Heatth Departrnent to candud their evaivations. I understand thffi i am responsible for nofifij+ing the
Heaith Departmes�t i� m perty coritains any weilands as designabecf by the Arrtry Corps af Enginee�s. �
' � -2 -o L
0 er or ai e{�resentative �� Date
. .PCS-!D, rev.10!'12198
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Tax Map #: /� U o� Parael #
AppitCant
L�anon:.
L
Townahip
�
NI
PIN '
PhaselSer.tton Lo1�F
�#`79S hc�i��d exis�F_;nq s�►�.o
Imarovement Pe�nit
New � Addition Type of Struaure J�� G�G ' (,�G �� � Wafer Suppiy Pr� UCC,tC CJ r//
# of Occupants � �'1UX # of gedrooms � Other
Projected Daiiy Row: (00 g.p.d. Pertnit Valid For. Fve Years ❑ No
Proposed Waste�nrater System: C -i' � � rA. ✓ i tY
ProposedRepair. Pum� nnova�E�uc aS9�2 t�cc_ � Ch�ti
��
S�rstem Type -�
Permit Conditions: �f15t� I � on Gan�oc,t� c�,�5 5tio�,an, FD/�OW COl1c�� �i'o/1S 0/l SJ'tG
�K �ti Qc: Ba,scrncnt �I- �nK /a cr Ta ' /Cror� �n.�s
uT
Owner or Legal Represe e Signature: I'""`� Date- � i) �'
Authorized State Agent ' Date: � � � �C7 /
The issuance of this permi�f by the Health Department in no way guaraMees the issuance of other permits. The peRnit holder is
responsible for checking with appropriate gaveming bodies in meeting their requirements. This site is subject to revocation if
the site plan, plat, or the intended use changes. The Improvemertt Permit shaU not be affected by a change in ownership
of the site. This permit is subject to campiiance wifih the provisions of the Laws and Rules for Sewage 'ireatment and
Disposal Systems of the North Carolina Administrative Code. �
• Authorizatiore i'o Construct VVastewater Svstem IRec�uired for �uiidinc� Permit�
WastewaterSystem Description: CD/1UC/1"�/C��� �'�'"�UitY WastewaterFlow: .p.d. Type; �
Faality 'ption: �I�f1 �/ �G 1 aml I�, (.J� IIi � New �
Basement? Yes � No Basement Fatures? es � No
Wastewater 3vstem Requinemerrts
Repair � Expansion ❑
Tankage: Septic Tank size I� OOO gal. Pump Tank size gai. Grease Trap size gal.
Trenches: Total length ��� R Trench Width � 3 fit Total Ar�ea � o� � sq. R
Max. Trench Depth:Q�� in. Aggtegate Depth:,�_ in. Soii Cover. �a in. Trench Separation �,ft. on center
Permit Ex�iration Dafe: � o� �0 — � l�
Authorized State Agent ` Date: � a�`� �
'See attached site pian addendum pages for aclditional permit canditions. _
The type of system permiited � does ❑ does noi d�fer rom e type specified on the appiication. 1 acr�pt !he
spec�cations of this permit ' -
OwneNLegal Repr�eserrtative Signatur+e: Date: ' n D I
O�e on Permit
System Type (in accordancs with Table Va)
This system has 6een installed in compiiance witt� applicable Nonh Carola�a Generai SfatuOes, Laws and Rules tor Sewage Treatrnert
and Disposai, and ail cot�itions of ihe lmpenvemerrt Pem�it and Construc3ion Autl�orization. lssuance of this pennit implies no
guaramee tfiat the sysbem installed will fundion property for a�ry given period of time.
Authorized State Agertt
Date
PCtiD, rev. �3/07/01
t
, Appiicatlon #: _
� Tax Map #:
Parcel #:
Pereon County Health Department
Environmental Health 8eation
SITE SKETCH .
�� (rl iC,hat ( �-L c� ma.5 _ N� A'
.Appiicant's Name � Subdivislon/Sectian/L.ot#
� �1 ac� o i
Au horized State Agent Date . �
System camponenl� represent approxdmate corttours anly. Th� conlractnr ntust f!'ag t/te syslem
prinr to be�lnnl�r� the lnstall�tlnn lo lnsure that proper grad� �S malntained
-�= F 6aSc rncnt �� «� -{,00 cl�cP �.
___.... �� � . Or G�a�i�� aro�nd homc
�cale: �"5� I n-�cr. Fcres W �-eh tan Ic Plac.cmcnt,
� � um CJiI� �c re c,�i�c-d �
PCHD. rev.10/12/88 � P P , �
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on Lp� s;dc.
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C.G. NICHOLS ESTATE "
18� p0� �
P.C. 6, P. 87-2 N�2•48,
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Owner: �`�
Location:
Subdivision: _
��,,,: .:�� .� ..-�-c? � (
��..,c�-,:.<,�,,��,,►rn� W��;�e� ��.� « c '.��� I� �J���;1: �.�
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'1:�� !\�Iap ��Z 1':u-ccl f� .� � Z
Lot !E �._
l���cll C�zist�•uctxoz�
Distancc Prom c�carest 1'ropc:rty Linc: (NTiniuzuin ! t; •t�et) r`� .��____._.._
]�istancc 6conx Scpcic Syscem (Ivliniu�um (i0lccc) �
Total Deptl�: �,�D ft Yicld: 3 d Gi'M Stalic Wacer i.,�v�t: �_.__ l'�
Water IIc:aring Zonc�: Dcpch ''zp t't 1,� it /3.�_'�� _ lt
Caszn�:
Dcpth: Ft'om !) lo �-i' Il. llianicicr: _� in .
Type: Galvanized St�e;l � '� , ��
Wei�ht: �_�.�.�hickncss: / n' � Il�i�l�t abovc Ground: __/ >� iil
Drive Slioc: ��'c:s No �1ny ��roblcros cucquul'crccl wliilc: sc:llili�; casii��? __ Y�s �No
(�'�CS" b1VC CCIISOIl: --- --------
GXOIIt:
Neat: Sand/Cement �� Coiacrcic Grave:llCcmci�t
�.nnular Sp�:cc Widt!t �� inches Waler ii� Aaiiiul;u S�acc Yes '� No
Ivlelliod of Grout. Pumpcd I'rwsure: ' 1'aured `� Dc���li �•�to �t.
iYXatcz'zsls Uscd:
No. F3a,r,s S'ortlaud ccmcn[ . Wci�;hc u�l' I 13a� _—_-___ l'auiuls
lt mixtw•c (sancl, �ravcl, cuttin�;�) — lZatio � r� __ �
ID platc�: �Yc� No �} ��� �lab �-�.'cs ,� No
JJrilliu�� �.c�� �,c�c:it'ioi� 1Ji•awiu�;
( hezeby eertify dl�t clac abo�rc in�on��atiot�. is cone:ct an.cl tllat tl�is wcl� was c:unstructcd in accordancc with regulations
scc �orcll by,thc Pcrsotl Couuly 1•lcaltl� Dc:�:1fC111CI11'. .
• ��� �� �� � ��:1iC ^ Z- ��� ."� (
, . .��.
Si�n,�cuxc oc Co�arr;��ror , ����,r, ,�„ n� ii �rn�
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
, � � � Parcel # �� �
Tax Map !F:
Zoning
Township ��� y FarX
AppUcant: �(�C'�� �' � L I a ma s
Locadon:
Subdivislon:
TYpe of Water SupplV:
Requirements•
SecUon: Lot:
Well Permit
Individual Community Public
Site Approved by � Z-��-o�
Grouting Approved by /�� � � o�
Well Log �.��'� �. �� o�
Well Tag
Air Vent
Hose Bib
Concrete Siab
Well Driller:
Well Approved By: Date:
**See Attached Site Sketch**
Wells must be 10 feet from property (ines.
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