A32 214� ,� � �iica�ton Date: '� '%G � �
Aenount Paid: ._�0 , U 0 �. � �
�t�caiat #: .J 2 4 �5
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�'srson C�unt� Fiealth i]e�aartment
�nvironmentai O�ealth Section
APPl.JCAT10P1 FOR SERVICES
Tax �ao #:
Parc�! #:
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IF THE INFORMATiON IN THE APPLlCA710N FOR AN IMPROVEiUlE3VT PERMIT IS F,4LSIFlED, CNANGED. OR THE SITE IS
ALTERED THEN TFiE IMIPROVEAflEA1T PERMIT APID AUTNORIZAT10iV TO CONSTRUCT SHALL BECOME INVALID.
1) Permit t�quested b�y: Owne�a entJprospective owner): 5 ��• a(�:
Home Phone: `� C��) - � �59� Address:
Business Phone: =3 i�-'�3 �- ��--�c c. 30:Z
2) Name and address of cumerrt owner. ��� 3���
'b� •e � , a�
3) Praperty Description: Lot size: °2 Township: c.�S K t
Directions to the property (Includin� road names and n�mbers�: � a�
���
M11C.. �20.
4) Proposed Use and Structure Description: answer eacii of the following questions:
a) Proposed � Existing �
b) Stick Built J�Modular �, Single Wide ❑, Double �de ❑ �
c) Number o# Bedrooms: 3-E- d) Number of occvpants or people to be served:
e�-- Basement Yes 0, No t�3'If yes. # of basement fixtures:_.,: w.:�. `- -- -- ---°-- -�
� _ ...--
_ . �i_.. Garb�ne �ispa�al: Yes �. No ❑ _ _ _..... n _ � ,
g) Dimensions of Proposed Strudure: Width: Depth: � � � � s �- '�`� �'t' � !•+' 't"k'ti'`
,5� Water Supply Type: Private �'(new � orexisting 0), Public �, Community 0, Spring Q
. Are any wells on adjoining property? Yes ❑ fVo � If yes, lacation
6) Please indicate Desired System i ype: (systems can be ranked in order of your preferenc�)
✓Converrtionai ,_Modifled Conventionai _ Altemative tnnavative
Other (specify):
CLEARLY STAaCE ALL CORNERS AND LIIdES OF THE PROPERTY.
ST�}CE THE CORNEitS OF ALL PROPOSED STRl7CTURES.
PLEf1SE ATfACH SURVEY PLAT OR SiTE PLAN TO TNIS APPLICATION
I hereby make application to the Person County Heaith Departrnent for a site evaluation for the o�-site sewage disposal system for
the abave-described. property. I agres that the cantents of this application are true and represent the maximum faalities to be
placed on the property. I understand if the site is altered or the irrtended use changes, the permit shall become invalid. I understand
that as applicant, I am responsible for identifying and marking properry lines, comers and making the site accessibie for the
personnel of the Persan Couaty Health Departmerrt to conduct their evaluations. I understand that i am responsibie for notifying the
Heaith Department if property contains any wetlands as designated by the Army Corps of Engi ee
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T��x Ma�� � P�rcel =
S�uhcliivi,s�ion � ��'� %�
Ph�a�se�Sect�ion Lot # �
Applicant: ��t,f,P � (�,r �
L ca.ti
�� ` e Ss --� � e-
Improvement Permit
Permit Valid for � Five Years _ No Ezpiration
Type of Facility: S• �� New �Addition Water Supply �
# of Occupants QaC # of B drooms Projected Daily Flow 3�c� g.p.d. ��
Proposed Wastewater System: �si.�r,�l � � . Type:
Proposed Repair: _ T,�,�ioUc�, Type:
Permit Conditions:
Owner or Legal
Authorized Sta.te
Date:
Date: � �3�
The issuance of this permit by the Health Department in does not guarantee the issuance of other pemuts. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for 5ewage Treatment and Duposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
- Autho.rization to Construc Wastewater Syste (Reqnired for Building Permit)
* See site plan and additional attachments (_� ����r' ar � Z�ct�✓
Proposed Wastewater System: '�,�y A—�-✓�Nc1UI��Te- Type�� Wastewater Flow �E'� ' g.p.d.
New � Repair Exp ians on _ Soil LTAR: _. ����' g.p.d./ ft 2
Type of Facility: �� ]�PS , Basement _ Yes 1� No
Wastewater System Requirements
Size: Septic Tank: ��o gal Pnmp Tank: l�� gal Crrease Trap: gal
field: Tota1 Area:��� sq ft Total Length '�3� ft Mazimum Trench Depth %� in
�h Width � ft Minimum Soil Cover: �o in Minimum Trench Separation: �_ ft��-•
Distribution: Distribution Box
Specifications• � �C�jy p -�- �
Authorized State Agent: �
Permit Exnira 'on Date:
The type of system permitted is
the permit.
Owner/Legal Representative: _
Serial
� Pressure Manifold
_ Date: ���. 3—�t('
Conventional � Innovative Alternative. I accept the specifications of
Date:
PCHD7/30/2002
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SITE SKETCH
Ta.x Map # �3 � Pa:rcel # � I �
Section/Lot# g
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Date
System corraponents represent apprvximate�contours only. The contructor must, flag the system prior to
beginning the installation to insure that propergrade i.s maintained
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IE:�-sra��aasaa�aa��ll IE-3L.o.m.11�67{a.
Tax Map: A 3� Parcel #: � 1 _ Date: ��"'d �
I�ine Tap Tap (Scl�) Tap �'low ]Line Length �'1ow / foot
# I2iameter in) ( m) �'. ft)
1 Z Lt v � c� , o$'�
2 �2 c� � v �o
3 Z o � '�� 3
4 L � � •0
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�i21 � ft of line x 65 gal. per 100 ft= 21`fSv Z�YS� ; 100 = Z�5 gal
75% x Z! �ga1= �v gal per dose ✓ gal per minute (gpm) _�'low ltat�e
Friction Head ,�
Loss: • 7 ft per 100 ft of supply line x��� ft of supply. line =100 = �� ft
� ft x 1.2 =��� ft of friction head
Manifold Size: �" Force Main Size: a " PVC
Total Dynamic �ead =�� ft of Elevation head�z' ft of Pressure head +S Sft of
Friction Head = ?� � TDH
�.'ump Require ent• �p GPM @� ft of He
Drawdown: �o� • al per dose � 21 gal per inch =� inch drawdown per dose
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