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A32 216,� iicatlon Daie: '4'16"� � �enount Paid: �00 �.� � ��c2ipt #: .:7 2 4 Z j C�/12'�"'� ,�2i16 S�� VQ�-s' ��erson �auntv Health d�enartment Environrroentai Heaith Section APP�ICAT10P1 FOR SERVIC�S Tax �iao �• Parc�! #: L -�- � � �y�d.� C1r-�� IF THE INFORAAATION IN THE APPLlCAT10N FOR AN IMPROVE�AENT PERMIT IS F,4LSIFIED, C9iANGED. OR THE SiTE IS A,LTERED THEAI THE 11UlPROVEME�IT PERMfT AP1D AUTHORIZATION TO CONSTRUCT SFIALL BECOME INVALlD. 1) Permit requesbed b�y: Owne ent/prospective owner): � +� �• o�l� Home Phone: Y 1�7 -� -�59�: Address: Business Phone: �i ry- "�3�- �G=-� Ir'��c..�t<.. r� ' 30;Z 2) Name and address of curr+ent owner. �� 3 - ^ a, � �% NZlswv 'C. �a k.c.l 3) Property Description: Lot size: Township: ►� uS � F�c-I /_ ��/ _ DirecKions to the property (Including road names and nNmbers�: � 7U/t�A�/QS �M l{-� ' or�lc._ ��. 4) Propased Use and Structure Desc�iptlon: answer each of the foliowing questions: a) Proposed G� Existing ❑ b) Sticic Built�Modular �. Single Wide �, Double Wide ❑ '' c) Number o Bedrooms: 3+ . d) Number of occupants or people to be served: s) �asement Yes �, No �If yes. # of bWsem�nt ��x;tc.e,�:__,_ _ fl, G�rbage Disposal: Ye� El, No ❑ : : .,-.. _ .�_. _ _ `_ g) Dimensions of Proposed Strudure: Width Depth: �� d 0 S� ��- �.► N; .uwi.� S� Water Supply Type: Private �'(new � ar existing �), Pubitc �, Community �, Spring ❑ . Are any weils on adjoining propert�t Yes � No � If yes. location 6) Please Indicate Desir�d System i ype: (systems can be ranked in order of your preference) ✓Converrtional _Modified Conventional ,_ Altemative Innovative Other (spec9fy): _ CLEARLY STAKE ALL CORMERS �►ND UIdES OF THE PROPERTY. ST�KE THE CORNERS OF ,4LL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SiTE PLAN TO THIS APPLCATION 1 hereby make application to the Person Caunty Heatth Departrnent for a site evaivation for the on-site sewage disposat system f�r the above-described property. I agree that the contents of this application are true and represent the maximum faalities to be placed on the property. I understand if the site is altered ar the intended use changes, the permit shall become invalid. I understand that as applicant, I am responsible for identifying and marldng property lines, camers and making the site accessibie far the personnei of the'Person Courtty Health Departmerit to condud their evaluations. I understand that I am responsible for notifying the Heaith Department if property cornains any wetlands as designated by the Army Corps of Engi ee . A/�e/ � � " wner or Legal Representative D e PCND, rev. 10h2199 _ :� � P�ERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACt-IED PLAN FOR SOIL AREA AND SYSTEM LAYOUT Tax Map #: �`I � � Parcel # � � Township �l�t56' 4 �r� PIN Appltcant S�m.�. �.� �T. R� rk.er s�baw�� I3ti ��s �i�� /!� Phase/SecUon �% 1�r�� Locano�: Lla,�, /r7 (C�,-,.�.�t �:0) �''iAs� ��,fo�e Cjfi.et�'l,'e. /�Zo.cfc �!. Improvement Permit New ✓ Addition Type of Structure s�i�, �!"Qin: ��S ic� �-�� Water Supply /��i �u. �✓e-�� # of Occupants � $ Projected Daily Flow: _ Proposed Wastewater Proposed Repair. � # of Bedrooms _� �_9.p.d.� P� Other __ �- Permit Conditions: I�SZc'- S�. s'ke��<i � Years ❑ No F�cpiration System Type� Owner or �egal Representative Signature: � � Date: ��—� � Authorized State Agent: i .S• Date: 9/.3 O/ The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if the site ptan, plat, or the intended use changes. The (mprovemerrt Pertnit shatl not be affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatmerrt and Disposal Systems of the IVorth Carolina Administrative Code. WastewaterSystem Description: �.�it�n��D�Cc.� Wastewater Flow: �O g,p.d. Type: � Facility Description: �Bi� ��1 �'zril>•�� f's.'r��r�� {Vew � Repair 0 Expansion ❑ Basement? 4 Y�s'"19�t�o Basemen F'ixtures? ❑ Yes Q�hta Wastewater Svstem Requirements Tankage: Septic Tank size�� gal. Pump Tank size gal. Grease Trap size — gal. Trenches: Total length S�. ft. Trench Width �_ft. Total Area �esao sq. ft. Max. Trench Depth: �� in. Aggregate Depth:_�_ in. Soil Cover. � in. Trench Separation �% ft. on center Permit Expiration Date: �- - 4 6 Authorized State Agent: /e�. Date: 9��3 o/ •See attached site plan and addendum pages for additional permit conditions. The type of system permitted ❑ does ❑ does not differ from the type specifed on the application. 1 accept the specifications of this permit Owner/Legal Represer�tative Signature: Date: Operation Permit System Type (in accordance with Table Vaj This system has been installed in compliance with applicabte North Carolirra General Statutes, Laws and Rules for 3ewage Treatrnetrt and Disposel, and all conditions of the Improvemerrt Permit and Construction Authorization. Issuance ofi this permit implies no guarantee ihat the system installed wi(f function properfy for any given period of time. Authorized State Agent Date PCHQ, rev. 03/07/01 ��';�� ~ � �i.� � �� 11 1l �' gn�n�aAna�a��a�.Il. ��.��n. SITE SKETCH �1 Name .Sa.0 u-e ��a r,�e r Tax Ma.p ## � 3� Pazcel # o� I� � Subdivision .�,rci�.s �1'eP� �,D Section/Lot# �% -Z � /D --��%�e� � %-/3-0/ Authorized Sta.te Agent Date �`a� - Sy.sirn� f�i�e�. `�, \\ 533'o��viv,�,'�es@.Z�{ �i/�jof� � � i ftda': � Afta ��Prnt%� Cor��5 a;s ` � � /ir/�e�'� �i /�7%r►IrLcu� Sc;T4�Gf.:. /'e cri/'e/�rB�v�s aS '_ is� Nc�c ��a�.i�� C�� $�,. �s �r sr�G t��.�� ;s�tt�u,�S�i.�s) �70' 2 , ,�,.s /u (( �i^P.cG'�s o,, /eve / Con �ur,s'. �t� ak f sysf�s., W i'�!t rt �rais: ��-�'of ^jo irrs7a � �c� , Sca1e: „_f ��= I n�' �� ooL \�C, , /�1�2� �.WaMaJ��- o� Yur�a.�- ' •�,� �,a,..,�.a ��.t � 5.�, ;r n pM^p s�s'",''"' 37i � � � ��2-OJ 2 �5 � ��,�� '��.�� -= � � � �-�� IE��aa-�� m�.�.71 IF3L��.Il�I� WELL PERMIT PI.EASE SEE A'I"I'ACHED PLAN FOR WELL SITE LAYOUT Tax Map #• �3 `'2 Pazcel # � � � Township �t�s`�, F��- Applicant: Sa« u.e. �� pa r' ,�e r Subdivision: ��.�f�s �i^ea.� �.�i Section• .1. Lot• l3 Location:_y� v S 7 ��.�s � � Ty�e of Water Suvnlv: Rec�uirements• Site Approved by Grouting Approved bp Well Log Well Ta;�; Air Vent Hose Bib Concrete Slab Well Driller. ✓ndiv�idual Community Public Well Approved By: Date: '�See Attached Site Sketch'�* Wells must be 10 feet kom property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from anp building foundation. O�er conditions• PC�ID, rev. 09/07/01