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A32 220. ,� * , . Application_Date; � �d'� % Tax Map #: t't �c� Amount Paid: �DO ,O (� Receipt #: 173 � ParcEl #: ��C� �60� ��,���� �f ���� �� _ _ _ � � � ���� ��-�-a�-���.-.. m�.,��.a ���.��� APPLICATION FOR SERVICES � Ca�� � o M�� o � � o-��r IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED. CHAiVGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. � 1) Pennit requested by: (Ownedagent/prospective owner :��n �.��'+ 550,� Hame Phone: �fr, 'S`1�1 � 7Ly $ Address: v� i<-: � Business Phone: :3��, �•�p3 --a�'i 6Z Z�5 4 2) iVame and address of current owner. 3) Property Description: Directions to the propei 4) P'roposed Use and Structure Description: answer each of the following questions: a Pro osed g ^ � �� ''� ) p �, Existin , ype of Structure: ..�, ;cSc. �,.� Width: .�c Depth: b) Number of Bedrooms: �� lob Number of occupants or people to be served: Z c) Basement: Yes�, No _� ill there be plumbing in the basement?, �V U_ d) �arbage Disposal: Yes � , No �, 5) Water Supply Type: Private �(new �c or existing�, Public� Community_, Spring _ Are any welis on adjoining property? Yes_ No �C If yes, please indicate approximate location on the �site plan. � 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No_,z,_C � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �, ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAF(ED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE F�R AN EVALUATION BY THE HEALTH DEPARTMEiVT STAFF: � I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the abo e�e cribed property. I agree that the contents of this applicatio.n are true and represent the maximum facilities to be pl�ed oy� the property. I understand if the site is aitered or the intended use changes, the permit shali �"�=_--� ..."`.-----__. ' Owner or Legal Representative ,, � i, �_ .. PCND, rev. 06/27l02 ' ��� ; �� ���� �� . `...�� � 1 , � _� ������ ������ � ��.�.S.Il Il: 3L��.]1� Applican� T�H 1��1�a�p � �rcei � . � � SU,b.C{;IVI�S'I�011 � � P�has�e-Sect+i.o�n,'Lat � Improve�nent �ermit - P�rmit Valid for / �ive ��s No �iiration Type of Facility: New ✓ Adtiition VVater S�ppiy (�e1 j # of Occupants '(� # of Be _ oms;' 3 �____. _ Projected Daily Flow ;�� _ g.p.d. Proposed Wastewater ��t��� �CC.�� C�SlG �c�c�;,.n GZ��tu�, �,�<1r,���;hPr� Type: Proposed Repair: P�:Im� .�C`C�, �� ,���=2-_%1��; ��X C�{-�zrr� �� Type: Permit Conditions• -�1�-�J S1 `�i`i�i�l Owner or Legal Representative Signature: Date: Authorized State Agent � �,�m � �$ Date: �3 � � I �� The issnance of this pe�it by the Health Departineut ia does not guarantes the issuance of other permits. It is the responsibility of the applicantfproPezt3' owner to in sure that all Person Coimty Plazmmg and Zamng and Building Inspections reqturemeats aze met This ImQrovement Permit is snbject to revocation if tlie site plan, plat or the intended use changes. The Improvemeat PErmit is not aifec#erl by a ci�ange in ownership of the properiy. This permit was issned in compliance with the provisions of the North Carolina Zaws and Rules ior Sewa.ge Treatment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person �onnty aor the Enviranmeatal Health Specialist�warrant$ ti�at the septic tank system wiil cnntinue ta function satisfactorily in the futnre or that the water supply will remain�potable. � =..: � � Authorization to Constraci Wastewater System (Required for Bu�ding Pe=mit) * See site plan and additional attachments (�• _. — . —^_ Proposed Wastewater System� �`�C��ci _�CZ �%1�.� �. r�' {���,e,��Type�q� Wastewater Flov��:p.d. New � Repair Expansion � Soil LTA� .�1J g.p.dJ ft 2 Type of Faeility:��,�,Ci no0� rci 9�� c�i, ,� � 4 � Basement�0 Yes _ No - � �aste�vater System k�ea�uirements 7Cank Size: Septic '�ank: �Q gal Pnmp Tank: -- gal Grease Trap: -- gal � �rainiaeld: Total Area: �1cX� '. sq ft Total I��ngth` ��_J� 't � 1Vla�mnm Trench Depth I� in Trenc�'4Vidth � ft lYg'inimnm Sail Cover: l�s in M'inimnm Trencli Separation: I ft �istribation: �- Di�tribution Bog X� Serial �istn7�ntioa Pressure Manifold Y � � � , W � � � .� _ .._ _�� : :r _ � � ,. � �: .� r � :� / Anthorizerl State A.g�nt `S� Permit Expiration Date: Date: The type of system permitted is ?� Conventional Acc�ted Alternative. I acc�t the specifications of the p�� b� �D� i�wne�/��gai �.tEpres��ative: / �L GU G� Date: 02 �o? ' PC� rev. 11110/OS ' . ;;.: �--���. � �Jl.d�d.J �J� "- � � ��� � ��..�cn-yas�sn�c�cn.�s:a���l �I�a.aa��lia SITE PLAN N:une L�('f'C lYl � 1� 15�A\ l Tax Map #� Patc�l # ca. �� Sui�division� , ' rc � Section/Lot �1 ���i(� �� � �. � ` .=�-� ��, >] Authorized State Agent Date System components represent appm�mate coatoars only. The contrvcto�musr t7ag t6e system paor to be�nnir�g the tnstallation ro Insure thar proper y�n. de is mainrained. � L�L,,��_'`SJ � '�'"'� . . ,\�= 1- �c��� �<, _ � 'mCs�.�—� �C�u�� C�5 5��-��� � S � 1��� ��c� �nS�P�� �-1 C���,� -� `��� n�� ���r�s�Q\\ v��,�� C� �, � on S !.� ��, ���c� � S��S���� �s� � �� ��e��-1� �s C._.-�s-r� C��-. �,��. ��s�� �-��_� 5�"7- i�� ���� �--� �� ��� 5��3 � � �� c�-�v . � � ,�e. �1���� --�r�r�l� c��`1� � ��� --=�_--�� �a�.,��� Ca-���n-h c�z:� ��� �� f �g� �� ��P,��/1 � �- ��,�ei,,-� � f��� �'� � (�%JPSn � -� � �'"-'� �M��'� � � 0 ���, �� . � ' `� �� �� �1 �. � � � � ��.. � � � I� �..�. �- � ��. � �. �.I1 I�33C � �. ]l. ��. Applicant: Locaiion: � �� � �P^n %/'i Sfa n �.Jla .H ; ��s GL , �n �� ��� � 3 �- p��� �� a �-� ���3�0�] � �r� S C �p h' (�l�Ol�6o��04 � �- �f ►1 �� a�o 00 �— �� ,� `�- �:: ���: t =� `� _ Syst�m Ty�e (ln Accardanc� Wiih Table Va}: � 9` T'H1S �`fST�i�A 93A� �EE�1 ileISTALLED �� CC9iV11Pl..��R�G� UViTH �1F?P�lCA�L� . NORTN Ci4Rl7LlY�e� GE�IE#'u�,L STATdlTE�, RUL.�S Ft�R SEWAGE ?RE�IT1VIEs�T AiVD DISPOSAL, A?dD ALi. CONDITiONS OF � THE 91VIPROV��E�lT PE}�1�i!? AND COi�STRUCTION AllT�iOF�f�TION. � . . '���,.s- ` o �/a-s/�� Authorized State Agent Date fnstalled By: T, � I1 i p Daie: ����� l �� . L, _ �O� La=F�v� �. ,� = 7v ' L � =�v, �o?f�"� = 300' I �1' i��'°J � � -� � --� -� � -� s v � � . � � � � �, �c<�,� � i S �•. c�ct� I 1��,7- S i � P a� �iovSP, � Cb�se��+ � . c� 7/� Sl v� � �T 5-1 oau � _ .. s s-r�-�a-1t- � N � v7 0 w � i o� �SGf1'L � % � Ts PCHD, rcv. 07/2910=� �-Z �'�o �, ���'�G �-��� ���������� ��E���S n �'9�e �@ - �� .�ll- Tax Map ��� a Rarc�! � a�a- v Sysiem Type (i'abis Va) OwnerlApplicant 61e�� L,rr ss�-,:, Subdivision ��r�s C�'er f� Address/Location [� � ��� s G �n r 1-, � S� Sec/Phase Lot # �e�31hC ��t9�t �681�9��/��$� �i�6 lC�f901'8 FH�� �!'1�'��� a� State �IDldate S? 1�-3�y J� �-�s-�8 Sg�a j o�-�s-� Trenct� Vllidth ft. S� o�-� s-o� Tee and Filter � Baffie Seaiant Riser (ifi applicabie) Tank Outtet Seal Permanent Marker Ptae�a� Tank Ca acit c�al. Water roof ISeaiant Riser Water Ti ht ��nrap Ct�eck ValvelGate Vaive Ant�-s� on o e Floats/Swiiches �11arm (visable and audible Electricai Components Rate (gpm) Appraver� Pump 1Vlode! Blocfc Under Pump � Pump Removal Rope/Ct�ain � D6s�rabu�on. Systerra Serial Distribution Pressure ani ol Low Pressure Pipe Aaqr: Pipe �iateriai and Grade � Trench De th T.rench Len th � a Trenct� Grade � Trencf� S acin Roc�. De th and Qua�i DamslS#e downs �#c. Pressure Laterals Ho(e S�acinq � Sieeve �ecguiresi� �e�a��s From� UVells From Pro�e�tv lines Surface Waters Public 1Nater Suppiie� Vertical Cuts (�2 ft.) Water Lines Vek�icle�Traffic � Adiac�nt Svstems � �Eas�ments/Righf of �' Ot�ae� 5�3�1� �-s-� Easernents Re�arded n> J ert� e erator oi i Tri-Partate Aareemen Coovamen� pc;�d rev. 3113/01 `'���:,�.+ ...:...:..:..:'...,:.;_,. . ' . . :..,;:, �� • :.�� . �`...' �'' �„ ..,�...�.�.:�.':'.�,.' �, �., :�� ' ,,, ►;... �.. �� �� . �,� �. • ,... . . ... . . . . . .. . . .� <�:�'r':�;1!r �.��: - . .�:.:�,: . .... � . . :,; :.. •. ; .., ...�� ...; .,;....,.:.:;.�.::..:;,• •.;:.,. .: •:•;•;:.:::;:-:.•: .•�; � ...., : .. . ..,.: •: .:.. ..........:...:::..:::r..,•.,,;,:•,:::..,,,.;,.,:.;...,. , :.;.., . : ..�.. . .• .:. ,_,..,..:..•.:,..,..,; , , ..•. • ,..; . • . •:...:. �: .. .. •.. . . ..,, . � . 7�� �•77�;�:ni']L�47?•:n''ri'��a+*•'++''R'•'a77:95:�`'..�.�Sl:�•`�'' •.� :,. . . .v..:,.:.: •,-.,•. �• • -. � .:.:.,..,:.,;;,""_:—�`;,^.? . :: .. �.:.:. ..:.: •. : �.��`.'�tII.lL' � �EL,L PERIVI.IT I'I,E.�S� S�+ E AT`�A�]D PLr�lY �'+O][� VVEY,L S� LAYOlfJ'I' Tax Map � Applicant: E, lPnn Subdivision:� Location: ! �� �r�l� Parcel # �_ Toutnship: Lot # Type of Water Supply:i� Tndividual _ Community Public Ytequirements: Site Approved By: � W O���o /p� Grouting Approved By: WellI.og: � Pump Tag: � . Well Tag: ✓ � Air Vent• ,i ` i � � Hose Bib: / � Caeing Heigh� / ' Concrete Slab: �� c.,,,�,�� c— n��, � Liner: 7nsta1led by: _ Depth set: ` Grouted: Date: Water Sample: Well Driller: ��i �'� � c � Q �� D r i ��t �� Well Approved by: �� ,� o \�E�- ****See Attached Site Sketch**** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: Date: I � � l�7 �o� PCHD rev O1/27104 12/05/2Q07 10:17 3355�77888 FERSON COUNTY ENVIRO P��E --ti.�. �i. l� UU � �� 3 � �-.�... . ..� �. .lr'.�.i�'�.�► tl..�l�l � , � � ,- � ..:: : .��� ..T..:�'�"�;�:' c� � ���, � �� ir �►- . �1. ���.��.���,.��.¢.W.�:: �,�►�,n� f� � .��� v d' _.e.� ��/�� �ct�t.' �ct�1L'��r Grom�t lLo� ��� �,(�.�,t.� �r � r. � � ,� Tax Iul��,a, Pucel # ,,,�p $u�tdtvisti�rit; .� ,. ,� �# �V�l �,�rnet�on Di�,atarnoe Fmm aearaet Fraperty L'mo {?�iinirnua�i 10 f�t) Di�4tuca frans tia 3yede:n {Miainmrnt 6pi� } Tabtl Do�th: fi Y�rxd: � �'M Stae�tic W Levol: �� R Watar He�rl�ug Zoa�s: Depdz _���' ,�+ g ��` R Cui�� � -�.�-' �,c .-�_ '� C�alvu�ia � 1 � � �. �rr�e:: tn Wes�br, ,�,� Thioic:u+ea: ,�,�,_, Fieig,'ht tbtrva Qrouad: � Y in Drire 3i+oa: .,,� Ya No �ay problema ea�ouater�nd wtn'lo � or�m,�? _..Yea 1�To Tf "y0otn gi�►o 10�acm; —"' C�r+aet: Nese� S�ud�Cet�nt � C�acs�e Gftuve2�Can�ont Anmui,ar Spa�x Rr'idth..� �,cho� Wa.�r � Mnuiar Spaca Yea � M�d af C�rou�t: � Fm�ur� �Pour�d Daptb�_ to �_ Ft. 1kL►t+r�0o U�ad: No. Bags Pataarxd ca�oa�ti____�, Wei t ot 1�sg ,�_ �'ouadY � If n�e {as�d, �ra�oi� cu��8�) — R4tio � ID pie�bc�: �''�'es � No 4 �c 4 atab !'` 'et ,�, No [.���: �h� Uite iit�txtled: __________�_ Cs�aut: Im�llad by� �: � I.ot�ttl�n� Drrnr.t�g .., _ -- -- 01 �� I hareby certify that tt�t s6nv�e fn.fon�t4irm ia curr+eet aad thiit thia we11 wns co�latr�0',�d i� a�cacdat��a with te�tione set farti� bY thc Pexevn Cau�ry �ita�.ir}t D�zaart�nt 5�►t+�se ai Co,�tra�dor I � N ���„ D�t� „�z .. d. � Y'mno� Ltet�l�rt P. uss�p Ini�llation Cants�ct�r• State Regiatretion N�bar: „__ Putr�r De�h; ft S`tsGic �'aYer �evet• � Fump l�i�ta Ba Model• P�ttt�p Sixe uid Rating: �hp _ g� I h�reby eettif�► thit tItit� ptaxtp w�as installed an�! tbe e�rell heer,d cont�le�tl ac�cox�ding bu the Pctsnn (:��,ty Wall Rule� in eff�ct an thfe data e�d tbat a oepy of t�ais trcotd hae bet� �o�vid�d t� tho watl ownar. �'n�p Iositalla�r �lgsttt�ra D�4r: i'C�IiD rev O V27IQ4