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A32 235�:ooiic�tion Date: - �OD� Amou�rt Paid• 6 . Rec�;ot #- �� '`._���_S� 1�- I�IE�.� �� -= � � � ��-�� ����_ _..�... e�.� ����. �d �oo 3 �,�6'b� � - �T�,+� �- A� 3 �� � �: '-� 3 APPIlCAT10N FOR SEiZVIC�S � • .1) � Permit requested by: (Owner/agentlprospeciive owner): eS � Rerc�- ��� Home Phone: 91'�t ,�11$. Si{ b_ Address: Q Q l�� Business Phane: ��4.�3 _��4D4 a o a`� � Z 2} 3j Name and address of curnerrt owne�� ����� . . D . o� t454 � �����oap�r�c.a�3�z Property Descripiion: Lot size: �� Township: gµ �,� Directions to the property (induding raad names and numbers): Ced� �� Subdivision: Lot# 4) Proposed Use�d Structure Description: answer eactt of the following questions: a) Proposeii Existing Type of Sttvcture:l��� Width: � Depth: b) Number of Bedrooms: Z�a- Number of accupants or peopie to be served: � c) . Basement: Yes . No _�il there be ptumbing in the basement?,�_ d) �arbage DisQosai: Yes . No ✓� — Z i�w�J �P� . �F �9. 5) Water Supply Type: Private ✓(new ✓ or existing�. Pubiic . Community_, Spring _ Are any welis on adjoining properiy? Yes_, No _ tF yes, please indicate approximate locatiori on the 'site ptan. . 6) Does your property carrtain previousfy identFfied jurisd➢ctional wetlands? Yes_ No P�EASE NOTE THE FaLLOWING: ➢ A PLAT OF THE PROPEiZTY OR SiTE PLAN MUST BE SUBMITfE� WITH THIS APPLICATiaN. ➢ PROPEi2TY LINES AND CORNERS MUST BE CLEARLY MARKEDa •, ➢ THE PROPOSED LOCATIOM OF ALL STRUCTURES MUST BE ST�D OR FIAGG�. ➢ THE SITE MUST BE READILY ACCESSIBLE FaR AN EVALUATION BY THE HEALTH DEPARTME31lT STAFF. � i hereby make application to the Person Caunty Health Department for a site evaluation for the on-site sewage disposai system for the above-described property. I agree that the contents af this application are true and represenf the maximum facitfies to be piac�l on the property. I understand ifi the siie is altered or the intended use c�anges, the pennii siiall bes�me irnalid. /1 �`1• 3,p04� Legai Representative PCN�, tev. U61Z7102 ��� i 1�� �li.lJ�� �� �' � � ���� 1���.a-��.,•-�„ ����.7L IF��.�.]L�]� r��,X r.i.��E, - P����Pi ;- _ _ s��� t��i �� ����� o �, Pi,���•tie SecGioi� L�t u Applicant: �i-�s � �� Location: �5b� s� 1s�s ��� l.Jc4��� C'� C.� � � �-�►- �•-• (� ,us�- c��c, ���-u. �3- �1�1� Improvement Permit Permit Valid for �Five Years _ No Eapiration Type of Facility: �'�,Gl� �,,,;�" �Q.A•,R_ __ New x Addition Water Supply ►���- # of Occupants �t �# of B ooms �_ Projected Daily Flow � c� g.p.d. � � Proposed Wastewater System: (°,er,�,,N.,..,G9 � . Type: �TQ, Proposed Repair: �o$.•�-�.51 Type: ��.. '"o.. . Permit Conditions: Owner or Legal Represe Authorized State Agent: Date: � �O�i-�Q-� Date• �� r2-r�c� The issuance of this permit by the Health Department in does not guardntee the issuance of other pemuts. It is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met This Improvement Permit is subject to revocahon i# 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 ,�or Sewage Treatment and Drsposal Svstems' (15A NCAC 18A .1900). Neither Person Connty nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that. the water supply w�l remain potable. Authorization to Construct Wastewater System �Required for Building Permit) * See site plan and addi#onal attachments (�. Proposed Wastewater System:S„���p,J,--,v..� Type d,le� Wastewater Flow 2�f o g.p.d. New ✓ Repair Expansion Soil LTAR: ,�7S g.p.d./ ft 2 Type of Facility: �,�,-�s� �c.,..,\�_� � ��09,.,, Basement �es �No Wastewater System Requirements Size: Septic Tank: Ic��� gal Pnmp Tank: -' gal , Grease Trap: --� gal field: Tota1 Area: �''73 sq ft Total Length �_ ft Ma�mum Trench Depth �_`�iri� eh Width �_ ft Minimum Soil Cover: �_ in Minimum Trench Separation: Q ft � Distn�bution Box Specifications: Authorized State Agent: ,,�, � Permit Expiration Date: Serial Distn�bution �� Pressure Manifold S Date: "� -� 1 a-c�-( The type of system permitted is � Conventio Innovative Alternative. I accept e specifications of the permit.� Owner/Legal Representa�ve: Date: � � 7/ 0/2002 �ry���� _ ���� `�.A.� V . . , . , � �� V.JI� �� ' �`atf.'m'ismo+�++*�*o7n��1n.� ��m�.r�n . • i . . . � �ITE S�E'I'C,,.� . � 3.� � . �� I�tame J�� , �lu,,,�s . •Tax Map # �3a Pazcel # � : , : � Sub 'viei � � Secdon/Lot# . G '7-r 3-t��� � "p.� � Auth rize tate Ag�nt � Date � �' • Syst�m corttportenta stsprnaeat a�iproaoitnate contourr on�jr. The cohtractor muat, fla� the {yat�� prlor to � � � begi�zni�ag t�iQ ittstallation ib lHaur�e tluttpt�vjiergra�de ls maintaissed . . ., . � . . . . ' �r' ' ' . . . , , ., . • � �.� _ � . . ' �, `� - . . . � � � . � � . ; . � . . , . .. � . � , � . � . � ' . � ,�°� .' , i-�--�_ , � . • . , ,�' . •�, • ' 1 , _ _ .. � ' • . � , = � , � — � cs . � , � � . � �., .. ! � , G • G �' . .� � , . � � . es ;a8 c. ► " � �` � 3 - . .� ' � � � . � � 3 f � � � � .. �, �� . � • . . �1' ' f,, . c zra �. 3� � �� . • , . • � • �. J `.-"���_'_ . ' . � � � ' f i ' . � V � . . � . _.. (� � pG 1! � .... )" . `� � � . 1 � � � � : ' � � , • `'�' �� ' r • , • � � �, P . , ��� _ . � � �" ��'-.� . '� • • � �� �� ` �`�"� � . . ' ' � � � � n o� ps � , � — � o �- � .� � . � � : s � s- � � t " � � � � � . . � . � � .. . � � . . � . � ' . .�.�'" 1 .. �� .. . : �. �.....�. �. .. �.� . . , � .�.. . . � . . . . .. c�:;�: � . . � � �r' � . � � � � � .. . . � �-� . � � . . � � . . �. � . .� � � ', . � � . - , � ��� . : � : ' : � . � , : . �. • 6 � � . , • • • . 7 l� ' . : . .�.. • ' ' ' . .• ' � � '� . . ��'} �, . : . . . . . . . . • . . . � : • . � G . . . • t� . � •. ., . .. .. • • ; : ' . .'. ,. • . ��-�-�� . , • : . ` ' , ' ' • . . u • • . . ' : �,���, % ' � • . � �. : • ' . • ' • . . . ' .. � . . . .n� . � f , , , . . .. . �1�ti ,', S,� ���� �� �..-.. : � � � � � � 11 I��rn�v-n�r-��n.irirn��rntE�,ll ���.�n.11�Il-n Applicani Location: � � � v � Tax M�p � F�rcel # - Suhciivision Ph�se, Section. Lot # # of B�drooms Operation Perm it � System Type (In Accordance With Table Va): THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND COIVSTRUCTION AUTHORIZATION. � Installed By: ► �i�i���'11�� . �� -' : - I . - � � � ,'� � - -- Nou.Se /�- /�- .� ./�- ./�- � �-- , -t� c�e. e L; n e. PCHD, rev. 07/29/04 0 S��L I J'�tl� S���G��IV i�i'7�Ln1.��7� ��� 1� �� Tax Map # �� Parc�! # JJ Systern Type (Table Va) .� � , OwmedA�Qiicarrt �a.rnes FloUi�S Subdivision AddresslLocation ��j�n I n��,k �-c�o� (',(� R�P . SecfPt�ase Lot # � � � St�te ID/date �°" ��- Capa ' Tee and Fiiter Baflie � • Sealarrt � Riser �f a licable Tank Outlet: Seai Pemtanent Marker � - - Pump Tank /Sealarrt � Riser Water �ecic Vatve/Gaie Valve . ; - � . � tt-si on o e . . .� �oats/Swiict�es �: . � � . . Alarm fvisable and audible) Rate (gpm} Approved Pump Model Block Under Pump Pump Removal RopelChain Distribution System s� pQ ressure an _ Low Pressure Pipe • Appr. Pipe Material and Grade Trenc� Width Trenct�. De�th 0`�.� �� ��� � Trench Grade Trenct� S aai� Rodc De and �ual' � � DamslSte owns etc. � Pressure Laterals � Hole S�aang � o e .. . . . ' Pipe Sieeve . � � - � � Tum-u siProtectors � �Required Se�ac�cs � From Wetis •. � � � Fmm Property lines � � _ : Struc�ut'es/8asemerrts.:: � .� � �t es � raina � e� a s� . . . _ : . . Surface` Waters � - � - � � Public Water Su Ges �/61t1Cd� CUtS �>2 �. . Water Llrtes Vehide Traific Easeme�rts/Right af 1N� � Other. Easemerrts Recarded . pe r r� Tri-Parta;te Aareemerrt 0 pcf�d rev. 31'13101 � 5as �x�,.��. ���,Sf ���:�'�� ��,,,� �. �. `_'- cC � �TT1���Y ��.�a�-��:,..,,.,, ����.a ���.��.� WELL PERMIT PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT as� . Tax Map p3a Parcel #� Township: �U���� �� ►� Applicant: ��Qs G Gw�s Subdivision: Lot # Location: �� S� 157 ��(�� r,r, ►��„-A- �� C� Cz� -� � o} w, � �- aFa-v �•o�-s� l� y�i Type of Water Supply: Requirements: ✓Individual _ Community Public �, Site Approved By: CS � � ►�- �5 Grouting Approved By: �w.,,��� �� CS i- i o-�r Well Log: � 1-1a-�� Pump Tag: 1-�e,o,,..�� `���� Well Tag: �/CS \ -2'�-o-S Air Vent: �/ CS 1- 2"�-o�S Hose Bib: ✓ ' CasingHeight: ,/ CS 1-�►�o-os Concrete Slab: ✓ �' S Well Driller: Liner: Installed by: Depth set: _ Grouted: Date: Water Sample: Well Approved ****See AttacL__ ____ _______ 1�ate: / - Z 7�a� �uw� ; ns�r�e Z 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: ��1 I .�� �� S � �-c1�. �� PCHD rev O1/27/04 L FROM : ACME WELL CO., INC. PHONE ND. : 5449417 Jan. 12 2005 11:43AM P02 •s�fnp 0£ ulR�lM `1ZZ£-ECL {GtG)'oH anoqd 9E9[-GG9LZ 1QOZ/G0 'A�'il f'M�J ua� �3, aa an� unar �f�� L� aa�x a uo s n 5q3 a� ir.0 a.ca a� >>>m n � ' a�l �y�latuu -�oana� aaEn�a5 qssW 9C9[ ` # S 3 p `.7 ` I'� A1 d i f!Q ! 1 � q S �1.dQ '7"��M 9H,T. �JNf.I.�f1�1.LSAIO� l�OS218d :IO S21Ci1.b'H�1S �'-� � �_,. . � � / ��.�. ��.. 2I3h1M0 '173M r�l•1.L OI. d34IA0�ld Hr78FI 53N �� �t ��ianii.i srto� s�M 7���M �,�i iwxz x,ii��� ������H oo i 'T7�M �Z �`d�N VS l Ii.LIM fl�NVd?IO�� �S�i�I��2t '9[ -�—�---.�3 ---�----oy uso�� �— �----���� ---�--�--oy---�--�"_tuo�� � ��i�a�eyv ar.ig ysdaa �}IaWd '7�AV21'J!aldVS ----�"_' •us �'""'_ .u►"""'�'a:I o.I. uina3 _....�.._. �ui — �u� - --.�,� - --o,L �uoa� `� ju»a�t+y� azi51o15 �al3uiaiQ q�dad ;1�I��2I�5 �'_-".�'" yr��o.,,L,aon.t 'f;i a,L�"�toi3 � �� ��5•�3 �1..,�p� -�-"'Luo�,� poy�ay,l ���aaluy� 4�QaQ . �,Lf1021�J �.� --„ .�� o�-�'�wo�� Sl 'bl 't 1 ^-�"- '�"_"'�d � 1, cuo��. �/-�-�- �-''» �°.L �-�-mo�3 ,t»w �eixattiy�, '�AR�l9�/ r .aH► s° .�a aw�ti� �daQ peol aq� apn�aul •sptiog F�uno� ao &p�o� naeaS on�t � ssau�asq3.11EM �;7u1SV� 'ZI unoiu� ""'"����,t. �I�IOI.L��:iN1S1❑ '1 i ys�al �n uio{� sa�}eu u� aauv�s�p puu uo��aaaip Mo��s �.�� �3`�i�SS'i � z �r ��-�- ,, Z � x. :{t��dap) S�NO2 b�.LdM '0! r 3.s�.L 30 aOH.L�W ��•(�aa) a�a►� �, • 'Fira•'�z ��'�N vsl li�ts e�unp�osaa u� ��uol.cne a•sa�jnbaa a�r�m� puct eto�a4 aops pa�nu�wxe� Eu�cr�}o do�,. ,,,, ��aa,�m�.pua� onoqW :,�- ,'� Sl �NtSd� :�0 dO.L '8 (�a,ca�,�o aol eno9v J1 „k., ��n) �s3 � � :9u�sv�3o day �,olaa ��ng� ��ibM �13.d�.S 'L ,�j o2�1 C� Sr�.0 L'I'�8A'l �JUI.L51X:3 ��'d'7d�2f '1'I�M S�OQ '9 �, --- ---�,��� --��--��+:Hsa�a �d.�oi •s ,. � .- c��z���a �a.�a •v _ aaqwnu auoqd -�po� say �...�,� �'� , ; po� d17. � .�m5 � uMoa.a0;c1� � uot�du�soQ uo�1' ,-_u �o� o,� wora I 0 i�`'� � � .(�o�y stnoy �o7aa,15) (xoa �a�y5) ss�zppW da�u �IydoaRodo,�,pSdJC]:•'a�nos apnai3uol/apnt!1c� � . 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