A32 25AAdditional appliances to be used: Disposal, dishwasher, washing
machine —�� F'
Recommended• Septic tan
Nitrification line:
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspecied and
approved by a member of the District HealYh Department sfaff before
any portion of the installation is covered.
Date Approved: R^�p —
By:
Countersigned
Signed
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
(Over)
NOTE:
Make sketch of installation showing location of house, septic tanks, privies, water supplies on ,�`�
adjacent property, etc. Write in measurements in order that installations may be located later �!�
date. ��b `�`�+,�,,�"
��
,�anllcation Date: � � � �
�mount Paid: ^�
r�@+CElpt r'�'.
�srson Caunhr Heaith �eaartment
Enviro�mentai iieaith Secrion
APPUCATIOPI FOR SEi�VtCES
'�ax �ao �: Tl 32
����� �• 2"� i�
IF THE INFORMATION IN THE APPLlCATION FOR AN IMPROVEMENT PERMIT IS F,4LSIFIED. CNANGED. OR THE SITE IS
AL'TERED. THEAi THE INIPROVE�flEA1T PERMIT AND AUTHORIZATiON TO CONSTRUCT SFIALL BECOME INVALlD.
1) Permit requesbed b:(Ownerlagerrt/prospective owner): ��r`�a- C V 1
Home Phone: — Address: ,�;�,
Business Phone: �
2) Name and address cf currertt owner. �,(,r�, �e i�t.t.��- �""' �
���` ���2 ���`�
3) Property Description: �ot s�ze: �L� �fownsnip: . 'U�' �� •�'v .
Diredions to the property (Induding road names and numbers): �� I/l�(,�. `�. �"�.
4) Proposed Use and Structure Description: answer each of the following questions:
a) Propased ❑, Existing �/
b) Stic1c Buift O�IGfodular �, Single Wide �, Double Wde ❑ �
c) Number of Hedrooms: � d) Number of occvpants or people to be served:
e) Basement Yes �, No t�-Ifyes. # of basement fixtures: '
fl Garbage Disposal: Yes O, No l3�
g) Dimensions of Proposed Structure: Width: Depth:
� Water Supply Type: Private IjY(new � orexisting �Public 0, Cammunity �, Spring ❑
. Are any wells on adjoining property? Yes e�IVo � If yes, tacation
6) Please Indlcate Desired System Type: (systems can be ranked in order of ycur preferenca)
✓Ccrnerrtional _Modifled Conventional ,_, Altemative Innovative
Other (specify):
CL�ARLY STAKE ALL CORNERS AND L1NES OF THE PROPERTY.
ST�KE THE CORNERS OF�ALL PROP05ED STRUCTURES.
PLEASE ATTACH SUR!/EY PLAT OR SITE PLAN TO TNIS APPLICATION
V � WU���-�'(e�)
� ��
I hereby make application to the Person County Heaith Department for a site evaluation for the on-site sewage dispasai system for
the above-described property. 1 agree that the contents of this application are true and represent the maximum facilities to be
placed an the property. I understand if the site is altered ar the irrtended use changes, the permit shall become invalid. I understand
that as applicant, I am respansible for identifying and maridng property lines, comers and making the site accessibie for the
personnel of the Persan Cour�ty Health Departrnent to conduct the9r evaluatians. I understand that i am responsibie for notifying the
Health Department if my property corrtains any wetlands as designated by the Army Corps of Erigineers.
Owner or Legal Representative
Date
PCfiD. rev.10/12/99
�
i
�
a
/S�Po i r re�i�,'t
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMP OVEMENT PERNIIT
Tax Map # � �a Parcel # o� ��
�
Zoning Townslup [� v hac
Owner/Contractor [�e�zl� � l�e� /%c��1l�c Date �%— l Z- 9y
Lo� ion/Address _ z Q; y�i 1?� ' �.� //7/�%s
� N��s� �� ,�� ,��� laws s��� ,�� s.x.#
Subdivision Name Lot#
r.�youc
,
� �s ��3
x
A 1467
as �uea
— �r,� I�N �
- C� e� � .S'v ..,'�Q�� %c
�� ,{ �' Cf�o.�..uz�
I , � v
I _ J�,'ve�s, ��' , c �
�,, a �e� a,.�a y �'�or� -scp�'`" a.c�
'—I U V SL '� �`I I
'� �� � ( N G �U �OLJ.J ,j�dil 7 C�V �T4f)
+� �t�e<�- ti,�-�-�� Awcy �'�'�,�
�P .l-� c a � c:e. .
fo lows s�r� ,��%
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area % /�e, Size of Tank Fx%s %�5�
SFD /�vvsc Mobile Home Size of Pump Tank
Business # of Bedrooms 3 Nitrification Line3GU �,�3� 15",� �s y� ��
��.�,, o/Gi rn,' Max Depth Trenches a�l Jr
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by �
Comments:
Date
Installed by
Approved by
Comments:
Date Installed by Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this pernut The
environmental health specialist is not responsible for false or mis(eading infonnation cocrtained in the application. The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application Neither Person County nor the environmental health speciatist wartants that the septic tank system will
continue to function satisfactorily in the future or that the watet supply will remain potable. c:\amipro�pe�mitsam O 1/95 rev.1.0
ORIGINAL
��
,C ,
No, of persons to be served Bedrooms 1, 2,�4.
Additional appliances . to be used: Disposal, dishwasher, wa�
machine _ .. ' ,
�------� � ..
Recommended• Septic tank I O D � G�'C1� ��
. lt
� ' 18�z� C� .
Nitrification line: -- ----
�,
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspected and
appzoved bp a member of the Disiric! Healih Deparfineat sfa.ff before
any portion of the installation is covered.
Date Approved: R�3 � 1�p .
Signe�
Sanitarian .
By' '
• O. David Garvin, M.D., M.P.H.
District Health Officer
' Countersigned
(Over)
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P �SOiV COl9 EdVVIRf.�NMEiVTAL HE�L�H
PLEASE SE� 'r'��ACHE� P�►IV FOR SOIL AREA AND SYSTE�fl LAYOUT
` Tax Map #: � a Parcel # c�5 � Township PIN '
E►pPi[cart� if JPl � , � � S� �Q �G �D � ^n Phaselsectlon / i c Lot� �r O� /�i ,
Locanon: �� ! � T �c� � � - '�c�l % /s � � �O c �
Imarovement Permit
New Addition Type of SUucture �� ��� � �'1 D �cB�-� Water Supply
# of OccupaMs �# of Bedrooms � Other � System Type
Projected Daily Flow: �� g.p.d. Pe!�j�it Valid For. 've Ye No Expiration
Proposed WastewaterSystem: `J�i�,l/o�7 ('�rr vP n�o�_�
Proposed Repair. � a '
Pertnit Conditions: O vJ
G �/?.
�_
Owner or Legal Represerrtative Signature: Date:
Authorized State Agent: / Date: � t�
The issuance of this permit by th ealth Department in no way guaraMees the issuance of other pertnits. The permit hoider is
responsible for checicing with appropriate goveming bodies in meeting their requirements. This site is subject to r+evocation if
the site plan, plat, or the intended use changes. The Improvemerrt Permit shall 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 Treatme� and
Disposal Systems of the North Carolina Administrative Code.
Wastewater System Description: C�� l)� Wastewater Flow: c3 � .p.d. Type:
Facility Description: �f�—"' New O Repair Expansion ❑
Basement4 0 Yes � o Basement Fixtures? 0 Yes o
Wastewater Svstem Requirements - -
Tankage: Septic Tank size ��"5�`' gal. Pump Tank size � gal. Grease Trap size � gal.
�
Trenches: Total length 0� ft. Trench Width �_ft. Total Area sq. ft.
Max. Trench Depth: � in. Agg gate Depth:� in. Soi! Cover. � in. Trench Separation �' ft. on center
Permit Expiration Date: � r �
Authorized State Agent Date: 6
*See attached site plan and ddendum pages for additional permit conditions.
The 4ype of system permitted ❑ does ❑ does not differ from the type spec�fied on the application. 1 accept the
specifications of this permit.
OwneNLegal Represerrtative Signature: Date:
Ooeration Perrnit
System Type (n accordance with Table Va)
This system has been installed in compliartce with applicable Norttt Carolina General Sta�Oes, Laws and Rules for Sewage Treatrnent
and Disposal, and all conditions of ihe Improvemerrt Permit and Construction Autl�o�¢ation. Issuance of this pertnit implies no
guararrtee that the sysbem installed wip functlon prope�ly for �y given period of time.
Authorized State AgeM Date
PCHD, rev. 03/07/01
. . . .------.. . . __._.,_.__ __._.._._..... .. _. _.. .
Psr�son ��unt�/ Meaith. i�epacdnent .
� Ernvironmentai Heaith 3ection T� Map *:
� � P�ccai #: a s,�
� Si�'� S�4E'd'C8� ... �_.
_ ... . .__ �'1
. . - .. -- - _ c� cCuf lo �
. _ , . AppUcarrt's Name � - � Su ivision/Sec�on/Lat# .
' `� /O � . .
. Authorized State Agerit Date � '
►Sy� ���' MP�� aPPrau�e ca�t°rrrs only. Tlu co�dactar mr�s,tllag tha sy�e.
pr�or io be� dia i��a�nn to inture tbat proper �rade is ntatataiaed
scaie:
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g��`c.� P IUs f-; �,,, �ac �-�� I�`�ren��
W►fh r�faV��� ��s-{��I� an��� u�rc�5
,
cove,�irnd{-f� ��oPe.'' � � �"- +°P s°� 1 .�o
Person County Health Department
�Environmental Health Section /�
Tax Map #: � � Parcel #: ��J� �7'
Zoning: Township: '
Subdivision: Section: Lot:
Applicant• ! � l GC
Locatton:. ( 7 � � �Gt � /�. ^� � I 5?� �r��� �'to c�.4�_
O vl r� �
O eration Permit U
System Type (in Accordance With Table Va): ���\
THIS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLlCABLE NORTH
CAROUNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS F THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION. _
� � ���� 1
Authorized State Agent Date
� sT (Ex�,����)
�S
t s� �y �� ^�--.
r
�----G�� 6��a�� n
`�' �� �
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Tax Map #: Parcel #•
PCHD, rev. 10/12/99