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A32 31Amn.,unt paid • Receipt /� . � N O � c� �o°g a�� g3l `� � G � X �% 3-t�-9� Date Improvements Pecmit.(EstablishedJRecorded Lot) I,_ Reinspection of Existing System (Loan Closing) ImpFovements Permit (Unrecorded Lot) lmprovements Permit (Mobile Home Replace) Improvements Permit (Addition) Rcpair/Replace existing Septic System _ Permit for New Well _ Replace Existing Well '" Permit requested by: wner/prospective owne ,ddress: •% -�/.,f _ �'� a w U Home Phone #: s�G �-/' 70 ��' � Business Phone �:�,?G v-.���/ 7. Dimensions or Proposed Structure: \Nidth: 1 �i X 7 � Depth: � 8. What type (if any, additions, expansions, or replacerrient is anticipated to the structure or facili[y ttiat this sewage disposai system is intended to serve? .�/6lvV Name and address of cucrent owner: 9. Water sup y t}'pe: _ s� private ' public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes �No [�. �j� If so, identify location: . Property Description: Lot size: � or�re s . Tax Map#: - Parcel#: � Tawnship: �s�,� � ��' , . Directions to property: State Road #& Road iames��tc. _ . I�Iumber of occupancs or people to be secved: �� I� Ty.pe of structurelfacility: Proposed: L(Existing: Q Type of dweiling: ,�� House: � Mobile Home: L�3usiness: ❑ Type of business: Numbec of Employees:�2 _ Number of bedrooms: � 2— P/tr No�i (3ra�� �`rr Garbage Disposal? Yes ❑ N 4�" 'i-5'99 Basement? Yes C� No f so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PeI'SOn COUIIty ��ealth Department for a site evaluation for the on-site sewage disposal system for the above described property. I agree that tt�e contents of this application are true and represent the maximum facilities to be placed on the property. I understand iE the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be issued, I mvst present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the propeny to the Heatth Dept. within 60 DAYS after the date of tt�e evaluation of the site by the Health Dept., this applica[ion shall become void and all fees paid forfeited. z Signcc� Owner or Auttiorized Agent ..r � a w � a � B 2854 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # A 3a Parcel # 3� Zoning Township '�.{.54,y (=c��" K Owner/Contractor N�,► � (=1ovd 6rr�d�5her Date `�-l�-`�9 Location/Address TaKc. Nu�dlc nn�11� Flw� � on Cb�ar��� MonIC (Zd Turn (� a-� Bra�Si�c� i3r05� i'�a� �cr on R S.R.#�//[n Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATIONS � Repair Lot Area �7'�, a/{c. F �m Size of Tank /�� (�,a /�on SFD Mobile Home�_ Size of Pump Tank - Business # of Bedrooms�_ Nitrification Line �(07' �.�' Max Depth Trenches o?y " Permits may be voided if site is altered or intende use changed. Well and Septic Layout by? ►� ' D Tgnao �� COmmentS:�Meet EN5 nn 5i e F�nr L-ct�0�.c� Dr�O� -f,o i�►Stall��tionylF (�nntr�s;���- nl_e,.v �_� _/'__�., _..a ..,..,,v_ ��.r-. n.....:-��. FIn�.���,.�1rtn�nnL,(� Fmn,-f-nnK•Fn N-F�'el�l Date I2 I��� Installed by Approved by. Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS �X i i N Individual Semi-Public Required Slab Public Replacement Air Vent Site Approved ! Required Well Log Well Head Approved Well Tag Grouting Approved Comments: Date Installed by Approved by. necds -E� , see C. A � For ccrdrtitns oF permi't. This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. Tbe environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic tank system will continue to functio� satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l Application Date: �� `� � �6 Amount Paid: �� 6� . Receipt #� �— Person Countv Heaith Department Environmental Health Section APPLICATION FOR SERVICES Tax Map #: � 3 � Parcel #: 3 � IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED, CHANGED, OR THE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID 1) Permit requested b:(Owner/agent/prospective owner): :J /l�il�"� ��'ods.lrr Home Phone: � 7�1�Y Address: --�o. J� (�� Business Phone: . ���,�/.�/ , , r �� s ,v, �, �>�y/ 2) Name and address of current owner: ,✓, ��j'�„�i� .,f�,.�,/•� � e.✓ fi /�/.� � /i'J�//s .t/, C .,77,f'�/� r 3) Property Description: �ot s�ze: Directions to the prope Township: �����/ 4) Proposed Use a Structure Description: answer each of the following questions: a) Proposed , xisting ❑ b) Stick Built o, Modular �, Single Wide �, Double Wide ❑ S� p �_� c) Number of Bedrooms:�v d) Number of occupants or people to be senred: e) Basement: Yes 0, No • f yes, # of basement fixtures: � Garbage Disposal: Yes �, No ❑ g) Dimensions of Proposed Structure: Width: � Depth: � C 5) Water Supply Type: Private �new 0 or existing 0), Public �, Comnaunity 0, Spring � Are any wells on adjoining property? Yes i�No � If yes, location 6) Plea�e Indicate Desired System Type: (systems can be ranked In order of your preference) �� ventional _Niodified Conventional _ Alternative _Innovative Other (specify): CLEARLY STAKE ALL CORidERS AND LItdE5 OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION I hereby make application to the Person County Heaith Depa�tment for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. 1 understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the Health Department if my property contains any wetlands as designated by the Army Corps of Engineers. ,�/= , �/� � �l/��^-� - - ?evz' Owner or Legal Representative Date PCHD, rev. 10/12/99 � �" " PE#�SON COUNTY E�iVIRONME�YTAL F�EAL-TH � � - PLF.�►SE SEE ATTACHEi3 PLAN FOR SOIL AREA AND S'YSTE�UI LAYOUT Tax lAap #: fT �� Parcrl i � f . Zoning TawnatJp � r� � . wl► { I S~ . �i -i n � .. APP�kanC � TM � 12�d 5 �.e r �e�: _-- �a✓�c e I/i�l a h • I � Subdivlaion: S�dlon: LoG � Improveme�t Permit . ✓A buildina aermit cannot be issued with oniv an Imorovement Permit New Repair Adc�ition Type of Struc�ue S'hess Water Supply e-k��; rer we �1 # of Ocraipants #•of Bedrooms Other S��1c,,�e�s Basement'T BasemeM Faicues? Projeded Daily Flow: ��.p.d. Pennit Vatid Fcc: �Five Years ❑ No Expiration Proposed Wastewatet SystemType: Cor�V��1an�; / Pump Required?' Yes �( � No Proposed Repat�: hova�— C�in�2r I Pecmit Condi#ions: �C�Pn Sus r�• /s � �r� h�ae o� �c� , _� � w �{`�a� w1K Owner o� Legal Represetrtative Authorized State Agerrt: r� a�� . �c.� Date: Date• % - / D � 0 � The issuance cf this permit by the Heattf� Departrn`�e.nt in no way guarantees the issuance of other p�rmits. The pem�it holder is responsible for d�edsing with appropriate goveming bodIes in mee�ng theu� requirements. This site is subJect to revocation if the slte plan, piat, or the icttended use changes. The Improvement PeRnit shall �ot be atfected by a change in ownership of the sifie. This pertnit is subjec! to camplianc8 with the provisions of the Laws and Ruies foc Sewage 7reatrnent and Disposat Systems of the North Carolina Administrative Code. Authorization To Construct Wastewater Svstem (ReQuired for Building Permitl Type oi Wastewater System _Cd r�VP.s,,7�"1v-n.%.� Wastewater Flow: /d S a.p.d. Fac�ity Type: S��M ��4�e �hS�K� 5g New�( RepaicOExpansion 0 Basement? 0 Yes �No 8asement Fixtiu�es? 0 Y�No Wastewatec Svstem Reauirements ' - � ' Septic Tank Size: 6 O ga�ilons Pump Tank Size: `-- gap�s Total Trench Length: �� ieet Maximum Trench Depth: �,� inches A99�9at� Depth:� in. /h�hirnurn � �m Soil Cover. � ind�es Trench Separation: �, Feet on Center f Other. ,� Gri r rlhA� ,�'0 /� C�✓Zr �t rlZ'� 0✓Q�' � 1!►'� S2p / t G -� �q� �`' Pertnit Expiratton Date: — � — � � Authorized State Age� Clata• '%�� � d� . The type of system pertnitted 0 daes 0 does not. differ from the type specified on the apptication. ( acr.spt tl�e speciftcations of thls permit OwnedLegal RepresetttaBve Signature: p�• PCHD, rev.11/18/99 . . . _---.. _.. _ .__...--�----.._.__ .._ ... --- � - s ��8P:3i9i9 �i�idtl�lf �':���. �6Q11'�i176� ' . � �r�nmera�al Heslth Seciior� � � Si'�'� S14E�C� � "..._ .._��� ._.�-��S�r � Tax� �Aap �: � 3 2- �1 Psresl #: � � . Appitc�nt's Nerne S�dhrisioNSec�ion/Lat# � . A�ttotiZed State Agent �a� � � . ,iy� co�p poxe� repr.esprt opprauri�mte c��totes oirly. Tdts caatr�actor mrmt, fJoa tha sy.�a,t - • pr�or to l��g tbs in�alladnn to u�e � P� R� is � . ; �N�F��.LI� i'��I� k �� � �X i srl t� b- s N-o P P�i�v�F �� o,�* s�: — � e�l �'��P �<<d; � b �r a � � �hve�{'w �P �2 S,�S u t� yv��Jc � Q,� 9� ��.� j2' t de � " ,. P = — �� � — sK �JY. �eP0.j 1 � � — - - — � Person County Health Department 2 Environmental Health Section Tax Map #: � ✓� Parcel #: .�% Zoning: Subdivision: Township: gl�l.�U r� Section: Lot: Applicant: ��%GI ,��,e�Y Location: � ��- �l �e ��v� �rad�i� o , v�u.cl�x vi� r�t� , Operation Permit 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 CONSTRUCTION AUTHORIZATION. c�l V1GJ�Y �. �o�21L��I I �—I �—�� �Authorized State Agent - Date �►s � p� �n, C� �c�� Z Se�Y�Zt� ,� � dcec� s Ct� Z�� �o v� � � VIiIOVe ��� ��e, � � � � .� s 1`° �_� '�i �t�.ve� �- p-�x �0-�9-�99 �rs �000 57�--1� � f� /.7��' Tax Map #: � �� Parcel #: �� yVI,D�JI ( � s � PCHD, rev. 10/12/99 Person County Health Department Environmental Health Secti n Zoning: Township: �15�� ��'� Subdivision: Section: Lot: Applicant: / V � Location: �G Operation Permit 1. LOCATION AND SEPARATION DISTANCES A) System meets .1950 setback requireme ts�;�_ B) Distance from system to any wells C) Distance from septic tank to foundation D) Distance from system to property lines �/D� 2. SEPTIC TANK A) Visually inspect the exterior walls and top of the tank _l� B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent, bottom, and water tight outlet ✓� C) Date of tank manufac re - D) Tank serial number — — Z E) Liquid capacity of tank 1 a Q11� D gallons 3. SUPPLY LINE TO T ENCHES A) Grade 1/8 inch per foot minimum B) Material suppl line � constructed from � V�i C) Diameter l� D) Length / �' �_� x E) Distance from tank to drainfield/distribution device i %D 4. DISTRIBUTION D VIC� (S) � A) Type � B) Is Device water tight C) Distance from the distribution device(s) to the trenches �� D) Is the device on a level foundation �,�_ E) Does the device perform according to its d�si�n s ecif��' at�ons _,�� F) Record the inlet and outlet elevations ,��9 �@ 9�'� 5. NITRIFICATION FIELD A) Trench depth o�'� inches B) Trench width �inches C) Distance between trenches 7�� D) Number of trenches Z E) Length(s) of trenches�0� � l� � F) Aggregate depth � inches G) Aggregate material and size �. _ H) Record septic tank utlet ele tion �� ��_. .,.^f�v1�1 ��C� CE$ '.'J I) Trench grade (< 1/4" per 10') 1�Z�Y V!/l� l�[� J) Step downs . Minimum of 2' of undisturbed earth � �b. Proper rise over step down c. Solid pipe used . Elevations of step downs (Record elevations and show on as built) See "as built" plan on attached sheet. PCHD, rev. 10/12/99