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A33 61-. �f: .:._�. _._�.. � Q7 N v � � O � � � m � � � R Q a � � � v1o`-'.� rr � •— �— �. _ ... . . i � ' . ; � `�G N � � � - Person County Hea1#� Qepartr�nent + � o . Se�+i►age Sy�stem lmprovem�nts Perrn�t W � ' Datc: ' g � '� Pernut Void After Years Permit # �' � �a � � �, : �Owper: ' . . SR# _��� 0 0 �1 I.4Gat�0I�/DICe�:tiOIIS: � ,- , . m • • • - - , . �. , .. ro . u • • , : ._.:_ � ��on ame. . ------... . - -�- - -- - -. 3.�t # _ _ _ � t.flf 1ze: -- �--�� ,- -�'ype of I3��ellin¢:�. _-- ...- --...... . 1 m � W�` Su l. priv te• Q� �, `� PP Y'- � Public; __ Community: � 8 ms:_,.� ��� Garba e Disposai .. � � BasPraent Basement Fix � � ' INFQ$MATION CER'T1FI�D BY NF - �nvironmentaI Health 5pecialist: or : ItBPAIR•_.� , REfiV A � . � : Sizd of Sepdc Tank: _ -- gaUons �ize of Pump Tank; �...� � Nisrifcadon iine: t • / . Depth of Srnne: 12 inches Max Depth af Trenches:.`. � - . Aiternati�e Systctt�: Conv. Yump LPP Pump - : Remarks; ' _ _.., ` _ .— ___. _ . ., �,' -- — f-- — — -- .—. .—. ...._ �. _ — — • Date Well Approvcd: °Well �tto�ld be 100 ft fmm any sewer system BY ' Environmental Health Specialist ° Date .° �/���'�mve�1� ,. /..2 _ ;� G} � �o � ..,_ �nvunnrnental Health Specialist � � Contrnctor. T�CATE 4F COMPLETiON o r t. � � i< ---.-.---_.,, _ _ _T.,.,.,, _ _.._, __,_,., _ _ _ _�__ � Sowage Syst�m location, ir�stalladon, and protection must meet state and local � reguladons. Scptic tank ahould be pumped out cvery 3 to 5 years and shall be mnintained by .owner in such m�u►er as nUt to creatc a public�health hazard 5eptic tank suid riitrifcation line musc be inspected and approveci by a m+anber of the person County Health pepaztment before any purtion nf ihe installatinn is covered and,ppf irtto use. Tf � Ihe site plans or int�nderl use change this perndt is sub,ject tn revocation ► (G.S.130 A-335F) Location of sewage dispo'sal sewage system sketched on bacic. ' (OVER) Applic� on Date: �� b— �� A�,aurit�aid: �0. �eipt #: _�� Person Countv Health Department Environmental Health Section APPLICATION FOR SERVICES Tax Maa #: �T3�'��b( Parcel #• 1) Pertnit requested by: (Owner/agent/prospective owner): �J� ,�% <• � Home Phone: s�17�`} S�/9 Address: 2 — •as Business Phone:�S�.,�� �' r . C ' / � �- 2) Name and address of current owner: b c✓ L► . o� �s / 2 � us d1 G il. C. Y�' 3) Property Description: Lot size: .!3 Township: �CaM AA -��-+�'� Directions to the proper�(InGudi g road names and nu lfers): c�r : l� �o � �'� e � 3 � �- � � rs �. S , . . �l d► 4) Proposed Use a�d Structure Description: answer each of the following questions: a) Proposed L�Existing ❑ , b) Stick Built e,'Modulaj';6, Single Wi e �, Double Wide ❑ c) Number of Bedroor�`is: % d) Number of occupants or people to be served: _ e) Basement: Yes 0, �la�s, # of basement fixtures: fl Garbage Disposal: Yes 0, No f� �1 � g) Dimensions of Proposed Structure: Wdth�Uf�Depth:�L Ff C �r�l1r� 0.�1.,> 0 5) Water Supply Type: Private �(new ❑ or existing �Public �, Community 0, Spring 0 Are any wells on adjoining property? Yes � No 0 If yes, location 6) Please Indicate Desired System Type: (systems can be ranked in order of your preference) �Conventional _Modi�ed Conventional _ Alternative _Innovative Other (specify): CLEARLY STAKE ALL CORNERS AND LINES 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 Health Department for a site evaluation for the on-site sewage disposal system for the above-described properly. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I 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 person I of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the Heal e e if m property ntains any wetlands as designated by the Army Corps of Engineers. 7-��- Q� Owne� r gal Representative Date PCHD, rev. 10/12/99 5 . ' �?� ��ri� _ _' ' � ..�i�,4;;::;:. "_ w� -;,•��= � . '_i =::-� .__ , . E'erson County Health Oepartment �xistinq Sewage System Report For: Hobile Home Replacement �/ Addition Requestee: 1'Y��%{�� <J � v���`7 _ Home Phone# 7- �{ 9 �07 �� %�f . Businessx ���� � � V� �7�� Tax HaP * �� ��.-=�-.�� Location��irections: �/�/U�� ��� � �lL �C�7�iS �,f.� - - _ ✓ , Oriqinal Permit Lacated Septic System Designed �'or:. _ _ ftesidential ✓ Business Other {specify) � t3edrooms � # Employees Other llate Installed 1 � ��, � Water supply c %/UI�VI � V� V1�JD{� Type or 5ystem Hitrificatian Line ���� x '>> Tank 5ize Certified Operat r Required �r�" On site wastewater disposal system sliowes nc visually apQarent malfunction on �! 22 —�� Permission is qranted to: ���a� According to the attached site plan. Environmental Health g �� 1 � �`��D �� DATE 0 May 26 11 12:03p Robert Jones 9194791010 p.3 w►r-25-Yvll 08:17A6� FRO�t- �; T-120 P.00',/00�3 F-T66 Applicatian Daic: �,��_") � � � ' '1'ax Map: Amouux Paid: (5'.qQ PazceF #: _� R�eceipt#: 3 7 Z � ' � �..��--,� ��- ����.�:,���� : __--~ , � � ��_�����- �: 1C..�".rxa�raa-cv aa �---- Ks.�a �:m 7l 1E -'. IC 8.aa.11 a i7la I � '' licatiau far$etvices 5e` nc S<ti ms and'IVelts ; �PF ( � ' y ) Gr Improvemtnt Pcrmis (Site 7 �zaaaa�oo.00 c�> � 0 Mobilo Home Iicplacement _ siso.4a ��S�s� V�� �q, D We11 Permit (NewlAentg�e;� ❑ Cdnstructi i i� Authariz. �tion ��e is drpi si �ent oa the t�e ❑ Pcrmit Re +i cion RCpair of ; :i�sting 5ep �c 3y�tem ,; Apptica ii�n: No Chaga/�A $1SO.Q0 orS300.00 1) 5ervice� u by;; ' .�' ' �, Naroe: r�r- �6�'Z�S Pi a nc #(horn e.3'3���5 ! 7-�'�?�� Addre�s:' I t-� �s � ({� ���N�ri�i��}� ` �! % � i �:J CIJ� �. , �I. � �3,� , �a Yc� . � 2)l�i�me aud �cldress of �urrent awner ('�f different t6an appiicsat; ; i�ame: ' � ; Address: � � ;: 3� Praperty Desct�iptio�.: Lot Size: Subdivisian: LAi #: Address andlor directid��as �n Pro ;2 —'� `""--' ; �'� _���f u.s ::�_._�_�_�2�. _ _S�_� ,��_c,. �7.�f�' .._.,�.. 4) Pro�osed tise an�a '�p�e of Strncture: Residen�a! �/ ' j 8usinessfl'YPe� Other Number of bedrooms'__�_� / N��� � p�Qie sErved �seat�/c rt; ployees); __- `7 Basemc,�t; Yes � No _�� _(with plumbing: Yes � No __.^� Garbag� disposa�: �'es �� No •� . ;; ;; 5) WaLer �upply: Private WeI� �Pr�posed Existiug�) Communiry WeII: i! P.ublic Water Syst�m: ' Arie there wells on t%e adjtiiuing properties? No �res ., _(ple�se ; �how Iocatian on site pIan) � � Note: A rompletrd �nCiccgtian mr�st also inc[ude: _...�.....,. . �.�......- — D A ptaffsite plate bf, �he property that shnws proper�y dlmen� ai �res and � 4e siz� a�d lncation of uf1 praposed struc�r,�uies � � A signe�t copy aj�tl're `L�t PlPpR1'RllOiZ � forrn verifying lhat t� �e prope� �r �r ready to he eyatuated � � I � sm sttbmittiag t6is �Aplicat�o� to t�equcst servi¢es from tbe Person Cau; ��y �ealth Dep�sEment. i anderst�ad t6at if ti�e infarmstifln provided i�9 �ncorrtet or if tLe sitc i� sa bseq uenily ai�er �� I, o� if #6E iatended nse cbanges, sf# permits anci approFvals sbalt beComc inva�id. � , �igngture (QvmcrlLcgal Rcprescntaiivc - � �-1�' )• �;'-tti ,�ate : , -- -- ! 0/08 Person County; Environinental Nealth, 325 5. Mot'gar►' St., Set� Y: C, Raxbc ra, NC 27573 (336-597-I?94) I�� � �� � � � ��� � T�x Map � P�,rcel # � � - �•� � � \ • I - � � Subd'ivi�sion �: � � � � �� � Ph�se Sect�ion Lot # Improvement Permit Permit Valid for Five Years _ No Expiration Type of Facility: ' Gi � � a re. m New Addition # of Occupants � #�f Bedrooms . Projected Daily Flow _ Proposed Wastewater System: Proposed Repair: � _- Permit Conditions: Owner or Legal Representative Signature: Authorized State Agent: Water Supply g.p.d. Type: _ Type: _ Date: The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. 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 revocation if 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 %r Sewa�e Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewater System (Required for Building Permit) * See site plan and additional attachments (_). � j �I\� _� Proposed Wastewater Sy�s m: �(;CP�d ���� W) Type j Wastewater Flow �� g.p.d. New _ Repair V Expansion Soil L�� p� g.p.d./ ft 2 TypeofFacility: �an.�;�,�2t�_�rnP Basement_Yes ✓ No Wastewater System Requirements Tank Size: Septic Tank: �s��l Pump Tank: —— gal Grease Trap: �"'"'—gal Drainfeld: Total Area: �� sq ft Total Length ��� ft Maximum Trench Depth ��¢ in O�C, Trench Width c.3 ft Minimum Soil Cover: � in Minimum Trench Separation: q ft Distribution: � Distribution Box '✓ Serial Di�tribution Pressure Manifold — ba�c, � S 0 Authorized State Agen�. t.../�_ Permit Expiration ate: (n — J � - � Date: ID —1 Ll—I% The type of system permitted is Conventional � Accepted Alternative. I accept the specifications of the permit. / Owner/Legal Representative: Date: �— � r — �� PCHD rev. 11/10/OS .����J./ J " �1111� �1.� V .�� l 7 �� � �� � `� `� 1 V � � lE,m�u•�,� ,�,.-„ ��.�,m.11 IL"-3[�.�ll�lEb Name �Cn�� I'am���� �-�om�. Subdivi �on - �X'^� ' L,N1l�-� �. \ —�Autho�ized Sta.te Agent SI'I'E ��TC�I Ta.g Ma.p # 3� Parcel #�_ Section/Lot# _ r� I�1- Date System components represent approximate�contours only. The contractor »aust, flag the systemlbrior to _ beginning the insta on to insure thntpropergmde it maintained �.,r,,,�� ?� ��� ��; � , f --.�>s� �� ��-��.ti� ��-� �- � �� ��►�-- �, , � ,, _ � f �1 , , 1 /�v � �' r �� , ._� ,\ ,; ',� �_ � � �� �� � � � � � �;� k� ' �� r -'� ,� �,r �C„ . S ; a•; � . +'T � � . _� �� +s`° ' �'f _ �s �� � a� � ,� �.:,r ->r r � .� - � � ; � ".� �' y�. � �� ��� � � � � {, � � ` `� a �� � . ',�° " "� ' � . F 5 q � a�"°id" ' ��... a °� �� � a r� � . .,� �"�'� �*�x R� � �� t� ��'� ".�` - , ' : �� '� �`�`.,� � $�g�. � ���*� �.'y i . � " � a'�� �� ,� i'+'t . " =,� �..at' � ���-. � � ��� ��/ iF�' � -� .. 7�f" � �^ � : . — r �� / �_ " �,�,,� . , � � � � /� � � D �� � p� � � � rt � '� t "�`� � / f " , �� w � � ' �` .� «..'A� � x � � � � � ��� . 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" _ �� - . _ > � � s. �� � .� A . t. � 1 ,.�`-_b _ - ���. s.f ���..� �.� �� � � ���� I��.��-���.-� ����..11 I�-3I��.11�I� Tax Map ��� Parcel # � Subdivision Phase/Section/Lot # # of Bedrooms � Operation Permit System Type (From Table Va): Product (IIIg): �Z 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. uthorized Agent) ��� �9' �� V \ V g'1l R'I� R'll �9' /n 9�A q �g 9 �k � ��' �1J�Z� �1�Z Il_2 � � // 2 J '2 //' Z — �z'/o /� �/a f '/a --..1�'/n / 2'/�_/2'/d Scale: 51 �p �p; ��0cl�C� 9—zs—/� -� (Date) R'�� ��- (Date) ^ \ �W (_��2� � r���,� �� �� 'r� \ . �. c �- �- . � . ,�� Tax Map: � Parcel #: � Septic Tank System Checklist (Type II-I� System Type: _1� L�_ Notes• Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes: NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP e-mail Date: