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A34 8AAualication bate: 7'�U'Oc� , . /`�.:�nount Paid: f �l .00 � Receiat#• �.[ 6 �3 o� a ���`.�v I �8�3�e� a� �, ZZ Person Countv Health Department Environmentai Health Section APPLICATION FOR SERVICES Improvements Permit (Recorded Lot),-$1 Improvements (Mobile Home ConsUucfion P 1) Permitrequeste Home Phone: � Business Phone: 2) 3) sted :-: Well Permit I Tax Map #: !`'� 3 � Parcel #: � � Inspection - $100.00 Existing System Pertnit owner):�EJr�J ?� S�{�JQ��1 ���:a'U��► Address: Name and address of current owner: C� Z� n�n1 _%pJ►S % Wv^JQS /.31k _-1�xr�.2� N.c. ��s�3 Property Description: � � • ��� .. l.\_.,,� „_. .- Directions to the prope �N (�F j 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed � Existing 0 b) Stick Built,�, Modular �, Single Wide �, Double Wide ❑ c) Number of Bedrooms: � d) Number of occupants or people to be served: e) Basement: Yes,� No ❑ If yes, # of basement fixtures: � Garbage Disposal: Yes �, No � / , g) Dimensions of Proposed Structure: Width;_,� Depth: 3 a 5) Water Supply Type: Private;�(new � or existing ❑), Public �, Community �, Spring ❑ Are any wells on adjoining property? Yes � No � If yes, location 6) Please Indicate Desired System Type: (systems can be ranked in order of your preference) �,Conventional _Modified Conventional _ Alternative _Innovative � Other (specify): � � SS� S �'�,.� 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 property. 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 personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the He epartment i y property contains any weUands as designated by the Army Corps of Engineers. � ��� � %��� -C� � Owner or Legal Representative Date PCHD, rev. 10/12/99 R i ! � a � ►, ,' �� .- � � ^_,.+.,,.I r�rnP,r , A;�� ed F. Cole, Jr. D.�=�. � 31-102 ►+ SaS���� �� � � �4 08 Ac. N84�5� 26" w . - •+-w. � .•� r � � , 9g�•i � . S20'06'34" 245.1 C' �b - ' � � � � �� � � -� 1.=09'45'18�,. � � � �- o � ,� � 416 . 9 7' �► L �, L► .� � t �' �° m d � � � J�.-�R.DO' � � - - � � , �"E "N ��= �='��2 �C0=0Zcn �1 � m oz�cn mm�mc{c Q�t•Q-0 t�1 r a, �.. c v, p� �-� m 3 z, D SU �� � o00 �o�� c�DO��r� � r � ,-mim-mi pDmz �o�cn �m o Rudolphn D�n ooN� mD���°� N � .� ncDi� cZncZn�� �'�mo=U'v � � Sarah � TXT o-��T �-Z+mm�m � � �.8. 2� � �o� m�Z� ��c�m� -P m N N cn�v �-Dn�cn Dr�30D � � �'�� �zp Zm{x =mnZ�� �..� ��-' m �-<v mc'�cn�, �ZN-im� ��� o Nm� mv'mz �cmi�z�� � � �-�NG� omma'�z Z Z ��mo �Dmo�z o m Z��� v����� cn �Dmcn x—�,< c � ��c m �=t �-�ic0'�v D =�-,"'�� � �'�=m mm =cn � Z-��C T Dmcmn cmn D j � � cn � � p N _ � PERSON COUNTY ENVIRONMENTAL HEALTH `r_. PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND S�(STEM LAYOUT Tax Map #: e � TT �� Parcel0 _ g� � + Zoning Township �il���c,f:c�2l� . i .. ApplicanL• S O ,� _ Locatlon: �_l//,'�/ p� . ' 7�i �LJnl2 [�-/z)�.tiP ��c, rr• � /oC� . � y Subdivislon: SecUon: Lot Improvement Permit A buildinq permit cannot be issued with oniv an Improvement Permit New _�Repair Addition Type of Struduref�� Water Supply�'y�,'�i� .�/z// # of Occupants � #�of Bedrooms � Othe� Basement? �_ Basement Fixtures?� Projeded Daily Flow: 36e g.p.d. Pe it Valid For. Proposed Wastewater System Type:_���i�`o� Pump Required? Yes _� o . Proposed Repair : �',.vZ,,,c�.,o���iC, fi,�.�SL Permit Conditions:���� ,c� �.� > � / Owner or Legal Representative Authorized State Agent: No Date: �� -�J— o 0 Date: The issuance of this permit by the Heatth Depa�tment in no way guarantees the issuance of other permits. The permit hoider is responsible for chedcing with appropriate goveming bodies in meeting their requirements. This site ts subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be affected by a change in ownership of the site. This peRnit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Type of Wastewater System �.�J ��az. Facility Type: �,8/Z !� i ��« d Basement? 0 Yes Ud�IQ"o Wastewater Svstem Reauirements Septic Tank Size: ? Dp gailons Flow:,�J �.p.d. New ❑ Repai� DExpansion ❑ Basement Fixtures? 0 Yes �o Pump Tank Size: ""—' gallons Total Trench Length: 3� feet Maximum Trench Depth: �_ inches Aggregate Depth: /� in. ta4exinwert Soil Cover. _� inches Trench Separation: _� Feet on Center � I /� Other. _ �� ��� �. l�2�'�.. � /AaAP�3 %� � o�.�� Permit Expiration Date: �"3/ — O Authorized State Agent: /�`� . Date: � f�"-��— � The type of system permitted �t'does ❑ does not differ from the type specifled on the application. I accept the specifications of this pertnit OwnedLegal Representative Signatur : � .� Date: �� ' 3� '� � � PCHD, rev. 11118/99 . -------. . -- ---------._ . . ... . _.. Person County Health_ Departrnent Environmental Health Section , S1TE Sf4ETCH _ ;�?t/�n � � ��'� �ei�� Appllcant's Name � � �•� ��, —�' Authorized State Agent Tax Map �: ,3 . Parcel #: �'.¢ � � Subdlvision/Section/Lot# >0 �3/—m� Date ,Sy�tem compone� represent appraxlmute cnntora� only. The raatractor mustJ7ag the systent prior to be� the ins�allation to i�sure that proper grade is maiirtaiNed � `�/ �o�'� �� DW"'`� � " ,Q �1 `V � S� a r�, D� '` �� DS � DPvdn ? r� �� � (I � f�� ���-�-1 ���a�.'�C�y,dl�'t.��s f- �a�i1.'T�rry � lB��� •�e�if��G� �n"/� _ � F �� � ���e l Cs�,T E� ��� `� ��9�iPY�D r 'fcj 'ir+5 � // �Byt . � / �..,�ion js:7� �-:�e.�ncn� %fl� �n✓. ��,,�t� f� . �/ n� Tn5 er 5� �� �? r�u�i'�e �oi� o� in s�-��. on � 3. G'•�es a�� ��'� on s.'� �/�; o�oc�,7-on �iti�kc,� ;- � /l� laya� �� �' ' . �. �ai.t�%n � s0 �5�7�[�-C�'7'/'Y�rs� �� � �✓ � rT 'r> �� 44 / / 57�en. or /'�,1�✓a i� Q/'�cp- . CJ� v � __ � \ � 1 � � \�1 3 1 '^ � � �� ����� �� �� � =� � M v � � � . �, � --� � . � a i r �� � /O � '� C�� ` J��� o�l � _ ,�>,.� � ������/ ���/ / � J_ . � Ih2.S � i�Gu'��h ��D �j ._ ,_, ?/r� � � +Lt � , — - - �-�' .J G r I � � ! . �rc�.l � ('�' 1 �". �—�" , �ot y ��-- _ � \\9�I� Y� �– � �s � � �iv' s'a� .._, . , �C..—_ �. . •--b -�" �ases�*.e��CI�� - -Fdi' ,�Up�? �lut�''c�/I �!','F/J -„ , s�ie: _ � � �� �ifl l � Q�,�o�jb` � � � CTlP.J'I �GY�'��C.JaUi� a � .� �/�� h��,� ��� /��f.t S fYc�'7� �a C_a�?i 6n- o,� C��..S2i2�'w� � a /�"�sc�,' �;�� � d � ��,� � � se���ea- � � Person County Heaith Department . � 3 ,/ Environmental Health Section � �� Tax Map �: 7 Parcei #: Zoning: Township: �G� �� Subdivision: Section: Lct APPlicari� �2 d� n�S �q ro/l ���� %�in �ocation• � G %i --5 %�%�� � oa.lC, G�o u�. i�'��z; o� cti� � �5a � ��� 4peration �Permit System Type (In Accordance With Table Va): ���F/� � �� ,o,sy� . THIS SYSTEM HAS BEEN INSTALLED lN COMPLlANCE WITH APPUCABLE NORTH S CAROLlNA GENERAL STATUTES, RULES FOR SEWAGE TREATMEiHT AND DISPOSAL, � AND ALL CONDtT10NS OF THE IMPROVFJIAENT PERMIT AND CONSTRUCTION AUTHORIZATION. S ,�,� � rized State Agecrt � '�°� ( 5 w� P y I � r�- 3 6� ���� no+ N' f �� -� O0� Date — 5T �-6-a°°a P 75-�000 �7�-�Na � PCHD, rev.10J12l99 Person Couniy Heafth Department Environmental Health Section `- %� Zoning: Township: �DodSd Subdivision: Section: Lot: Applicant: � � � ��/�� ==_— Location: 4%lG G�te.– S /�% �/ l t� C�1C Gr Operation Permit 1. LOCATlON AND SEPARATION DISTANCES A) System meets .1950 setback requirements B) Distance from system to any welis ��� 6����� C) Distance from septic tank to foundation D) Distance from system to property lines 2. SEPTIC TANK A) Visually inspect the exterior walls and top of the tank � B) VisuaAy inspect the interior walls, baffle, tee, filter, riser, lids, air vent, bottom, and water tight outlet �� C) Date of tank manufacture �.-(�-d�o0 D) Tank serial number .5'c1�__I Nh E) Liquid capacity of tank I� o gallons 3. SUPPLY LINE TO TRENCHES . A) Grade (1/8 inch per foot minimu ) � B) Material supply line is constructed from S� 0,� 1� C) Diameter „ D) Length yo o �� E) Distance from tank to drainfield/distribution device 4. DISTRIBUTION DEVICE(S) A) Type B) Is Device water tight n/ C) Distance from the distribution device(s) to the trenches I'� D) Is the device on a level foundation E) Does the device perform according to its design specifications F) Record the inlet and outlet elevations 5, NITRIFICATION FIELD A) Trench depth _f �_ inches B) Trench width � inches �' p� �� � C) Distance between trenches D) Number of trenches _ � E) Length(s) of trenches F) Aggregate depth inches �1f�- G) Aggregate material and size H) Record septic tank outlet elevation I) Trench grade (< 1/4" per 10') J) Step downs a. Minimum of 2' of undisturbed earth b. Praper rise over step down c. Solid pipe used / d. Elevations of step downs (Record elevations and show on as built) See "�s built" plan on attached sheet. ,� PCHD, rev. 10/12/99 PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: �� L� Parcel # �" � Zoning Township .�l�,6 � �� / Applicant: �.Y.�c�l/D/'/ O�ri��� Locatlon• v a � `-' r� ' —" ' Subdivision: �pe of Water SupplV: Requirements• SecUon• � �O� Well Permit ✓Individual Community Public Site Approved by ✓ �-S 3 `2�� �� Grouting Approved by S� // i3��t� Well Log �t� �-zG-o� Well Tag ,� 25 3� 2(0 -�� Air Vent ✓ S 3-� 6�a � Hose Bib �� f 3� 26 -°� Concrete Slab,� S �i�Z��a ( Well Driller: � ���5 Well Approved By: J Date: �" Z� � �� **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: PCHD, rev. 11/29/99 y � ��+(�r � �`LL�� .. , � ��i:u:;ur•� cuii���r1� i:rvv.i.uc�Nr:::N't•hi. tt�.nt.'r.0 lJl:l.l. I.uc: Da te: `.�,�--� o , �a � Owner: � . L.00atiOn ---�.. .� r, c. r� " . /DircctiUns: __���- K �r��Q �( _.._..._______ S�#� --� ______ .. . ... . .. .... _ . �,: �;! � v s Ul'1� N�l,�-, �: --- .... --- Drillir�� ContrZcto�•: �� . ...... ... ... ......__.._----�- o[ � . ... ---� /�� ...- I,% /( ....� r_..�.1 L::� -- -- -�-- ���_ w i : � . t �� �-=__...___._. Dis�ar�cc fxorn Nc:u-cst �� '.�- .�-'C)N �-1'I� l JCT�'�t�N Pollution � o�� � 1�°���i��y [_.ii��: . --� ._`s /��1.�-� _._. ll;:;�,u,cc; �i-om Source o,� � Total Depth:. . � Ft. �'ic:lcl:-�--5- -----� _ ���'M Wa[er Bearing ;Gones: Ue L1i ,/ ; . �_ - .Strltic Wa�erLeye] c� • C • �� P ._. a �- 1 r.. ....____ ��t. �• � �� asu��= Ueptli: � From � .__......._. � ��- _._._rt. YPE: lc� ..__ ----�[- T Steel ------_. ...��- t'�. .Uianictcr. 6 % � --�.___.._ G�ilv.u�izccl Stccl � Inches X.f Scccl, docs owncr rip��rov�:: �'c:, --._... . . Weight: •--�='�'hick,iic ,.. _ No . � . s�. 1�� - Dtive Shoc: Ycs � N�-.—.Hc,ght`,�:(�ovc Ground:�L �.�rjches �� Werc Problcros ��lcot�i�tcrccl i��i ,�c:��n1; �lc C:�si ,'� , ... .r�r�- xcs .. ., �� Y���� �;ive; i'ctisai: _�_ p Grout: 'lypc; Ncat ------�---.S:i,ic.1/Ccmcilt�-----.._.._._ _"--: A.nnular.�Spacc Wie1�Ii �, ---- _ _____rCoricrete • . . ::�r;� Watcr in Aiini�1•u- — _. _ _ .--_I��clics :;'%, � SJ);icc: Y�::. Mct�iod: I'w�i x.c � , . : .. . ..___.._. ��_---� `.� � �cp[�i: From I �v.. ...._ 1 rc..,:.ur�:______.. ___. !'c,urccl_ �_ �. . .. • . , . � � , —•—____— •r Matez'ials Uscd: _- _.. _ � ..__.`.._i�t. . . ' . No. ,�ia�;� ,('c�r�l,iricl Cc�ilcnt Zf mz::[L1I'C �S1I]CJ • ._._..... __._ WciL}it o.f.l�ba ,... ID �� , �r:►��c:l, cu�.►in;',ti) - R�t[io:� �—=---_lbs:�: lztcs: �'c� IVo ---------. t� ``"��a� l� x �� :;lab Ycs_�_----- -----_ Nc� _. .. . ..- . � � :. � : - � ":; __. ___ ..._.. _._ . ------------...____....._ ......��1� I.1.1..1 NC� 7.;�)C�__ ' - : Dep[h .. .__ , �r�m — ---.------�-_...._--� -...----_... -- v _--- T°-- --- _ .._... I=c7rmation U ,tic c� �. —_ � ..: , z tion _� � —�'�.�.._-- _.� - ________ _ � "'_� c�.��. � -� --�---- --� �r.. -� -.......�,�� � �� ..�_�_'� — . . -- —�---- —.— ,� ��� _.. �d � � -� _.... ____— � � _� . � —=__-- — ...r..�t y_ .r��� z �E�E�x c��zT�rar r•�z�•�..�,l.z� ��. I . j(�V�"�N�=U�ZM�1'�'�ON.�S CORRECTAND T�s WE�,L Wns coNs�����uc��Li� Irv nc:� �'�RT� �Y•TI-I� P�IZSON c"'nU.N 1'Y I�II;A1.-�O1Z1J,�I,NCE W�TI-I 1ZEGULA"TZOI� .. .. I I I�LP�11;'I'M,cN"1', � .... � . ,��� �t/� .St �n;iturc i�(' � �-.. ....�... __ !� C,or�� � ,��:t�,r :� _ - .� a� � ��� —�-! �: : Dacc "' ;�