A34 8AAualication bate: 7'�U'Oc�
, . /`�.:�nount Paid: f �l .00
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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
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_ � 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
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� � 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
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Date —
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P 75-�000
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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
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