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A35 46--rr----J�--� ��-C' S i ax Map: �%�-3.� Amount Paid: ( ;�,� p �`— arcel �: Recei t#• � �°�' �7 ) p' - � - -._.._------------.._._.,,�,� y �} �//�� :��`'� � � I���'�� �� _ � ' V + � ^i � ' � _ y � � �� �L% '��..J .S. ' 7 Ji� �.1L ` f �r � � � . � 1[�v.CZ. S+�LII^`aY.Dli'21:I�T�s-,�z.�.�,,.11 IF-�7L.��.�.li.�r.:1i�. ��j �`� '� � j.� . . ` ��Plieation fo�- Se�-vic�s �� �l� � Se tic Sysfems and Wells) ' � � ' � � „ ;�,. �ee=�aces Re uested � . ❑ Improvement Permit (Site Evaluation) '• . ❑ Construction AuthqTiza#ion { � ` $200.00/�300.00 (if> 600 _ d) � (Fee is de endent on the fy e of syste`ni- €r-xnitted� I G Mobile Home Replacement or Building Addition L: Permit Reviszon i' `` v $150.00 (if site visit re uired) $75.00 ' �� 1� r Well Permit w lacement) ❑ Repair of Existing Septic System �, $225.0 /� 125.001 � � No Charee T ' .�� � j ( �mportant: If t1:e infonnation in tfie applicatiayr for an Improveme�tt Permit is incorreci, falsified, or the siie is �rliered, tl:en tfie Pmprovement Permit and the Autlzorization to Construct sl:all becon:e invalid. � �:� �.:1) Servtces Requested by: ; Name: Q� 1 st� SO � � � _ Phone # (home): .S�i� ��Cj� Address: �� �_ �jd �� A rndv � ��— (wot•k/cell): - � . , , �-�-e--�:� �-� ` 2)1Vame and addres� of current o�vs�er (if d�f�'ere�t tban applicani): (�, �� ��i ` Name: S'-A��r S2 � � Address: - � � . . �,:;s�bi" � � �� �bi� � 3} Property Deseripiion: Lot Size: Subdivision: Lot #: Cn�''-�� � Address and/or directions to Property: _ q—� � K1 c. G� }-�t�Y� nl � , ����"t � ��.���� �� , �� S'��� 4) Prop ed Use and Type oi S�rn�e�are: Residential Business/Type: Other Number of bedroom� / Number of people served (seats/employees): Basement: Yes� No _(�vith plumbing: Yes _ No� Garbage disposal: Yes , No Approxianate size o�' �uildimg iF�randatioa�s I.ength Width S) Water Supply: Private W'e]1�_ (proposed Existing _) � Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A comnleted ap�vlEcatioaa naust radso dtaelr�de• � A,plat/site plan of tlge pPoperty thut �hows prop�a�ty di�rae�saons and �he .�aze ahd fora�aot� of rall proposed structu�es. � A�igned copy of tlie `Lot �s•eparratio3a' forsrz verafying �hat tlie proper�y i� �eady to �� evar'usaie�l � arn submitting this apptieation to r�quest servi�e5 from tbe �ersoa� County �ea�tia �e�arta�ne��. �'he inaorznation provided is accurate. I understand that ii a�sy site is alte�ed o�- tfl�e intended use �iaanges, ali pe�-aa�a;ts s3�aIi k�eeome invalid. � �ig�ai�are (Owner/Legal Representative): ' � �,� ����, j �3 j`{��rZ C`� 1 I/07 Person Cou;:ty Environmental Health, 32� S. Mergan St., Suite C, RoxUaro, NC 275Z3 {336-597-1790) . Oct O1 04 03:50p 10/al/20G� 10:43 AM I� )A.: 1 ' � ��y.• Griles Htg & Rir � 919-563-2785 Peraon Co. Environmental H��Ith p.2 3�688T7S08 2/2 � �� T�1 m � a� � ' o!- � �� � I� �#� �a '��► � P��4u, �A .io P� �! � � �! �m � �� �3 t�o �d 4q w � uma�w vyE ��da� iwe �1 e�e uo��dde ��o s�ua��s ey� i�A � I'�t+�ad Pac�saw�ano4e �It�ol� �s � v9a�s e9R-uo o� �og uo�qe�y� a�c ���Q �I�H ��d � 04 �p�d�e e�esu 14��ac1 i '�I�L� .11�f.L�11fd�0 i�L'11�f 3FI�. A8 NOLLtilfll�/!9 ly1/ � 37��1f A'rQtl3t! 361Sf�13LS 3LL Q '�JY'd 2!0 �EEDjr1� � u� ��'i`[11 d0 �IOLL1rJ01 m�d �FLt Q ''�illr A� 38 �frl B?�10� �Nr► S3M'1 ul�dDYd d 'NOt1Y� ��.L KiiM Ci3,L1�S 381Sf�[ NVid 3tlS �!G J�i�O?3d 3Hi �0 t1f'fd r Q . �°�'I �� � l�a� PwPMPI ��1 a� diMdoud ,madl aa0 l9 ay� u�o t�p�o� e�Paa�dcie �9ealP�N easald `�A °N��A b��ad Biat�o[Pe w apaN►14�e vuy/ .. ' ��'`��'J '��d '� �o "'� �au)� �M�+d �i �� �,M ts � � oN '� �l. �10 �4�9 (P . lau��+o�ea � w�a� �a o►�st w�► .._ ��'""�� �u,�ee i� `�-r" �°1A� �4 ��l�d m �d�a�o,�qr,mp .�,-� �uaoo.��o ��1�1 t� �� '��� �� �I � � �aixvtae . � �1 � �11�� '— P�d i� • . '�O � P� �!1 �d {fr � bq� ��i . , r_��.L� Pue Qwtietr pe�ou . /I}�acia+d eq} 04 �40 �1��1 �b � i�l �G ��+d �E -c:: f'1`=: .•.� ":,i ' r�- «rw�wo �t�e�lo tw��Ps'Pat �o�eN i� 9 ,g �� ��ts _tb�uo�;d �1�8 �- '� � � ��4d �id �O� �4 P�� �d {L t�v�n��o�d.�r.� �'i�'��"�� E'�;�s�'�es�-�' t+�c�+ore.� � � ��"_ N' f'li � � . l'�L� � �i. ►�L� � ���`��--� �� � �` � . � ���� � ho-i-c��� • �'� � � � �' � � ��' i 1�� �1S�Ll ��./ �� � ~� �/ � ���� � aa.�as���� �aa��.�. �'���n.�.�hn Applicani Location: Permit Valid for ✓ Five Years Type of Facility # of Occupants Proposed Wastew�ter Sy Proposed Repair: �� � Ta�x M���� � P�rc�l � . S'U�hC�IVIS�IO11 PIa.��s.e�Secti�o;ipjLolt # ImproveBnent Permit No Ezpiration # of Bedrooms _ � New Addition � Water Supply Projected Daily Flow _s3j�d g.p.d. � Type: Type: / ; �t�:��.r� Owner or Legal Representative Si ture: Date: Authorized State Agent: r,�l� �� Date: �- 6-D The issuance of this permit by the Health Departinent in �es not guarantee the issua�lce of other permits. It is the responsibility of the applicandproperty 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 `Lax�s and Rules for Sewage Treatment and Disposal stems' (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. Authori�ation to Construc� �Vastewater System �Reqnired for Building Permit) * See site plan and additional attachments (�. Proposed Wastewater System: �/��1/(/_ Type �_ Wastewater Fiow�( D g.p.d. New Repair�' Ex ansion _ Soil LTAR: /l� g.p.d./ ft 2 Type of Facility: U„ Basement _ Yes �/ No V�astewater System Requirements �5��� ,�Tank Size: Septic Tank'/ _ gal Pump Tank: -� gal. Grease Trap: — gal Drainfield: Tota1 Area y�� sq ft Total Length J��O ft Ma�imum Trench Depth �� in "�+ch Width ? ft Minimum Soil Cover: �v _ in Minimum Trench Separation: ^- 4 ft --- �,�,3�nnution: ;-� Distribution Box Serial Distribution Pressure Manifold Specifications: Authorized State Agent: �j Permit Expiration Date: The type of system permitted is � Conventional the permit. Owner/Legal Representative:. 0 Innovative a Date:lp .- � -O � Alternative. I accept the specifications of Date: PCHD7/30/2002 . :���� )� �/��ld �?l�y�l���� . �' L �� �. `- ~" � �� ' V 'V � .11 JL • 7E��a-�� � �m�.Il IE�T�.�.]l�. " SI'Y"�. S��'I'C�. Nam.e �.2/ �f� Tag lYla.p #_��Pascel # `f� Subdivision � Section/Lot# Authorized t t � Date . System components represent upproximate�contours only. The contructor must, fTag the system prior to beginning t.he irrstaAativn to insure that propergrade is maintraned : ,� 9�,� ����°',/� ������ ��-� �.s�� -���o s���: �� : Y� �,,,�`�CC �'r%/y S'�`�L�L� �2 ,��jpA-�/L, y�/�,� �o,���e��'b� �5 i��P����T �,�p �n i�✓s � �- �� � �''� �,�,� �A . f � �L��� �zf -,3�" r��uf .-7-�3ox 2��ht5 15D `+� . -� � ►�do c..r.t . �^-• OF '�P�,N �� � `G �oc�G/r2f�S/tijv��� ��-/�c%r�����1 �o����C ��1���� - ��q'- /7qa � ,� � c����s M, � � �� . =—�- pG�, =ev. 09/12/Ol ���* i , l � ���� �� �_. � � � � ���� �' irn�-n�c-��n.n�n.��.a�.�n.� ���.mll.��a Tax Map Parcel # • S�ubci'ivision Fhase Sect,ion Lot # # of Bed�rooms Applicant: �lo.s -Location: q'71 Yvt`C�t� ,�,.\\ S� � :3 y 33 �- � $S �3 Operat�on Permit System Type ((n Accordance With Table Va):�c� THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH CAROLlNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION AUTHORIZATION. , � a'" c�S'Uy Authorized tate A nt Date Installed By: CicaC'!t �a1an-rn Date:�� - 3- v� � �vSS' r----� �uK C� ti`°L .}�\� J, 8'- (o "O`'I � p'i5-►cx�c7 �,,a., ,. � S`T�-3a-�1 n.�+ �J r �a' '�'I� C'x3`-� � � 4U � � �. � i� 4'�0 � ex���� � S��y � �i�=: �.s� PCHD, rev. 07/29/04 S��'CiC TAPI�C di�S���T1ON C�iE��IS�' (Typ� ll�f� Tax MaQ # � Parc�! # �/Co � System Type (Table Va) �G , OwnedAQQiicarit G��c�,. Csr\�s Subdivision AddresslLoc�tidn �7 � C��„�.,.�� �u.a� � Se�fPi�ase _ Lat # � , . . - • . . � a � pcf�ci rev. 3113I0y •��� J!� ���� �� • ! �T ' � � � i V �� IE���-�,.,, ,.,r„ ��.�.ffi.11 ]E3Cm�fl� 5i1'.E S�'I'C�-I �� . � Naine __� �,v ' d �� �; Taa Map # �'3 S � Pa�cel #� . Sub ' ' i n - _ � Section/Lot# � � l�l-oFf � . Autho�ized State Agent . � Date . System com�ionents �re�iresent u�i�ir�oximate�contours only: The contmctor must fTag the system prior to beginning the installation to i�esure that propergnxde rs maintairied � � � „ � Sc��; � _ � o � �' ��� ���� ! � d'� � q� � M�Ghe�es M� i� Qd, L�i(h.`��/1 `�T ���. �D' -�YovVl a1I ���rG � ` �' l��PiWts Z S -�o j'►�1 --�u,�c� a.�7 c�n S � Gt t� � � `p' -�ror�►� r �,� �,s. � . � , .� �.r� . .': �.:���'':: � .c::�. ��/ ...� ..�,. '�': -'y`�:: .�� :::���'+--�+���� •.�•'.•�..�'..'...•..�'' � �� . . ��^,v :1;... .{:�'::•''.���.•.•'•� . ... ....... .,.• :::n,::: �..: �.v.: •:;:::.,�.; ,..,,;y..� �, ;.� � �. �.� �� . .�:. .,�...,�:.:..�.,...r :....: . . :......: . . .` . � ... .,. . . . . . . ...: .. . . .,.m � J7�:;'s��9"Sli7i'!49• �rn-n 9i�3CA::i�::�i:1L•�':• : ..... . .: :.. . . : 7�� .,...;; ... : •.:.•. .. • •.. � ..:.: ::...: -�.-i�:... ...,.. •.. •. �.� r – .. .. ..... ..... . „ '�'A.11:�� '. 'Yt'JV�JV Y.''L1�1'Y9�I,S � �1LJl.�' a'�1�11J 17�dJ �S S1-'i0...+� m•� gJL.1L'�.L� Y'�� Y'f/S'JJ1J.9_I IJEJLlL�. e'� �I �LLJ 3 Tax Map � 5 Parc�l #�( _ Township: Applicant: � �, 0� Subdivision: Lot # Location: ��� � M c Gltip P S 1�� � � 0� ����$' ��H � : �. YP p� y _, Individual �eqaair��aaen�: Community Public Site Approved By: �� 1��..> a 3/ao�d Grouting Approved By: 'SI,3� c� 31 ��� Well Log. � Pump Tag: . Well Tag: � Air Vent: ` . Hose Bib: � � Caeing Height: � Concrete Slab: � � ` � Weil Driller: Well Approved by: �*��Se�.A���aed Site 5keich*��:�: Liner: Tnstalled by: _ Depth set: _ Grouted: Date: �►U�atea� Sample: Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems, Vs7ells must be at least 25 fest $om any buiiding foundation. ather canditions: Date:, PCHT rev 01!27/�� :... . . . .: . . ,. a'c Y.: ��, i ,- � „�' " �' :..,,.;. •: : �..; �• � � � 0���� - 3`� / � `y^= a ,aa� ' s ,}x ����� ��� ��� r �---�:�, ' � _:� -� ` ` . • . f. - C�� G'm� £� �� � 9NP, lI ��1�� -: : : :- - : -; ... ':�_� =��:;- �:. �y"� � . . .r . ..... _: -- - . ... . . .. ri_: � . ... .. _. . ��:�:�.,�.�---.��.��=: ���.:�:� . , 0� Ort�s! � �� d � - � - � Locc�ation' Subdivisi�: c�out I.og . " Tax Map 'S Parcel # � Lot # --- • WeII Construdion Distance Fromne�f Property Line (]1r�nimum 10 fcet) �� Dista�ace f�om Septic System {M'mimum 60 feet) 1 O z7 'Tottal Depth: 2`6a ft Yield: Z- GPM • Siatic Wat�er LeveL- 2 S $ Waier Bearing Z�e,s: Depth S`�S ft 9� ft ft ft Depih: From .�( _ to � 2. $. Diam�et+e�: � in Type: Galwani�ed Stee1 , - � Weigi� iriclmes� �� Height above Gramd: . Q n m- �� Dciv+e Shae: Yes Na Any problems enco� whle � �g �gi Xes " No ���" �e r�: __ - (�out: - � /- - . ' Nea� SandJCen�t V Concnete GasveUCement _/ . -'. A�u1ar Space Width - mches Water m Annular Space Yes d' No � ' Method of Gmu� Pumped Pre�ure - Poured �/ Depth _�-Z to 3� Ft Materials IIsecL - _ No. Bags Por@and cem�t " Weight o� 1 Bag � Pamds - - If mn�tte (sand, gravel, cut�ngs) -ltatio to -� IDplat�_Yes_No 4a4slab Yes No - Liner. ' - . - .ti — — Depti�: Daze Tnstatled: Grou� InstaIled by: Dritling Log I�acation Drawing I�om To Rorma�i,on . • 2 ° 5�� 2 [ 3 re � Z �v " s . - � ��� . _ - �5 '�, � _ - - �,ti _ �,/�,G �" 1 [ Lereby c�tify that tt�e above� iafa�rati�t is comect an�d t�at this we11 was cun.�d in a� wi� regulatia�s set forW by the Persou CaimtyHealih De�t _ - � o���tor m# 3��i n�.3-IQ-o� r�p i�eat � �n�tla�n c�act�- 9��t,rv� G1�L �l �%r'l/i� sr�e �ho� N�: ��a `1� � Pu�up D�: �D D Sfatic W� Le.wel; e ft Pump Make � Ntodel: __ �e � ffa�(� ` Pu� size and Ra�in�.�hp �_ �m [ Lereby ceztify that nus pump was mstalIed and ti� well he�d. �comple�cl acc�ding to ti�e Person Cuimty Well Rn1es ia effect xi t�is dabe and t�at a copy of t�is �d has l�eenp�nv_ided to-t�e well owner. . � <<„�� .�,� � � 3'l �a� rc��ovz�ro4