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Building Additions/ Mobile Home Replacevments
Tax Ma.p #: �D
Approval Requested for:
Parcel#: D
✓ Mobile Home Replacement
Building Addition �
Applicant Name:
Address: � " ve
Roscla�ora �JUC Z?vr7�
Phone#'s: 5R7— 2°lIa
Permit Located: ✓ Yes No
Installation Date: -27 Design flow: .3Lpf� (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: z/ Well Public or Commu.nity
Wastewater system shows no visual evidence of failure on: j0 —�—D G� (date)
(Applicant's signattue if site visit is not required)
Addition/Replacem�nt Approved
�
Enviro ental Health Specialist
� 11/15/OS
iv-s-�
Date
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Name e au r�e Taz Map #�,�,P�rce1 #� 7
Su ' � �on n o _ � Section/Lot#
. . `D_ _Q,
Autho�ized State Agent . � Date .
sy�„ �,�o�� �,�s� �c,p„�„��contours only: Tha conimctor must, fTag the system�rior to
beginning the installa�'ion to i�sure thatpropergrade is maintained �
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Tax
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Map # % id Parcel # a�'%
1g Township L i4T � ��'�
�r/Contractor �v r_ { Date a� S
c�/�
on �-F- i n-Fo 5;�6 —�� �. S.R.#
Subdivision Name �/�IT R i J�� ��-N ��TIo� Lot# r�9
Iayout
As
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank OD p
SFD Mobile Home ✓ Size of Pump Tank i� �
Business # of Bedrooms�_ Nitrification Line �i00 �X' 3�
Max Depth Trenches �?�o
Permit Void after 60 months. Permit Void if not in compliance with zoning regulatio,ns.
Permits may be voided if site is alt�red or �ended use�n�_
Well and Septic Layout by_�
Comments: '
Date� � 7- 9S Installed by �`� _ Approved by Gv �,2 0.�9 �-_-,-�
Comments:
Installedby �nK�n W%���aMsanApprovedby
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit."The
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 repoR that may have resulted fmm false or
misleading statements provided ro him in the application. Neither Person Counry 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. c:�amipro\permitsam 01/95 rev.1.0
�
Application Date: � r�� ^D� Tax Ma #: �
Amount Paid: ��
Receipt#: ParcEl#: ��
�"� � �� S 1�'I�I�..� ��
�____ �
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�a�a_�aa-oaa�+-TM� maa�.�.11 ���.eo.712I%a
APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Owner/agent/prospective owner): C�wFN`l��u��croN ��lnu.1 rt,c�HuM
Home Phone: � - o"t Address: Ib E e E � _
Business Phone: - o a-S$aj fZckl�ofb NL a1 �'7
2) Name and address of current owner. - � � t1�S i I hl
k 2r! .
� � , �
3) Property Description: Lot size: I' 0� Township: e r o�
Directions to the property (Including road names and numbers): _
.� „ , , -
#�
4) Proposed Use ar}d Structure Description: answer each of the following questions: � ,
a) Proposed t�, Existing _, Type of Structure: �ekL,i� w;dP Width: '� Depth: 3a
b) Number of Bedrooms: �_ Number of occupants or people to be served: 02
c) Basement: Yes , No � Will there be plumbing in the basement? �10
d) �arbage Disposal: Yes �, No _
5) Water Supply Type: Private �(new _ or existing�, Public� Community_, Spring _
Are any wells on adjoining propei-ty? Yes_ No �, If yes, please indicate approximate location on the
'site plan. � ;
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No )C
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITfED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAICED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE liEALTH DEPARTMENT
STAFF.
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.
��' C�
ate
PCHD, rev. 06127/02
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Building Additions/ Mobile Home Replacements
- Tax Map #: � y d
Approval Requested for:
Applicant Name:
Address: "
Phon� #'s:
Parcel#: 20 7
�Mobile Home Replacement
Building Addition �
Permit Located: '/es No
Instal�lation Date: �27 Design flow: �l�d (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: ✓ Well Public or Community
Wastewater system shows no visual evidence of failure on: 1[�-3 d(o (date)
(Applicant's signature if site visit is not required)
Addition/lteplacement Approved
�
. ��_� �
Enviro ental Health Specialist Date
G
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1��.�-a.��„-,*,.,r„ ���.�..Il IL33C�.�.11�
Applicant: l�u��l L�,
Location: /S7 S_. _ �
T�ix h�la� � / ' �rcel'.� �
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SUIbL�'IVIS.1011 �u �� � � r
Ph�:s�e,`Sect,ian:'Lot + �►�
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Ampraveffient �ermit
Parmit Valid for _�ave Years _ lYo �gpiration
Type of Facility: � New Addition _
# of Occupants # of Bedrooms Projected Daily Flow
Proposed Wastewater System: � �
rr�os�a x��: � � , ..
p�.t c�a�tio�:
n
V6�ate� SnppiY
g.p.d.
Type:
Owner or Legal Representative Siguature: .-- - --- -Date:
Authorized State Agent: � • Date•
The issuance of this pemnit by the Health Department in does not g�arantee the issuance of other permits. Iti is the responsibility of the
applicant/property owaes to in sure that all Person County Planning and Zoning and Bu�ing Inspections requu-ements are met This .
Improvement �'srmit is snbject to revocation if the site plan;�pl"at�'or the intended use changes. The Impruvement Permit is not
a�'ected by a change in owner"s�ip of the property. This permit was isgued in compliance with the provisions of the North Carolina, .�
`Laws and Rules for Sewa�e Treabnent and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person �oun#y�: nor��t}ie.'` �� =
Environmental Health Speeialist warrants that the septic tank system w�l continue to f�ction satisfactorily in the fntnre or�t}�af.
the-water supply will remain potable. � � _
�
� Authorization to Constrnct VVastewater System (Requarerl for Bnilding Permit) �
* See site plan and additional attachments (_). � _-. .
Proposed Wastewater System: 0 t,QtT�vr� � 'Ij.�pe � Q Wastewatez Flow 3�v g.p.d.
New Re�air F�pansion � .� Soil LTAR: , 3 _ g.p.dJ ft 2 �
Type of Facility: � i J�f� Y, Sc�c,F . � � Basement _ Yes �/No
�astewate� System Requirements
'iank Size: 5eptic Tan.k:� �dsfi'�1 PnmP Tankt--�� Grease Trap: —'"""�al � .
Iarai.nfield: Total Area: sq it Total Length 0 fl ft � 1Vta��nnffi Trench Depi� � in �
. ���#t
Trench Width � ft 1VYinimnm Soil Cover: �� in M'in'imnm �ench Separation:
Dista-ibution: Distribn#ion �oz �Serial �istribntion Pressnre Manifold . �
Specifications: /'T� �� ( fTr l cn� 6it�} �H� 6� �rt5�ina f�G St/�f�/yt �: :
Authorized State Agen ti Date• /� � C)"� -
Permit Expirati ate• /o —5 =!/
The type of system permitterl is " Conventional cc�ted Alternative. I acc�pt the specifications of the
P��-
�e`r/It�al �t�presEntat�ve: Date: /0 �/
' CHD rev.11/10/QS...
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A�plicant w �
LocatiQn: �5 > K � a (
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�x cu� � � � P�r� �
Subdiv�i�i.an � � . ,
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:� a. ediraoms
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� Sysiem Type (In Ac�ordanc� Wiih Tai�ie Va�: �q �
TH1S SYSTE�di HAS BE�i►d iMST�i.i.Ei� iN CDMPLy4NC� WITH AP.PLICABL.E NORTI-f '�
C�►ROL• 1�, G�i�Ei�AI. STA'TCITE�, RULEB FaR S�HA�E TRF�T�itE�11T ANO DISPtOSAL,
�D �,1;L CflNDlTit)NS � OF ' THE iB11PRflVE�sE�1T PE3�iT AI�Q CONSTRUCT10iV
� Ai]T�IOR � . � � � . .
. �` . . �„�,�/a� - _
� orized St�ate Agerrt ' , Date �
installed By: ,,,f�"�� _ ` ' Daie: /•� ��(o . .
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rCHD, r�v. Gi!_?lG�
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Tax Nla� � P2rc�� # � � Sys�n Type ('i'a�le Va) •
Qwne�l�pp(icc�nfi Subdivisio�
Addi�sslLn�cation SeclPf�2se _ � � �
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, SiTE S�TC�I .� . . .
Name � ��� n � Tag Ma.p # '�D . Patcel # 207 . .
. .on c �'an on . � Section/Lot# /Q�
: - — !�� —S'O� �
. Authorized State Agent . � Date .
0
System cnmponents rep�erent appmximata�contours only: Tlu coniractor must, flag the system�rior to
begirining the instaldai�ion ta i�sure thatp�,niiergmde �s maint�iied �
,. �
+ . �u'� � 2,'Sf ��"� e r�r
.:,:- . . . • �S�r $�J�f"epY� � Cann��'
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� �an K �i�ec;�l � Z l�n�,
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Date:
l'liltSUN I:UUN'I'Y liNV.11tONMliN'I'Al. IILAI�'l'll
WELL LOG
Owner: �c�V I L�
Location/Directions:
C���r����l0inn �Tmm�•.
Drilling Contractor:
SR#
T . "
LV L JI
y
WELI� CONSTRUCTION
Dist;incc from Nearest Property Lir.c Distancc froin Source; of
Pollution
Total Depth: Ft. Yield: GPM Static Water Level Ft.
Water Bearing Zones: Dcpth Ft. Ft� F� Ft.
Casing: Dcpth: From � t— o�� Diameter: � Inches
TYPE: Steel Galvanized Steel t/
If Stecl, does owner approve: Yes No
Weight: Thickness: . Height Above Ground: Inches
Drive Shoe: Yes No . � ;
Were Problems Encountered in Setting the Casing? Yes No �
If "ycs" �ivc : cason:
Grout: Type: Neat SandJCement ✓ Concrete
Annular Space Widch ��. Inches
Water in Annular Space: Yes No
Mechod: Pumped Pressure Roured ✓ - � �
Dcpth: From � to 20 Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (sand, gravel, cuttings) - Ratio: to
!D Plates: Yes ✓ No � �
4 x 4 slab Yes ✓ No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS� CONSTRUCTED IN ACCORDANCE WITH REGULATIOI�IS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
. � . . ..
.
; �� � �s
Signature of Contra -' ate