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Roxcoro, N.C. 2l57� � Qo
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LICATION FOR S1�RVICES � R30 C,�.�'��, � �
�mprovements Permi[. (Established/Recorded L,ot) _ Reinspection of Existing System (Loan Closing)
Imp.Fovements Permit (Unrecorded Lot) Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) Replace Existing Well
;,s y �.` k �' "yQA"st'i�i :X w� � zrt #: i� .,�.�k ,+.� 4rv?'� w . ' .y, ' . .. = k � +. �.�: ,.4' dn.. '�ie.'Cry`.�aG �i'' �.r .:?' � z.,:^! �;�
;",�^i � �3 r5 `s �..oE r.:>�ak � ��wc„�.,,Ys' �..,,�<.,t� Sv*�Water:Satnple to b�e Collectec�- �� s� :° ,w�'�c � q r .. �z � : i i ^ �s;� q i
•,v .�., .f„a ,.3,us 3»:, n,>...�, ,. ..,=.S.wrnr x�`:§'I &�„Yro: ,. �m—�+..r �ws�u..... 'z .�., z..,xk.x""`�. �iu. i".,.�;._'w�,+,- «,.,.a..., �.<:
_. Bacteria _ Chemica] _ Petroleum Pesticide _ Lead
1. Permit requested by: . 7. Dimensions or Prcposed Struc[Lre:
owner/prospective owner/agent: :.nhe .�a�t' Width: � O
Address: /%S/y �1���.;✓er CL,�r�L. R�� Dep[h: �02 .
- 8. What type (if any, additions, expansions, or
repIacement is anticipated to the structure or facility
that this.sewage disposal system is intended to serve?
Home Phone #:�334)�9�-8"�y9' ��.,,..:,is� o-� -��re�
usiness Phone #:[�9�G� • G�3�
2. Name and addre�s of current owner:C�qceR;C'� /�/�� �Water su�ty type:
;,. e 6� private Q�public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �
If so, identify location:
3. Property Description: Lot size: /• D/�i
. Tax Map#: �4�0 I0. Type of structure/facility: Proposed: �Existing: Q
ParceI#: �/ Type of dwelling:��p�,��,g,�e�,�
Township: C 5ar�. _����� - House: C�lobile Home: � Business: �
5. Directions to property: State Road #& Road Tyge of business:
ames,�tc. �Q�, �
Number of Employees:
b l So�. _�4ss �x r�� mA�t `Q � o Number of bedrooms: .3
-EG� e��'�,�.- �l�f i J e r � s � hf Garbage Disposal? Yes ❑ No ��
c b' �, L s; Basement? Yes ❑ I�Io�'I�o, # of basement fixtures:
6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND TH� CUKIv�;tc� vr aUU
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COUIIfy Health DepartmeIIt for a site evaluation for the on-site
se�vage disposal system for the above described property. I agree that the conten[s 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 before an Improvements Permi[ can be
issued, I must present a survey plat of the propecty to the Health Dept. I understand that in the event I have not
deiivered a survey plat of the property [o the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
� �.� - ��-
Signce� Owner or Authorized Agent
b�JL7IlyyL 17:�r yly-�y4d��� LHLLI�UII r'tiU� �1:
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.�,b �i�.r...�►'� .c'��vT R.; v�.� 7"�.w�.u.�,��.� .E�•xt�a,�.ra ,Iv c. na,,wa err ..
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��,;��p,�� }.�, C. �reen�boro, NC Z7403� '
�.... ' - e _ _ -�.�,- �_�.— c�o�c ao : L.L.S. ,,,,� .
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PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM
Tax Map #: � � �U Parcel # ��
Zoning /1�/!)�I�%�f}"�' Township ��� /��U�
Applicant: �
Location: �
Subdivision:
improver�ent Permit
/ MUau(GY
New✓ Repair_ Addition _ Type of Structure(�OVUeWater Supply�rtV�i� ��
# of Occupants� �# of Bedrooms -3 Other .
Basement? �_ Basement Fixtures o
Projected Daily Flow: �� g.p.d. Permit Valid For: IB'Five Years ❑ No Expiration
Proposed Wastewater System Type: �������0�!/'4L �j��A��
Pump Required? Yes ✓No
Permit Conditions: �iY�LG O/l/ L�JV%du,e //�%'����f� �'E�%�( ��''� `� ~•
.S�S %� ,s'L�� I? S' 1r�7Y1 GACfI'l/aN•
Owner or Legal Representative Signature: - � Date: � �'�- �
Authorized State Agent: � �S Date: �� G��
7he issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit
holder is responsible for checking with appropriate governing bodies in meeting their requirements. This site is
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 permit is subject to compliance wiih the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Type of Wastewater System �
Facility Type: q u� �b��
Basement? 0 Yes �3�1 0
Wastewater Svstem Requirements
Septic Tank Size: �j p U gallons
� Wastewater Flow: „�g.p.d.
New �' Repair OExpansion ❑
Basement Fixtures? 0 Yes I9�t�o
Pump Tank Size: n% /"� gallons
Total Trench Length: � feet Maximum Trench Depth: � inches Aggregate Depth: �Zin.
M�mum Soil Cover: � inches Trench Separation: R Feet on Center
Other: � �VS�� �� i/����
Permit Expiration Date: II 16J 6�(
Authorized State Agent: Date: // G
The type of system permitted does ❑ doe not differ from the type specified on the application. I accept
the speciflcations of this permit. �
Owner/Legal Representative Signature: � Date: � �' 8"� �
PCHD, rev/ 10/12/99
Person County Health Department
. � Q Environmental Health Section
Tax Map #: l� 4 C� Parcel #: � �
Zoning:
Subdivision•
Township: Fla-� R � �� �
Section• Lot•
Appiicant: I� � m1��� � L-� � � -
Location: �9N�1 F�a`� 1�� Ucr �'��(�rc.� �c�c�
Operation Perm it
System Type (In Accordance With Table Va):��
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
AUT RIZATION.
� � � -a�o�
Authorized State Agent Date
�� �� �51 �
� 1�c, �.�5 �
��° �;nv` � �$ � �
1 �^ q'�� �a
� `�` � �o ��a 5q`
�'� 1 � ^� � �3�
Tax Map #: Parcel #:
PCHD, rev. 10/12/99
Person County Hea(th Department
Environmental Health Section ,
Zoning: Township: �/ a-�- R i Ve r
Subdivision:
Section• Lot•
Applicant: i mbt ��� Lo v �
Location: �� y y ��� %� i v�r Ch c�.r�-�- � o�
Operation Permit
1. LOCATION AND SEPARATION DISTANCES `/
A) System meets .1950 setback requirements
B) Distance from system to any wells i ���—
C) Distance from septic tank to foundation ��S �
D) Distance from system to property lines i0'
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank �
B) Visually inspect the interior walls, b ffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet �
C) Date of tank manufacture —5' 9`f
D) Tank serial number 'v!T �ya
E) Liquid capacity of tank i OC� gallons
3. SUPPLY LINE TO TRE ES
A) Grade (1/8 inch per foot minirr�um)
B) Material supply ��e is constructed from `� ��� 4 O P��
C) Diameter `�
D) Length � � �
E) Distance from tank to drainfield/distribution device
4. DISTRIBUTION DEVICE�(S��
A) Type
B) fs Device water tight
C) Distance from the distribution device(s) to the trenches
D) Is the device on a level foundation
E) Does the device pertorm according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth mches
B) Trench width inches ,
C) Distance between trenches Q
D) Number of trenches �
E) Length(s) of trenches �15� 75��.��( S,�"7a.S �
F) Aggregate depth 1�-?_ inches
G) Aggregate material and size �
H) Record septic tank outlet elevation 7' b'� 2
I) Trench grade '7`s�� (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed e�cth
b. Proper rise over step n-�
c. Solid pipe used
d. Elevations of step downs (Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
�
�
�
I
V
E
Application #: 0?08�3
Tax Map #: d
Parcel #: � 3/
Person County Health Department
Environmental Health Section
SITE SKETCH
Kr�1 a��2�y �ov�
. Applicant's Name Subdivision/Section/Lot#
' ,.,�- ! 6 f
Aut �ze t te Agent ate
System components represent approximate cvntours only. Tlie contractor n:ust flag tlie system
Scale: / — � U /�D w��� f��}-.
� PCHD, rev. 10/12/99
�
� Tax Map #:
Zoning _
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
� � � Parcel # � '
�I�-�R; Vcr
T.....n�hin _
Applicant: K i mb-c.r �x Lo � e
Location:
Subdivision:
Section:
Well Permit
Tvpe of Water Supalv: ✓Individual
Requirements•
Lot
Community Public
Site Approved by ./ ,
Grouting Approved by IVot +� ��tn��s��-� �a�f �-� t 0�'dno-t c.o ����ss Grou�. 7& was �.61c
Well Log 1� I-�5 aooc� � V�.-rr Fr t��-�-Eh� wttl w�� oper� �o'ar��aa-Z,
Well Tag �,/ � �
Air Vent �
Hose Bib
Concrete Slab
Well Driller: �i � �� ;��(� n t��
Well Approved By: �
Date: a ' � - OO
**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
01/12/20�t� 10:30
r •
8044547843
6ENNETT WELLDRILLING
�ERa,�N Cr.�uvrr ��N��r � �+,.y; � ; �: lif�n:,�� ��
�F.�.� 'r-'�i
PAGE 03
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