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R e c e i p t �� ' �� �'" � ��%�COfO. N.C. Zi ��
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APPI,iCATION F�R SERViCES
• .h i � t .� , . �..Y'( a: �t,�.t+s . , ^r"'y • ..,y.�..-o+
. .�;�� �� _ . --- ._.__ �,'_ ..: __.. -�.� � "'���_SefVICCS�Requesfed:M � . .
3 —� — 00
' Date
�
✓Imprcveme�ts Permit.(Fstablished/Recocded L,ot) �_ Reinspection oE Existing System (Loan
Im�ovements Permit (Unrecorded Lot)
Improveme�ts Permit (Mobile F-Iome Replace)
_ Improvements Permit (Addition)
ir/Replace existing Septic S
Permit for �Iew Well
_ Replace Existing Well
Pe �, it :equested by: .
ner/p; ospective owne:
dress: � .�"�f S.� �
� �� 7. Dimensions or Prop � �tructure:
nt: � Width: �- 8 ��'17_ `�i
� -� Depth: � o , . �
'` . 8. What type (if any, additions, expansions, oc
repiacement is anticipated to the structure or'acility
that this sewa�e disposal system is intended :o ser�e?
Home P�cne =�: 3 `f �.�6 �--
Business Phone ;:
2. Name an addre s o[ current ownec: 9. Wacer suoply type:
�'G ' 0 .t h e privace t`��'. p.ublic ❑ communiry ❑ spring `
� i_ -. Are any wells on adjoining property?Yes�No [j
' � � Ir so, identify location: ��T �, 7
. Prope�y Description: Lot size: 1� 0 2- �
Tax Map": . �- S �
ParceIz: �Pr :- � v
Townshio: �-.t- A `f. � �` v � �,
. Direccions to property: State Road �& Road
fames,gtc.
i� �.s- l�� ,
Number of occupants or people to be secved:
I0. Type of structure/faciiity: Proposed: �Existing: Ci
Tyge of dwelling:
House: ❑ Mobile Home: �usiness: C
Tyge of business:
Number of Employees: P-�",,,�
Num e s: 3) S�-u"" 3.�(�6
Garbage Disposal? Yes 0 No 3 �
Basement? Yes ❑ No�If so, n of b eme�t fixtures:
CLEARLY STAKE ALL CORNERS OF TIi`� PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pei'SOII COUIIty He3lth Depat'tmeRt for a site evaluation foc the on-site
sewage disposal system for the above described propecty. I agrec that the contents of this application ace 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 unders[and that before an Improvements Permit can b
issued, I must present a survey plat of the propeRy to the Health Dept. I understand that in the event I have not
delivered a survey piat of the property to the Health Dept. witiiin 60 DAYS afte� the date of the evaluation of
the site by the Health Dept., this application shalt become void and all fecs paid forfciced.
cG,,�, a�..��
_ r`2 �
Signca Ownc� oc Authorized Agent
� •
�
PLEASE SEE ATTAC
Tax Map #: _ � _ I �
Zoning _
Appiicant:
Location:
EA AND SYSTEM LA'
Parcel # ��0
Ta,�,,,sh,P Flat R� v'cr
Subdivisioo: �ki� c1SC RCiCS SecUon:
-�
Lot: �_.
c Fo�< <-' u 1-De -Sczc
Improvement Permit
A buildinq permit cannot be issued with onlv an Improvement Permit
Ne�v � Repair _ Addition _ Type of Structure � Water Supply �ri �Gt� W� ��
# of Occupants -i # of Bedrooms � Other .
Basement? I��Basement Fixtures�
Projected Daily Flow:� g.p.d. Permit Valid For: [➢�Five Years ❑ No Expiration
Proposed Wastewater System T e: C�nUZ.(l�i�rla- ( Ur0.V� b� �I,yP� �
Pump Required? Yes �No
PermitConditions:�� �G ��'oFF�ro Zi �-'���� ��OF�bLtl��a��n�i �C/��a-'�Iv/1/
'm um Fea �� Ic d�` •�ncc.. c.�c i r t n� ks6-�tian foc� ;-rn �fl a5 /ay�d a�' �a-�,
Owner or Legal Represeyrt�tive Signature� Date: �/S-Op
Authorized State Agent:
Date: �� "" �4 "aC�
The issuance of this perm� by the Health Department in no way guarantees the issuance of other permits. The permit
holder is responsible for checking with appropriate goveming 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 with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Buildinq Permit)
Type of Wastewater System C�Gr1UCr1'EJa�1�� Wastewater Flow: �(�g.p.d.
Facility Type: ���� � �ome
Basement? O Yes �lo
Wastewater Svstem Requirements
New C�Repair DExpansion ❑��
Basement Fixtures? 0 Yes GLtvo
Septic Tank Size: �/ �Da gallons Pump Tank Size: �.._ gallons
Total Trench Length: �'� feet Maximum Trench Depth:�Q_ inches Aggregate Depth:�ai in.
Maximum Soil Cover: � inches Trench Separation: -1 Feet on Center
Other: ��l��Il � ��1oc.�n an draca�nti
Permit Expiration Date: � 'o?oDS
Authorized State Agent: Date: '� 7�(�O
The type of system per tted O does Q does not differ from the type specified on the applicatian. I accept
the specifications of this pennit.
Owner/Legal Representative Signature. A Date: �^�-���
PCHD, rev/ 10/12/99
Appiication #:
Tax Map #: �
Parcel #: a�'8
Person County Health Department
Environmental Health Section
���
�cmmy c�K� nS
Applicant's Name
Authorized State Agent
�
SITE SKETCH
Qa,kri d� c f��r�.s ( c7
Subdivision/Section/Lot#
3 --�-o�
Date
System components represent approzinrate contours only. Tlie contractor n:ust flag the system
»r;�r ro hpninn�nn the installation to insure that proper grade is maintained
\ �
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Scale:
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o� lot.
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$�, DF ,n
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PCHD, rev. 10/12/99
. ' PERSON COUNTY ENVIRONMEMTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �: �"T v Parcel # � ��
Zoning
Townsh(p �'� " � � U C �
ApplicanL• ���..�m m T �� I� � n S
Locatlon: �+L- �� """"�
� /�- Lot: I �
Subdivislon: Kr� � � / �C� Section•
Well Permit
Tvae of Water Supplv: �Individual Community Public
Re4uirements•
Site Approved by � S � �� �G
Grouting Approved by � S �S'�D
Well Log — ZS �
Well Tag .i d 6�
Air Vent /v,�� ia %66
Hose Bib a i� ��
Concrete Slab .�
Well Driller:,.� ��
Well Approved By:
Date: l � � 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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i3rillir�g Cor�tractuc; .
F�l.:.r..It.: :a�i� :�:d+i�:
PERStIt� �OtlNTY �t►l'Jitt}>>hC�Y!►t.. �}�.��.��
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I>istuicc fraRt Nc�test �'topgrry t,ir�� , flis�,;,r�c�; t��n� 5�,���r.,� <ft
�'o{tu�io,�
.-._� . . _.
'i'utal Ij�-�th:,�,,�' . Ft. Yie1d: o�U (,��M Static: ti'r/ater 1.,�:•�ei�. Ft.
1Y�t�r peazin Z,onc ��`�._�
g s: Q�pth _�t. Ft. I�c. Ft. �s
______r.
C'asing: �)�pth_ ��rvrn.--C,�`_;�j�,�`�_Ft. �.)iame�-r: � [sjc.hc.
'i'Yi��: S�re�._.�._. . _ _..�„GelYs,�.;ze�i Ss.�1,� �
rf-...�... _ _ _ .
St+ecl. d��s �+�rt:s �pp�a�►�: Y�s �, �. �,�
w��a�� �,.��..N ......�_--
�_.�.'���-ihickness:�. ��ei�ht Ah�c��•e �rc�t�std:, f� _ Inches
t7rive 5hoe: Yes �/ j�jq�
, _ ,�.,�
1�ere !'tfl�3�rns �s�co�terod in Senir; the t'a '., .--
�!' .. .. 8 si���; 1'rs _ �'�fa�... _.
j'C5 Si�'� i:.�SJt1: _`" �
t;ruuc: �'y�pe: Nt�t �/' S�ttd/C�tr-�erit i` .
A�}j',1�/1 `�"—`• .o;�► tc•tt
I L N • �Y17M � ^ ` �'���� Wv`�yr�1
pi�� ��j�l�►_� � �11C�tCS
_-.�- _ ._..__.
Water in Annu)ar Space: Yes.. .� ✓
_�_. , o
Mclhod� ��� �✓_ �'tessure_ }��� �
I��pth: t��am ,� to �.o � -�----- _-..
� ......._ ....._.�._ .... __l�t.
A�iateriats tlsed: No. �a�,s Pvrtlanc� C�meszt �4�'eigi�� E,i l ba6._�.� it,�.
U l�tiix�r� (s�d, gfavel, cuttin�s} - l�acio� �
IJ �'latas• ''Y�s ✓ Na�. -- =��� �� _ _
. ,,.,,...,..,.�,
� x d si�b Yes_,/ No �
�
� ts�R�BYc�K�rtrY7HA1�T1i�AIIav��N�f)kht:��i'ii:}N l:� �~t)ki<E:C��' a���� J tl�a�i.�
Tl�15 1��ELi, WAS C4NSTRUCFED rN ACr.:(�KU;�?•iC�. Wrff-t R�;C;t�LA'l�1��N� �t�'�
Ft)K"I'� BY TN� P�RSON CJL•^,YT�' ���At.;rE� (�Fn�c��r�,�►:►.�•r
� - Person County Health Departm.�nt
Environmental Health Section
Tax Map #: ,� �C Parcei #: � �
Zoning: Township: �� ►,iV'P,�
Subdivision: � Section: Lot: �_
Applicant: �ilbll�l�l �IN1+l,�
Locatiom i� �� (�j,(� �,
Operatian Permit
System Type (in Accordance With Table Va): ,�q_
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
AUTH _ IZATION. �
l � f 7 �7 �2
� � Date
Tax Map 7�: rt w u Parcei �: d o�
� PCHD, rev. 10/12l99
, r
Person County Health Department -
Environmental Health Section ,
Zoning: Township: _� 1
Subdivision: Section• Lot: �_
Appllcant:
, �n
Location: ���� � �C� •
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requiremer� �
B) Distance from system to any wells �
C) Distance from septic tank to foundation
D) Distance from system to property lines ,�0�-
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank
B) Visually inspect the interior walls, b e, tee, fliter, riser, lids, air vent,
bottom, and water tight outlet
C) Date�of tank manufacture 3�-Z�l.-Zov�v
D) Tank serial number S� l 4Z _
E) Liquid capacity of tank _j d o gallons
3. SUPPLY LINE TO T NCHES
A) Grade (1/8 inch per foot minimum)
B) Material suppi line is constructed from SG�,{ �� �1fG Q�i
C) Diameter `'�
D) Length 3 �
E) Distance from tank to drainfield/distribution device �_
4. DISTRIBUTION DEVICE S)
, A) Type
� B) Is Device wat tight
C) Distance from the distribu 'on device(s) t the trenches �l.
D) is the device on a level foundation �_ �
E) Ooes the device pertorm according to its desi n speciflcations �_
F) Record the inlet and outlet elevations vl��.►f�
5. NITRIFICATION FIELD _
A) T�ench depth �7 mches
B) Trench width _�inches �
C) Distance between trenches
D) Number of trenches �
E) Length(s) of trenches �i��f'
F) Aggregate depth inches
G) Aggregate materia and size
H) Record septic tank ou et elevation ►
I) Trench grade (< 1/4" per 40')
J) Step downs �
� a. Minimum of 2' of undisturbed eartiy
b. Proper rise over step�iown ^�
c. Solid pipe used �/
d. Elevations of step downs (Record elevations and show on as built)
. ►
See "as built" plan attached sheet.
PCHD, rev. 10/12/99