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A40 297� �, 'S . / � - iicatlon Date• �` ���� � !4mduht Paid. � D • � � ' Receipt #: � I � I ZZ ('��-� �b �' ���' 4�� Person Countv Heaith Department �°� Environmental Health Section �o� � -�j f0 6 C�0 �� Permit - �� �APPLICATION FOR SERVICES GI o26-d0 -,;< SeEvicesF�eqties�ed�=� ���:' ..,.: :,.. ,,... ... :.�.�.. �. :.: :corded Lot) - 3150.00 ❑ Weil PertnR (Newl (Mobile Home RepiacemeM/Addidon) ' � Tax �Ulao #• Parcel #: Inspection - $100.00 E�asdng System Pem - 575.00 . ::..:.t 1) Permit raquested by: (Ownedagent/prospective owner): �ir' �/� . ��f�o� Home Phone: 36'1- S'�g� Address: �o v� �.. , Business Phone: t'o3�dHoo �d � -�3 2) Name and address of cun�ent owner. r*N► ���"� � � �r o C � i'Si � ��faf"/'i�Y 3) Property Descrlption: Lots�s: ��� G Township: cr Di�edions to the prope Indudir�g d�r s and num e�s): � l � f�`� •��"f °�/� � � .� �-- ;� ;��g v c-lcr� 5 �y� 4) Proposed Use,and Structure Desc�iption: answer each of the following questions: a) Proposed PI Existing � / b) Sticic Built �, Modular a, Single Wide �, Double wde [�' c) Number of Bedrooms:� - d) Number of occupants or people to be served: 2 e) Basement: Yes �, No f yes, # of basement fixtures: � Garbage Disposal: Yes 0, No [� r �; � g) Dtmensions of Proposed Strudure: Wdth: %� Depth: �.b 5� Water Supply Type: Private �new ET or existing o), Public ❑, Commun'�l 0, Spring 0 Are any wells on adjoining property? Yes ❑ No C�'if yes, location 6) Please Indicate Desired System Type: (systems can be ranked in order of your preference) ./ Conventional l,,,Modified Conventlonal _ Altemative _Innovative Other (specify): CLEARLY STAKE ALL CORNERS AND UNES 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 evaluatlon 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 faalities to be placed on the property. 1 understand if the site is aftered or the intended use changes, the permit shall become invalid. 1 understand that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessibie for the personnel of P rson Cou Department to conduct their evaluations. I understand that i am responsibie for notiiying the Health Dep t if my prop i s any wetlands as designated by the Army Corps of Engineers. � f� 0 er or Legal presentative . D e PCHD. rev. 10/12/99 ,�.uS•L�• LUOU 12�UOFP�1 � �PdO•�10y F. 1 , � • . . . .. , .. � • �\ IF , . .J « r, 41 � • • • , , • , , • • , ' • � i.07 1• • .. ��;�, . � ' • , ^ , . , . . ' ..vtiti` tilu�c , . . . :.>- • ' . Ai,CCCJ' 0' � _ . _ . . . = P!!.�iSE ���� • , %� i . . •.. � v - � • • , • ' • ' • P.C. 11.. �P. '57=F• .. l.. ' . �, 1� ?,� ' ' , . ' • . �. � ... � - � • ,. '. • • e� � � .� ���F � � � . , . . . � � 1'�p : . ' , ' ; '��=��. � '. , � � I , , , . . .. � s,� �� •.,��`.� . � .'S���.�. �� �`� Z9 :. . . � � • _ . ..• • . . . i:. ��.�: : /�. ` � �� �Q � . � . . ' . . . � \ .. , S??.�, .. � / ` , . • �r . * . ' ' . .. . . \ `:' .. 6918%;`;` , � • • ` , h���r Y', ^�/ . , . . .. , , ��� �rA 96. ot� , �• , ... '• :E:•' .. • - r "�" . . . . � � • � �. ! L� I •yi, �fi .4 `� ' S . 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' v��' EASEMENT � . � • 1 ., . . i � '.:� :I:.i;:, , .< �;,: �r •e . �,�Yr�� �� ���• J4;.i.:�`Va•��Y 0 �.. .�J • , , i , � �.• • 6:' � � � � • . • t ' � . � "�,.• `� ..r: '.� ; ,: d ,.. '' �-y � v . .. - . + '� ' i ' .. y • � .. . •i.. ~`• I• �Y)'.l.I •�1�, •�,�.T• ���'' .4 �` /v/�. ' .. ' ' , , iJ . � • l .� .. � ,t. .� � ,' , n . '� .�� �. h' , ,`:r � . . . . y' . .. � o // . . • .. l � • . . .. _��~:� i"•,.• ' � I L , ••� �A I • � .. s �►polia�io� Oat�• l�b�—ov Amount Paid: __ • �'�. �i�� � ��c tYlaR #: �" � O Pau+cs! #: �o'� 1 `� - • : � � : � �ii _ii 1 � r Lt1 ��y � • � �-_ � � i� �►i� �ix 1) Permit roquestied by: �O,wrtaia���os pacllw c�wne�:_ Home Phoae: 3 6�F � s'�� � � Addmax Bttsiness Phone: � � . Zj Name and add�ess of cun+snt owner: •.SA-�r, % 3� Property Descrtption: Lotsix� �- � 7 Taw� �� // ,, /� Diredio�ts ta fho propesty (Inc�td6'�g toad names and n�k �7� �. G �- �,S'� 3 4) P�oQosed Use and Structctre DescrlQttatx anawe� eadt of the fo0awin9 Qu�iona: a1 Pto�oaed �. E�rW 0 b) Stldc 8u� Q ModWar Q Singie W(de 4 Doubla Wide 0� c� Numbet of Bedroomx �. �'Nutt�er of ocapants� ar peopla to be sacve� � e) Baseme� Yes Q No,�i tf yea. � of baaement t�cex . •� Garbage Disposa� Yss q t�cj,�7 � D6nensiatsof Proposed Strix�uta: VVidth: �$� papltr �e i H►� �PPhI �IP� Ptivaie E3'�new � ac mdatin9 �I. PubRc 4 CoRurnu�Y 4 SpdnQ 0. Are arty we�a on a�oin�ig pcopert��? Yas�O'I�o � ttya, Iocatlon 6) Plas� Indicab D�aiitid Syaiam 1ype: (systema can be ranbd In ocd� oi Y� P�l �ca�ventlonal I�o� c«ry.ntlo�i _ A�nauM. ,�nnova�v Ot1� (sp�cify): CLEARLY. STAKE All CORNERS ANO LINES OF THE PROP�RTY. 3TAKE THE CORNEiiS OF ALL Pf�OPOSED STRUCTURES. PLEA►3E ATT� SURVEY PLAT OR SRE PtJ1t�! TO THIS APP�ICATION i het�bY � ePP� to tl�e Peraon Co�mty Fbalth Departrnak iior a a�s ava�tion Yor the ar�i�e sawa�s dtspoaal sya�m' tha above�iescxibad propetly. l apnee that ltte cantents of this appi�ion ars tn� and repcesent ttte rtw�dmtun faa�[es to ptecad on ttte pnoQecty. ! undesstand � ths siEe is attec�ed cr the ��m�ded uss ct�anpes.ltte pean� shaY bec�xne inva�d. l und�s tl�t as ap�BCatrt, 1 am �espo�e fo� IdaiWj�ing and rtmrian9 P�'�Y �, � and maici�g the site aa�e tor t persau�d of Pecsort Courrty HesNh Oapartrnent fio cand�ct their eyak�tiac�s. l ta�nd ihat 1 am ta�ots� ��9 ' Hesah D if mY P�'oP�Y anY �� desi�ad bY ��Y ���S. „ � ,_�b�po L�al Rep�i�►e . Oaie � _ � ` a � ' . < . . � . '- ��� � .. � PLEASE SEE ATTACHED Pt�►N rUK svlL AREA AND SYSTEM LAYOUT � Taz Alap � f�40 �� �9 � Zoning __ Townshtp , �l a� RI � V Gi� �►PP�lcs�rt: 11'11Y1 (..7%ITn S Location: � le u�r , le 1 va L t L Ot On i� (,�t /� fZrSCe'�r`o/� �F su���: C�Krid9c Rc� es g.�,o�: �:__L q__ f,�i ld �Xi �� Lan c�� ' � Improvement Permit ��� n pr� vc A buildin� pennit cannat be issued with oniv an imarovement Permit New� Repair _ Addfion _ Type of Strudure�ll� Water Supply�ri va-Ec �c 1( # of Occupantsl0 �'1(�X # of Bedrooms �, Other _ • Basement? �Q Basement Fixhires? �Q Projeded Daily Flow�,�:t/Q g.p.d. Permit Valid For. I�Five Years ❑ No Expiration Proposed Wastewate � ysterri Type: � C� n U C�j' 1/)Q � l� rGt-V r'� Pump Required? �Yes No Fo r R � pa i r . Permit Qc5 F�Ct �� �.�il d�` c� � d e cl �v�.rs ` ;-�c h r r r'rc.d ,` c� u d "d F� ra-v�l, . ` / �� Owner or Legaf Represen "ve S nature: Date: Autho�ized State Agent Date: — C7 The issuance of this permi 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 mee6ng thefr requfrements. This�site is . aubject to revocation if ths slte plan� plat, or the Intended use changes. The Improvement Permit shall not be affected by a change in ewnership of the site. This permit is subJect to compliance wlth the prov�fons of the Laws and RWes for Sewage Treatment and Disposa) Systems of the North Carolina Aciministrattva Code. Autho�ization To Construct Wastewater Svstem (Reauired for Buildin� Permit) Type of Wastewater SysiemCanlf�nfi o�Gt I Csr�zvi�Vastewater Flow: �� g.p.d. • Fadti T e: m l7 . New�RepairOExpanslon0 Baseme t? 0 Yes �No Basement Fixtures? C� Yes �!t No Y„Ilsstewater 3vstem Reauiremerrts For RGPa� r Septic Tank Size: r, 00 o gaUons Pump Tank Size: � 000 gallons Total Trench Length: � fset Max(mum T�ench Depth: �� inches Aggregate Depth:� in. Maximum Soii Cover. � inches Trench SeparaUon: �1 Feet on CeMer . Other. �n Pertnit E�iration Oate: ' 1�'� o� ��S � Authorized State Agent: ' Date: ��� o��� The typa of system perml d❑ does 0 does r�pt diffe�frg�r�the type specified on the applicatlon: I accept the speciftcatlons af this pertnit �� ��� � OwneNLegal Representative Dete: � v� PCHD, rev/ 10/12/99 � . . , �� � -. � , , � . . , • � , , '' t Application #: � � � "` Tax Map #: _ 4O � Parcel #: �9� ' Person County Health Department Environmental Health Section SITE SKETCH � 'fG.(.J��t�,5 �K��ciyG �C�t.S ��% fY�. A plicant's Name Su ivision/Section/Lot# _ � q- � 9-oc� Authorized State Agent Date System components represent approzimate contours only. The contractor must flag the system rior to be innin the installation tn insure that ro er rade is maintained � 7, Cre�,�aF i�fr rl �/ � �ivers;�n ci�fxl� P�mP REP�.r �.. .%rWld� , � 2'd«f' 55 �nn� va�� �t L D Q 9'COrrutab� U � . N� p�,i�E ��P� �/��/� ' 3o�I y � � POtn'Gnq "'1• 0 �s �o 'xt1 T�►�5 (� �'IkdWfrock, � �,��0- a Pk�ce Scrcens Q1 5a � Ovtr �ndS oF � , � � '° , K P;o�. � ��- � ,- �5 , L '�` �`s- as � �s, �,o' � Sy f�cm h 7 � ' � �o - � 6et�t �+�5�� S P77c 9y �P�u�S °�s- O/1 �p� R�f+r � 10 � �► '�ct 7i � DrQ'�-�rq/ o _ I ^C � � �7 � � /L A�t,�,tu.mr� n �+� � L3 c u.l v er-� ��, . ,, �,,_ �,�, �`��� Scale: PCHD, rev. 10/12/99 � � Person County Health Department . - � - . Environmental Health Section Tax Map #: (7 Parcel #: 0�9 % Zoning: Subdivision• lXlKrtciqC, �Cr'�.S Appiicant: �l.rn My {+Qc,���i nS Location: l7�.t,FF %� � Township: FiG.� ��U�r Section• Lot• i � Operation Permit 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 ORIZATION. . � /0-9-0� Authorized State Agent Date Tax Map #: Parcei �: PCHD, rev. 10/12/99 Person County Health Department Environmental Health Section Zoning: � Township: �/�.'� � i � �r Subdivislon: (� K�� d q c I� C �cs Section: Lot: � Applicant: � m mv �Cc�ICIn S Location• Operation Permit 1. LOCATION AND SEPARATIOW DISTANCES A) System meets .1950 setback requirements � B) Distance from system to any wells ' I S �wcu not7n d�� "�. �^SP��ti°^� C) Distance from septic tank to foundation Cr' D) Distance from system to property lines ( O� lu,S 2. SEPTIC TANK A) Visually inspect the exterior walfs and top of the tank _� B} Visually inspect the interior walls, b e, tee, filter, riser, lids, air vent, bottom, and water tight outlet C) Date of tank manufacture �� a D) Tank serial number _,�T a E} Liquid capacity of tank 00 gallons 3. SUPPLY LINE TO TR CHES A) Grade (1/8 inch per foot minimum) B) Material supplX �ine is constructed from P VG C) Diameter `t � D) Length � E) Distance from tank to drainfield/distribution device �/� 4. DISTRIBUTION DEVICE(S) A) Type N � �' B) Is 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 �_ inches - B) Trench width ��_ inches� , � C) Distance between trenchGs D) Number of trenches `t E) Length(s) of trenches la ' ` 1/ " o' F) Aggregate depth / inc es G) Aggregate material and size #��7 H) Record septic tank oy�let elevation I) Trench grade �/ (< 1!4" per 10') J) Step downs a. Minimum of 2' of undisturbed ea h✓ b. Proper rise over step wn �_ c. Solid pipe used _� d. Elevations of step downs,� (Record elevations and show on as built) See "�� built" plan on attached sheet. ,� PCHD, rev. 10/12/99 � �q� � Pe��� �9 7 Tax Map #: Zoning Township �/� � � V� r Applicanx �a m m v Na � 1�1 �l'� � Locatlon: � �`'+ �� r �i ! � � '� Subdivislon: �K r i dq c., %cn-s Section: Lot TVpe of Water Supp1Y: Reauirements• Site Approved by � Grouting Approved by _ Well Log ./- � i Well Tag r/ � c'� a` Air Vent - �a � Hose Bib� s o Concrete SI� ' " Well Driller Well Appro Well Permit � Individuai Community Public ia G ��,� = yu-c�� V�ad' � U�� � v�i�eG��e� � �� 9 ro u-��e� w�`� ���= v�-ea-w1 f Vl l� ���f 0 20 d��°1� Date: � �� d� **See Attached Site Sketch** Welis must be 10 feet from property lines. Wells must be 100 feet from septic systems. Welis must be �at least 25 feet from any building foundation. Other conditions: =n�5�.f 1(��I as ���'� �� S`� '�`�t��'` 1� cv �ac.I (�(� a' 01 u�5 From cz. I f S��f� c.4 �' ra cii �crs � on d� tc.�,, �� �' L�a ' O � CaS �`n � fYl i � i m u-n'� PCHD, rev. 11/29/99 � t � � . _.. Date:�o-�v •� ' Owner. ��o �w I,ocation/Directions Subdivision Name: Drilling Contractor: PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG .� , ��� c.��e. � r � �o /( � r • �� Lot # l � WELT. CONSTRUCTION � Distance from Nearest Properry Line 1 v Distance from Source of Pollution ( G � Total_Dep.th: FG Yield: U GPM Static Water Level QZ,S—' Ft. Water Bearing Zones: Depth d._Ft. F� Ft� Ft. Casing: Depth: From 6 to�Ft. Diameter: Inches TYPE: Steel � Galvanized Steel If Steel, does owner approve: Y�s No � Weight: Thickness:� '� Height� Aliove Ground: I�i Inches Drive Shoe: Yes ✓ No . Were Problems Encountered in Setting the Casing? Yes No � If "yes" give reason: � G.rout: Type: Neat Sand/Cement / Coricrete Annular Space Width � Inches � Water in ATuiular Space: Yes No _ .. Method: Pumped - Pr�ssure � � Poured � � - � - � � Depth: From O to �, C� Fc. Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs. If mixtuie (sand, gravel; cuttings) - Ratio: to ID Plates: Yes � No � � � � � 4 x 4 slab Yes i No I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERSON C�Li�ITY HEALTH DEPARTMENT. O� G� gnatur f Contr tor Dacc � ;�