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A40 306• - � a ?er.s:.r� ����unty �:�sith ��_' � � p� f —'7—oZ3 Amount paid IJ� •U �'��S.�'•�!,2f1$if2�t ,� S%; � R e e e i p t ;� _.�, j 6� 6�j �O�cCOfO. N.i. L: �� �, �- _ � b�,o ��C:'^er �"�2•�'3-15 D a t e � � APPLiCATiON F�R SERViCES ,.. . . _,; . �,� �' _ ,._._ ';;f '� '''� � Secv�ce'`s'`Requ_-�`�`e,,.sfeci ' =-�., � `•� '� �.L���:� , . .�: y_ _ _ _ .. .. .---._ .._,. ..__. . .�_ . .�. � .. -•s_. _�� �..r _.. _�.. ... . . . . - K . ...:: �.�v ...�..;,:���: o, F� O � � :� U � ¢ a z �� Impreveme�ts Permit.(Established/Recorded L,ot) I_ Reinspection of Existing System (Loan Closing) ImG:ovements Permit (Unrecorded Lot) improvements Pe�rnit (Mobile Home Replace) Improvements Permit (Addition) Repair/Replace existing Septic System _ Permi[ foc �1ew Well _ Replace Existing Well l. Permit :equested by: . 7. Dimensions or Pronose Stru ture:� �wnec/prospective owne:/agenC �f� /%�G� Width: .�-� � D� ��/ � Address: /-i�� �► ��' 1- � ` De�th: --G°' �� l . 8. What type (if any, additions, expansions, or replacement is anticipated io the stcucture oc 'acility that this sewage disposal system is intended :o ser�e? Home P� ene =�: 3�� ��� �— ,, Business Phone ;: 2. N� e and add Ss ",cunent owner: 9. Water suoply t}'pe: G�w . � priva[e �. public ❑ community ❑ spring C S�f s� -�2� h� � r'�re any wells on adjoining property?Yes ❑ No (� i iY. �'. �� s � J If so, identify (ocation: 3. Property Description: Loc size: /, �� 4. Tax Ma�: ..�� �� n I0. Type of structurelfaciliry: Proposed: �Existing: �i Parcel�: _� 0�6 Tyge of dwelling: ,,,.�/ Township: �.�.c� ��^�► House: ❑ Mobile Home: L� 13usiness: Cl 5. Directions to propeRy: State Road n& Road Type of business: Names,�tc. � � Number of Employees: -�.� - ���� Garbase Disrosal? Yes ❑ No i B asement? Yes o so, n o tiasement fixtures: I�Iumbec of occupants or people to be secved: ��_ CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORTIERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PerSOn COUI1ty �iealth Depax'tmeRt for a site evaluacion foc the on-sit scwage disposal system for the above described propecty. I agree that the concents of this application are true and represent the maximum facilieies to be placed vn the propecty. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Pecmi[ can b '�ssued, 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 pcoperty to the Hcalth Dept. wittiin 60 DAYS aftec the date oE the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. Signe�%wncr or Authorized Agent ,. .. _. . � PERSON COUNTY ENVIRONMENTAL HEALTH � �: PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT Tax Map #: � i O Parcei # ' Zoning Township � Ap�licant: I%1 Location• ' Subdivision: 1� � C�4�ectton: buildi New �/ Repair Addition �mprovernent Permit Lot: � � be issued with oniv an Improvement Permit Type of Structure �% � Water Supply �� ��(�J�x� # of Occupants # of Bedrooms �, Other Basement? �o Basement Fixtures? .�. Projected Daily Flow: � g.p.d. Permit Valid For: Q Fiye Years ❑ No Expiration Proposed Wastewater System Type: GD n Ue n-F,��n � Pump Required? Yes ✓�No Proposed Repair: Pu,mD .�n/1aU ; � �c¢55a�� Permit Conditions: '�'n��� �n Co n%oc.v` . � ,.. y Owner or Legal Authorized State Agent: Date: � — 2/ — � � Date: %—� ��D O s i The issuance of this permit�y 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 �ot 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 S stem _ � � y c�a/l UP�n ��o� Wastewater Flow: �l8 s.p.d. •tC� '�.� Facili T e: � New ���rs��n �+ i� ���e c� tY YP d Repair DExpansion ❑ Q� t �; d< < �r Basement? 0 Yes ! o Basement Fixtures? 0 Yes � No -• � i�.� )(C d � Q� un d iD�-'� • K�-P'P`" Wastewater Svstem Requirements � (,��(tx- �n F,� [d � 5�dr.. oF d �u Septic Tank Size: � � gallons Pump Tank Size: �_ gallons Total Trench Length: ,�,� feet Maximum Trench Depth: � inches Aggregate Depth/a in. !h: �l Mazimum Soil Cover: �, inches Trench Separation: � Feet on Center Other: Kt{Q (,.�C [ � ��17 � Ff aMSCr `^`c�, J�� F�c�M d �Rin� C CaS�/r� Permit Expiration Date: —1 3` 0 ( Authorized State Agent: , Date: �-( �" �/ The type of system perm ed ❑ does ❑ does no differ from th p specified on the application. I accept the specifications of this permit. L� OwnerlLegal Representative Signature: c -� Date: � � PCHD, rev. 11/18/99 Application #: Tax Map #: � Parcel #: 3 0 � Person County Health Department Environmental Health Section SITE SKETCH rh ` � S � g Applica ' Name Subdivision/ ction/Lot# - ' l�l�,r�n Authorized State Agent Date System components represent approzimate con[ours on[y. The conlractor must flag the system nrior to beQinnin� the installation to insure that proper grade is maintained aa � (,� ; � �j � c� K L a n �. ___._____--- (J; �ers� o� d� +�-� (� n2e�J -�-D be.. Ia r� 'To �S �� W tG�- • � Iso, i �- /12e�s -fo b � �8 „ �eep . l�o�-e-d � ���p� �eed fo b�. -�- �ac��q u • � GoPY �� c� J � Lc� K a- �`-� rQ( n a`�' f /�� P��� �� s�� � � '� �s���� �o�., Scale: Iv O7 TO .SC��-� PCHD, rev. 10/12/99 � ., . Person County Health Department ' Environmental Health Se tion Tax Map #: ��� Parcel #: �% Zonfng: Township: �j� Q� �Y Subdivision• ���l�� /�i/�GJ Section: Lot: � --�- Applicant: ��Qj'1/IVYi(� ��fi(��i�s Location• ILW"K K��C1 �G!eS O eration Perm it p System Type (In Accordance With Table Va): �Gt� 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 AUTHORIZATION. �l./I /. / .1� % ���J i /> / . -. - �.- '_ - ��{�5K �_�-oo P����, 5ysfz►� � dc�^'''n` a�°"`taNcd. DF �-l.;n� ;n5 N� p, � � y.� � icd Tax Map #: �'�� �,�� �� i1�`�� (� � �� � � � �� ��� � � �,���� a � ,1\ �` .� �' Parcel #: �0'��P PCHD, rev. 10/12/99 Person County Health Department Environmental Health Section Zoning: Township: Subdivision: cQ/.P� i2i�G�' �,i�P� Section: Lot: Z�J _ Appilcant: � Location: ' Operation Permit 1. LOCATION AND SEPARATION DISTANCES A) System meets .1950 setback requirements ✓ B) Distance from system to any welis C) Distance from septic tank to foundation � D) Distance from system to property lines Z/� 2. SEPTIC TANK A) Visually inspect the exterior walis and top of the tank � B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent, bottom, and water tight outiet ✓ C) Date of tank manufacture Z " D) Tank serial number D — E) Liquid capacity of tank gallons 3. SUPPLY LINE TO TRENCHES A) Grade ' (1/8 inch per foot minimum B) Material su �ply lin ' constructed from G C) Diameter D) Length 2� i E) Distance from tank to dra, infieldldistribution device 2 . 4. DISTRIBUTION DEVICE(S) A) Type � B) Is Device water tight ,� 1�� C) Distance from the distribution device(s) to the trenches �U D) Is the device on a level foundation E) Does the device perform according to its design specifications F) Record the inlet and outlet elevations 5. NITRIFICATION FIELD 2�, A) Trench depth inches B) Trench width �inches C) Distance between trenches �� � ov� �zv�eY D) Number of trenches E) Length(s) of trenches �1�1 F) Aggregate depth � inches G) Aggregate material and size ,��7 C/1'� H) Record septic tank o tlet etevation � I) Trench grade ' (< 1/4" per 1' J) Step downs a. Minimum of 2' of undisturbed earth �_, b. Proper rise over step down _� a Solid pipe used _�, d. Elevations of step downs {Record elevations and show on as built) {'GLf�(%� �/l� See "as built" plan o ttached sheet. PCHD, rev. 10/12/99 PERSON COUNTY ENVIRONMENTAL HEALTH , PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: � l D Parcei # v� `"' Zcning Township �`a� � � ��� Applicant: Location: Subdivision: Ty�e Qf VNater SupplV: Rec�uirements• �ection: Lot: �� Well Permit �� � unit Public Individual __Comm y Site Approved by �/KS 3' �`� Grouting Approved by � Well Log ✓ Well Tag � Air Vent � Hose Bib Concrete Slab Well Driller: 1\ • �` � �i�h� �1 Well Approved By: Date: 3 � �� � **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 f�et from any building foundation. Other conditions: M�-� � `"4 � � c- �} �s� � v�� !b ` ��O m / � c�r° P���'''l � � � a��p��� �.�5 �n S�`�e `�z� C� �S�e.� � PCHD, rev. 11/29/99 �!' l/� � ��( V � � /1� � 03/2�4/20(�0 22:05 8044547843 EEhI�dETT WELLDRILLING FEFSnt� Cdi►;t�'F �,1t'IpO��`�F'':T.�I, {it'Al.tl ►'�3.t. 1 ���. 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