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�_ Imprcveme�ts Permit.(Established/Recorded L,ot)
i/Imc�rovements Permit (Unrecorded Lot)
'_ Improvements Permit (Mobile Eiome Replace)
I_ Improvements Permit (Addition)
� ���m
Da te
,,...y _, .. ,
'equ'"`.�`esfed •' -` " j '':�':�
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ti.,A-�.... ...tds.=:i: �;�+. .�
_ Reinspection of Existing System (Loan Closing)
Re�air/Replace existing Septic System
r�Permi[ for vew Well
lace Existing Well
0
Petmi� :equested by: :
nec/p;ospeccive owne:/age
dress: � . S YSS
G�
ome Phcne `: �3 6 `f a-S�z
usiness Phone #:
'/� 7. Dimensions or Proposed Structure:
1� �Vicch: �- �
' " ea �PB. Deoth: `'I' �
�s�-3 . 8. What type (if any, additions, expansions, oc
replacement is anticipated to the stcucture or'acility
that [his sewa;e disposal system is intended :o serve?
t
__ Name and addre$s of.current owner: 9. Water suoply t}•pe:
' q- n, E
.p 3. Prope: �y Description: Lot size: /, /S
� . Tax Ma�:_ . �" � ° QQ
�: Parcel-: 3 /'7
�
Township: . �" ��
¢ 5. Direccions to property: Sta[e Road n& Road
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private �ublic ❑ community ❑ spring C
Are any wells on adjoining property?Yes ❑ No [�
Ii so, identify tocation:
�IO. Type of structurelfaciliry: Proposed: �Existing: C'►
Tyge of dwelling:
House: �Iobile Hame: 0 Business. C
Tyge of business:
Number af Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No �
B asement? Yes ❑ No �If so, n oE basemcnt fixtures:
�6. Number of occupancs or people to be served: ,�� �
CLEARLY STAKE ALL CORNERS OF` THE PROPERTY AND THE CORNERS OF ALL.
PROPOSED STRUCTURES.
I hereby make application to the PeL'SOn COu11ty He3lth Department for a site evaluation foc the on-sit
sewage disposal system for the above deseribed pcopeccy. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the propecty. I understand if the site is altcred or the
yntended use changes, the permit shall become invalid. I understand-that before an Improvements Permit ean b
issued, I must present a survey plat of the propercy to the Health Dept. I understand that in the event I have not
detivered a sucvey piat of the propecty to the Health Dept: witfiin 60 DAYS after the date oP the evaluation of
the site by the Hea(th Dept., [his application shall become void and all fees paid focfeited.
Signec� O�ner or Authocized Agene
� ; . ` � PERSON COUNTY ENVIRONMENTAL HEALTH
,, �� �' � PLEASE SEE ATTACHED PLAN FOR WELL SI7E LAYOUY
. Q,�j/� 3 i --�
Tax Map #: 1 1� 1 v Parcel #
Zoning
Township 1� � a-f' 1� I � C r
Applicant �C.t-rr1 m y r'Cl,� �� n`5
Locatlon•
Subdivision: � akr I C�QG 1"IC�C$ Sactlan: ��`--
Tvpe of Water Supplv:
Requirements•
Well Permit
�Individual
Site Approved by ��►J � � 3a -oo
Grouting Approved by �� �t '8-3� -�
Well Log ✓
Weli Tag
Air Vent
Hose Bib '
Concrete Slab �
Well Driller: c�;
Well �Approved By:
Community
Pubfic
Date: � � � `� �� _
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
Welis must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions: I���P �'��� mU.x� mu.m � 1 IDc���c c�-i5-tan ce Frt�r�
��-,�'�i C � -
PCHD, rev.11/29/99
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PLEASE S�E ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: I"t �'i� Parcei # � ��
Zoning Townshfp Flat Rivcr
Applicant: �� mm V �GL;L� � � ns
Locadon:�, %S � NuFF(�d, �DuS�r�nS Lanc Znd� Lo-t �n L� On F}u-t`�`mn �Pr��c
Subdivlsion: Q�_ 1�r�d-�G 1'IC-rC,s SecUon: Lot: ��
Improvement Permit
A buildinq permit cannot be issued with oniv an Imarovement Permit
New� Repair _ Addition _ Type of Structure �1i+ Water Supply �t�ivat� W� ��
# of Occupants�. # of Bedrooms � Other •
Basement? �_ Basement Fixtures�
Projeded Daily Flow�� g.p.d. Permit Valid For: � Five Years ❑ No Expiration
Proposed Wastewat System Type: Can U���� `� �-� ��"�V l�
Pump Required? � Yes No.� F'pr Rt a�r
PermitConditions:L�r��vSE�►'"� �m��-t �F��Ti�o� n ������a�i�n. D�vcrSi c�n
c�.i��� 5tioutd �c inS�+.i[cd r�s �5(�ocan
Owner or Legal Represen ve S'gnature: Date:
Authorized State Agent: Date: "��
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 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 Permitl
Type of Wastewater Syst� C�An V�r1-� � a!l aJ Wastewater Flow: �� g.p.d.
FacifityType:Im�b11C, fiOmt
Basement? 0 Yes o
Wastewater Svstem Reauirements
Septic Tank Size: �� �� gallons
New CY Repair DExpansion�
Basement Fixtures? 0 Yes o
�Fn� RcP�]
Pump Tank Size: gatlons
Total Trench Length: ,�� feet Maximum Trench Depth:o�`T inches Aggregate Depth:� in.
Maximum Soil Cover: �o� inches Trench Separation: —T Feet on Center
Other: �lee-Q W�II mG�Ximl,t.fY1 c111o�,�a(�I�, c��v�ance. FrDM 5��'��
Permit F�cpiration Date: o� t� 0�0
Authorized State Agent: Date: o��c'�
The type of system per ed 0 does Q does not differ from the type speciiied on the application. I accept
the specifications of this pertnit.
Owner/Legal Representative Signature:
Date:
?CHD, rev/ 10/12/99
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Application #: _
Tax Map #: �—
Parcel #: �I'1
Person County Health Department
Environmental Health Section
SITE SKETCH .
�� �arnmy �k; ns �a.K���c. (�cre� �4
Appiicant's Name S division/Section/Lot#
' � aC� �oc�
Authorized State Agent Date
Syslem components represent approximate contours only. The contractor must f lag the system
rior to be innin the installation tn insure tliat ro er rade is maintained.
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PCHD, rev. 10/12/99
, • • ' Person County Health Department
Environmental Health Section
Tax Map #: Parcel #:
Zoning: Township: ��a� ��Utt
Subdivision: �K���i� ���s Section: Lot: �
Applicant:
Location: !'1 t.t. �� /` 0�. �
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
AUTHORIZATION.
�-�-o�
Authorized State Agent Date
Tax Map #:
V �v.
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Parcel #:
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PCHD, rev. 10/12/99
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Person County Health Department
Environmental Heaith Section
Zoning: Township: Flat �i ��cr
Subdivision: Q7�Kri dyc (�Cr�S Section: Lot: ?J4
Applicant: �
Locati"on:
Operation Permit
1. LOCATlON AND SEPARATION DISTANCES /
A) System meets .1950 setback requirem �ts \/
B) Distance from system to any welts �_
C) Distance from septic tank to foundation i S�
D) Distance from system to property lines ln' D l(i S
2. SEPTIC TANK
A) Visuaily inspect the exterior walis and top of the tank ✓
B) Visuaily inspect the interior waiis, ba , tee, filter, riser, lids, air vent,
bottom, and water tight outlet -
C) Date of tank manufacture a- �
D) Tank seriai number f� 1 DOO S TR�q�.
E) Liquid capacity of tank /ODO galions
3. SUPPLY LINE TO TRENC�HES
A) Grade ./ (1/8 inch perfoot minimum� �C
B) Material sup�►y �ine is constructed from �C1�,4'
C) Diameter �3
D) Length � 4��
E) Distance from tank ta drainfieldldistribution device
4. DISTRIBUTION DEVICE( )
A) Type i� / -
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 perform according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth q inches
, B) Trench width inches �,
C) Distance between trenches
D) Number of trenches
E) Length(s) of trenches 35� 7' � I oa �/D� �
'F) Aggregate depth /a inches
G) Aggregate material and size ��
H) Record septic tank outlet elevation
I) Trench grade � (<_ 1/4° per 10')
, J) Step downs
a. Minimum of 2' of undisturbed eart ��
b. Proper rise over step dqum
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
Barnet2e Wa12 Drilling I�c 336 598 9275 d8/8�/f� 01:$4�P P.p02
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fJwner. � P� ���1.,, N1 ��t�-��-�tt•� Sl�#
I�oc=atipn,/Iaire�tiQn�: � "
5ubdivision Name: �� ' --t� Lo� # (..)
Drilling �on tractor: c=1 �� , c�t! � � �i- �c --
w��,L corrsrRucrroN �
�ic�-anrn frf�m No�w` �a�ir:n( i.+i.nv � G �ii�iia�VC 11l�Jiil J�J�arV� d�
a`I WI�IV V�ll � lV �
rdiiuti�n i � a
Tocal.U�p.ch:�.� �c. Yicla; �_ GPlvi Scatic Water Level �5" _�c.
Water Bearing Zones: Deprh t�Fc.C�_�t t�,_,_Fc. �'t. .
C^sin;: L�er�h: Fr�m____�_�t� �,� �s. Dia,.z�t�� �r�ch�s
'�'YP�: Stee� • Galvaniz� 5t�ei
��teel, does owner approv$; y� No______
� Weight: � Thickness:�� Height Abavc Ground: ��_ Inches
I?*ikP Chee: �eS ,� NO� , '
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Y�cre it8bl�rn� En�c�unier� in Seeting the �asing" Yes i�o / •�
�x "yes" giG e rcason:
Crout Type: Neac SandlCemenc .� Concr�te •
1a..T��1�.11�.r ��.+��'e Y1�idL}: �.*2�h�F. .
ti�. at�r iri l�r�nular 5paec: �t'� ivTo
_ . lvicmod: i'urnped Pressure �,�,,;_ Pouzed!�; . .
Depch: Fxom � U to '� Fc.
Mate*±als U��: N�. Bags Pezti?nd Cw*n�.: 17�ei^.��-,: �f .I bug :b�.
�?liXttllc. �S�ci�u, graYzi� Ciii�il'laSj - ��3i10: [O
� t�ia[es: x e5 � �0 '
. 4 x 4 slab Xes � No
I H�R�E$X CER'I�FY THAT THE ABOVE Il�ORM,r�TION IS CQRRECT AND THAT
T;�S w•E�,�, �v'�S C�NSTRUC?�D �i ACCORDAriCE WiTH REGULATIO�rS SE7
rGKT� AY�THE PERSO� C^vJiJTY HEALTH DEPARTIvfE�IT.
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gnature of Concractor � ' Ua��:
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