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A40 344� q-a7-oo AQollc�«, oat�►: � o Amount P�id: � ! �6 . �' ��a C� ��'63�6 ' � ao ., P a��,�,��. .� Perso� Courrtv Hesith Deoartm�nt Frrviro�me�! Heaith Sectlon �- � • �• - � �;�� �?= ,4=• � r 1F THE INFORIIAATION IN THE APPUCATION FOR�AN IMPROVEiIAENT PERMIT IS FAL91R�. C�WNGED OR THE SiTE IS At.TERm, THEN'THE IMPROVEiIAENT PERMIT ANO AUTHORfZATiON Ta CONSTRUCT SHALL BECOME INVALID �) F�:mit i+squestied by: (Ownerlag4ntlprospor.tlw ownec�: �Q m r, r� �l Ci t,J k i N 4 HOtIfA Pt10t1� ��a LM -�� C�-, �.. � A� .��`I `�1 S �i• u �<-/ l a Yi1 � I 1,5 �G(, B1i31110�5 PhOne: i� ' K' [aa �, r� r r-s Zj Nams attd add�ess ot c�ur�snt �oMrner. <'� a�; r, 3) Prop�rty O�scriQtioa: Lot s� 1, ta c� Ta� � D�sdions ta the proPertY (lrx�q toad r�smes and ntunbe�ak 4) P�opoa�d tlss and Sbruct�sre Descriptlon: anawa each of the fa0owrirW que�ons: ai ProPcsed Cr�E�d�ny � b) Stidc Bu�t Q Moduiar Q W(de 0. Double Wfde �--'"' c� Number at Bedtoacrss:�_ y�ai� � Ntunber af ocwpaNs ot peopi� to be sanre� L� e) Baaement Yes Q No (9�` yea. � of basert�ant tf�tuax • t� Garbage OisQosa� Yes Q No 8� m qh�siatis of Proposed Strudure: Widtt�: � 8 Depttr 6 0 ��r �PPht �YPo: Prtva�e 0(r�w � ac �d�p �� Puh�c 4 Cortrn�a�Y 0. Sp�inq �. Are any weUs on a�oidng propeti�t Yas 0 No O�ifye�, {ocation 6j PI� Indicad Gaiisd SYs�m TYPe= �sya�n�s can bs ranla�d in arda� ot Y� P�� �Cotivattlonal Modtfled Canranliosai _ Atb�tntiiv� ,�nnovdtw 01t� (sp�ity): CLEARLY STAKE At1 CORNERS AND LINES OE THE PROP9tTY. STAKE THE CORNERS OF ALL P�OPOSED STRUCTURES. PIEASE ATTACti SURVEY PU1T OR SRE PLAN TO THIS APPt1CATION I h�ebY �k�e a�8� tc the Pe�on Coucdy Health D��tibr a s�s av�k�tion for the on-dte saMwas dtsPosa► sYatem tha a�bo�e�escribed prope�ty. t a�roe th�t the con�ents of thia applkatton a�s tnm and re�sant the cna�dRuan � tQ Plscsd on �te pc+c�ecty. 1 undas�nd if the sim is altsred ac ths intm�ded uss � tt�e penn� shaY bec�ne invdid. i u�d� tt�t as ap�nt, I am tespan�ie fa idauf[ying and ma�idn9 ProP�Y iinoa. comecs and mnldng the ai6e a�e tar petsoctnal ot the Perscn County Hesqt► Dapattrnettt to condtu� tt�ir evakmtl,ons. l tautecatand that 1 am t� ��9 Hea�h D i! my �µ�� anY wetlanda aa dai�0ed bY ��Y �Ps ��rs- _a6-�� c� t�f RepceaaNauve . oate y� -- - �i�T15� �7�� � T��� _ � ' � viv►�m ,.� �5�t 5 F��SaAI GL3U� ��1VfRt3NlIAEt�ITAL 4�E�►�:Tl-1i nS �;. �'7 � 44� T� �id,-t- � �;,�ec,r -. � _(L� �s�s �' ' 1 - " s� a ��� o �, � � b� f'e � tmprovemer�t Permi# . �� � A buildinqaermit cannot 6e issued with onty an improvement Permit � Ne+�► ./ �e�r . ,� ry� a� srru� s�� � watec s�hr �( . # af o«x,pa� �-of Eedrooa�s '1 -3 ot� • • 8as�crt? � Base�ne�rt Fo�u+es? /� ' - � Projecbed Da�iy Fbw: ��'�i.d. Perm� Va� F � � � TYP� CD n i�elr PumP Requ�d?' Yes �No� p�po� �; c� n IrC' H PermitCon�ianx t%e<� Sus' tn � S ah Owner ac Legal Repr�ve i�� �,�r�:.� irl�� =�ir 0 Years Cl No � r. (o � Date: `� - 6 -o � Date: /a' �� o-a The i�uance ef ihis per�n� by the H�th Departrnecrt In no way gtrara� the � of otha p�n�s. The pe�n� holder is respons�le for ch�9 � aPP�P� 9aveminp bodies In meding their r�ne�ts. This sibe is subjed to revoc�tEon if the stbe pian. pfal, or the irttsnded use cl�anges. The haQrovema�t Permit slriU not be affec�ed hy a d�ange in ormocaf�ip af ihe aite. This permit ts sabjec! to s:amQl'�anea vrlth the provisions af the Laws and Rules for Sewage Tr�trnanE and Dispoeai SysEmas of !he Nocth CarcMa Administrativa Cade. Type ctll�tewatbr �OH1i' M �a wwt � IM� �_��SO.d �Y TYR�` , ��� .. . Newj�` Repa�O� Q 8a�met►t't D Yes �No 8�nt �? 0 Ye� I� � Wast�rater Svatem Reauireme� ' ' _ - . . Septic Tacdc S"¢e: dt7 � Pwnp T�dc Size: gaitons Totai Trestc�t Leng�t �� M�dm�an TrEnc3� �eptk �L �ftes Ag� DePttt� in- M�dmwn Soq Cover: � incfies T� �on: � Fast on Ca�er Pamit Exp�ation DaEe: a- a` � �� Ac�hotm.ed State Agent � Da�e: ' a� �'� • _ The type af sys�em permitted ❑ does Q does not. �fer from tt�e type specifled on the appUcatian. ! ac:xpt tho specifir.afiians of th� parmit �1ARi�� �iE.98l1�3hY� Si�l[S: r'� � ��� �: '7 S ' � `_ . . PCNn, �+►. zln�rss e . . __�_.. _._ .. .__...__.__._...___. .... .. --- - ��r��n Cz�unty iiealtla. flepart�nent n- �D � ��v�ronmeniaa Health Sec$ion Zax��ap �: •�'� _ . . � � Paresi #: � . � S�i"� S14ETC� _ . -. _ . �'ot�nrn� __�w-���..g . �v,��Oe . -�s �� �� s Name Subd sioNSedio ot# • /�-la� lou . Authorized S A �� � � . Sy�nr compu� �epr.esent apprau�e carrtn� only. The cnntractor nurst, fiag the syshm - Dri�ir ta berinn�rre 1�ire in�al�ion fo inrur� �P�Pu' Ri'� is malntained � �el( A,��, l�C ttiA i'�c'.t��� . fsi , � ► �O( � �� . I ��` ^'� > �r .- �� �5' �� .:�o m��. � � � ; sa' sa � Zg',��o' ` � ��i !�o r,..� 0 sc�ie: ( = � b � -- JMuMMMMt � �"V�frJ� x 3' �►,-� v�y,,�'o ►-w,/ S�r�'� S'� s�� ��. ti � 2-� �. �-X � r� �� �,. c�e j� CO�vPn rahq,� �/lcc,�r' 1 �. �}-1�L�. � l�=- I � L o �rt��,,,�, . . . . , • ' �.,��� � � �� ' • ��� ' . ' • . . , • '�. '+ai"r� ' . . . � . ��:.J'r``..�� . ,. a . . . �.::..:� ... . . . . � . . �31'�'3ZC�'a71 "^"" o'^' �.LL ��� . . �� . . .. ��l� ��� . � - �-..--- ..._.... -- _ .. �.T��.,.� � . � ZoNng; Townshi�x • . _ . . � ' �. -�� � � . 91�div�n: ` y •:_ . . ,8ec�ton: _, Lo� � .• p�� S /'� � G/��`�2 . . : �; � i - ��'�' 1.OcaNOtf: � - . . • .:; . . � � • . � � � � eration. �PerrYiit . . �� � � � . _ . . System "�ype (ln A�ordar�ce 1�'thi Tabte Va): - . . . . , _ . . . THIS S1fSiE�l! HAS 9E�1 tNSTAL9.ED IN � COYPl.lANCE WITF� A�PUCAHL.E N�3RTH � �AROUNA GENERAL STATU'�ES, RULES FOR SEWAGE '�REATiI�ENT AIND DfSP03/0.!, ��`� � ANID ALL CONDITIQNS OF THE UdPROVE�IENT PERAIR A�ID CONSTRUCT{OH . � � f�� /�Ui'i�0 N. � . . � � � � � `�%��- . :-{ � . . orizea state Agent � . ..��..._... _ _ . . � - - .. . .. . . � . ... . . . ... . . . _ _ .. _ . t . � ::r:� . _ . ,��c�" � r wt,r �S • , • �:/ �.� . :. . �q.�,Tt , ' � ' . � . • • � .•~ • • � • � • • ." � � . . � � . � �`� ,� � . � � �. � �a .Z�� �s� .� �z� , � . . . , . � � � � �'��1Z s� � �T � s2 << � . . � Yz r N [ -. • l� �r �� �,,.? , ':�� , �� ���., � . "_ :��� . . � � . . � . '��Z�► �� �� � : . . _. . � � � . : . � � � �-,�,� ---� � � �,� .. . . � . � � � � �� �� � � � � � ��b ���z �� � ��� � � � . 6 PERSON COUNTY ENVIRONMEAITAL HEALTH PLEASE SEE ATTACHED PLAN FaR WELL SITE tAYOUT ��� ��o � �� 3 �- �- • ToaiasdlP �L ��� � 1 � Q.� �6 . ��A i11 M, W 6= hs � � � � S a ►�.-��� � `Id 4�� � ��-a��fi �..� , � . . � � � �� � �= �� . � � � w�n Pa�it � � � Tvae of Water Suaolv: ReauirEmenfs• ��Md� Communify . _____ Public Sifie Approved by ��L 9- i9-a �. Grouting Approved by � Weit Log CSS 12-z �z. Wetl Tag � ✓� � � Air Vent ✓ � . Hose Btb _ Concrefie Stab _ ..f�" �' z✓' �r �V�'1-Ot..� '�aJfL.k1�'�-�- �s�r- n/a-r� �v'v.eaP�o, / �i�d8 v�frs f'.cl. Well Driller.����%�" Well Approved By �' Date: � 2-2�''2 "See atEached Site Sketch*' � Wells must be 10 feet from propecty Iines• Wells must be 100 feet from septic systems. Welis must be at least 25 feet from any building foundation. � � Other conditions: � � PCHD, rev. 11I29199 �1/1911995 �3:36 80a45478a3 BE��raETT wEI.LDRILLING PAGE 02 �-�,� II�I�IE�.� �� � � � _ �g � . � � � � � �� r.r� .� s w • � �1f `�/ �� � ��� - /�- G 2. 3�i�.a+�iac�.a�e�s.E.o.H ��e���E�. �i Ow� � I,ocati�o�: �S Subdiviaion: ,p�� y�g 3 4 �{ Taat � Pa�ccl # , �,,.,,_._ � .� w�u co� � g�, n�t pmpeaty Lino (Miuimutn tQ teoc) � fi�sn Soptia 3yat�n (Mi� � �� .�-- -- ft Tot�ttl Dapt� � ft Y'ield: �•� OPM Static Wstac La�' R 'Rietar Bearin8 Zonas: Dcpt� -1L�— ft � S _ — � _...--- C�i'°�' � �lZ ft. Diamebe�: �'n �to�m �_ __----.-- Zjr�pp, Cialvsnizod 3ooc1,�,�.,�...... ��: f�, —� We�g�: �'�• --L-�-- Height above Xes No Dtivo Shoc: �_ Y� _..._ No AmY I?a�blc�ns mco�barcd whiie adtia$ ca�in$'t _„_... .1�! If "yes" give rea�wn: t�a� �� _� C3raveUCem�t . � ✓ Na Noat: ✓ Sand/Canr�nt _..._ Anaulat gps�o Ri'ic� _,s� --� w� A�nulsr S��� Lo �. 4_" Ft Mcsbiod of Ci�ou� Pumpmd _/�„�. Ps'� ._---. Ms�et�ab UKd: �y�g� af 1 Bag �,� Pa�ds No. Bage Portl+md c�e�at �.-- If mixdu'a (eaad+ .Srg�n�„ �i — �io �-- b� --- m py�s; � Yas `.No 4 a 4 sl�►b � Yas � No ,� , _ ,� ,,,r Loca�loa Drat�g I heceby cGrtify thst the above i�nfoimatian i$ cotrect snd thai ti,is wall was co�structed in accor�ance with regu,latiot� sec finr� by t�e P� couccy xe��h nopa�tma�. ' /A///J/�� �l///� m s �9�/• n �- /i -�.Z. Qiww�iww w�/rww�Mww�n� �„/� '`.f /y(/�� �( %�'� � . �/��rJj'„'ti"`r` 029 79