Loading...
A40 9�� - . . . .. - The District He�lth Department Orange, Person, Chatham, Lee Counties SEPTIC T�►t�OiC PERMIT C�,�l w �-�t�e-+�'� ate �� � � � � "� lVame of owner ' �' ' � 5`� �? 1-{ wrr.�i�P i�l� l�S � Address and Directions � �� f Person or firm doing installation: ✓'� �`'���'� ''r��, �'''����""'��-'� � i�_7 �-�� (�� ..1 L,t f �� . Address f �-,.' No. of persons to be served bedrooms 1, 2, 3, 4. Additional appiiances to be' used: Disposal, dishwasher, washing machine _ / � Minimum� uirements: Septic tank ` "�� �'� � �'" � J �j� �` -- j�"� � Nitrification line: � � � l �.- l ..� Septic tank and nitrification line must be inspecfed and approved by a member of the Health Depaztment staff before any portion of the � installation is covered. Date Approved: � l'� �'''' �y e `�' � 1,� ,.1_::.... �,. .P,� / 1 ' � ' v � By: � � " %'' ' �> Sanitar�an � ' O. David Garvin, M.D., M.P.H. District Health Officer Countersigned (Over) • i NOTE: �, Make sketch of installation showing location of house, septic tanks, privies, water supplies on adjacent property, etc. Write in measurements in order that installations may be located at later date. � ' r. ,t � ', � t � r �' . Y--� ... _,__ �� `.`�..1' � _ � ����' �i a� c- �} ��,rn � -I--�' : . �f, , � , � A 13 2 4 •� - �� • PERSON COUNTY HEALTH DEPARTMENT � � WEL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT Tax Map # �yb Parcel # q' Zoning Township � �a.-� �; � e..r Owner/Contractor c- c� � LJ GL.1 ��(" Date (o -u - 4� Location/Address 5�'NZ N t.��c�1� M� 1�S �- S.R.# Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATIONS Repair ✓ Lot Area Size of Tank i Si�' - 5l)<' SFD L� Mobile Home Size of Pump Tank N) Business # of Bedrooms�_ Nitrification Line 2� x�' Max Depth Trenches Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is red or intended use hanged. Well and Septic Layout by �- � � Comments: � � L � -�-- ��' � ` � � Date Installe by Approved by WELL SYSTEM SPECIFICATIONS Individual 1� Semi-Public Required Slab _�,�-�'��( �'7 ���%c�-- Public Replacement ►i- Air Vent Site Approved Required Well Lo� � D Well Head Approved Well Tag Grouting Approved C���! c7��'t � Comments: Date Installed by ��n 2�-'-f-C� Approved by. t� � This report is based in part on inforniation provided the homeowner or his/her representative in the application submitted for this pemut. The environmental health specialist is not responsible for false or misleading infotmation contained in the application The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the envuonmental health specialist warranfs that the septic fank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�peimitsam O1/95 rev.1.0 ORIGINAL 06/04/2014 10:32 3363228640 REGISTER DEEDS PAGE 01/01 Apgiication Date: w D ro%l.Ko��'/� �.��� ��!L'J��`L-�� Tsyc 11xap: �� Amannt Psld: _ _ A 1 f�,_ � � ��.�.� �'arcel#i �, Receipt #: _ � l � �3r'm..3.n«oa.�ea�sa4�..R ]HL.e,�ll�3b. -�-1) Appitcaat �n ri�uatRon: Name: ,i� � Gt�3 �.LIC' rr , _ Address: �;,� G� l.l r e�w � 2) Name sad addresii of currea owner (#f difFereat than a,ppllcsrr#)a Na:tee: Addreas: � 3) Praperry Descripf:ion: L,at Siu: .l G Y 3ubdivision: Addross andlo� diAections w,PraRorty:. S�. �,�. Phona {homa): f V (worrwaeu>: e�i 7-� 2 3.� T'•'�'�f� � aG ca W �c�3--����� �_ ���,.� Phon� #: C] yas o Does tha sits cantain any juris� tmsl Wett�p �7 (J����.�•� `h �'/�-�„1 �-j'i'"es C1ya' Doe9 the site contain an exie waatawatear s stema? C� J ❑ yes �ny •. Is arry wastewater going o0 6e gaaeraoad ou ti�e aita ot�ar tbsr► damestic sawage7 [7 yea �.�Yn�o . ie ths aite suhjeat w approval isy any other pcsi�lic aganay? ❑ yes �•!Io qra theca any cascments or rtght of ways on t�n prop��ty� (if'yea' is oheckad, please provida supparting dacumeuratton) oi� ' 4) ased Uso and'�ype of Structure: n q I•faw Siagla �ami�y iteaidanca Maxi:num number p£bedrooms: - p�B�anslntl of 8xistiag $ystem IiexFansian: C�ent number of h�rooms: . tr m al ctionl�g Sysient Will there be a basement? ❑ yes CI tto With plutnbtag fixtaues7 O yas CJ ao G1.J ��l�.CtE:' ct.�-� � a�r,�- h ea v�¢��-- C,�'��r,-1-�c. ,�'��'-t�,f•, c�� :�C ��-�Q/-{�.� p� Cl�i,se,..-x�ald attal � � � c�ui. �-�� ..---,� � � TyPe of businesa: Tofial Square R�Otage of Buiidiug: 1Vlaximum rtumber a�emFaloyees: Msximum numberoFseats: g� W4ter guppJy, 01Vaw well ❑ Existing Woll ❑ Community Weii � Public Watar il Spring Ara ihere any e�tisting wolls, spiings. or existing waterliaes octthis ProPert}�t ❑ yes Q no 6) If applytng for `A,a�thorl�at,ion to �Canstrrxct'� p[ease indir.�te pr+eferred ayetem lYF��)� C] ConvenYioaal CI Acceptad ❑ innavatsvo CI Aiternative ❑ Other 0�y j cert � that ehe informatian provided a6ove is complete asad carrect. I also undersfas�d tkat �'tha i�+'orrr�aaaorr,provided is tricrccur-ate, or if the s#� is subsequaretly alt�rsd nr the int�srded use changes, al1 peryRits and q�prwals shall be imalid. perptits are vauEld for either 60 atonths or ara noa-exPfring w'b@n accompanled by an approved glat. A complebad `.Lot Prepm°ateon' form must scaompauy any appficution reqWr�ng a afte evalnation. !t!1/1 �1 Po.�a�.� (`n��..t�� Frfin�/�NY�o�I�ol TxP�O�YM Q7ri �. iVlnr�satt Ct .G�ii1fP� 1?..vh..r.. 1�7l� ^1^7C^7'� /'1'}L CC1^7 ��snn� Application Date: � 6` ��` OS Amoun4 Paid: Rec�iat �#: iax iVla� �: � `[" O Parcal �: 1 _ ��1�� �� ���� �� — - : � � �.� � � �� 7� �_�aa-oaa,�-�--^ .Dsa�.eal1 ��L�.�.IL�.]La /3►PP�ICATIOtd FOR SERVIC�S IF THE IN�ORNIATIORI IN T�IE ,Q►PPL1CATlOP! F�Oi� ,4i�! IMPRO!lEiViENT PE'Rtlfll'i IS INCORRE�'T, FALSIFaE�, CHd�i�GE� OR THE SiT� IS ALTERED T�lEiil 'THE IfVIPliO�'EilfiEiVT F�EH�f�il iT A►ND Al9TH�RIZZx�T1�N Tt� CORISTRUCT SHALL SE�OME IPIVALI�. � ���e�' �� � ��N. �) Permit recgta�ted by: (Ovunerla ent/prospective owner): ��'`� � e� �� � Home Phone: _� � � 3 r1 Address: .S-�'�a e/�� ` lS .'eCr�- Business Phone: 03— ! r7o3 �,s��ob , /1.�n _ � �I__S��fC � , 2) Name and ac8dress of current owrnea: ��OL c� �`J��iC�/e. ��8�i-ol L�c�� �e �,!(S /�� � . o��z �U� �.�JU �� 3j Property Description: Lot size: Township: �`d� Subdivision: Lot # Directions to the property.(Including road n�mes and numbers): __ _^ �, 4) 5) c� � 1 - c� �� v � � i� w � ��cr �' S'�' �u- ^ eh l � �, �t-b �c� � . Proposed Use arad SQcvcture Descnptoon: answer each of the following questions: a) Proposed _, Existing , Type of Structure: Width: Depth: b) Number of Bedrooms: �_ Number of occupants or people to be served: c) Basement: Yes� No Will there be plumbing in the basemeni? d) 6arbage Disposal: Yes No ' l�lat�r Suppiy T�pe: Private (new _ or existing�, Pubtic� Community� , Spring _ Are any wells on adjoining property? Yes_ No _ If yes, piease indicate approximate location on the `siie pian. G) Does your property c�ntain previously ident�ed Jur�sc9ictional weilands? Yes_ I�o1� PL�►SE 1�OTE THE �OLL�WING: 9 A PL�1T �F THE �ROPERTI.OR SiTE PLAN iUiUST BE SUBMITTE� IAfITi�l '�'i-!IS �►PPL�CATaON. ➢ P4�OP�RTY LIPIES AND CORIdE32S MUST BE CLEa1RLY MARI�ED. �, 9 THE PROP�SED LOCATIOId OF AL�. STRUC'Y'URES flflUSi' 8E STAKED OR FL4GG�D. 9 T�iE Sl� MUST �E i2EADILV �►CCESSiBL� FOR AN EVALUATI�W IB'l'i➢-iE 9�EALTH �3EPARTi�iENT STAFF. I hereby make appiication to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this appiication are true and represent the maximum facilities to be placed on the property. I understand ifi the site is altered or the intended use cnanges, the permit shalf become invalid. Representative �' � U � 01'� Date PCND, 2v. a6127l02 � ��� . ' �) T�x M�� f'�rce:l # � I•' I�. I� ���) \ s��.b����s.�o„ � � ��� � S � � Fh��s• Section Lot # I�, . „ .., �„� , � I I I - - I � !, Applicant: �s�� ln��e�' - Location: �L'� � �r `�� � 1� � Improvement Permit Permit Valid for � Five Years No Expiration Type of Facility: ' � '� New Addition _ Water 5upply LVC � # of Occupants � # of Bedr oms Projected Daily Flow a�lv g.p.d. Proposed Wastewater ystem: ' Type: Proposed Repair: _�M���r,;�r,nD TYP� Q-- Permit Conditions: Owner or Legal Representative Signature: Authorized State Agent: ���p �-{ Date: /b�/a��C� Date: � The issuance of this permit by the Health Department in does not guarantee the issuance of other pemuts. It is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules %r Sew�e Treatment and DisPosal Svstems' (15A NCAC 1�A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewater System �Required for Building Permit) * See site plan and additional attachments (_�. Proposed Wastewater S stem: �l'�V�����1(,�1D Typ�Loa Wastewater Flow �g.p.d. New Repair Expansion _ Soil LTAR: g.p.d./ ft 2 Type of Facility: Basement _ Yes No Wastewater System Requirements Tank Size: Septic Tank: — gal Pump Tank: — gal Grease Trap: -- gal Drainfield: Tota1 Area: �� sq ft Total Length � ft Maximum Trench Depth ��_ in Fxz�l � �. . Trench Width � ft Minimum Soil Cover: �_ i� Minimum Trench Separation: � ft Distribution: Specifications: �Distribution Box '� Seria1 Distribution Pressure Manifold Authorized State Agent: c� Pernut Expiration Date: 9 Date: g�/ The type of system pernutted is � Conventional Innovative Alternative. I accept the specifications of the perniit. / Owner/Legal Representative: �� �� Date: a/O ( d PCHD7/30/2002 �.�� ?, 9 � 1L J!_e�� �� - �- �.�����' " lCaawa�c-�,,,,,,-,•-,,.eva�.�.]L IHL�.m.Il�1ia SITE PLAN Name �QY�I �I �f'►� Tax Map # r�� Pazcel # Q division Section/Lot# �.�. � y Nz� 9/��/ �l Authozized State Agent Date System camponeats representappmadmare conmurs only. T3e coatracrormustl7ag the system pdar ro beb ��ina theinsra!/ation tn iasure thatpmpergrade is maintained _ n��aan�.r allse�irx�ci�s � �- .�� '�, i---� � . 5y ' �- I�a�.l �n � � ► n �- ��� I c�ver � �� c3 '� r�er ce��r d.yGU n�p r���k5��\e �� dX�veway — ---� �'� �—�- 1171 .l.s�cale: ,�-�a�-e M;��g 0 zd--�. g5 � N�,.rd��e M�,�is +��aca (�j���) ��� 'C���1���5� �-, S �- �ep.�-yp1 ��� ► 5;'7-17�ifl `�.�:,� .� rcxD> re... o�/iz/oi ���, �� ���� �� ` � � � � ���� �aad-n.���*-�+,�,�„ ����.� ����n.Il.��a. Applicant: Location: :'.;, �. , . ,�. !� . `.� ax Map � P�rcel # • Su�bcilivision Fh�se Sect�ioniLot # # of Bed!rooms System Type (In Accordance With Table Va): i� ��"L ����a) THIS SYSTEM i-�AS BEEN IlVSTALLED IN COMPLIANCE WITH APPLICABLE NORTH CAROLlNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, • AND ALL COIVDIT10iVS OF THE IMPROVEMENT PERMIT AND COi11STRUCTION AUTHORtZATION. � �����,� � . , � l���c -� � Authorized State Agent Date Installed By: c�P�S�e �s%v cc��- � d-�"v)C . � C(1r1'le� � o� hou�e� = �5 Date: t 1 �! u�1� d ,, � � � _ _�C'5:��' _ �(1 I` P � a� , 1/ l-iurd le N�i II� (� PCHD, rev ,; =� �o�,�� 07/29/04 �����C r,Q��� ��si����-ao� �ui����.�sT R�@,� �i -� Tax Map #� Parcel #`�f Sysitem Type (Table Va) �— q Owner/Applicant CGtrc� I INC� �-KP� Subdivision Address/Location Sec/Phase Lot # ���1� �-1urd�� ��ll���cl � Sept�c Tank n�t�a Date itr� �ca on anes Inetaa ate State ID/date Trench �dth ft. �� �� � Ca aci al. � � Trench De th in. Tee and Fiiter T,rench Len th ��ft. ✓ Bafffe Trench Grade ✓ � Sealant Trench S acin � Riser ifi a licable � Rock De th and Qual' Tank Outlet Seal Dams/Ste downs etc. � Permanent Marker Pressure Laterals � Pump Tank { Hole Spacing tate ate o e �ze Ca aci al. Pi e. Sleeve Wate roof /Sealant Turn-�t s/P.rotectors Riser Requirecl� Setbacks Water Ti ht From Wells i� i I Pump �( From Prope lines Check Valve/Gate Valve Structures/Basements ✓, Ant�-si on o e itc es raina e a s Fioats/Switches Surface Waters t4larm visable and audible Public 11Vater Su lies ✓ � Electrical Com onents � Vertical Cuts >2 ft. ,/ Rate m Water Lines ✓ A roved Pum Mode! Vehicle Traffic � ✓ Blocic Under Pum Ad'acent S tems ✓ Pum Removal Ro e/Chain � �Easements/Ri ht of Wa s . ��Distribution. System Other s << r�z�5 Easements Recorded ressure ani o erti ie erator ontract Low Pressure Pi e l"ri-Partate A reement A r. Pi e htlaterial and Grade Valves � Comment� . � � pct�d rev. 3113101 � i . . . .. :..... ... ;. ... .. .�.. .. ..._ ... _...... .PERSON COUNTY ENVIROtiMENTAL HEALTH WELL LOG . i h .� I �t i`�k� S'^1�.,� � . ,. .. J� � : , Date: � Owner. _ � �:',��c� 1� ► �, �, � SR# Location/Directions: Ta�►+_ . ��, r_ � �{2L� '3t� ��TN ��,u �, ,� . � e''�SVG /�ELt S2'["8 diil ( �T -�"�r- �� Z � Subdivision �Name. ___ Lot # Drilling Contractor:�A�4�rt�1�-iC'E ��"�TL/ T� , WELL CONSTRUCTION Distance from Nearest Property Line_�p' Distance from Source of Pollution 1ao � ' Total D:ep.th:�0_.__ Ft. yold: ZS __ __ GPM Static Water Level�� ��_ Water Bearing Zones: Depth�.3 ��I�t.�!_�_Ft���� �t. � Casing: Dept}l: From e3 to�_Ft. Diameter:_�'�_ ��}l�s TYPE: Steel � Galvartized Ste�l /r If Steel, does owner app:ove: Yes No � Weight: Thickness: . t88 Height�Above Ground: �� Inches Drive Shoe: Yes .�No Were Problems Encountered in Setting the Casing? Yes No � If "yes" give r�ason: Grout: Type: Neat Sand/Cemert Concrete Annular.Space Width Inches Water in Annular Space: Yes No _ .. Method: Pumped . _ Pr�ssure � � � Pourui��_ � � �. : . Depth: Fr�m_ es to Zd Ft. � � Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs. If mixture (sand, gravel; cuttings) - Ratio: to �ID Plates: Yes / No � " �� � . �� 4 x 4 slab Yes / No r i HEREBY CERTIFY THAT THE ABOVE INFbRM�1TI0N IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERS0�1 C�ui�'I'Y HEALTH DEPARTMENT. - ignature of Contractor Da�c � ►,.