A40 88Appiication Date: �—�6' � �
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APPUCAT1f3N Ft3R SERViCES �
IF T'HE INFaRMATIOR! IN THE APPl:�CATION F�R AN IMPROVEMEAIT PERMIT IS IIdCORREi:T FALS1FiE�.
CHANGED OR TFIE SiTE IS ALTERED THE3� THE IAAP4�OVE�IIENT PERMIT AP1D AUTHORIZ�►'�IOM TO .
COIVSTRUCT SHALL BECOME INVALlD.
1) Permit requested by: (Owner/ager�t/prospec�ive owner): T�N�' �, T�'��{//1�E�
Home Phone: ' 3!0 4- 2 ilc� Address: •� �9 E/a/A�P ]�' 3�7P2j' RD,
Business Phone: �,�(aGC2=�¢,3.3 —; ��-�€{�'-f�4k� �/. �' � `"�r�3
2) Name and �dclress of current ownec TO�'VY k'E�NETT
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1 � y r��2� �e� , ��'. � �.�r� 3
3) Pro{�erty Description: Lot size: 273 Townshlp: FL�4T 1P/I�c�ubdivision: Lot #
Dire�tions to the properly_(Induding road names�and numbers): �� �xIFl1 O�' /�/�/� 5�
4) Proposed llse and Structure DescriQtion: answer each of the foilowing questions: j��,� s�1 �+; �k1 �w�
a) Proposed �, Existing , Type of Structure: f10lISE �dth: Depth:
b) Number of Bedrooms: ,�_ Number of occupants or people to be served: �
c) Basement Yes , No,,C, Will there be plumbing in the�basement?
d) 6arbage Disposal: Yes , No � _
5) Water Supply Type: Private �(new � or existing�, Pubiic , Cammunity� . Spring .
Are any wells on adjoining property? Yes� No _ tf yes, piease indicate approximate locatiori on the
�site plan.
6) Dces your property canYain_previously identified �wisdlctionai wetlands? Yes No �
PL�EASE NOTE THE FOL.LOUHiNG:
➢ A Pl.AT OF i1E PROPE32TY OR SIT� PLAN MUST �E SUBMRTE� WITH THIS APPL1CAYlON.
➢ PROPERTY LINES AWD CORNERS MUST BE CLEARLY MAR�D. �,
9 THE PROPOSED L�?CATtON OF ALL STRUCTURES MUST BE STAi�D OR FIAGGED.
9 THE SITE MUST BE RE�►DILY ACCESSIBL� FOR AiV EVALUATION BY THE HE�4L.T;i DEPARTNiEAIT
STAFF.
f hereby make application ta the Person Caunty 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 application are true and represent the maximum
faciiiiies to be placed on the property. I understand ifi the s9ie is aitered or the intended use changes, the permii shall
become invalid. „
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Cwner o� Legal
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Date
PCSiD, rev. 06127/02
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C. B.C. REAL ESTATE CO., INC.
Ruth Crumpton Esrot� Traef
Fiat River Tap., Por� Co., tlG.
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Paul L8aI1�y,RLS-1561,Racbav,N.G
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Applicant: (8
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T��x M��
S�enh c1!i v i,s�i o n
♦
Parcel � � •
Ph�as•e Section,Lot #
�
Improvement Permit
Permit Valid for � Five rs _ No Ezpiration
T e of Facili : � �� • New Additi n Water Supply
� � '2 d ail Fl � � d
# of OccupantsV►�tf.i. of edrooms Pro�ecte D y ow g.p. .
Proposed Wastewa Syst � �'l�pv . Type: ��
rropos�d Repair: �l' , f d� Typc: �
n . . ,. _ �.
Owner or Legal Representative
Authorized State Agent: _�f
The issuance of this pemut by the Health Department in does not guarantee the issuance of other permits. 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 for Sewage Treatment and Duposal Svstems' (15A NCAC 18A .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.
�Autho.rization to Const�uct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_�.
Proposed astewater System: (�l�r'����/�il Type�� Wastewater Flow ��'t� g.p.d.
New Repair Expansion _ Soil LTAR: � c� g.p.d./ ft 2
Type of Facility: ;, Basement _ Yes No
Wastewater System Requirements
Tank Size: Septic Tank: �' C)1? gal Pump Tank: gal Grease Trap: gal
Drainfield: Tota1 Area: �1D sq ft Total Length � ft Mazimum Trench Depth �� in
Trench Width � ft Minimum Soil Cover: �Q_ in Minimum Trench Separation: � ft
Distribution: � Distribution Box � Serial Distribution
Specifications: %� —�K � �A ,r r` U �
Authorized State Agent:
P ermit Exx
l.�
ion Date: I' Q9�Y—
Pressure Manifold
Date: l(%`��2
The type of system pernzitted is � Conventional Innovative Alternative. I accept the specifications of
the permit. -
Owner/Legal Representative: �,l�lil.� �,I..Q.�c�-�..� Date: I o- ��-�a
PCHD7/30/2002
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Applicant: s �,�1
Location:
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T�x M��p i• : P�rc�el � � : •
S�ubcllivis�ion
Ph:�s•e�tS`�clt�io�a-'Lot �
C�peration Perrni�
� System Type (In Accordance With'Table Va): ��
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GEIdER�4L STATUTES, RULES FOR SEWAGE .TREATMENT AiVD DISPOSAL,
AND ALL CONDITIONS ..OF THE IMPROVEMENT PERMIT AND. CONS'�RUCTION
�AUTHORI TION.
/ : ._ . . . Z �.. • •
Authonzed ta gent ' Date
Installed By: �//i5.��✓ • Date: 2���6 � .
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PCHD, rev. 07/29/02
�,; � 5���'9C �'�►N� !RlSP��T7�N ��iE�9�LSS�' (iy�e fi - I�
Tax MaQ # 1 o Parc�! # �5� System Type (Table Va)
Owner/Appficant � .,,/,,/f� Subdivision �
Address/Location Sec/Phase Lot #
St�te ID/date ' � ""
�i�
Capaciiy. fa� a
Tee and Filter
Baffle
Sealant
Riser (ifi applicable)
Tank Outiet.Seal
Permanerrt Marker
Pump Tank
0
ISealant
J
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� r�ncn. uepu� /� L
Trench Length � �
Trench Grade
Trench Spacing �
Rocic Depth and Quali
Dams/Stepdowns _ etc.
Pressure Laterals
Hole Spacing
o e �ze
Pi�e Sleeve �
. Riser � Required Setbacks
Water Tight From Welis �:
Pump From Property lines
. . . _ G�ieck Valve/Gate Vaive : StructuresBasements
� Ant�-sip on o e .- �� itc es cainage ays
. .... . . Fioats/Switches �. � . . . . _: . .. _ . . _ . Sarface`Waters
Alarm visabie and audible Public Water Supplies
Electrical Components Vertical Cuts >2 ft.
Rate (gpm Water Lines �
Approved Pump Model Vehicle Traffic
Blocic Under Pump
Pump Removal Rope/Chain
� Distrlbution System
Serial Distribution '
ressure an o
Low Pressure Pipe •
Appr. Pipe Material and Grade
Valves
Comments
artate
�/Right of W�
Other
� Recarded .
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pchd reu. 3/13101
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WELL PERMIT
PLF�lSE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: ��' d Pazcel # g o Townslup .
Applican�
�
Subdivision: Section• Lot•
Twe of Water Su�nlv: � IndiPidual
Rec�uirements• �
Site Approved by
Grouring App�e6ved bg ��'�r�3
Well Log �/
Well Ta� ✓
Air Vent �
Hose Bib �
Concrete Slab
Well Driller. T���S
��"Z'D�
Communitp Public
Well Approved By:_%�.�11 �C.�i_(��1�(/1 Date: '�� -2-�3
'�See Attached Site Sketch*'�
Wells must be 10 feet from propesty lines.
Wells must be 100 feet from sepric systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PC�ID, rev. 09/07/01
�`} � 11--' I.�JI�.� �U�::`� �ut,u�ti ..� � :.-�� � ,
. �� - ` " : � - - � • �\7" �l�llIll b ' � Wiai�Nl� � '�l c r � I , n. �,
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� .u.�.vr�i n-•C� 3i7i7L?�:n.�t: li.T. �L..:�,. li. 7.E�.L•v-..:n.�l iL�l:n. �C� ��.iG��� , � .� � � � ?�3
Owner:
Location:
Subdivision:
�c:� �Ob
�L�.L\ IY�:I() � l�:ll'CC� ir ��
Loc IE _�
ti�!�cll Cozistx'ttcfic�xt
Diseancc From ncarest 1'ropcx-ty Liuc (Ivliniinum 1 C�teet) r`� ._______.._._
Distancc £rom Scptic System (lviinimum GO fcct) �
Total Dcpth: —/ ��R Yicld: 3 � GI'M St:�lic Wacec L�ve;l: ,�� ____ l�t
.� Water IIcarinb oncs: Dcp[li � !t �c _ :'t _ 1�c
Casing: .
Dcpch: rrom _[L_ to �f t i1. Diacncic�-: _� in
;;.� Type: Galvanized Stccl '� �
. Wci�h[: / � '.'.�hickness: � I-Ie:iUht abovc Grouncl: __� >� in
Drive Shoc: ./ �'cs No �1.ny ��roUlc;rn� cnc:ouulcrc�l wliilc: sc:lli�i�; c:��in�'? __ 1'c� �—No
(f "yes" bive rcason: �.__
Grout:
Neat: S1l1CUCCIT1C11[ ✓� Concrcic Gravel/Ccmcnt
�A.nnular Space Widtli �_ inches Wciler in A.,unular Space Yes `� No
Mcliioci ofGrout: Pumpcd I'rc;ssure: ' 1'oured `�_ Dcp�li `� to rt.
�YT,atcrials Uscd:
No. IIa�s Portlacid ccm�nt Wc:i�;lit ��i' 1 13:�� Gi�__ ['c�u�icls
I� I1�1Yh11'C �S111(I, �r�vcl, cuttia�;s) — J.Zatio _� lo l
ID platc�: �''cs No �� x�� slab .�1'e� �__ No
1Jrzllixib �.ob �,c�c:ifioii �)r:lwii��;
i hereby certify t�lat thc aUovc intonnacion is cone:ct an,d thac tlus wcl! tivas c:onscructcd :n accordancc with re�ulations
;ct forth by thc Pcrson County i-lc:• ch Dc:partment.
Si aturc of Contracto�� � � 11)1E �. _ U:►tc �� �- �
�" � PCI�.D tcv O1116102;