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A40 97Aopiication Date; Amount �aid: � Rec�iot �� C��-�� ����� �� I�I��� �l� -- � � ����- 1�s3�-3rao�--,• �-,•-,• �o�_��.11. g�o�.11�S�a. APPLICAT10lV FaR SE3iVIC�S_, . . i ax ��lao �: �7"' Darca� �: �-�%---- 1� THE iRlFORflAAT10iV il� THE APPLfCAT10� ��R APl IIVIPROVEi1�Ei�T P��fVIIT IS INCDRRE�'T ��LSiF3�i� �HA►�GE�. �R THE SITE iS ALi'�Ci�ED. THEi1! i�iE IMPROVEiI(!E�lT P��MI�i' �,ND �UTNaRfZA'�'ION TO COPlSTRdICT SHALL BE�OME IPIVALID. � '1) �ermii requested by: (Owner/ageni/prospeciive owner): �QWE� . �R�3�'s7' � �E� Home Phone: S Address ,�SG3�u RK� � s'�` 'R��r Business Phane: � 2) �lame and address o� cvrrent owner. . � � 1� 3j ProQeriy Description: Lot size:,z��- Townshi Directions to the proRert}� (lncluding road n�nes ar Lot 4) �roposed Use,and Structure Description: answer ea h of the fol�pwing questions: J a) Proposed ✓. Existing Type of Structure: ��cl%eM h�Usri �Nldth:� Depth:� b) Number of Bedrooms: Number of occupants or people to be served: ,�_ c) Basement Yes , No Will there be plumbing in the basement?� d) �arbage Disposal: Yes � No _ 5) 1iVater Supply Type: Private �(new _ or existin , Pubiic� Community_, Spring _ Are any wells on adjoining proper#y? Yes�No _ If yes, please indicate approximate location on the '.� •siis plan. 6) Does your properiy cantain pr�viousiy id�nie�ied jur�sdic�ional weilan�is? Ves_ fdc� � P��ASE i�OTE THE FOLLOWING: 9!� PL.AT OF THE PROP�3ZiY OR SiT'E P.l�N 1�iUST BE SUBiYI1TTE� 1M'T�i 'i'3�IS A6'PLiCA3'101V. � Pi�OP�RTY LINES I•1ND CORiVERS MUST �E CL�,RLY MARKED. �, ➢'ii-iE PROPOS� LOC.�1T10(d OF ALL STRUCTURES tlflUST HE ST�i] OR FLAGG�i?. 9 Z}�IE S1TE MUST BE REA►DILY ACC�SSiBL� FOR AM E1/ALlJAi'10N S`t TD-IE HE�LTNJ i�EaARTME�T STAFF. � I hereby make application to the Person County Health Department for a s9te evaluation for the on-siie sewage disposal system for the above-described property. I agres that the cantents of this application are true and represant the maximum faciliiies to be plac�d o� the property. I understand if ihe siie is altered or the intended use changes, the permit shall became invalicf. �i _ _ . ��, �s Cwner or Le�al epres�ntative �� aie PCiiD, rev. 06/27l02 . � , � , �, , , ,� ,, .� • ,�.. �. �..,... _....._......___..... �._...,..... , _.�_......,.�,._.............,_.._...w,........__......_...�.,.._..M..._._-.._.,.._..Y....�..,,,,., ,:: , . • � ��� � �� . ' • . I 9 � I •. ,,``����iu��i�,,,,�, � 11 �- a,, � � ,, . `�� ��',�. ����M�.•�•�, ii� . ,j1���111111N��� ' � a r . ' <`\'•' • a 1 •' • '`- "- � ..�.',, , , ,�� � � : � C (J �� � �, .• .,� . -��� � �, � ^ � W � '� m : :.'` , .• ,� � ��� . ' „¢�'� � . . � �T: r x m= _�-,;: . � ,r :�• b s''"� �'., C� .� � �2' : . � �; ''' � � �1 �„ `' _ w ` :�„ :r• '� (/� .O �'4 t� �� •..... ''.�`� -� � �� r, �i � � ` � � � ��' '' .� ; •, •'' b��,r ,,`��.� �; f, :�,� � � � '�►�r���i�►�� �.,�� �''•,.....•••'� •,`ti. ♦ ,,�'''i,r,����i���`��` � a � � z � ..-. � � .. I o � �- � cn s � : - z X+ i :: � m .. ... �L w �. .,, �= `� ^ � � � O � � -= -: c1 —. ` � , � "` '] Q, �i m fu � R`] .:7 � 7 (J ':' � � 0 � �� Gi: ro C tD ,� 'h�,, �_ '/; � �•` � � � � :27 A �^ � D V �p � � � � . C: ^� � � O � ` J � � � !1 Z7 , � .', ..; . . :, = Q O �_:.r � `a X r° �, c= C7 �.� ::� � n �a. ..i : �. iC" �J � . !) r-, � � .[7 J � `T D � `r,�' �r ;� ' . ~ 1 � . ,�� 1 � :� -• ��• � � � '�' �' ;�:z7 � � ` �� �' ,_; .`� �i �i .. �� .� i � '3 c: . �:I I �; -1 i�• � 2 r a �`� �o t1 J� '�' � � � � � j ' `u . � �Z' '. ,, � �� � : [1 . tn y u' y � rn `< N I in r: r Z Q � tP �� C r� r C7 Y-� D � � cD �' . J � t, ; 7 • '� � ' � �- � c�' D b ro � '" �`,.'^<' < � � 1 � �- c�_ � �� ' m � h" °' 't7 a ��--r ., 3� ti r, � av o � r�,3`) � v' N� m 0 . p' :� -. c,, N n N p, � 2 j � � �� U � o X' tu lD O � cy � -r� u r� � a � Z r► .� � f'j � °' `o � �' �" � N � n � � r- a �. � . � � F., in ,-. � � � . ([� 1 � � C �W � � C � i1J [l � � �J"" � i — � ,. � � .......,... ....._.. ..,. ......... .. .................._.__......_.........--...:..r..,..._... . ..... ..... . . ... ._. .... _ .., .. . ., , �. •. �.. _. ..... ..... � "Y.T' �������� ���� �� �.' � � �l.J �� !L � �aava3a-�„-^-,^�+��aa�.Ii. ����n.71.�Ida Applicant Q � � Location: 15� s ? T ��H �11�� r� ' i .��,r r:, i� S�n�:f�.cl i v i��i o�i� FL���;�_�.�'S�cti;�ia�L.a't � �',� C'Fh �d � l�%- c� (2� �- °, . �prm�ea�ea�t Pea�t Permit Valid for ✓�'+ive Years. 2�Tq Ezgirai�n �� + TypeofFacilifi,�: �i�a i •���� 'O�•e5��:-••, � New ✓ �ddition �iater�npply�)�nvc�J-e # of Occupants �x # of Bedrooms y�. Prnjected Dai1y Flow �� g.p.d. � Praposed Wastewater S jst�m: C�.�w�.ti�•cQ r.�,N..� � . Type: � b PropoBed Repair: � ���c..�-,ve Ca5'/. reu.�c.t:w� r.�...� ' � - - - T�pe: `� 6 . Peanit Conditions: � f'� ��n, � �� c..�Qor,h., I � �- . � � � - . . - - • - —� - � n�„� „-___^i— Owner or Legal Representative Signatare: . : � . . . � � Date: Au�thorized State Agent: • �- � Date: �- b�-oS 'The issuavice nf tt�is permit by the Health Department does nnt guaranteo the isaua�aca of other pcanits. It is the respons��ity of the $PP��PmP�Y ��iner to in stue that all Person Couniy P'laffiing and• Zoning and Bwlding Inapections requirements are met 7CJhis Improvement Pennit is subject to revocation ii ti►e $ite plan, plat or the intended use changes. The �nprovemaen# �ermit is nat affected by a'change � owner�tup of the property. �his permit was i�aued h► complianc� wtfii► the provisiona of the Noa th Carol�ma `Zmvs and �s for Set�aQe TS'eatment rmd Di�nosaY 5'�rstenu' (15A NCAC.I8A .1900). Neither Person (:oanty nor the Environm�ntal ]�ealt�► Specialist warranta that tLe septic tank system wili cont�►ue to funcdion satisfactorily in the future or that`the vvater suPP1Y will semam potable. - � ' . �An�aorizaiaon to Co�tra� ���tewater� S�sterii (�uir� �or �ua�� �e�mit) . * See site plan and addittonal ctttaahments (�1 � � Praposed Wastewater System• �,,nu�nr.� ���_ `�e �(2 Wastewat�r Flow �/$� • g.p.d. New ✓ Repair F.gpans�on So� I,TA�.t: , 30 g.p-d.! $ 2 Type of Facility:. �r.�nlQ c�••l ci �� I l�� �•�Basement �Yes x No . i�as�ewater S�ste�m Reqnirements �� 1���s � a, O�'} �� Size: Septic T�mik:1�� g�l .. Pump `�anl�: "' � g�l' Grease Trap: — gal fie1d: Total Area: �Q� sq $ Total Length 53� ft 1Vla�muffi Tre�ch Dept�a aa in �h W�th �## �wan 5oi1 C�ver: �� Lo iaa Minimum'I'rench �eparation: �} ft ibn#ion: Distn'bution Boz Seris�l Distabution _�G �Pressure Manifold Aaa�nor�ae�i State Agent: Peunit Exp' n l�ate: -- � no� �s�� s�l Date: Z-��5 The type of system peimittad is � Conventional Innovative Altemative. I ac�ept th� specificatians of the peimit ' ! O�eslL�g� ��r�e�aia�e: . . . . Date: � � � PCHD7/3012002 .ti�--��„�?� �''����� �� � � r\ ' V "V ��� ]E�.���� � ���.�.8. ]E33L��lfl�fl�. ' � ���. ��.�C�. Name �� �- ���s� i�.Nes . 'Tag lYla.p #�Pascel # 9 � Subdivision � �ection/Lot# . . a- �- �s Autb.o�azed te Agent • Date . �� Syst�m co»rponents �pr�eserit upproximate�conteurs onl,y. The aontratctor mustffag the syste� prior to . Isegisaning the installation to insure thatpmpergmde is mcdntained ° . ._k�a;a.Q : � �i -, V�o � � ' �1 � ' • �3 c.'�'f}R '�n�ouc.A-�v�. �a5r/, red...c�..�.� i � 5ay f�- : �,��,6�9 . � ��� �� �� �� a�S old �occ` Se� a8V• �5 S c5: �33 Coex�-+ a�15 "�H (.�7��� S�'!t; �. ,:'�D` ,, ' ��¢szp w��1 , . ' �� � 5 F� '�vn. � �� � � � . h�� �, �c� . �,�' i-�- �w�.,. � � t � ��. q a 2tl• �-i�+z ?i -- I � 1, Y,¢� c�- � ��. � P �.n��Q �G � / I �O �.� eac�, / I - k�, �„c � . ` , �5 �. � � � � . . a�� � � � �z � o � � � . 1 �a�, � � � . . � � � � ��� w � � � � �s�x � � r . / ! I � � 1�FQ - cc�►�r�-c,�ck.a�. �: � � o� � ���� ;- . \ � 2�� I � � � , � i' \ � � � � \ . �� / � ; � u r : � \ / � i P .� j i \ / ;' � � � . �, � ` a . • • �°' �- ,_� , �� sot �0.� � � . 8s.� � i�.tiv �"Z,4. i�� 8'�►.S � �i (Z�c hF-� _ & �� ' �S�E.�1�S� v2Q�d"c.�vQ, Ce�J�2r :��j� � TO )S'7 U Ps�hrQ, `',�2�L ��.- �v �pr�VE.��- QIbS�b.r�, , . J ., �, � SCa].C' - PCHD, seY. 09/12/Ol ...��:�::,4;',.'��� ��:'.' . .. ,.;�, .. �.: � .':�'����.'..l`�.�'�=...... . ;�:. .� . � ::.�..y.•il.. �� ., . :;. �: . . �.;.. :..:: ::: •. •.�.. •..:: • �� _ •.: }..:'': . .�..r, .:f:'' "i �.'���.�. „ny�:::•,^Z'�. 7�� • �JM,��„3Y';.'yV'9i'7L�.T]}''r�`Ar' ^� ,�—„�R"�.`�5�;�`.c'��'�f•JL�': WELL PERMIT � � PLEASE SEE ATTACHED PLAN FOR WELL 3ITE LAYOUT Tax Map A, tic� Parcel #�_ Township: _�Ic� ��� ` 1 ��� . APPlicant: Te�. � E�s� �Wz� Subdivision: Lot # � Location: 15"l S�� cn �1G�- ��ar �'l, i►��' � I u� c�+ 2^- '/y �,•1e. Type of Water�Snpply: r/Individual _ Community Public Ytequirements: Site Approved By: Grouting Approved By: � Well Log. Pump Tag: � Well Tag• ' Air Vent: � � Hose Bib• � Casing Height: � Concrete Slab: � � � Well Driller: Well Approved by: � *�"**See Attached Site Sketch**** Liner. 'Installed by: Depth set: _ Grouted: _ Date: Water Sample: � Wells must be 10 feet from property lines. ells muat be 100 feet from s�ptic systems. - Wells must be at least 25 feet from any building foundation. , ther conditions:�� �vu� �i �2 s�.�l� Date:, PCHD rev O1/27/Q4