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' �� ' ��-� .,:a�: �;a �:.i3. !!CL'U� NYwL�7 � — �1 � P� r+���t . � �i:'�-v:'7� �� �,r��✓f . �!►� �P� � � !�S P�w� _3 �1 .." 6 � Addresec � �s"� u:, � n� , � �rna►��sa F�on� ,, � 7 .� . � �7 ` '� -`.� ::; �Sm� andacld�s� ot csar� o�r: T=_) <_�n.�'_ . l � � ^ 105 �➢ �► �cn: l.ct siz� . / �G;, Ta�dp: ��' /i" � • E� �1��,�: �. ��.� irv# #; %� -- l �"� Dit+�dloas 6o t!� �perty (� n�,d.�ntmve altid ►ltatt�be�a); �ic?�%4/� ""--� �} Prc+��d L�i Nd �I�npir,ttp� O�ar�ion: art�r �Bct10t th9 A�lba�r�8 � �� �d �. � E�d�t�n9 � � ot �u�C � ���,,. pep� -..� b) �iurnbe�r af 8edtocert� � i+ktmber t� q�p�r�m or people bD A4 �.....,` c) ' B�nemet�k YNs ,_, Nt� _ Y1�19 �uoria be p�g in tts� ba�tr�anC� • .. d) t�a�pe Dbpq�k Yes ,_, W�p ._ . *�3 riVae�r ��p�y �yP�c p'1'r+�' U��c�sw ..... � �d�k+s .�. puh�e_, � ..,.., gP� _ . A�s-oty � an ��7ti Y+o� _ No ,... I!Y'e� Fie� �� �� an 1t� a�a pi�t �D � tt» p�op.� o�o�4itn, p+ts�riaus�y 1�d i�'M�tdi w.tl�dp�? Yas _ t�lo � � . 3� A Pt,�►7 OFi'�� �y► t� SiT,E Pl.J1N YU$T AC � WR}i'iNIS APPLyr„p17pN; . �' P�O�R3'1f i.8� �ND ��]$7' HE p.�,1t' IiAl�. �' Tti� E�P08� L.�Or'.NTIS9N O� A�..1L. �!'��;�� �� �� C�it �lJ1[,�6�. � � 7'4!{� �'7'� iR�'i' � R1rAE31L,Y J4� �R.iN EUA1.tlATDON BY THE I'�Ai.T�i DE�JIR'1'1�iT S7l1FF. l• f�ffifF R� applc�lon bo the P� C�SI Hedth Oep�rtrr� ffor a si� en�tr�On tb� 1hn �+�m � tts aba�cr�ed p��tll• �� fltat tt� � a� t� � are tr�a and r+�rese�t � m�oonwm �Cotne InVaiid.� on the p . 1 u��der�cui i� tha 9� ia alb� ar tha uttiendeQ t�e cl�ges.lha p� shatl ,,r/2� � ��rrvf'r�� �; r:L� �"'—'`—' . . � ;� � . r ,� -> O�nec ot L;�I - � �. � tarr7� ������� ��' ' ��� �_. ` �^ : � � �J � � Ji � I����a-��-Y„-„ ���.�.1i I����,II�I� Applicant: Location: �l ,� � , � � I • �x �� �,r�:i � s�u�b d�� �. � o �, � - � - . . , ii !� h:a�=- Se�ction Lot r �ffi��'O�'�ffi�3fl$ ��iffifl$ Peranii �Ialasd fo� �iv�e ��aa-s �o ��pir��aon � Type of Facility: S'�:,.,�, j�'�6:,e °��;t�.s; ��`�`� �•_;, New �'Addition r: �'d..;.�-z �l�te�' S�p�i� z>'�r/ # of Occupants �- � # of Bedrooms '� Projected Daily Flow �- -� g.p.d. Proposed Wastewater System: • , � ' Proposed Repair: ��1� {y ��y • e ��J��S(/ - Pernut Conditions: _ Owner or Lega1 Representative Signature: Authorized State Agent: Type: �',� Type: ��� Date: r%• ZS=v� Date: 9� S=o3 The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is khe responsibility of the applicantJproperry owner to in sure that all Person County Planning and Zoning and Buildi.ng Inspections requirements are met. ihis Improvement Permit is subject to revocation if the site pian, plat or the intended use changes. The Improvement Permit is not affected by a change in ownerslup of the property. 'Y'�ais permit was issued in compliance with the provisions of the North Carolina `Laws and Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 1�A .1900). 1�leither Person County� nor the Environ�►ental �ealth Specialist wax�rants that the septic tank system will continue to function satisfactorily in the future or that the water §upply will remain potable. Aut�or�atflon to �oa�s��a�ct �as��yva�e� Sy�teffi (Required for �ui�ding Perffiit) * See site plan and additional attachments (�. Proposed Wastewater System: (�,�a.v����-�'a,��; � Type �� Wastewater Flow ��.p.d. New � Repair Expansion Soil L'T�: � 3 g.p.d./ ft 2 Type of Facility: �j� 5�;,�%� �s�•-, � � >�..s,'���,.c �� Basement _ Yes ,�/No Wasiewater Systeffi Requir�men$§ Tank Size: Septac Tank: ',c°'c? gal Pa�p 'Taa�: -- ga� Grease Trap: �-- gal Drainfield: Total Area: % C9� .sq ft 'I'otal I.eaagth �.S3.S� ft l�%a�uBn'Trench Dep�n �� in Trench Wnc�th � �t l�Ianianuffi �oa� Covea�: 6 an �Distrabutaan: ✓ Distribution Box Serial Distribution 5pecnficatio�s: S ,° Minimum Trench Separation: � ft Aut9ao�nzesd State ?�gent: ,��C..�� �t �/�. Permit Expiration Date: �- S- o g� Pressure Manifold Date: �- ..$ - �� The type of system permitte�i is � Conventional Innovative Alternative. I accept the specifications of the permit. � �Owner/�.�gai �2��tresentative: � Date '7 - Z �-US PCHDl/17/2003 ���� �.� ���� �J� . �� � �� ������ l�aav as�,.-n,.,.-^ �aa�.�.n �"3L.omll�l� SITE PLAN Name sa+s t�..lr . r Tax ;�fap # _ Parcel # Subdivision �%, ►��'C r c Secrion/Lot�# _/OS � � f�.C? q•.S.- 0,3 . 3uthozized State Agent Date Sysrem components represent �ppmximate coamurs only. The cvntractor must flag tlre system prfar to begiruiing the installation to insure t6at pmpergrade Is maintaiaed . YELLl��TQ�! DR�1/E ; _ ' , �Q' R,/W � ,; _. �vo�le : ��s� �/�) �o�' aa� ���� 154. ?' . , l;��es as s/� �Ji�i 7S � I ; w: �FGL d- box . ,� �ao' v� c� � o p �� O � � C�t � Scale: � /'- 3c7 / iap' 3 � , � � �,� a; � �9�e0. �o S3 �i' i in �� �J /1 �/� �/� @ ��"����, ���� �� �a: � .., � ��'. i5' PCHD, rev. 09/L/Ol w � H J �- F- Ac 0 0.1I . �• o��, �� .�" ��� �� �'�� C���T��� • c� 1L�'B.3�T9.3L` K� �Z.3_..'*'TM^� �C.3L�L ��0..� � �. a�'1.1L'�� Applicant: �`�^-�^� � Locaiion: H�-vle „�; !1< . �. �. u'� v � (P -�'7`. ►a � a w Ni �� ,.. �F !- `�`- �; r .� � M1� �. �� ��►� �1-�c� p�� � � � �S, ����OW C� IY�i v�P P /'tG/`PS pi�t�3�6o��0� � � o�- 1 c�S � oQ�j� e ^a oo � . .---� System Type (ln Accordanc� Wifih Table Va}: � THIS S�ST�iili �-3e4S �3E�� iN�T�LLEi3 I�! COfVIPl�j4A�C� WtZi-I Af?P�.lCA�L� . NLIRTH CAROLl�e� GE�E�tRL �TATUTES, RU��S FflR SEIPVAGE TREA?1�tEiVT Ai�1D DISPOSAL, AND ALL COi1lt31i'iONS Or � T�3E lI1�Pl�OVE�E�iT �ERl�lli AND CONS3RUCT10N At3Ti-f ORt�T10N. � . %���' . �`�. 1 R 1 �� . ,4uthorized State Agent Daie I nstalled By: 1�. � P �J � S Date: b� ��/ �� . ��� �, = �3a' L}- r31� L � = �3 3 � � � _ i3 �' rto��� _ �a 9 � io' � � � H J �C/y'�� : �117'S PCHD, rev. 07/29/04 ��:'�'9G �'�,�� �P���'����Oh� ��iE��9` s ���e 7� - l�� �' Tax Niap #�y" �arc�! # 39S Sys�e� Type (Ta�Oie Va) OwnerlApplicant �M,� �! 1 lGkf IL1 ns Subdivision �`'r�a.�a �i-� �rs Address/Location Q �� ,��,g �c �, Se�fPhase Lot # �� S Se��ac �'�rnk �a�i�aa6/�a� a�a���tcat�ora r��s ?n���� / at� State-lDldate �`�' - 14 %o�� �,,�109_�-� Trencfi Width 3 f�. �'gw�aq_Lq� Ca aci �oo . Tee and F�lter � � Baffie Sealant � Riser ifi a licable - Tank Outiet Seai Permanent Marlcer Puanp �'�nk Ca acit al. Wate �roof /Sealant Riser Wat�r Ti ht �ump Chec�c Valve/Gate Vaive Ant�-si o� o e Flaats/Switches �41arm visable and autlibie Electrical Com onents � Rate m A roved Pum Ndodei Bfocic Under Pum Pumo Removal Ro�oe/Chai u-no ressure an� o Low i?ressure Pipe Anor. Piae I�ateriai and Grade • Trenct� De th a- Trench Len th S Trenct� Grade Trenc� S acin Roc�c De th and Quaii Dams/Ste dovvns �#c. Pressure Laterals � Hoie S�ac9nq � Pipe. Sieeve Tum-ups/P.rotectors �eqtaie�d� Se�a�� From� Wells � From Property lines Structures/Baseinents Surface Waters Pubiic VVa#er Suppi Verticai Cuts (>2 ft. Water Lines Vek�icle �Traffic TR. _, t ,.4_ � 1 �o�amen� �1Right o� Wa�/s �thee� � Re�arded ,�erator ontract Aqres�rient - - - � � � pc;�d rev. �l1y/01 ; ��,�.��' ��1.�.� �� , �., .� � � ����- ��.�a���� ��.�.� ���.��� ��� ���� ���� ���������� ������� ���� ����� '��x l�ap #: � � O Parc�:l # 3 � � 'g'own��ip ���. �� „�'��-e,^ �pplacamm� � Subdiunsaon: ,�� �2 i^►'c�• e ."t>,.: Se�tioa�: I.mt: �� 5 g..oca�io�a: � 'I'�e of �ater Su���.�, �ndividual Community Public Re�anise�aents• Site Approved bp Grouting Appr ed bp � 5 0� Well Log � Well T Air Vent � Hos� Bib Concrete Slab � We�fl �raller. W�ll A.pprove� �y: k^ "��a�e• � z3 � � �See A��esi Site Skeicla� Wells must be 10 feet from property lines. Wells must be 100 feet from septic spstems. Wells must be at least 25 feet from anp building foundation. Other � PC�ID, rev. 09/07/01 PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant ��5�-�-A�- r' fL� ,.� l�� Address �%� �1 �LL,I ��32 t�, �-1�►. County ��(��c7 S� Collected By ��`Z�\/ Date Collected � Z ( Time Collected �: Z a Source: L�Well ❑ Spring ❑ Other Location: f5'House Tap ❑ Well Tap ❑ Other 0 No Charge l�Charge ........................................................................� ******************************************************************�***** Results Present A se t Total Coliform ❑ FecaVE. Coli ❑ � � Reported By � ��— Date Reported � �f �� I � ( Sep 05 08 01:36p Keith L. Barnette :.< ... __ _. .�- , . _ ��x-.:_,:.. �.:, . .�-_ ,_ .�_. _,.,, , _ - • -�i. �� u k - - .._ � = ;'< r �:i " �*=�.�=�<".:�� i:;� '.._y , : ' _ : ;::!::..<. ' <s ' �` �� • ' ':��; _ ir ����tJF;��= '-� • _. -�� - �v'•.M1 �:. _.�„_ ��"�`, N........��' y,,, ,� �, • • ' _�,�.'� , .. �_ . �r 1� � ::.��=, �����.�:.�:: - �� :��::. �� Sli�Otl: ,�_ 336-598-9275 p.1 ����- 3<«� � � . �G� ��.� Wc.t {i i�f � o� o�o�r �_s-o� _ . ,. c�o� � . ' Tax Map A�'ira Pac�el #� � RS IA# # [ P s' D1�IICC �ID II� WEH CO�(CEiOQ �"°F�Y� (�iinitwun 10 f,ect) pt Distanve fc�xn Segfic Sys�euc �mi� 6Q �t) 19 0 Tata� I)c�: �,�_ ft Yeld: I 2� .(''spM • Siatic Water LeveL- Z-r � Wafcr Bearing Z',onc� Dep��� g ft g � _ � . � F�m___�___� �' b ,. �. nR�a� � �`Q � � . . Weig�� Th;ckness: �2_ z s .Heig�t above Crc�ntma: _, l. Z in Drive SI� Ycs No AaY �oblems enco� wh�e � j I f `� res" give reasau: �� �€� Xes ✓ No (tinuu� � - . � - ' • . ' N� �� / Canca�te • . -�i��_ Gca.veUC,�n�i . '- A.�ular SYsaae Wi�th • mches Water in A�nular Spao� Yes _, /�No �od of Gro� Putt�ea. p�e Pouc�d Ma#�ials IIsed: -•� �.,-�._ to �s� Ft No- �a&s Pordand oem�eai ' Weig�t o� 1$ag Pounds 7f� tsaud, g�� �) -12a#io bo ID ptat� ✓Yes No 4 a 4 slab _��es � No Liaer: ' • — i�m � � ' ~ Date Instailed: Gra� . InstalIed by: • . ---- . Z2� DriDing Log � Location DcAwing yY�ersou C.uim g,��, �iou is c�oa�ct and �St t�is �rell �vas oonst�tc�d in a� ���� �� � � . _. _ . .�j� N� If � :1� rry /�� ,_._. m►#�i � ,�, R_� _ �. � � �,�� - - 'a� ins�llati,o� contrad�- C . �� srate R�gistraao,n Nambec: ,��� � � � � , � S�ic �Q{Tat�x I�eveL- _ � S� $ � . . Ptiunp Size mo�d Ra�.�� � �� �Y �Y � t�s permp t�ras i�aII�d and the wdl �xead �� �c�g to ti�e Persan � t� c�e and f6af a oopg of tfiis has beru tot�e weII owne� _ �' �eI1 Rz�ies ia effe�t a�np�ar� . ... - '��� . p . Dat� 1 `5 " � � .PC�I:) rev 01�7IiJ4 9�s`°`� " � o� ' /J w. �i ��G,�.� � �� � �� ��ti ' � f�t cv i.(� 6� !^/5�-Llf� �/' ��' �,/���l�.� .� � �� o � � �P� (�.G, ,�e,,;� �