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A40 343� R a 7-�0 _ • �il.-„ • 1 • ,c _,.�.� �.1 I'. .1 l i_ lr •• I I ►_ �., '1 I / � �%/� �� � ^y/� 2 V ��f JOV - /L /� ��6 ' • • 11 -' � L! � � L! 11 :11 • r `l� � : �� • �.' � • i� _ . �►�! �i�= �.L� : _ r� 1F THE INFORMATION IN THE APPUCATION FOR�AN IMPROVEi�AENT PERMIT 18 FAL91Fi�. C�WNGED OR THE S1TE iS A�TEREfl. THEi�! THE 1MPROVEiIAEi�IT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME tNVALlD 1) Psrmi# requeated by: (Owtleclagq[ltlprospoc�tva Ow11ec�: ��ra m rr 1� ��k ► nS Homs Phon� �3 � �I -�..5 �� � A�d� S `��� � < 1� r��: E►.s �,ci, e1�1� �Otia � � � [s'�,� n r r-� ���iR10 Afid i�lOii Of .f'LIITeRt OWRAf: �Q n� 'C, 3) Prop�rty O�scrlption: Lat stmK 1. r� � Tar.�td� _L!'�._ D�ectlons ta tha propedy �rn�d names� rxunbarak R,,,.. � ,,. � . � � � 4) Ptopos�d Use and Sbructut+� Doscriptlon: anawer asch af the fa�W que�oc�a: a1 ProPcsed �Ex�,q ❑ b) Stidc Bu�t Q Moduiar L'. Slcqle Wfde a. Double Wide C�' � Numbar ct eedrooma: �3 �6'/l- � Number of oa�anb ar peopi. m t�e sa�va� �/ e) Basem� Yes Q No C�tt yea. � ot basstnent iGdtuex • t� GactiaQe Disposa� Yes Q No � �I 4�onaof Proposed Suuc�u�: VVidtt�: 2B Dep�r � 6I �� �+PPhI �IP� P�ivats q(new � or eodaW9 �. PubRc o, Ca�mxa�Y o. spdn� 0. Ars arry wems on a�oining pnpaty? Yes � No m-H� loca�on 6j Pl�as� indicab D�aind Syatam 7YPe: (systema can bs r.u�io�d In ard� of Y� P�l �Caaventlonal llodifted Coav�ntional _ Aibrt�iw �nnova�lw Ott� (sQ�: CLEARl.Y. 9TAKE ALL CARNER3 AND UNES OF TNE PROP9tTY. 3TAKE THE CORNERS OF ALL Pi�OP08ED STRUCTU[tFS. PLEASE ATTACtI SURVEY PU1T OR SiTE PU1N TO TiiIS APPUCAi70N ���Y �� tc the Pe�an Camiy Health DeQa�tr��t �or a a�+e av�tuaUon tor the a�-aiis sewaqe dbPosal syst�m ths sbove�desaibed pi+ope[ty. t agrea that the coc�Genb o( thia app�tion a[e tnss and oe�t tha n�uun �es bD PF�ecad on the pcoQecty. ! undesstar�d if the s�e is altered ar the int�nded ttq cl�attqes. the penn$ s�adl bemcns inw�d. l undetst� t�at as app6rant� I am rospa�a�bie tar ideNiiying and maddn9 WnP�Y �. � and nwidng tha aiDe a�� !ar persannal af the Person County Hea�h Depattrnerrt bo canduct their evdimtlor�s. l ta�detatand tt� 1 am teap� ��9 Heslth D !t my �s any wavanda as dGsi�Oed bY ��m1f �� ��- l'i1Y � <J'- �. ( - O, � o� L�al Repr�a��tathre . oate - -_- PERSON COUNTY ENVIRONMENI"AL I�EALTH PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND S'YSTEiIA LAYOUT Tax IYlap i� f�� Pacw! / ' c3 " Zontng Town�ip `��eY � • . r � . .. �PWp �ocatlo Suhdivisloa: `��G e��►` S�!(on; � L� �� Improveme�t Permit A buildinq aermit cannot be lssued with onlv an Imarovement Permit New '� Repaic Addition _L Type of Struc�u�e -e� Watec Suppiy �{ � of o«�,� ��� aea��3 easemer�t? c� lo easemerrt F'f�+es? � Projected Daily. . g.p.d. Permit Vaiid Proposed Wastewater System T�ype. H ve Pump Required? Yes X. N Proposed Repair�nvCn c Pemiit Con�itions: l�ao Susf�i� 5 � Owne� or Legal ReQrese.�ta�ve o�,� ❑ No Expira�oa Date: �f- 5 - 6 v Date: ll—a� -,oa The Issuance cf this pemut by the Heaith Department in no way guarantees the issuanc� qf other p�rmits. The pem�it hoider is �espons�bie far cheddng wiih . appropriate goveming bodies in meeting their requirements. This site is subject to revocation if the sit� plan, �lat, or the i�rtended use changes. The Improventent Permit shail not be affected by a char�ge in ownershlp of tt►e site. This permit is subject to campllance with tha provisions of the � Laws and Rules fo� Sewage Treatment and Disposal Sysbems of the North Caroiina Adminlstrative Code. Type of Wastewater System Lo nv�n i v na. i W�� �� Fac�7Ry Typ� Br• S;�e� I�a.� New�( RepairOExpansion 0 Basement? ❑. es � No Basement Fatures? 0 Yes � No Wastewat�v Svstem Reauireme� ' • - ' • � �8`( d�'! �9� :Septic Tank S'ae• I� a v g�� Pump Tank Size: "'— gailons Total Trend� Lengtfi�� feet Ma�dmum Trench Deptt� iru�es P+99r�te Depth: /�- i�. Maximum Sal Cover: � ind�es � Other�' (Q u 1�dd��On� � �o t� Pertnit Expiratlon Oate: Authorized State Agen� Trench Separation: � Feet cn Center — r /� /� Cpr�_/ 21,�G� �✓�d O✓Br �r�-fi r?' �� .�j e�d' _ - �a •o� The type of system pertnitted 0 does �❑ the specificatlons of thts perniit Ownef/Legal Represantative Signature: r�ate: f l e�.2- -a e not differ from the type specifled on the application. 1 accept Date• '� ` � ' d }` PCHD, rev.11/18199 . � ' .�1� J� � � ��.l��l:.��� ". ' . � • . .�.. •} �-�t�;^� . � , � . : �L,,sj'Ly` . ' '�" aa�-aa��,,,r,..v,«,.�,� ��'�a. . : ' . •- — ....,- �i"�` m".�'.9.-�: (-'� : .. • Pac�! � ` � � � Zoninq: Towr��ip: ' • � � . S��bn: � � '.�4 • . . .Sectton: L;o� c�� - �� ��� ' � .� � : . - �_.�€- r..�r,: � - . • 4 . � ., y �p�r�t�on. P'er�mit . '� e In Accordance VYrth Table Ve : G� . .s�� � c � . . . . ,, , . THIS �YS'8'�A tlAS BE�i IN3TALl.E� IA1 � COAAPLIANC� IARTti APPUCA�I..E N�Jt�7'H �AROUNA GENERAt. STATUTES RULFS FOti SEWAGE TREAi'iI�E�IT �fND DISPOS/�l., � .; � , .:,`" � AND �ILI. CONDITIQNS �F THE INIPROVE�IENT P�IT A�1D COPIS�'R'R!lCT1�iV � :-A:� . ���� AU'i�10 ON. . � . � �� � . � � �, 3,��, . . . . :<< . . Authorized State ent � Date - ....��..._... _ _ . . � . _ .. . _ . . . ... . . . ... . . _ _ .. - , f . . �� � . t� l�, . � ' � .� ' C� C 3t'�� �� t �d a t �.,� �«, . �UV�I "' ���� y . � ` �vl q �'��-�� . � �� . S� � �Z �� �� � ����t ����lz� r z �� � �l� . �6 t . � pl� . . , � - ------�._ ... . _._....-- ..._ __ .._.__._. ... _ . _. . Person County Health. Departrnent � Environmental Health Section T� AAap #: � _ _ Parcel #: SITE Sf4ETCH .. - - �h,�n._ l�Grc��iai_i • ��r�d AGfPS JrS App cant's Name Sub vision/Sec�tioNLot# . Authorized State Agent Date � Systun cony�orte�rt� represent appraurimrrte cnntor�rs only. The contractor Jlag the system prior to be� tl�e installation fo insure that proper grade is maintaiired � �kA �`�e r art-e, R� . �D� RJW � 6�. ` s` � w � , ,� 4; � � o �ao .SO � ✓�O� 2 '��0� Br• M'� � _ 3 �z� ����� a 6� �Zl G�� � L`'�� . ( N �� /a - �,reh�-:ana/ Sep�iL�sfe�s� �' l.�'' r�cax�N.u� �e fi� � (� u aa(�l�f�o�l Sa,/ cover �,�� r� e�ea-- e�;�re .se�t-'� c.�ler�. r: 1 �oe�v�NTiaK�� i2�p��R A�t�A scale: �aa.37' y 6� '�a-'% . t�s_� �� �� ,___,�--,�,.s� ��I�.��� �= -x--�- �����-�- IE�����.�.����.I! IHL��,.Il�I�. WELL PERNIIT PLE1lSE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: �`CU Parcel # � Township Applican� - � Subdivision• mC� �� 1���y Section• - Lot• �� ✓ ' lic Twe of Water Sunnlv: Indtvrdual Communitp Pub Rec�uirements: Site Approved by �� Grouting Approved by + . ��(�' �� Well Log ✓ Well Tag; . Air Vent U Hose Bib _ � Concrete Slab Well Driller. Well A roved B. ���'�V`� Date: 1 t 'l o� `� � a PP Y' 'k*See Attached Site Sketch'� Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from anp building foundation. Other conditions: � PC�ID, rev. 09/07/01 fii/29/1995 03:36 80445478�13 BEPJNETT WELLDRILLIP�G PAGE 03 ��aG�'�� � 9 7 ..,�,—� �,�.J �''.��.i��..y.1,.�! �� , .��/.�%u�' � '"` �: � ��'�� �- y- o�- ��.�-¢�•a�#..1 �•0�.1�7�•. � � W�$ � Taac Mtp � F�ac�d � � O�et= L1` .. „{' ,Q � Loc�ia�: � � � -5.� $abd�+iai�o�. � '6V� Caa�� pi� Fro�ta naaceet PmpactY 1�S iM� 1Q �t) . �da�ce �om'��� $ � � � se�c'RT�ar I.av�oi. ,�,,,.�._, � ��acH��: �.�..ft..�.�._.�.�...----$-�-�--� � �� �o �� S. Dtemdeber: � ia �� � � .� ! � � Ae;,g�t aha�e t'�C,00ack � ian Didv+o 3�x ,JG,_ Yas � No A►aiY P�1a� � w� �� Yes ✓ No If"�ee" Biv��e�o�: � � ✓ g�� Ca�e�t��UGam�� � s�w-� �. � w�ma� s�oe �r� �r� Metbod of �C+o� Pu�pod � Praearua�,,. p�d ���m � Ft . ��No. B�s Fo�rdmd ��mtuent �. .�o -. W�ig�t of 1�+8 qv� ., pvas�}e If mnct�o �a�d, � �) � � ._--. � ._.,.._ � m p�me� ✓ Y°a .,_„_No 4 a 4 e� � Y�a No Dr�t�rt Y.o� • Y.oaGtl�oo A�e"s�$ I ba�by cartiiY that t6�o abrrve 's�a�tiaa is oo�tec.t aad tb+od thia �+11 �vaa const�uc,t+od in ac«�c+du�ce ovith �e�n1� set � by tl�a �'sx�o�t Co�ty i%a2th D�ma�- vi.+..+.a,e..�rn..�r.�er+. `1 'r . !�. `,�c� x�u.� ID � .� � 7� Da�a �- .�1.�