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A41 3A�piication Date: � �°?�-o � Tax Map #: Amount Pa1d: a6�� Recelpt #: I 7.3� � Parce! #: �� '`������ ������ �� � —� � � -��-�� ���.���,.,.,-.. m��ma ���.�.�� - APPLICATION FOR SEi2VICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT F�►LSIFIED CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AiVD AUTHORIZ�►TION TO CONSTRUCT SHALL BECOME INVALID. � 1) Permit requested by: (Owner/agent/prospective owner): �% ilV����/ (T� �����u� Home Phone: 5 9�t� S���S Address: f-1-�s ���`� �o�..� X�' Business Phone: 336� 5�17- u�21+� bc7�'t� � NL �?S�� 2) Name and address of current owner: 1�'"`��� �/ `� ��M�e^ly G�'/��`ai�'l. 3) Property Description: Lot size: Directions to the property (Includ �3�•��c,Township: �M��� Subdivision:. �g road names and numbers): Lot # 4) �roposed Use�d $tructure Description: answer each of the following questions: a) Proposed _, Existing , Type of Structure: Width: Depth: b) Number of Bedrooms: 1 Number of occupants or people to be served: c) Basement: Yes ✓ No _ Will there be plumbing in the basement?_� d) 6arbage Disposal: Yes � , No ✓ r� y�. 5) Water Supply. Type: Private ✓(new ✓or existing�, Public , Community , Spring _ Are any wells on adjoining property? Yes_ No _ If yes, piease indicate approximate location on the �site plan. � 6) Does your property contain previousl� identified jurisdictionai wetiands? Yes_ No_ � PLEASE AIOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. . ➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. �; ➢ THE PROP.OSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF: � I hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I,�nders and if the site is altered or the intended use changes, the permit shall becom ' valid. ,�,� _ / ' �, � Ow er or Legal Representative ate PCND, rev. 06127/02 j� �1�� ��i �1:�..G7 �� �� `�w y � r~��� `L� �-���� ���-a.��� � <���.�.Il I�33L��.I1� Applican� �I �i tc� � � 1\ � ��� .� 1. _ �.. � T�x Map , �rc�ei .; Su,bd!ivi,s,ian Fh�s�e S�ct+ian:Lat � Iuaprovement ��rmit - �ea mit Va�id for �D�ive �e� 1+To �apiration Type ofFacility: '�',',-�� �;i � Cr el Li New,,,�Addition �ate� S�pply liv�!/ # of Occupants $�� # of�earo � Projected Dai�y Flow 44�� g.p.d. Proposed Wastewater S tem: �v�ni,'�1nc�S1 � Type: � Q Proposed Repair: �vP n�ii � � Type' � � Permit �Conditions• � I � �� � Sl �te ,D�(�h , Uwner or Legal Representative Signa,itue: Authorized State �Agent � i�i�2n�1� � Date: The issuance of this pe�it by the Health Department in does not guaiantes the s�s�sa of other permits. It is the responsibi7ity of the' applicant/property owner to in sure tha# all Person Cotmty Plannmg and Zc��g and Bu�iding Iuspections requiiemeats are me� This �nprovement �ermit is snbject to revocation if the site plan, plat or the intenderl use c�anges. The Ymprovement Permit is aot affec#ed by a change in ownership of the property. This permit was issned in compliaace.with tlte provisions of the North Carolina `Laws and Rules for Sewage Tretttment and �isnosal Svstems' (15A NCAC 18A .1900). Neither Person �Connty nor t3xe Envirannaeutal �eatth Specialist'warranis Wat.thg septic tank system w�71 continue ta function satisiactorily in the futim-e or'that the water supply wi71 remaiu�potabie. - -- .. . " . Authorization to Constrac� Wastewater SysEem (Reqnired for �wlding Pex�muit) * Ses site plan and additional uttachments (�/ ). _ Proposed Wastewater Syste�m: C��EP f'T�'I �I�G'� � Type �� Wastewater Flow �i�D g:p.d. New �,/ Repair Exgansion _,,, - Soil LTAR: , c37S g.p.d1$ Z� Type of Fac�ity. �-1%�' i n� I� � i_� �(`��,�,�P� �/t9 Basement ✓Yes _ No � � . �aste�vater Systean A�eq�irements � Tank Size: Septic Tank: 1�� , gal Pnmp'Tank: — gal Grease Trap: L gai �rainf�eicl: Total Area: � sq it -Total Y.,ength � ft � 1Vla�mum Trenc�► Depth �� in Tremch RVidth � ft l�iaauma Soil Cover: �D in lOTwimtam Trench Separation: � �t �istribntgon: �istribution �og �O , Seriai �istribntion Spe�ifications: Anthorizesl State Ag$nt . Permit Fxpiration Date: The type of system permitted is� Conventionai P�� �w�erli��ga1 �apres�utative: Pressure Manifold Date: Acce�te3 Alternative. I accspt the spe�ifications of the Date: pC'�ID rev.11110/OS ���?,�� �1Le���� .. `—= "'– �: � ��� � . IE��s�mm�.a���.]L IHC��.Il�IIa SITE PLAN Name� M�� �, � a1V� Tax Map #� Pascel # 3 �.bdivision Section/Lot# � m �� !� - 1 o I�W �i1 Authorized State Agent Date Sysrem camponents repiesent app�aadmatt conmurs only. The contraaormust 17�g rfie system pdor to begianing rhe instnllnion m insure that propergrade is malntained _ _ _ _ _ _. .� n�.a�n�e��n a�� �4bac�,5 � �a��� � '�ns�a\1 �j�"" `� ca-���r �'� „�� '�r�141\ B�S�em'�r� wek c�,c��-�+�s � '�- ►�y 4��,.es�i�s G�r�ack �r�v. �_`�� � �7- ��90 �n��� �1 bed �-1 �o �p� 5�3a ��- �C c�-w. � �'ne l� ic�`EC'e►1Ch c1e(�� �le-1,,.�, -b ao' AccPss Ea�'�'� 0 .'•��•.':`�.��..�'.••'.':...'�.:: �: . .. �. .,.,.� .. �,�. :.������'��� '� .1:"i"1.. �. \r..��.'.n.~a .: `.:, ..'�'J� • ...:. . . : . ......... .. .. .... ... . ..... '��:�!:�:'��.�• '.11: ' �... ;...,..�.+: ::•: :•::.;....: •:r�;: �:t::.> ....::.:...::'•, . .::;,, ; : ; �.. : .m ... . . . .1•...� �.ZL�:�L:31'e]L,:, dA'•lr�ri: �i-.�m�.++��9C:i3l:�:�:.iH1�:11'�'.' � a�'�II-�'[f -�•. .. 9'1'3�L� ro�•e��Y11J1 ' P�,EASE SEE A�A�D PI,�' I'aDlt �LL S� LAxOiT'�' Tax Map ��l 1 Parcel # 3 .. Applicaut: -t;n.� �`i i I li0.m Subdivision; ' Location: uo l 5--� �R cx� . R—�1bo�r�1 � Tavynship: Lot # '�ype of �Vater 5upply: �Jndividual _ Community Public �.tequireffients: 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 Sketc�i**** Liner: Tnatalled by: _ Depth set: _ Grouted: Date: Wate� Sample: Wells must be 10 feet from property tines. � Wells must be 100 feet from s�ptic systems. Wells must be at least 25 feet from any building foundation. , Other conditions: Date: PCHI� rev OI127/04 �r���r� oF�z�r,rmt�rr ��r� � �x.�i e�saint�. ��lE�L �� a� �� Jl r ,. ,. �1 �' L�"`�,R����L. �51�1+� , . • iQi�P���i 1� .:—s: ��^ �L�IQt��i.�'{.� J� . C'.:.��Tl��' ���:/�*�.:�i.�� �%������! _ � �'a� �3i��,�� ����T��""� �'�.� o�: �► �v. ��\\, c�m 1.-�- \ ��i�ori � � . ADDR.�SS: .. DATE �TALUr1TE�_ i PROP09ID F4CiLITY FRflPOSED DESIGi�F�OW (.1949): Pi�OPER2Y S1ZEE: . L�C.�TION OF STTE:. � FRflPERTY RE�flRDID: -- WATEItSUPPLY• � Pablic Wdl 0 Sgriag Q Other EtTALI7�+sTI(3i�i141ETHOD: �,4ugcBoring � Pit. Q C'at � �iv�7sb10 Space (-194� s9�i�Type�s) Si�s LT_�R. 1 �illf • M�•• -2� ; _� _�: y�Y.�..N •, u s � • � � u • � '�.Li O'1�EFtFACI'�ORS (.1945): S1TE CI.AS�iCAT'iON { 1945)• Ev�,.�.U�� �: `�- I A (k 0'L�t(5� FRES .F�itT: - . . . .� , . . '�'' •�'..,. . . ;� ' . . ' Ys�#�e-i,odlaovn�.�,���t3�e� . . . � - - . 5� L� �A�DQ! . T.��3��:'i`,3�*CPr t���'? �y ,1.!S?,�*' ��7T'1'�'_�t`''. C'.�T�["r, g�II .. �x ' C.:'(C�e 9oQr.� G'�{G'.�Q9IaQe)- ���� ns'��s�) � ��. ���) g��� i (7���) N (Nms sto�ei 8 �e). 3 (�aaldrr.SlcQa) T (T� � . ��_ �.� :9.A amm�S�a,l . sct�r�� � �� � �� ��-� ��� . SCL , ab'd3 �� � (S�rCIay3�amY c � cz c�y r� � . �tGL. (S�dp��) ' .r'�' 1 i3�tL��}' . - . � ��� �5�' �. ,. Q(�) 0:4-0:1 DTaoe Q's-QLi `��`T�} C (��) 5E�' (�lig5dy$m�ive)• Td(DBa�ve� �i .. �t��3'' . . � .�te�t ��� aes��c�• Ps �ffiyj . ' ' ��� . ��) f:p_ .c�e ygs�p� • xg�- a.a-ofls �t�a ,: ss�a,� . ��i- s �] 9Fi(4aT��9ts�) �i9a7� �(�ri� ' r�crTm.pa� ' s�t�r� ' �Ad'�tiTARdma�odepl�.,�e.�s.sai�aomea.�apqP�w+�c$awmdqoa�y:., • PCpy� ' �' _. ' r • ' `�ty��f . . . iamr�ns l�Osa.e�aai:�mt �e . Z1�fQPF4Z ?a�eis:t$�mm.i�da�ca . , , • . R�PEE�N . '�icima��ddep�hframlemd� .. -�� ' Sfa�telazII�e) ' : ' • SLIIL � Ta��1�ds�amsofreels�s�mcL�$omi�dsm�msmiml�ax��2�3s�-ss�d�tmodlco�driPdmgsm�a fy,a��sr�+rr�s�r�mu S t9�blej,P3 (Pmvi�eIIY 3�blal a�i7(�amombie) ' • . H9a�ad�aoP��lm byp�a. . ' _ . . ���e.(LT� S��' • � : .. ' .