A41 70,
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PERSON �QLT.NT�' �;�ALTH DEPARTMEI`� _
WELL AND SEWAGE SITE, LOLt�TION IMI'ROVEMENT PERNIIT
Tax Iv�iap # �}- � / Parcel # �
Zaning Township j=-d�
Owner/Contractor �,v— Date � - � — � .S
Location/Address .�o,•�. �� �'�t , ��� , I,S .�'-�. ��L
J.�7 � �,� .��) S.R.# /j s� D
Subdivision Name `� Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area seu��c- Size of Tank /�-r�-�'
SFD V Mobile Home 1/ Size of Pump Tank /✓/�}
Business # of Bedrooms 3 Nitrification Line �OQ' x 3�
Max Depth Trenches � .
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations
Permits may be voided if site is altered or intended use changed. , �, �
Well and Septic Layout by�
Comments:
Date /�� /�- - C%� Installed by.
D� .�
WELL SYSTEM SPECIFICATIONS
t/ � Semi-Public IRequired Slab
Replacement Air Vent
te Approved_�
ell Head Approved,
�outing Approved_
Comments:
Required Well Lo�
Well Tag �
Date Installed by ���} W� i<< �"'� S� Approved by
J�
This report is based in part on infonnation provided the homeowner or his/her representative in the application submitted for this pemvt The
environmental health specialist is not responsible for false or misleading information contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application Neither Person County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water suQply will remain potable. c:�amipro�permitsam O1/95 rev.1.0
ORIGINAL
Apalicatton Date: � �""�O J� �
Amount Paid: �
Receiqt #:
Tax Map #: � � I
Parcel #: ��
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APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFIED
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Owner/agent/prospective owner): Kc r- L-. S� a�
Home Phone: '36�1-�`/�`l � Address:
Business Phone: Sis- G�o -3SS' ( '
2) Name and address of current owner: l�c � S.. .�
�[�r -se.��3 s��� �K
�oX�br� (�( C v�'!S'i"3
3) Property Description: Lot size:, � t Township: Su
Directions to the property (Including road names and nu�bers): I-/G.
�t w� ,/ �� i _, .
Lot #
4) Proposed Use d Structure Description: answer each of the following questions: , ,
a) Proposed �, Existing _, Type of Structure�T.�.�,;� L�',�. -� Width:� Depth:�
b) Number of Bedrooms: � Number of occupants or people to be served: 1 �
c) Basement: Yes_, No �I there be plumbing in the basement?
d) Garbage Disposal: Yes _, No ��
5) Water Supply Type: Private _ new _ or existing�, Public_, Community_, Spring _
Are any welis on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No �— �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED 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-site 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 understand if the site is altered or the intended use changes, the permit shall
become invalid.
�
Owner or Legal Representative
� � � 6%3
Date
PCHD, rev. 06127/02
_ - - - _ - :�� � .� ���` `�: �� �
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Taa �r%ap # �� Pa=cxi # �
�+ V �m,�t
S'•�Cr�ng Sewage Spste�n �ort Fa� Mob�e ]�ome Re�Iac . .
• - �on Tp�c: �
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1-l'7� '�c�t�s S�ov�e j� � Bu�es9 #��q' - iP,�� - 3g�' l
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S •c System I)esi�ne� For. •VBesid�ntial Bnsinesa �er
� .
# Bedroams � # Emplope�s Othe� �
. System Type; 1-0�.t1�,✓i.�i7.�� �
. . �� r�n�: 12-1 � -2 �
�ank S3z� � "�D � Ni�tio�n �ne: ��� r l� �
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- c�� op� ��: %U � .
�a-site wastew�ter cins�osal spst�m siaows no �� si�ns �f m�lfimctiosd aax
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T�x M��� P�.rcel #
S�uibci�ivi�s�ion
P�h.a•s_e�Sect�iion`Lot #
Applicant: �'e,vt �Vt�v✓ .
Location:
�S . c��s ��e
Permit Valid for
Type of Facility: _
# of Occupants �
Proposed Wastew
Prorosed Repair:
Permit Conditions:
Improvement Permit ���s�
� Five Y ars No Ezpiration ;`�
��P New � Addition Water Supply i�Jf � 1"
3� # of Bedrooms Projected Daily Flow _�pp g.p.d. �
ter System: C9�LU � ( Type: � q
C_M,VQ,��;u�.�.q Type: .��
J��P�P D CI l� DG�-fS �-� �I,?- S�$� O�F � S�- �o f
Owner or Legal Representative 5i
Authorized State Agent:
� v�'-- —� Date: e , �3
,v�%� Date: � ( �D �
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicantlproperty 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 Sewa,�e Treatment and Disposal 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. �
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_�.
Proposed_Wastewater System: ti�%e.✓`� ��`'� � Type�ci Wastewater Flow r0O .p.d.
New �� �� Repair Ex ansion Soil LTAR: • O g.p.d./ ft 2
Type of Facility: �� . Basement Yes � No
Wastewater System Requirements
�'s��'� �
Tank Size: Septic Tank: ga Pump Tank: gal Grease Trap: gal
Drainfield: Tota1 Area: �� sq ft Total Length aC9 O ft Mazimum Trench Depth a� in
Trench Width 3 ft Minimum Soil Cover: �_ in Minimum Trench Sepazation: � ft�•�
Distribution:
Specifications:
Distribution Box i� Seria1 Distribution
',P Si � �,�'�P � i IM,t� �
Authorized State Agent: __���
Permit Expira on Date:
Pressure Manifold
r/GL S �a c l 5���- r
�
Date: � Z`o� ��0 3
The type of system permitted is �Gonventional Innovative Alternative. I accept the specifications of
the permit.
Owner/I.egal Representative: x � �.�-� Date: ( ! �Z
PCHD 1/17/2003
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Applicar� 1� Cfi�
ax ��:r��� � � a rc �f � �
S�u h cii� �r i-4i a r�
Pf�r.a,��e,:Se�'t�i��a'Lo� �
Operation P�rmi�t . .
� � � System Type (ln Accor+danc� Witfi Tabie Va): .
T�i1S SY5TE3Y1 HAS BE�A1 INSTALLED IN COMPt1ANCE WtTH APPl.1CABLE NORTH
CAROLINA GEiVERAL STATUTES, �RULES FOR�SEWAGE.TRE�►TaAE3�IT dND D15POSAt, :
AND- ALL' C�fdDITi�NS ..OF THE IMPROV�IIEiNT PE'RAA1T AND. CONS'FRUCTION
•AUTHO 770N:��,` � �
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� Author¢ed S�ite Agetrt � .. � � . • Date ' '
Installed By. � � �- ��/ts%wl�� . Date• . . � � � �� . . . .
_ � ..� �:..�`„�PS.._ .'..�� .
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Ta: MaQ # r, � l�arr.�i ��` D_ � System Type (Table Va) �
Owrier�AQ�iicarrk � Subdivision �
AddresslLocation SecfPhase Lot #
: ID/date �'�r'n Trenc�t Width
aciiy. . gai. � Trenct�. D
and F�iter Trenct� Len
e Trenct� Grade
Rtser i� ap licable) Rodc D and Qtraiiiy
Tank Ou�et:�Seai Dams/S owns. etc.
Pem�aner�t Marke� � ' � Presstue Latetals
Pump Tank � tiale �Spaang -
e � � oe � �
Ca aciiy. ' � gal. ' Pi e Sleeve. .-
W rocrf 1Sealant . Tum-upslProier.�ors
Riser � � • . . iteqeiined Setbacl�
Wafie�- Ti fit - . From Wells :
Psun�a � From Pro�er��lines
Chec�c Value/Gate Valve � � • : StructureslBaserrierrts
�� on o e ' - � ��•• es n e ay:
Floats/Swiic�es -' . . ... . • St�rFacelNaters_
Alartn visab(e and audible Pubi[c Wa�er Sup lies
a
_,
�-, -
�a '
Eiedricai Cam onerrts Verttcal Cuts -�2 f%
Rafie pm Water Lir�es .
Q roved Pum Madel Vehide TrafHc �
81ock Unde� Pump A acerrt• s
P Removal R� e/Chain EasementslRi of W •
Distributlon System Other �
S'eriai Disti�ibutian ' � Easemerrts Recarded .
, ressure r rttract
Low Pressure P e • Tri-Patt�te A reemerit
AQpr. Pipe Material and Grade •
Valves . • -
� CommeMs' -
pc�td rev. 3l�S 310'1