A41 78�
�o� o�: �_� �roa
ount Paid• t �� �
ecei t #:
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Perso� Countv Health Departmeot
Environmentai Health 3ecilo�
APQUCATfON FOR SERVICES
Tax Maa #: �� �
ti�_� �.. � �S � d
IF THE INFORMATION IN THE APPIlCATION FOR �AN IMPROVEMENT PERMIT IS FALSiFl�. CHANGED. OR THE SiTE 15
ALTERED. THEN'THE 1MPROVEiV1EiVT PERMIT AND AUTHORiZAT10N TO CONSTRUCT SHALL BE�OME iNVAL1D,
i) Permit requestad by� Owrterlagent/prospective ovmerj: � A� �LD .. �pCQJi��-( N�
Hame Pho�e: C 3 tr ����-�t 22� Addres� D
8usiness Pha�e: Ca t a S- 3� �-l-'1 I} 1F A N 'l �
2j Name and addt�ess of currer►t owner. � if,�A�t' -+-� � i�lxUt S
3) PrcQerty DeserIption: Latstza: I�ox�nahta �� lt ,f ���) S
Oiredions to the arooertv, qndudin� road names and numbersk � Q
15� �s�
4) Propoaed Use and Structare Descriptiaa: answer each af the tollowing questbns:
a) Proposed� Existing ❑
b) SHdc Suultt�9, Moduiar S1n Wtde Q Ocuble Wtde 0
c) Numbec of 8edraoms:�� � Number of ccas�ants or peopte to be se�ved: 2
e) Hasemen� Yes Q No�lf yas. # of basement fixburex
� f� Gariiage Disposai: Yes Q No�
gj DUnensia�s of Proposed Strnc�cue: Width: � Oepth: �a
f�P2C-2
� W�tBr SuPP�Y TYPe: Private'�(new 0 oc e�fin9 �. Pu61ie 0. Commun�l �. Spdn9 �.
Are any wells on adjoining propect�? Yes�No 0 If yes, lor�tioe b�a�e� t,�'1 ►'�2ar
. �'c�
b� Please indicata Desiied Systam Type: (systems can be ranloed in ocde� of your pcetec�enca)
1� �errtional Modified Comrentionat _ Ai�ve innovative
other (ap�ctiy):
CLEARLY. STAKE ALL CORNERS AND UNES OF THE PROPERTY.
STAKE THE CORNER.S OF ALL PROPOSED STRUCTURES.
P�EASE ATTACH SURVEY PI.AT OR SITE PLAN TO THIS AP4l.iCATION
I hereby malce app6catlon to the Petson Couniy Health Departrnes�t for a sibe etiabuatlOn for the on-site sewage disp�l system fcc
thn above-desabed prope�iy. t agree that the contenb of this appNcation are true and rep�sent the ma�dmum faa'�ttes to be
piaced on the propedy. 1 understand if the s�e is altec+ed or the intended use d�anges. ihe pem�it shaii become invaQd. I undecstanc
that as aPg�cant. 1 am respo�sbte, for iden�fying and �9 P�lI �. comers and malcing the s�e a�e tor the
petsonnei Person Coutrty Health Oepartrneat to condud their gvaluatians. I ta�arid ihat f am respon�e 60� no�i7M9 �E
Heaah ent if my perty a��r�ds as desi9� blf ��f ���9�-
, . .1 �
� � � —l'7- d�
or Legal R . Oate
���
. PERSON COUNTY ENVIRONMENTAL HEALTH
E ATTACHED P�AN FnR snii eRFe eNn cvc-r�iu i
Tax Map #: {�� 1 Parcel # J� ��
Zon(ng Township FYAQ�[� m\I.LS
Appticant: _ ��i�.Ql��L1AiC, \ �L�
LocaUon: _ _ l�Q6EQ.S " 1J��1'�'�1 �1,� (Z[�
Subdivision• R—^ Section: � Lot ^
�� Y '� �
�—
Improvement Permit
A buildinq permit cannot be issued with only an Improvement Permit
New � Repair AddiGon Type of Strudure 1�OUSt�
# of Occupants ('�� �# of Bedrooms 3 Other
Basement? nl0 Basement Fixtures? v
Water Supply '��lL
Projeded Daily Flow: 3(0� g,p.d. Permit Valid For. C7Five Years ❑ No Expiration
Proposed Wastewater System Type: Qu�P GorydE►Jj�0�•1,� l
Pump Required? _GYes No
Proposed Repair : PaH1P PC�n1Vr�IT►�1{�t-
Permit Conditions: ,n15<F�
0 � i-Q�'CLoN
Owner or Legal Representative
Authorized State Agent: �
Date: - - �
Date:_ 5-25-OU
The issuance of this permit by�e Health Department in no way guarantees the issuance of other permits. The permit
holder is responsible for chedcing with appropriate goveming bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (ReQuired for Buildinq Permit)
Type of Wastewater System QUr'1P C�N�'�.1Ttri,Pi7 Wastewate� Flow: �6O Q.p.d.
�
Facility Type: �t1�,1,5�
Basement? 0 Yes �o
Wastewater Svstem Requirements
Septic Tank Size: � OC`iC� gallons
New Cf Repair DExpansian ❑
Basement F'ixtures? 0 Yes�-t�o
Pump Tank Size: 001� gallons
Total Trench Length: �_ feet Maximum Trench Depth: 2� inches Aggregate Depth: j� in.
Maximum Soil Cover. � Z inches Trench Separation: � Feet on Center
Other. �� \1�1� (�01�liE�l'� pE,�(Y1L""�"'
Permit Expiration Date: __ s�2� � Q�
Authorized State Agent: J Date: J`�'ZS'6b
The type of system penni .�does � doe t differ from the e specified on the application. I accept
the specifications of this permit
Owner/Legal Representative Signature:. Date: i�i cX/ �
PCHD, rev. 11/18/99
Application #:
Tax Map #:
Parcel #:
• Person Couniy Health Department
Environmentat Health Section
SITE SKETCH
S�e u�L��c P �E�: � �
Applicant's Name SubdivisionlSection/Lot#
Sora K ���ucE�, �- . ��25-CCY�
Authorized State Agent Date
Svstem components represeni approzimate contours only. The contractor must flag the system
Scale: I `' = �op�
PCHD, �ev.10J12199
���,�� ��I�.���
_._ � � � ����-
�������.��.�.�.�. ���.�.��
WELL PERMIT
1'I.Et�SE SEE ATTACI�ED PLAN FOR WELL SITE LAYOUT
Tax Map #: ��� Parcel # � � Township
Applicant:
Subdivision:
r—
Tvs�e of Water Suvulv:
Requirements:
Secaon• Lot• 2
� Individual Comnlunitp Public
Site Approved by /�?l� � " �7' 0-3
G=outing APP�ed by,�1' ' �� %-�
Well Log i/
Well Tag�
Air Vent
Hose Bib�
Concrete Slab
Well Driller.
Well Approved By: I"�l� Date: ,2���-� �
'�°5ee Attached Site Sketch'�
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from sepfiic spstems.
Wells must be at least 25 feet from any building foundation.
4ther conditions:
PC�ID, rev. 09/07/01
FROM : ACME WELL CO., INC. PHONE N0. : 5449417 Dec. 09 2�04 05:49PM P01
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Appiicani
Locatian:
T��x Ma,p � P�rcMel = �
S�uhd!ivis�ion
'Ph��s�e Sec�t+ioi,� Lo�t z
�peration Permit . �
System Type (In Accordance With Tabie Va): .
THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPLlCABLE N�RTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AIVD ALL CONDITIOIdS OF T�iE IMPROVEMENT PERMIT AND. CONS�RUCTION
AUTHOR1ZATiON. �
�'�7��i�► C�i ��nrt;� � � . � %2. "�� . �
v
Authorized State Agent � Date
Instailed By: � �i`S � Date: /�- 3 � �
I �z � . � .
o' . . .. . . .
ll�� !�D�.I . .' . . .�. , � .: ..
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S'S�'
�PCHD, rev. 07/29IO2
S��'iIC T�aNK 1P�SPlE�C'�10N CHE�B�LIST (Type 11- Il�j
Tax Map # �� Parce! # � � � System Type (T�bie Va) ?IT.�
OwnerlA�plicant� �: c :... Subdivision --�
Address/Location s� -�,' � �� SecfPhase Lot # —
State I D/date � �-�5-0 �
Capaciiy. ( o0 0
Tee and Fiiter,/ .
8affle ✓
Sealant �
Riser (if applicable)
Tank Outlet:Seai ✓
Permanerrt Marker N/
Pump Tank
Wate� ro�o-f /Sealant
Riser ✓
; Checic V�lvelGate Vaive �
. tt-si on o e �
.- . Floats/Switches � ✓
Alarm visabie and audible
Etectrical Com onents -
\�5 ,� Rate pm
�������` Approved Pum Model �/
��o Biock Under Pump ✓
Pump Removal Rope/Chain ✓
� Distribution System
Serial Distribution '
. ressure an o
Low Pressure Pipe •
Appr: Piqe Maieriai and Grade
�
�n�vauuaie �imncauon unes
'� rench Width ft.
Trench. Depth � in.
Trench Length 4�� ft.
Trench Grade �
Trench Spac9ng ✓
Rock Depth and Quality ✓
Dams/Stepdowns etc. �
Pressure Laterals
Hole Spacing .
o e �ze �
Pipe Sieeve
' I�equired Setbac�cs
From Welis �: .
From Property lines.
. r- �� uncnes luramage �
.. . . a� . � . SurFace Waters
Public Water Sup i'
Vertical Cuts >2 ft
� WaterLines
�lRight of Ways�
Other
3 Recorded . �
aerator ontract
Tri-Partate
I
Comments�
pc�d rev, 3/13101