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A41 149
. . � . ��va � � �,�z`2�� Aaalication Daie• q- q-0 �;' � 3� �� 5�� Tax Ma #: Amcunt Paid• a o�a lLr1 -- ecei S� ��9 4—'r Parc:e! #� 7�� �i b 3� � �._�1�. � IC' ��.� �� � Lo �C � �Tl�T'��-� lC'+..�a-aa�v�aa-saaa�raram�rn�.m.71 ]E�[m.es.71�71-n APPLICATION FOR SERVICES � :men[s rem�n - � � au.w •+ ••••••.•••••••,•••.. • ..... Hom@ Re�acemenUAdd�n) S15Q.001�2Q0.00 1) 2) 3) Permit requested by: (OwneNagent/prospective owner): �' L u`� �� �� -�'�-' Home Phone: �� � 3c�� Address: .. � • Business Phone: �' / ""'�' � C— �'� tdame and address of cun�ent owner. ` c �rh¢. �n�� 3ts �c � C(_ �� rc �ur"��► � 7 , '��� Property Description: Lot size: ��'��c-Township: ��"��/' Subdivisio�: �►' Directions ta the propertv (inaludi�q road names and numbers): 1���� ! s Lot 4) Proposed Use and Structure Description: answer each of the fallowing quesfions: a) Proposed _ j,__, Existing _(Z,, Type of Structure:�Q Width:� Depth:�-�, b) Number of Bedrooms: 3 Number of occupants or �ople to be served: �—S"'? c) Basemen� Yes_, No �Wiil the be plumbing in the basement? d) Garbage Disposal: Yes , No „� 6) Water S�appfy Type: Private �new �r extisting_�, Publj.c . Community . Spring � Are any weils on adjoining propert�t Yes No �f yes..ptease ind'�cate approximate �cation on the site pfan. 6) Does your praperty cor�tain previously Idsrrtlfi�d jur�dictlonal �►etiands? Y�s No � PLEASE NOTE THE FOLLOWiNG: ➢ A Pl.AT O� THE PR�PERTY OR SITE PLAN NAUST BE SUBMITTED WITH THlS APPLICAT�ON. ➢ PROPERTY UNES AND CQRNERS MUST BE CLEARIY MARKED. A THE PROPOSEO LOCATION O� ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ TNE StTE MUST BE READILY ACCESSlBLE FOR AN EVALUATION BY THE H�At.TH DEPARTl4�EIdT STAFF. i heneby make application to the Person CouMy Health Department for a site evaluation for the on-site sewage disposai system far the above-described property. I agcee that the contents of this applic�tion are true and represent the maximum facilities to be placed on the property. ( understand if the site is attered or the intended use changes, the permit shall � � � Da PCHD, rev. OBi27f02 . . � �.�..T ���� J. � ���� �� �� � �.�� 1L !L • I�aava.s-�� � ���•.71 IE-��,aL1L�I�n. Applican Location: „ Wc� � T��x �li��:i�� ! � �a,rr_ :..I � � S�uei�cl!i v i-ti in �a P'I,r�:�;.�_���ecri,����t L�t � ][anpa�oveffiemt Permat Petwit Valid for �ive Years. Nq �rirat�on �� � . T�ype of Facilifig: ' ' � � -�.r�� New � Addition '4'V�tea� Supply��x�.�c # of Occupanta t� ^�x # of Bedrooms � jected Dai1y'Flow.�� . g.p.d. • Proposed WasteWa#er 3�st�m: C�s�..,�.. �w.QQ . . Type: �1 a Praposed Rep�ir: 4-.��.�.,y.�.� Ca57. �Q��-�.,i � � T�rpe: Q Peanit Condit�ons: �o.o �,�v� ��r, �c���c`. or�.. � r��. �� � 5� sa\. �� �J�. i � GCSZ SQi+i��r' l�S�^'�C�-�`!' � �� � a lnn . _. ....,�.,\��L ..,,,n�� �.,e �.,..� � �aiQ� •�i�k�rC� SQ.l��2 '�7 �t�4�n� Q/l..�S�(91. _ . Qwner or Legal Represe Authorized State Agent: m � 'Tha iaeuance uf tfiia permit by t�o Health Dopm�ent 3nvdoes noi guarantea tha issaanca of oiher peanits. It is the responsbility of ihe $PP��P�P�Y owaer to in a�un that aIl Potson Cowriy F'lanning and� Zoning and Bw7d'mg Iusgectiona requirements are me� 7f�is Improvement permit ie sub jeet to revocation if the �ite plsn, plat or the inteuded uae changes. The Tmprovemnent 1'ermlt is nut affected by a•change in ownershtp of the propertg. This permit was issued bn complianca wtth the provisions of the Noeth Carol�a `Laws and ,lp for �'P++►ase TF'gadnent and D��osaY S`vstemx' (15A NCAC.IBA .1900). Neitf�er Person County nor the Enviro�mental IIealth Specialist wat cants that the aeptic tank 8yatem will conW►ue to function satiefactorit�* in the future or that the tiwa�er aupply will remain potable. - � . AII�o�1Z8t1QII t0 CoIIB$t11Ct �a�te�PSte� ►S�S�C�il �Reqnired for Building �'ermit) * See site plan and additlonal c�ttnchments (� Proposed Wastewater 3Ystem: l���r`�'� Z`Ype 1�a Wastewater Flow 3L �• g.p.d. New ✓ Repsir P.gpansinn Soil LTAR: ;�'1 S g-P-d.! $ 2 TypaofEacilifiy:.� +c�:.1�� T-���,�_ � �Basement �Yes ✓No — � �astewater System Reqniremep►ts � . Size: 3eptic T�nk: J�Z gal .. PnmP �ank: � gal' . Grease Trap: " gal fie1d: Total Area: Ls�� aq ft Total Length �/ �/C7 ft Mazimunn Treueh Depth � fn eh'W�dth �_� Minimnm Soll Cover :�� CP in Minimum Trench �eparation: �_ ft Distr.tibution Boa X Seri�ll Dishribution �Pressure Manifold ....� �,,,. . co n�c,4 �.�, c.r.,t:..a.r�.� :Sa \ . i Au�or3zed St�te Ageait: Pe�it F.xpiration Date: The typa of system pe�utted is� i the permit. ' Oe�nerLLega� �tep�sseni:aiiv`%w� :a Da#e. J� �o�� �� Innovative Alternative. I pt the ecifications of . D�:� � � � � � CHD� 0�20�2 • `���j�� � �a �.��./ �� ' ^� ' V 'V �� JL 1E��aa-o+� � �a��.Il ]E33LL�c��fla. ��� ��.�C�. Name ` n�n� Tag Ma.p # N i Pascel #� Subdivision � �ection/Lot# , � � � a �a-o�i Autho ' ed S Agent • Date . �� Systern componenrs r�epresent approximate�contours only. The contrdc�tar must, flag the systemprior to Isegirening tlee irutadlation to insure thatpropergmde is mas�tained ° � • ,r Scale: � 1 �� � 1 O7 �\� ' � `�`�x.., � C�,� ��. — — i�O.�aA. Cl�� �v-Q.J�), � �.�.�\1 i� '' � ��-I�ic�, - - - 33�- �i � _.1nfi`�.52 3'� �' � �oq �� � , ��5 c.'I�.z � u0-�-.Lw]nV4/��hb� � 18,, ,�..�,Q,.�,, �\.p�'h �`, �-�-��►�r ����M ��- '��� . '�,.,�,�;� c-a57. � �.�� - C,�e\ \ �'s�c �a� `� ^^J`�-� c�.� � �� �, � c� �E� ��w�c� � � ^..Q � _--- ��,,�se�,-ti�- " ,�� �pD 7 , - � ��� �� � �� � �5 _ ,M,►�� `��- �,� ,�-i �. -� ,`'�1,c...QQ o1..�r. ^ ��.s} je�}c,b�l;gti, v¢�c��e �c.�er U C�Qr ��`�'� SQ��Z � �`�- • •: . PCHI), tev. 09/12/Ol !.:�.:.:`_ :....::<�,:..,�..: . ..'. .� ; ::' '��.�_ :`. �;:' `::: , :.. ;:, �: � , ..:. � ::�.� `''�'1'�`'.� ',: ; �.'.,....,:.`�:? � �,' �, � . : ' . ::... � ,,:: .� .. . :.. : . ...:...:... . . . ... � �� . -.�..�,.r,.!.��?'.:: ` ... . . %��:::?1�:{Y..��:��� . ... ...,.. .: ..: ::::::.....: •.... ...... ..,,.: ,.,... : ... : .. . .: . . •: � • .•:. ••:,��... •������:';:t.•,...,.;..,� ..,.., .. . . . ..; .. . . .. . . . .: •., 7� 7�� T �::. �j{'iIli',.,�.'.71i`�1C�,�D''A"Ir-� � 0.0.�'.17�:']L:Qi.iHi;:7L'':�':1L':•.1�.��?'�iii-L:�': '• •��m�w.': WELL PERMIT � PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map ,R�I 1 Parcel # i y4 Township: � f�v� Applicant• C_�nk� _ (ninu En�-. 5ubdivision: Lot # � Location: ��--�-� S� C. o-+ ��rs �Y4J1 �d >/�t.s ur, �- .�- �/a r►,�IR >3"� v 10l- , Type of'Water 5upply: ✓Individual _ Community Public kequfrements: Site Approved By: �� `^, �l � � �b �Grouting ApProved By: �-' oh o Well LoS: 5 � `"� vc��l � �o,� Pump Tag: ��,.� 0 4�o�/' od� Well Tag: � Air Vent: � � Hose Bib: Casing Height: � ' Concrete Slab: Well Driller: �� �5�.•� C'`� P �� Well Approved by: .�,► c�., � . ****See Attached 5ite Sketch**** Liner: �Installed by: Depth set: _ Grouted• _ Date: Water Sample: Wells must be 10 feet from property lines. � �Wells must be 100 feet from septic systems. Wells must be at least ZS feet from any building foundation. Other conditions: /� ��f Sl�uU-� . Date:, � �! �o � l �� PCHD rev O1/27104 ����.s:..� .��.�.��� � . � �C � �Y�-�, �.. I�'.s�•►�a�v�s�xeaxE�Il ��,�s.Il�l�a. ca . � � ►. ., ,,� � � . Ccrr��'�. +!�,r N-.,ii�, • ,� � L , �D;��t� � �� �E�, ;{ � � • � �wner: a ic,� 1; u �, t,,.._ Well Log Lr�catioa: ~ � _. Tax MaP �,L. Parce.l # ,�� QtY�1f�i �riai...... ^"�"`�^W-r — .aa�via. �Ot � Wdt Canitr�ectiaa Dis�ance Frc�m n�arest 'Prupercy Liae (Minimnm i a feet) _. Distance frrna ��p4c System (Muumum 60 fee�) . To� �P�: � ft Yicld: __,�____ GPM Static Water I.eveI: �_ g Water Hraring Zanes: Depth ��►�} � f} �� ft c�a�tn�: Co 3 Depth: Frorn �� to �` �, Diametv: —� in Type: Ga�lvaniz�d Stccl r,,�_ �'p8ht: � L ' � 'Iluckntss• . �> � S�� Height �bave Ground• 1 � in T1Tive Sho�: _ es I�o . Any pmblems c�ncountercd while � srttwg casiag? Yes li1G�o ��' "yrs" giv� re�san: --- Croat. iVeat: SaudlCement Canc�ete GzaveUCemcat Anuular S�Sacc Width ,,,,r inc�es Water i� Atwular Spac� r Yes No ?�itthod of Groui: Pumpcci .M__ � Pressu� _ Poured L)epth to r F� '.�ixtrrLtis �Jsed: _._.._ ?Jo. 9ags� P�rt]and cameat Wcig,�t of 1 Beg ,_,__ Pounds� ii m.ixture (saad, grav�l, cutting�� — ltatio to ID plaus• � Yes ____ No 4 r 4 slab ____ Y�s � No b�11�a� � L�don Drawiug I hereby certir'y th�.t the above informution iq corr�ct aud that this wel] was cansuucted in accorclance w�ith regutations sct farti� by *_he Pc�n County Health t�cgartmeat. Si�aature nf t'uatrttctor�� II� * u�___ ���L� Dste _, ��.� Pcxv n� oii� �.�e� ���, �� ���� ��. �! ��-. v " `.�.� � � � � � � 7� �.�a �- � ��. � m. �.II I�L � �. ]1 ¢1� � Applicant: �bv��- �- �'' p ��7'p� l`� S� . Locaiion: I S 7 S� o-, C4 re s/�-r � 1I .� 10 T �� ��►� �� ���o � � I�� ���do�, 11'IIIl@1�I��iSll�tluYL�l°Jl5 fa� � �ofi ��� �a 3 "- �� ,�„r� -� 3 �� /o ���ti � �r 1� _ Syst�m Type (In Accordanc� Wiih Table Va}: `� `� THIS S`tST�i�I �-3A5 �EE� ifVSTALLED IN COIV1PiJAi�C� UVIi'H �►PP�.lC�,�LE . NORTH Ci4Rt3L.1�lA GE�E�i�4L STATdlT�S, RUL.�S �'�OR SEiNAGE TRE�4Ti91[E�T AND DISPO$AL, ,4ND AL:L CONi�ITiO1�S C1F � i'HE 1fViP�01lE�E�lT i�ER1VllT AND C�NS3RUCT10N AllTHOiel�Tl01V . _ . ..—Z z-° a � . Authorized St Agent Date f nstalled By: � M M� L P�1 � S Date: d 6� a7 /b� � • E . ,� � N OpG�� Q� �, = 5 �-, L a = �'�' L.� = li S' � �.:. la5' �S = 5�-�. b � m PCHD, re�. 07/29/Q4 y � ����� ��f� ���������� '�u��'��g�� ���� 0� - �� —, Tax Map #�_ Rarc�! # � 4 9 Sysiern Type (Tabie Va) -�- �' OwnerlAppiicanf C��� t C i-► e£,� � �isr Subdivision Address/Location I��S -� � e� �G1�s Se�/Phase Lot #� /� � ( ( � L� r s . o-� �/��- n.. �'j� -� � /'� /07� " State �IDldate STB -I �ta %o►-oa-b� ��Itw , Caoacitv lo�c> .4a1. Tee and Filter � Bafffe Seaiant Riser (ifi applicabie). Tank Outlet Sea! Permanent Marker Ptamp 'fan6� /Sealant Riser Water Tight ���� Checic ValvelGate Vaive � Ant�-s� on o e FioatslSwiiches �41arm (visable and autlible Rate (gpm) Approves� Pump Mode! Blocic Unde� Pump PumQ Removal RopelC . ��Dis�rabu�on. �y: Serial Distribution Low Pressure Pipe Appr. Pi�e I�ate�iai and Grade Va(v�s Trenct� �dth Trench Depth Trenc� Length Trenci� Grade � � Rock De th and Dams/Ste do�r Pressure Latera rv ,4 Hoie Spacing � o e �ze PiQe. Sleeve Required� �etba��� From Wells From Propertv lines Surface W�ters Public 1Nater Suppi Vertical Cuts (�2 ft. Water Lines Ve�iicle�Traffic Ad'ac�nt S tems � �EasementsJRight of W Oti�er s,� o� �,oio Easemen#s Re�arded �vA ert e erator on I Tri-Partate Aaresmer�� Commen� o E/ pc:�d rev. 3/13/0�