A23 116�,
Person County Health Depart�ment
Sewage Syster�n In�tip�-��yementa Permi#.
Date:�.�'1�is Permit Void Aft�r�Years f 5� ��� ��
Owner: . ' �, SR� _La�����
Lcxauon/Direcdons: � �'
� � �..! ! ' ;.
��� —
z
Subdivision Name: �1 �v�'��� #
Lot Sizc: �, ��tF��!� .� " ,,,�yi� of Dwelling: — � .
Watcr.Supply: Privatc: Public: Cominunity.�
Becirooms: 3 Garbage Disposal
Basement Basement Fixtures — ��/���-
INFORMA C BY _
$c1111Ic1fic'lll: owncr or rcpres�rauvc
REPAIR: REE�lA.LUATION: _
Size of Septic Tank: —,��- ga�lons Size of Pump T ' ,•
� s �
Nitrification Line: �°f�1�_ —
Depth of Stone: 12 inches -
Max Depth of Trenches: �"�� � � �-
Altemative System: Conv. Pump � LPP Pump _ ��) f�
--�1-- =-------------�---_._—
Date Well Approved: � Well should L�e l00 ft. from any sewer syseem
gy Sanitarian
Date Sewage System Approved: , --
gy Sanitarian
� CERiTFICATF. OF COMPLETION
Contractor. � t � 1�,ui:s — �
Sewage System location, installacion, and protection must meet state and local ��
regulations. Sepuc tank should be pumped out every..3� to 5 years and shall be maintainc.�i a
by owner in such manner as not to cr�:ate a public health hazard. Septic tuilc aud''d
nitrif'ication line must be inspected and approved by a member of the Person Coun.ry �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this petlnit is subject to reva:ation.
(G.S. 130 A-335�
Location of sewage disposal sewage system sketched on back.
�A� �OVER � � � s C�. Y
C.�1�� ��� � v
� . � �k,-�f � lo�t � I
Amount paid ��� aO '-'
Receipt 1� ` � I �
q'/q !
�" � � APPLICATION
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,
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n.::.Y�3
R a Improvements Permit. (EstablishedlRecorded Lot)
Improvements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
_ Improvements Permit (Addition)
�
� Y:�v� Y � k -'k r'.
O : � � u.. r:3�t �'
� .i. .-,�.,.x .....,
_ Bacteria
g �J �o��
3 � J��
��� a
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Date
Reinspection of Existing System (Loan Cl
_ RepaidReplace existing Septic System
t for New Well
_ Replace Existing Well
, ...... .. ... .............
_ Chemical Petroleum _ Pesticide _ ea
l. Permit requested by: . .�.o '��g9J� �• Dimensions or Proposed Structure:
owner/prospective owner/agent:�SICA � S-���-� Width: `4'� �
Address: � c� Depth: `-i�� '
� - � 8. What type (if any, additions, expansions, or
� � � replacement is anticipated to the structure or facility
W oY' a� 3 3 that this sewage disposal system is intended to serve?
�F-iome Phone #: `� � �f - `i�`l � � 3�� , ►.� R�
usiness Phone #: `'1 �y-��� 3°a� �`�'�
a - -
w
¢
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N
_�•�
of current owner: 9. Water suppiy ty pe:
` private �Sj . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
L L � 7c� If so, identify location:
Property Description: Lot size: •9a. a�--
Tax Map#: Ft o� � �-� � �
Parcel#: � �e Y' �"O�
T,,.�,.,��,;.,• 'a anv,���,� n �„n . Narb�r
5. Directions to property: St
Names,�tc.
s� tJ -Fo �14 1-+�- n:t' ;
��
Number of occupants or
; Road # & Road
,
n.�' �� Cunn��
. - .. n . �
le to be served: Z
10. Type of structurelfacility: Proposed: [�lExisting: Q �
Type of dwelling:
House: � Mobile Home: C� Business: ❑
Type of business: ----
Number of Employees: —
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No �l
Basement? Yes � Nofl If so, # of basement fixtures:
, �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTIJRES•
I hereby make application to the Pet'sOn COunty He31th Depai'tment 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 facili[ies to be placed on the property. I understand if the site is altered or the
intended use changes, the pecmit shall become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Healt� Dept. wi[hin 60 DAYS after the date oP the evaluation of
the site by the Health Dept., this applicat�n shall become void and all fees paid forfeited.
ignec� Owner or Authorized
B 2506
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # A 2� Parcel # � � lp
Zoning __ __ _ Township '
Owner/Contractor
Location/Address
Subdivisid�' Name
0
ti-
�
�i
Lot# /
SEWAGE SYSTEM SPECIFICATIONS
� Repair Lot Area a � Size of Tank���
SFD t�- Mobile Home Size of Pump Tank�
Business # of Bedrooms 3 Nitrification Line
Max Depth Trenches
�
U
�
a
�i����
�, '.
! ZSr�
. ,_�� �-
Permits may be voided if ' e is altered or �in,ft �nded use changed. ���1��
Well and Septic Layo t by C�C_ 3�
. ,
Comments: -- 4�_
� � (/ �
Date 5�,3 )� In tall by 1��1 . D.�;�f `► S Approved b ,
� (��c� B--Q a' ,
Well Permit aid WELL SYSTEM 5PECIFICATIONS
Individual �/ Semi-Public Required Slab L�
Public Replacement Air Vent ��
Site Approved `-' Required Well Log ��� .�'9
Well Head Approved �� C� Well Tag ��
Grouting Approved �
Comments:
Date
Installed by.
Approved
This report is based in part on information provided the tiomeowner or his/her
representative in the application submitted for this permit. 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
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warraots that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
�
AUTHORIZATIOI�I FOR WASTEWATER SYSTEM COI�ISTRUCTIpH
(Void sixty (60) months from date of issuance)
DATE: �,I —`� � q� IMPROVEIviENT PERMIT #: 2.5�
TAX MAP #: 2, PARCEL #: I �
OWNER/OWNER'S REPRESENTATIVE: �J -�' •
LOCATION/ADDRESS:
SUBDIVISION 1�IAME: ��„� ; 2�. �C�C b � (� LOT #: �_
SECTIOI�I OR BLOCK:
. AUTHORIZATION FOR CONSTRUCTIOI�I ISSUED,$Y:
AUTHORIZATIOI�I CONDITIONS
I. The Wastewater system constniction and instal[ation must meet all of the conditions of the
attached site plan and specifrcations as set forth in Improvements Pern�it #���. The
construction and instatlation must also meet aII appiicab[e cules and laws.
2. I�Io portion of the Wastewater system shali be covered or placed into use untii inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil condifions Cnciuding structure Iocations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and applicaiion, may void this authorization and associated pentuts.
4. Conditions:
�,� �� O� "
Person Requesting: 4���eJ`� �__
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Appiication Date: ������6
Amount Paid:
Recelpt #:
Tax Map #: /eY � �
Parcel #: � � :(�
� � � ����_ S� 1C� J.i1l ��I' ��
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�Ea�a_vaa-�a-n.��• �axca�m.Il �E�o�.Il.��a
APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEFAENY PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. -
1) Permit requested by: (Own /age prospective owner : , �� �s CG��'���-� ��'�''s�, �v J
Home Phone: 6 -c Address;i v vl ���
Business Phone: ' — - KS` � - �- .� �
2) Name and address of current owner: �� '� U���
t��� 6M .
3) Property Description: Lot size: _�2�fiownship: ���' �
Directions to the propei�y (Includin,g road ames and numbers): _
f'I� d�. ��J ( r�. � V� �.c' �1.-- /��i�.l r
e¢i �,��i���� �� �
4) Proposed Use �nd Structure Description: answer each � the followin sfons: � �
a) Proposed �, Existing Type of Structure: i � Width: �- �-v Depth: ;� S� D
b) Number of Bedrooms: ��'✓ Number of occupants or eople to be se d: �.
c) Basement: YesJ No _ Will there be plumbing in the basement?�
d) Garbage Disposal: Yes , No _ /
/
5) Water Supply Type: Private _(new _ or existing�, Public_, Community� Spring _
Are any weils on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
'site plan.
reviousi identified 'urisdictional wetlands? Yes No y
6) Does your p�operty contain p y � _ _
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 STAI(ED OR FLAGGED.
➢ THE SITE MUS'� 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.
or`Legal Representative
3 b�
ate
PCHD, rev. O6l27/02
�
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s /� �
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� �w.�� Y � � . � � � .�.� � �
.17�.�.�sf�.�a.�i�}i.��.1i]�..��.�.�i.� .1L 1L .'�ii�i.�U..�
�ua�ding �e�dfltionsl 1@ilobii� �oane �e�la��me�ts
Tax Map #: � a3
Approval Requested for:
Parcel#: ► 1 �o
Mobile Home Replacement
X Building AdditionGcrao�p. � �'1''`1y ��^'�
Applicant Name: �1 �l `�\\ � �r-al,� Coti,� ��
Address: 320o C.r-oosa�►:1� '9r- �,:.at '�c�3
�1� a, 6�C 2"')'�os
Phone #'s: 33(.0 --23���Qte� �ilq - 3g3 - �-cs �
Permit Located: ✓ Yes No
Installation Date: ��1 ^$ l S- 3t-�Ei Design flow: 2�c� (gpd)
Current Contract with Certified Operator on file (if required): n�
Water Supply: �t Well Public or Community
Wastewater system shows no visual evidence of failure on: 3^aa-o� (date)
(Applicant's signaiure if site visit is not required)
� �
• � . . � � _��
� � — � . • .� �. �
Addii���a/�eplae�meni App��ved
, 1�S 3 • aa --c��
Environmental He Speciali Date
11/15/OS
'`�� J� / ������
� ��\ 4
• �` � � V i V �� .
IE,m.-�-ny-�,r„ ,.,.-„ ��¢�.11 1Ht��.fl�l�.
Name ���, �. �u�.�
S division 1-1�++� �,,,-
,`�?..S
Autho ed S te Agent
SI'I'E SI�E'I'CH
Tax Map # A23 .Pa:tcel # 111�
Section/Lot# �
3--aa-�
Date
System cbmponents represent approximate�contours only: The contructor must, flag the systemprior to
beginning the installaiion to insure that propergrade is maintained
,
�cale: � ��
�
— )-a11.�.�
8��e. Sk�c�
_ (y�Q,�n.}o,,,Y, c�-i
��c�es.
,�.
�.�.�,, � lsz��
�� �h�c, o►�.
�� �,�jaQ.l.
-}a+k riyar'
'N�,�. � �
PGHD, rev. 09/12/01
z,2s "�1�,.�•�.
PERSON COUNTY HEALTH DEPARTME1�iT
SUBSUR�ACE VVASTEWATER SYSTEM[ NdONIT'ORING REPORT
�2�—! ��j�� � �' 9' � L �� ---L�
Date of Inspection System Installahon Date Type Tax Map rarcel #
Z C(
Properiy
Instructions: Check yes or no for appropriate items and explain inspace provided for remarks and
comments. If an item is not applicable, inflicate by "NA". Tf an item is not or cannot be evaluated, indicate
by "N" and explain. Not� thai this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in t�e permit are to be carried out.
INSPECTION RESULTS
�OLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infiltration and surface water diverted 7
5eptic tank needs pumping ?
�nches of solids:
Septic tank filter cleaned 7
YES / NO
❑ � ❑
a°%o
❑ �
FFFLUENT DOSING SYSTFM:
Required pnmps present & functional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Eff�uent free of excess solids 7 � �
Inches of solids(pumpldose t•): � 3
Elapsed time raadings ?
Counter readings 7 vt �
Drawdown rate:
DISPOSAL FIELD:
Evidence of eftIuent surfacing ? ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively d:verted ? �
Di��ersioas/swales propsrly �ai.ntainPd ?
Vegetative cover maintained 7 ❑
Protected from trafiic/unauthurized uses ?
Distribution devices in good coadidon ?
F' !d free of settled or Iow azeas ?
■�
!■
■
REMARKS
;� � �� r�tn�- ac�eess�'bl,-e 6�c-�
5�
� �C� �e� Y�ec-e�.�71'��,�
(���d"�c��.es�Q 5��,� ( v,,•�t� j�l 1—�—
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�
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0 `t' ��t l' ��— �t� f/t �"� '
� s��Yd�.� ��mP o a�- Q�� �-�,
�'� C� Va �v�e �tti►�- �u�c c-� �N�
� v�t v�� �L' �
0 — t�/aS�fwc��r � rM� �
� a �-� ��^1p �o� s!-� u+ o%�,✓►�t,�
� �(�i��+►� �ac�i� D�t�-'J��w,�.
❑
te
PRESSURE DISTRIBUTION SYSTEI�i: �'c ��-�'t.d�'� �� � �"'`"t `� � - �J�T`�
Tumups/cleanouts/valves/taps intact & t�t
accessible ? 1r r / ❑
Pressi,re head properiy adjusted ? ❑ I ❑►'l� �✓� �ssu�"e �a�� �
�
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
�
EHS
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ra��I�laC K .
I�.SP 111r dc��l'Qr- v'ad'�'
r�� �i- e � c�