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A23 178. . ���,���� �-�- � � -� �-� � . .. d � �' -� � '�- ;�Qvsc�nrsa aaid- 3`O�tl" n � � , l�� ����� � � a�, 6Q; D L � � • q ealtta De�artment • � - � �,.rson�Cacat�tv �? � ... . ....-. .:��,ndiroera��rrtal Health Ser�ion ' . . � . . ' ':;:. APFt1CAT10N FaR S�VtC�3 T=.: �l1aa� � �.� � ��� T � 17 � � . ;; j��' r �/1�.� .:.: V . t 1} Pertniirequs�bed by: (Ownedage�prospec3�e owner�: �SSi � � %��RVeSi • Flome F�tone: 3l0 - s'y - 9 3 Addr�ss: f�9 ?� /h ��h e� �/h,v/ Business Ptwrte: . . . 2) tuams and addre��of c�urerrt owner. W t• 1�i o�Jdv� 1- . Sa ei('�l e.� . � .-c�, �. . 1�-�- �� 3) Properly Descaiption: Lot s�za: ' 1 Ta�nst�lp: �cc,v.v; ;v `i« � • . DL�ons to the property�includin� raad•names and n� _ -'- -•-- /' ! n„�n /_ i_ ..� . � i �g3� �0 C01 � � � � - ���� �. � pSS�'h(� ��' w�� v� ��� i3 �UL4.�ic� '�p� 4) Propa��d Uae and Stntctuee Descri�itlon: answer eact� of the foilawing questfons: a) ProPosed 4 ExIs�ng ❑ • . - b) SHdc 8wlt 4 Maduiar 4 Single WWe �, Doubie Wtde g� � c) Numi�er af 8edrooms: 3 • � Nwnber of occupar�ts ar peo�ie fio 6e se[ved: �_ � �). ..8asemer� : Y�es• Q No• !f yes. ��of basemerrt fndures: . . . : . . _ . .. � - . - -- � � � � • C'oark�age. Dtspc.sai:'(es �; � � �- -• • _ �...� .. _ . ...� .. : ._ - .. . . . .. � .,.. . . _ _._.._ - . ._ . _ . • -� .- ��imensiar� of Ptoposed Striu�ul�: Width: �, Depth: � � � Water St�ply Type;. Private �(new � or e�dsiing � P�61[c Q Community Q Spring Q . •� Ara acry weils cn ac�aning prppeirty? Yes �No [I If yes, loc�ttan . \ S) Please Indir.aie Da�sired Sys�am Type: (syslems can he ranked in anle� of your prefei encs) � � on e�ia�al _B�o�fled Ca�en�onai _,Altema�. I�nov�ve ' CL.EARl.Y STAi� ALi. CORNEi�S AND UNE3 OF T�iE PROPEiZTY. STAKE THE CaRf+lEitS OF ALL PROPOSF.D STRUCfURES. PLE4SE ATTACN SURVEY PLAT OR S1TE Pl.AN TO THIS APPl1CATlON 1 hereby make a�lic�tion to the Person Caunty Hea�h Oe{�artment for a site evaluation for the an-sit�e sewage dispasai sysbem far the a6ove-descnbed Qroperty. 1 agree that the carrter�ts of this applic�#ian are true and �+epresent' tha m�drntun fac�es ta Be placed an the praperty- I understand i� the site is altered or the i�rtendecf use ct�anges, the permit shail �ame imieiIci. I understa�td that as apg�cant, I am responsibfe for ider�ifying and mar�ng pro�erty Gnes, cqmeis and making th� siie �ssibie for the persaru�ei of the Pesson Cawriy Hesith Departrnerrt to canduct the�r evalua8ons. I understand that 1 am eespans�ie for nahiying the Heaith Departmer�2 ii my praperty caritains am/ wettands as designater! !�y the Army Carps af E�gineers. �.�- � ��..�.�� � 9-026 -�1 � . Owner or Legal Representative . Date � PC2�D. [ev.10112l99 ����C3R� ��3LliV�'1 ��!/I���lI�IE��'A� �1���'�i ��.��� ��� � r'�'.�,��lE� �L,�� ��R �t71L �i�E� �iVD 5Y5i��i �� Tax Map �: � � Psrca! � � �� Township �l�el�lAf�i PIN �ppttcant ���C� f��%� rr�7 SubdiWsiort � �' PhasdSeciton - - /.IC/_ _ /i� /. . L , . /..� � �Lf�L�t�it � L� l� r�' ZAn, —,�_ . ,-- - - , �m�rove�aeni. �ermit �°� `� �� tof# � 9,c�/� New � Addition Type of Structure ��} r�r3 .s- Jrr/iZ�� Watec Supply 11��,G� # of Occuparrts of Bedrooms 3 Other System Type�_ Projected Daily Flow: ��� g.p.d. Permit Vaiid F r. ive Years � No Expiration Proposed Wastewater em: �'��/✓ L%a�'��S S T,on�� �.� �--.�* Proposed Repair. ��/✓ / �.✓r �, Permit Conditions: ,�/�c,J ��4�t �L-�� — - Owner or Legai Representative Signature: it 5�ifi�a�. �! 1�� ve � Date: �� ^ 2�1 — u� _ Authorized State Date: //�'/9�- �� / The issuance of this pertnit by the Health Depai�ment in no way guarantees the issuance of ather peRnits. The permit holder is responsible for checking with appropriate goveming bodies in meeGng their requirements. This site is subjecf to revocation if the site plan, plat, or the irrtencled use ahanges. The Improvement Permit shall not be affected by a change in ownership of the site. This permit is subject 4o comp{ianc� wii�h the provisions of the Laws and Rutes for Sewage Treatment and Disposal Systems of the fVorth Carolina Administrative Code. �►uthorizaiion To C�nstru�t 9Nast�waier S�rstem IReauired �r �uiidinca Permitl Wastewater S stem Descri tion: � y p LDA%( �./o✓f� r� ��4• Wastewater Flow: „_?G�O q.p.d. Type: Facility Description: %�n��R�� t�vl'D�l, ' New �B� Repair ❑ Expansion ❑ Basement? ❑ Yes "C�o Basement Fi�dures? 0 Yes o / ov � �lNastewater Svstem Requir+ements / ��� ��L �o - 30 �`�� I Tankage: Septic Tank size Do0 gal. Pump iank size �—" gal. Grease Trap size — gaL .:�i 4-`T�'�. Trenches: Total iength .�on ft Trench Wdth � ft. Total Area g4A. sq. ft. Max. Trench Depth�� in. Aggregate Depth:� in. Soil Cover. � in. Trench Separation �ft. on center . �lr Permit Expiration Date: j%— /4�' 20G �' Authorized State Agent ��./� .� Date: !f�//��?G o� *See attached site plan and addendum pages for additional �ermit conditions. The type of system permitted ❑ does ��oes na# differ from the type specified on the application. t accept the specifications of this permit OwnerlLegal Represerrtative Signature: �� �<�.��� Date: ��'2(�"�S Operation Permit System Type (in accor+dance with Table Va) �_ This sysbem has been installed in compliartce with applicable North Carol'm$ Generat Statubes, Laws and Rules for Sewage Treatrnerrt arni Dtsposal, and all conditions of the Improvement Permit and Constrvction Autl�orization. issuance ofi U�is permit implies no guararrtee that tfie system i�lled wiil function ProPe�hl for any given period of time. G�—� p Authoriz tat ent te _ PCHD, rev. 03/07/01 � � • ' �� ) �. , � ���� �� . . y^' � � ^� ������ 1E�.�s��,� ��¢�.�. IE3[��.11�ll� SITE SBETCH W��t� -� /��q-t� � Name _ .f i �� �� Tft�Z� Subdivision � Authorized te Agent T� �. # A" ZP��� # l? 8' r se�tion/Lot# //�/���a / Date System components represent approximate contours only. T'he contractor must flag the system prior to be�innin� the installation to insure that �rof�er �rade is maintained. � :4�-� -� ,� �r,�-�, �:,�-. ...T,�,, ,,.,,,.,..,.,�.� .._.,_ .—.-�.r.--, ,.,�-TM. �„�-.. � �, � �� � � � � � , � � a � ' � ' /� . � , i x � A x� ' 't� , � V� �- �i� :, s � i � ;; a O� j 1 �PC1 ' � , � ,� t r � ' r ' 'r . � i �e i t�'. � � ii ?�.t t / , � � , i� , f ; ` ,s 1'` { '� , ��d� 5 ,. ; . `• , . ��� •�.L: ca1 H.3o-�.� � �' �.. C .�=a�t 4 $p 'ad�st . � , / � � __�1�d�� �9�rf T.�� , ��� � Go,�y � ' �a��s � .y��✓ ,�.ri � �.�/G3 . yv��— g� w .. o^' C�/m�� � �� � �b h ,� � j ` � � 1 ��� �,�,a��`' '1'1�/-��C �j ' � � veS �ne f�ro � _� � posed 5�� P��'a t e Road� , 1 � f ` �� � � � 1 4 r � �v I � ' � , � � ' ;, , ` N76°3 '?2"W 124.30 � ,. . 11 -Zzr• �- 3�� �'�" � , --� 'N�°4 �.,yv zo3.io ,: �z �', ` r � ,: .' � z •., : � -D-� N63�4 2�,W 908•90 3 ��-'ao'�l' � o ��t �.-rn. �--� 900 �i � � � �/. fi .3p�� -�'����' ����� C�`3�//�,� ��-�.��. �—�. ��--t-� � -x��� 1 " = ��s �• � �����t�I ����'Y' ��1�'�����+9�:�9 a'�.�i. ����-i � �� . . �'9 �.'�.�� ��°' .i��.:��e'��".� ��9� �� ��' � �� �� .�.� i � . • �23 :` . .17� . i��� .�� . � . . . . ,�� ! 1 / ��l1/f �'fFl� � . � � � . �� . . . ... _ .. . , _ . ..._�._,. . i �r. . , . . . � �� •�� � � / _...'_' _ �� , �!�s��:��s..si�� rr...=���:.._.-- - 1Nei1 Permit T�� of 1Nater S�s�iv: L/ ind'�vid\= ommuniiy Public Reauirements: Siie Approved by e�s ��-2�-�� Groufi�gAPProved by.C�� ��-a�-�� --1Ne11 Log �- ' Z� z�� � � Wel1 Ta . z - � Air. Verrt h _ Hos� Bib '' � ' Concrefie Siab � �� _ a �0,,�� ��,� ��� � �� 'Pa� c� ��-f�' �JHefl Dritlec: 2 � ��^�— �"�� �`�`'��� . . ,. . � . 2 �l/e8i �lpprovecl Sy: � � Data. Z -��--z�cs. **S� Atiact�ed Si�te Si�ict�'"` Welis must be 14 feet from proQerty lines. . 1�/eils must be 100 fee# from septic systems. V1/ells must be �at leasi 25 feei from any buiiding founda�ion. Qther condi�ons: + � 0 PCHQ, rev.11PL9I99 � �1/la/1995 01:47 .:; • � , i �'a a L �!: `E 8044547843 T +i 1 :'�'! llat�: � �',,,,;�/ n�rner:.� ' • I ,cx:�ci��i/�)ireccio�is: '�UhC1i �'1�Ip11 N1ji1�: Uriliing C�naactur: ���.��.K���� � v Ui�t:uue fTom Ncat�esi Ptoprrry [.is1c. _ Dist:��n:�; fioni S�>>,ic�: c�f Poliutiqn.., 'i'u�;�l n..�th:_ o��� Fc. Yicld:.,.,� UE�tv! Sta��� Watcr 1..c��el��Ft. Water Deating Zoncs: Depth _�__�___Fi. __ �t., 1=t, w �ii� �' • C�sing: t�epth: �roin,�_ty,��,,,. �t. Uiarttet�t: G- ��C Guhcs Tlfl'E: Seee1 __. ... r. __.__...Gaivenixeci St�l„�„�� - tt Ste��, dves awt�er appcoy�: Yes__,______.No_ � �� iti►aigh���'I'hieknass:���„_ i�eigh� At�v•�e (�ro�uxl:,,,�/'� inchGs DriYe Shot: Yes,�,._ No_--� � - — Were ProW�ms �sxowterod in Settir.g t1�e �'asi,i�;7 YKs�,_ �._� i'�iov l!' ,.�,�5.. g�` � +y�� - - - c.;ruut: Typc: Nc�� _ SanJ�Cem�nt �_, �:o;,crr�c: _ Annulat 5pace Width__� _ _ __�Inc)�Cs Water in qnnulu Spare: Yes. ,.. No,_ ✓ Mcthod: Pumped„ � Nressure�- - - Nou�t�i Dcp1h: �tom�l�� to,� _ i�t. — Materi�l� Usad: No. Bags Portland Cemcnt l,_„titi'eigt�t of 1 bag ��it,>. 1! mi�ctura {s�d, �ravel, cutcings) - Racio:__. _ :� 1D Pletas: Ycs.,� , No.",._ 4 x a sisb Yes�_ � No �____ BENNETT WELL�RILLING F�.:.i,..,l�;� :aiG :�:i11r. P�as�r� cou�Fr k�ti'!Rt}�INf����. Nk.�1.l�F NE�L L0� PAGE 02 Sitit 1 �t • 111E:RE.BYCER'i'iFY'rHA�"lIiEABOY�TTJFC)K.�j:1�t'I��N i:i C:(�)ttltt:C�l' At'1t� 1'ttA"1' Tl�11S V�'ELL WAS CONSTRUCTED 2N ACCORU.a'•ZCF WI'f!� Rf:Ct,1LA'!'lc �N� �E�"' ��)k'i'H RY TNE P�RSON C�U��'T�' t�lEAr.:1'�� i)EP�R71�1�:N'f. t,�. � ,� ��- x� .�,