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A23 190
Appiication Date: � �-6-d�' !� �� Tax Maa #• Amount Paid• ,�00 T� � a�j- ,b� RecEipt #: I 7� 3 3 A( ��' ParcEl #: � ��.��_s� �I�I�� �� �� � � � (, � � ���.a-��.,-.-,.� � �� � � � C�\ \,3 � 6 0 � � p � Me�� APPLICATION FOR SERVICES 'C� � ra �� � IF THE INFORMATION IN TFiE APPLICATION FOR A(d IMPROVEMEPIT PERMIT 1S INCORRECT. FALSIFiED, Ct-iAIVGED OR THE SITE IS ALTERED. THEiV THE IMPROVEiVIEiVT PERMIT AiVD AUTHORIZl4TION TO COIVSTRUCT SHALL BECOME INVALID. � ,� � G po � � .� 1) Permit requeste_d by:�(�� r���� � b�ective owner�: K�- � Home Phone: �� Address �G �`1 �,Q..t�1 Business Phone: c� _?, � 1- �tjpa �j '�j . 2) Name and address of current own r. ��L�� J �r `"�1�-� T' �.. � - s�' ro � a s� � l�(h� ('�l',�wh�i"�,4,a'�--� D 3) Property Description: Lot size:'• 4 T..ownship: division: Lot #�-' Directions to the ro e�/ I ludin road names and numbers : i!� . p� S' I��-Yj-�. � n C�v�C_c)+�� >�T=� _ a r1. �__ -� � � r�,�cn�- r� � c�7�. �r I P o� o� r ` � 4) P'rcposed Us�e a� Structure Description: answer@� ch�o the following qu 'ons: a) Proposed V, Existing Type of Structure: tTD (�e W'dth:� Depth:Z � b) Number �f Bedrooms•.� Number of occupants or people to be served: � c) Basement: Yes�No Wiil there be plumbing in the basement?� d) 6arbage Disposal: Yes No �� 5) Water Supply Type: Private� (new or existing , Public_, Community� , Spring _ Are an wells on a'a oinin ro e? Yes No ff es, piease indicate approximate location on the : Y 1 9 P �Y �— Y �site�pian. �� ��' � 6) Does your property cantain previousfy identified jurisdictional wetlands? Yes_ No � PLEASE NOTE THE FOLLOWING: ; 9 A PLAT OF THE PROPEl2TY 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 ACCESSIBL� FOR AN EVALUATION BY THE HEALTH DEPARTME�YT STAFF. I hereby make application to the Person County Health Department for a siie evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true nd represent the maximum facilities to be pla he.property. I understand if the site is altered or the intended u e changes, the permit shall beco e invalid. ��� "� , ! U - W � wner or Leaal Reflresentative � Date PCHD, rev. 06127102 :, ' ���� �� ���� �� , �� >�. � � � ���� �7Ta.�Y'�.�QD'^'n'*'^''� ���.�1..� �aB�.�� T��x Cvlraµ `� ' � ��rcei » • � S�i�,b.cf i vi s�i a n P�MaS�e:�Sect+ion:'La��t +� �mprave�ent �?ermrt P�r�it S7alid for �'ave i�ears lYo �piration Type of Fac�7ity: �r� �� ai-e ReS;�� P �r.e, � New Additian # of Occupants �1,,+, # of Bedrooms Proje�te3 Daily F1ow,s�Q_ ��ea w�� sy�: ��c�e � z-�ta e� Q�, Propose3 Repair: cce . Pe�rrmiit Conditions: Owner or Legal ] Anthorized State Water Snppiy g.p.d. �— Type: -� , �7 '�pe: . � The issuancx of this permit l5y the Health Departaaent in does aot g+�antee the ic��Arr.z of othe� perm[fs. It is the mspo�bility of the . aPPli��P�Y owner to in snre that aII Person Countp Pianning and Z,oning and Bw7c3ing insQections requa�ments are met This Ymprovement Permit is sub ject to revocation if the site plan; �plsat''oi� the intended use c�anges. T7ie Improvement Permit is not a�ecterl by a c�ange 9n owner"ship of the property. This permit was iasued in compliance with the pmvisions of the North Carolina, . 'Laws and Rules for Sewa�e Treutmen�t and Drsnosal Svstems' (7.5A NCAC 18A .1900). Neither Person �Conn�►.;no�*��tlie.`'� � Environmental Hesith Sper.ialist warrants that the septic tank �ystem w�31 canttnue to function satisfactor�y in the futnre�or�t4at. th�water suPP�3' � remain potable. • • Authorization to Constrnct �astewater System (�tequaed for Bu�ding Permit) � � * SeE site�lan crnd additional attachments (_J. . . . . . • �a��� . ed astewater s �i'G� ., u�� CZ � 1: �°� 'I�, e"� wastewater Flow 3� bg.p.a. New�$ � Repair ��on -: � ' • Soil LT R � � Z � d.! $ 2 � . g•P- T�pe of Fac�ity: P r � ✓ . � �- - : - � ' � Basement _ Yes _ No . i�Vastewater System Ytequirements '��nk Size: Septic Tank:� 000 gal Pnmp Tank: G'00 gai Grease Trap: ` ---b�.� � Drainfieid: Total Area: 0 D sq ft Total T���h �_ ft ' Ma�mum Trench Depth __ j2___ in ' �� G. Tr,enc� Width 3 ft tl�'inimnm Soil Cover. �� in M�nimnm TI'CriC�I SC}1St3tI0II: �_ . Dist�ibntion: 1Disbn'lbmtion �oz Serial �Distribni3on �e.gsnre l0i.wifold . � Specifications: /`1 A � ��7Ar�, P AUR � �e»4 �7l �in �2 S � � — . -. . nf .. . �ilT�f / )' / �. '/ n_ ._, ... � ._! . State Agent Permit F.�i The type of system permitied is P��- . �e�f��al �3�pres�tive: � � D�• �� - s-�� � �v u �Alternative. I ac��t the spe�ififications of the Date: 9?-� - d � pC� rey. l l/10/OS-_ � . .. �: � _ ���, s .f I�]E�.� ��T �---= �--� ������- 1�':na-s-nn-aanaana�aa�[.ar.�L �HL�can.�L�EJIn Owner: Ta�c Map: Parcel #: Date: Line Tap Tap (Sch) Tap Flow Line Length Flow / foot # Diameter(in) ( m) (ft) 1 �2 D ,� D � 2 , 3 � � 4 5 6 7 8 � 9 10 � ft of line x 65 gal. per 100 ft = ;' l00 = 23 gal 75% x gal = f'[s gal per dose � gal per minute (gpm) = Flow Rate Friction He d � Loss: �ft per 100 ft of su ply line x'�'ZZSft of supply line =]00 =�_ft ft x 1.2 =� ft of friction head . Nlanifold Size: _3— �" Force Main Size: �- " PVC Total Dynamic Head =�ft of Elevation head +_�ft of Pressure head +�'' ft of Friction Head = ��TDH Pump Requirement: 3o GPM @� ft of He _ Drawdown: �.gal per dose = 2l gal per inch =� inch drawdown per dose ��� �:. �� � � ��:�„ '' - � = � =�i�����iti — ... � : . . , , I - ': ' I I I I �[(�)1�0000 1�1 1�1 (�I 1�1 iiiiiiiiiiiiiiiiiiiiiii�i�iiiii � 1 1 I � - i��������������.�:���i��a��:���.�i� :, �- i�����i� � � , ....r.t.-.�.� , . , , . , . , , , � , 2" min I I Sched Ce 40 (�_ � 9mo�re q» 16 f>" 40+ " Flow er Ta �- Si�.e it�aterial Flow GP�1i ;. " Sched 30 5.5 ;�s " Sched �U 7.1 % " Sclred 80 1Q.1 3, .. Sched 40 11..i ��� j•' � �iY.fJ �� �� �-.. Y '�� �J � � � � � T�arnw�a�c-�u�n.�� ae�sa�an.Il. �'�aa.m.Il��s NE14SA 4X Simplrx Contml Panel � = —I +4" X 4" Preasura Treated Po�t_ I� . Sloped To Shed Water 12� S`p�rj{ion � Electrieal Conduit = . . •� .: . • er , b° Covar • ' , Acce» Courr. � • • : ; ' •1 , � � . _ �. � .�. , �� i rr ,'' • . ' . �� , . . �;, Opesiin= Filled Wit�, . Anti Siphon Hok' � Ixtlet From Soptic Tanlc 1'o:tlan,d Cement Gxvut �� g�� 4" SCH 40 PVC Pipa � ' . ' Check � • Valve � • High Watar Alazm Level . , (6" Sepazation� Hi�h Lav�el - Pump On �� ' � % rVapoY Lock . . '. ' ' o�` Hole . , . � �4.�Drawdrnm �Up Hill). . I, � . Law Lavel -Pump Ofi --f-'-'"' ' �'' . � •• 5 T�x M����� ' P��rc�:l # '� S U�,�) C��I Vi S I 0 Ll Ph•��s•e Sc�ct,ic�n Lot # Duct Saal Botk Enda Of Tha Con�uit -� 24" Miniz�nim .. .� Tiireadad Csaf e Valre ; Zip Co:d Tie� 1 ' Pzecast Concret� Tuilc � 4" Concrat� ' • ;.; Mate:ial Stre h y3500 P Hlock ,� . . , . . � :`�: • : � ', . ' . . ' ' . . '` • ' . . ' ' .� Coxicreta R'vex b" Saparatictt 4,,:,._...rPo,rrtland Conczata Gsout _ , i: Mastic • - : . . � Opexing FiUed With Supply � ' � portland Cement Crraut � Lina • • ` 4utkt To D'utnbntion 2" SCH40PVC Pipa 'Q � Float Wit�� � � . ` � P7oata ,�; �Kemovabk '.:' F1oat Tna � .� 1.. r ( .. . •',�:�1• ',' �• � O6 GALLQl`t PIT1V�' T�TK �::. . � �� ` 3G �P� �71 � he� 0 . . • ' .���,�� ������ '• . 7� � V ��� �g .L V �� 'r'']m.^Pd]L`Oan �e�w� �ObI.T..�.B ��C�� 5I_TE SSETCH Name .� � � .� p�:;a�Q� Ta.a Map # 23 �Pa:tcel # I`�o . Subdtvis � Section/Lot# � � � J- • � thorized State Agent � Date . System cvmponents r�epi�esent cspp�,oximata �contours only: The coms�ac�tor must flag the rystem prior to . beginning the inrtallatinn to i�sure that propergmde rs �raintai�ed . . t. _. _ __ : - .-- . . .' �, , , � �r..�, r � �ti + t _ 4 �/� .�, � � � , � �11. -..' 1 �:e 3 �� L��� � ., •� ! J ..�� l �y.` . , i� •i.� ����. • ,..:, {�� � , � ,�, rrh'a� S Sfevh ,�3�a ��P,a f 7 �e�. �- Ce�' �cc �'/�u 1 3 �"" � 2 � � b�m -- '' �nc. Cp� o t,�lV►s �C�a�. si ��) , ,�,�e �a � Sot � ,�''P�aC� g�'-�p,� add Cover 6,��r sYsfern ` 1, '� : `� -! `- � t t�. � ! . � �� � N i i,� ' �, � 0 �' �,�k • . 1p � �,,, l � �l � ,'✓y �� � � ! � a �, � ��� ° ` ; ��D �``� �� , � � \ \1� ''' . ` b` � � `F �� / i; � , . � ` 'i i % i • •'� `�', ! � t � l . ! � SCAL� � �"-So� ;t • � • •V�• ��3�.�.� trl��Iif Y� •� • � . . . • ..� • � � .� y ,� _. , 'M'.�,.t J � � + � • ' •Y y r y 'r { + ' �.'xs r� � *.f �' •S . i �•~ �' . . •,2,'L � '. • ' ii �* . , r� . . . M .�� i �,�• +` .y' '�'"' � •��i: r � �� � . • • � l.dlfi�i f� �� � �� � � �� , �. . � - _ ' . •T�� �_ r�i# .� �,i..i:v;a:n�.• R �� . : . • • Tppe aif �(is�r �►: � � � C�' P�ia ; 1 ;. r � . • � • .� �m�a� ` . .- .. : •. . , 5i�o Ap�a'v+od B�i: ' i� � . � �f�+�8-�Hf'9�'- a� ' � by; • . �� ��. . � � . . wan�� . ..� - . _ . � - . . a�v� � - . . . ��am� �._.. W�� .. . � � � . � .. w�� a _ -�� �-� ' _ . won.�vy: n�, �=lC¢� - . ���a� s��*. � � . ' . : ����lo�t��cy�. � � . . W��� l�a ��� sy�,. � � � . � wa��ve ��s ������.� _ � - , . . a� " � � � " e}`sri , � t,� � Y �� .� �,� � �.'��' � �� � �� � yl.c�� /� � _ b � V � �i V � iL•i' � ']�' �vT���-�+-� �:�.�sac.�.� ����s.��.�. n13( i�'�r. • � ■ c�l f"C � 5l!1Q.[]�I V1 �!I Q tl i Z ��� '7:Fil.^L•�'Q' .�T �- a'�� �dlra:a:ms � � r���� r� � �� . � � �� � Sys#e�m Type (tn Acxardanc� Wiihh Tai�le Va): � �� ) . , , � i'I-3!S SYSTEi�I i�id�SS HE£�id II�dST.�►L�Ei) il� CaMPI�4NC� WiiH AP.QLl�ABL.E MORTi-t ' ��ROL-l.�► G�vF�at ST�;'i'UTE�, RUL.ES F�]R S�IA�� TREAi'�+IiE�iT AAtD DtS�E�SAL; �41�dD A,l;L � CaNDI'Tit}NS • OF ' i'�!� i�AeROVV�[E%ii PE�IlIT �,NCa Cflf�dS"t'RllGTio� • ,�,L1THfJ � (.'�N. ,_ . � ' ' • . . . .,,�� - � - �. g-2a-�7 - _ � o tate Agerrt � • Da� . . � , . Inst-alie�i �� � - � - ' t7aie: 3 : �S 67 . . . . ��3r r . . /Z . .. � .. (� `3 %2 � � � � �3%z � �Id .� �. .. � �r . �%2• ' ►.�/� ' � , � ' . ' 1• ' •• � � • • . % ' ' � � . , P Z � � _ �'�%Z. . � y �s �z - � . � _ . � � � . , ' � '. �� r��-;t� r--�, r„i^ �rr� 4 , � �������� ������� ����� ��� �� � � , . T� I�a� a 2�� P2.�� # D � ' Sys�n TyQ� (Table V�) CZ Owne���piican# S�tbdivis�on Add���ion Ser,�Pn2s� �# � � � � a � (a/i � QC ln f � U`�� ��. t f (� '� %°�SS�,q,'l-� �l-.�.,.�-�\ � y �t9���! 1 V �' `�" � � �p 7 p . � . � - � .� � �Lrt ..,.a 9f-{�Sf1�i � ��~' ��:� n�l'. SJy' v.. . . ��.� �..:. .' }�•�' � .~.L� 'h` {i�' '�♦ �•{4 ' X ��'• .' rt"' . ..i.. _ _ '�.:•�:L_ �� :�y���.v.��v.:..�� ����.��{•y� �?n.� ��` Y ii� ����•N. �`-��'-:�"�=="w.�:=' :.:�'�:����:::�� f�� - �- - � :�Y:�-� . . . :��.��.,�:'�.3;�.�:3i:_ . 7HC�,.�.]t:;�:- . ��D� . 32�� 7 - �r, .,� ����,�-N� r� �� p�;�lC��� � o , �� -3�,�� -�. .. .. o� ..� c�a� �� � � �aa� G � � f T�� 23 r�t #�U subdivision: � � Lot # . : ��a rri � WeIl Coastracti�n ����� Distance From ne�est Prop�ty L'me {M'inimum IQ feet) --/() � Distaace irom Septic Systecn �ni� 60 feet} D t� Tot�.l Dept�: '���, $ Yeid: (o GPiVI • Static Wai�r LeveL• �} ' � Water Bearing Z.ones: Depfli�� ii i� ft ft . � ' - ne�h: Firorn� _. ro . U Z e. nia�b�: _� r/y �'Pc: Galvan'r�ed St�e1 � � Weig� ����: .�$`6 Height above Ground: .l Z. in • � �� �e �Yes No AnY Problems encoum�tered wh�e se.�ting casing? �Xes ✓No GSron� _ . - • ' • . " N� ���t Concrete Giave}lCem�at • =• Annular Space Wi�th • mches Water m S�ace Yes r� Na •- Metbod of Grou� P� Pressur� - Pauz�ed��� DcPt��_ to _�? rJ Ft 1Kaierials IIsed: No. Bags Porti�nd cem�;t ' Wcigi�t oE l$ag � Poun�s . If �(�, Sm� cut#�ngs) — Ratio to . m P�� � Yes ", No 4 x 4 siab� � No -- L�er: - . �� - -:,. . Date Installed: Grou� �nstalled by-. � Dritiing Lag To C� Location Dx�wiug x�a�►��m��-��a����a�����������u���f� i�y t�e Pasoti Cpunty geatfli Dep�t . �rc o# Coni6cs,ct�or �r�--- I/ � ID # � �% % . n�,�_ "3- 3 v -�� _ . r �'�r 3r�am�t - . � InsbDafion Conhactor: r �� � � �� � ft St�tic Puu�p Nfa� & Modei: - a n/ �, r I / ,'r ` /�' State Registratioa Number. � 10 - . L.evcl: Z � � Ptunp Sir�e and Rating_-�I,p � v ggm i he�neby cetti{y t�at this p�p was inshaIled aud the well head comPlet� a�x�l�g to flte Persaa vn �his da.te and �at a copy of tms ��pcond bas bee� p�,4vidsd to-ti�e vveIl oarne� , �O�' wetl Rnl�s iit effect PamP 3tt�aRer � �,�.,,,.... - �j- ,,.��-�- . . �� � "L.'Di PC� rerr n�/���ru l'd 9LZ6-869-9££ e}}auae8 •� y}iay{ d�Z:bO LO 96 s�b' PERSON COUNTY HEALTH DEPARTMENT SiJBSURFACE WASTEWATER SYSTEM MO1vITORING REPORT (L t3 3 15 0`l �� �4a3 1`1b Date of Inspection System stallation Date Type Tax Map Parcel # �IgS Mc GttE�s M�� 14A4 Property Address Instructions: Check yes or no for appropriate items and explain in space provided for remarks and. comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infittration and surface water diverted 7 Septic tank rieeds umpm 7 Inches of solids: � 1 � , Septic tank filter cleaned ? ' EFFLUENT DOSING SYSTEM: P.equired pumps present & functional ? High water alarm operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids ? Inches of solids(pump/dose tank): Elapsed time readings ? Counter readings ? Drawdown rate: YES / NO ❑ � � t� ■ ■ � ,� ■ ►: ■ �. ■ �� ■ il ■ DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ Evidence of effluent ponding in trenches 7❑ Surface water effectively diverted ? � Diversions/swales properly msir.tained ? � Vegetativ� cever maintz�ed ? Protected from traffic/unauthorized uses ? � Distribution devi�es in good �oiidiaon ? Field free of settled or low areas ? '� / / / / / / / . r. ►: ■ .� ■ ■ PRESSURE DISTRIB'JTION SYSTEM: Turnups/cleanouts/valvesJtaps intact & accessible 7 � ❑ Pressure head properly adjusted 7 ��❑ COMPLIANCE: Compliant Non-compliant Needs Maintenance rii�i�iTiGivt�L i.vivitviEi3TS EHS REMARKS ' p�A�,,� Qov� i4t�. I�t't Cqa.c.►.�+�.r4'�'E 4 O�l�. �v c.�-�. � �► Pw++p -�1tJ,lt. c