A23 43AnAlication Date: 3 30 -0�
Amount ;�aid: __����
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APf�tICATION F-0R S8i1/1C��� .
CO�ISTRUCT SHALL BE�t)t�lE 1WVALlD.
1) Perme� re�uested by (Owrneriageni/pros��iive ovunerj: C7 � y CAIr� V ei�
Home P1�one: �� 4— 8'6 6d � Address: %2 ��"e t-re � I• � �c�
8usiness Pi�orie: .
2) Pdam� and address cf cvrrent owner. �� . �,
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3) Propesiy Descriptian: Lnt size: �g'3� Townshl�: �u�'�� °�� �`Subdivisn
Directions to the property�(�ndud�ing mad namessand num�ers�: G� A,tc�
d)
.,
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proposed Llse and Structur+a aescri�ation: answer eact� of the fallrnnring questions: � .. .
a) Propos� _, Existing ✓, T�pe of Struc�.tre: 1� o u�- � �IVldti�: � De�th:
b) Number af Bedrooms: �_ Number of ocra�par�ts or people to be ser.ved:
c) Basemer� Yes , IVo % Will titere be plumbing in the basemerrt?.
d) 6arbage Disposal: Yes No / . �
5} UUa�r Su�Qly T�pe: Priva�e �new _ or exis#ing_�, Pubiic , Communiiy, �•. Spring
Are any wells on ad�oining prope.riy?; Yes_ �lo _ If yes, please indic�te aQprr�cima#� locaiion on the
� 7 'sifie pian_ : . .
6) Does you� pmpeFiy cantain p�eviousiy ident'�i'[td jurisdictionai weiiands? Yes_ �u_�
Pt�,4SE �iOTE THE FaLLOWiNG:
➢� P�AT 0� THE Pl40P�Tt OR SBTE P.9�A1 IlflllST' BE SU80fl1i7Ei)1Nfi'�i TH1S A6'QL��ATi�Af.
? PftOP�T'( L!R►llEB �1PlD CaRPIEiiS MUS'T HIE CLE�RLY MAR4�.. ,
y THE �ROPOSF� LDCA?70{d �3F �4LL S'TRlJC't'UR�S hflUST HE ST�CE� OR �iAG��.
� 7"}iE SITE �UST 8E �DtLY �C��SiHi� ��R �M EVALLIA�'IO�d 8�( 'T}�iE �Li't�] 3�E.aARTitii�lT
STAF'�. . �
I hereby mak� apQiic�tic� tfl the Person Courrty Healifi .Depac�trnent far a siie evaluation far the on-site s�wage disposal
system for the abw�des�ribed property. I agres that ti�e ca�rtents of this apQiicatibn are true and re�resen# the m�imum
�cii'�ies to be pla�� on the property. 1 unders�nd i� �he siie is aliered or ti�e intende� use ci-ianges, the permi� shali
be�am,e irnaiid.
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Applicant:
Location:
--� �7�5
T�x M�� � . P�rcel #
S�u�hcllivi•s,ioia
'P'h:�,s�e'Section Lot =
Improvement Permit
Permit Valid for _ Five Years _ No �zpiration
Type of Facility:
# of Occupants of
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Owner or Legal l
Authorized State
Signature:
New Addition
Projected Daily Flow �
��
.�G"s-�
Water Supply L�(/�-'�
g.p.d. .
Type:
Type:
Date:
Date:
The issuance of this permit by the Health Depar�ent in does not guarantee the issuance of other peimits. It is the responsibility of the
applicanbproperty owner to in sure that all Person County Planning and Zoning and Building.Inspections requirements aze met This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rule�or Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
�Authoriaation to Const�uct V6�astewater System (Required for Building Permit)
* See site plan and additional attachments (_).
Proposed Wastewater System: �K�`�r{i d�� ( Type � Wastewater Flow �� � g.p.d.
New Repair� Expansion _ Soil LTAR: � 3� g.p.d./ ft 2
Type of Facility: �� � , Basement Yes _ No
Size: Septic Tank•��'�al
Wastewater System Requirements
Pump Tank: gal Grease Trap: ga1
ld: Total Area: Qd� sq ft Total Length �Dc� ft Mazimum Trench Depth � in
w�atn � ft Minimum 5oi1 Cover: �_ in Minimum Trench Separation: �' ft �, C.
Distribution: �IC Distribution Box Serial Distribution Pressure Manifold
Specifications• �,, 5�Q �� �✓l ��.�v� -
Authorized State Agent:
Permit Ex�
The type of system permitted is �Conventional
the permit:
Owner/Legal Representative:
Date: y �v�
C�[>
Innovative Alternative. I accept the specifications of
Date:
PCHD7/30/2002
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3���a-�� � m��.Il IE-�m�.Il�]Ea
STTE PLAN
Nam C( VUe� � Taa Map #��3 Parcel # `�
Sub ' ' ' n Seaioa/Lot#
S
Authorized Stau Ageat Date �
System compaaeuts rrpresmt appsnsimsm coamurs aaly: T75e caaaacmrmust Sag r6e sysum prior m begiaaiag the iasnllatioa m
inc,�.,• �atP�P�d'r�delemsfntlfaed
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Applicant: � y`�'`�
Location:
.
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ax M�p ! �,rc I
Subdlivision
Phase Sec ion, ot #
# o�f Bed�room.s
- . �rati�n er it
System Type (in Accordance With Table Va): � G
TNIS SYSTEM H.4S �EEA! 1NSTeo►LL�i] IN COMPLIANCE WIiH APPLIC�.BLE . NORTH
G'�4ROLIRIA GENER�4L STATUTES, RU�ES EDR SEINAGE TRE�4TMEAlT AND DISPOSAL,
AND • ALL CONDITiOiVS OF � THE lMPROVEIVIENT PERMtT Ai�D C�NSTRUCTiON
AUTHOFZ T ON.
. � �v`r�-,� ..��3�v�
- thorize�State Agent � Date
I nstalled By: cJ � ��``e� Date: � 1� '�3 �� S� �
e
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Q,n�
PCHD, rev. 07/29/0�
����9C ��i4 �NS���Ti�R� ��iE��..�ST' �YPe �8 - !�
Tax Ma� #� .�� Parce! # Sys�em Type (Tabie Va)
OwnerlApplicanf Subdivision
Address/Location SeclPhase Lot # �
State �lD/date
Capacii�/ al.
Tee and Fiiter '�/`-�
Baff(e
Sealant
Riser (ifi applicable)
Tank Outlet Seal
Permanent Marker
Pump Tank �
0
Waterproof 1Sealant
Riser
Water Tight
' Purn�
Checic ValvelGate Va(ve
�able and audible
Components
Rate (gpm) :
Approved Pump IViodei
Bloci� Under Pump �
Pump Removai RopelC
. �Disi�ibu�ion:Sys�
Serial Distribution
Pressure Mlani o
Low Pressure Pipe
A�pr. Pipe I�liaterial and
Valves "
�
Trencf� �dttt � ft.
� Trench De th in.
T.rench Lenath `3�v �t.
Trencf� Gtade �
Trench S ac9n
Rocic De th and Qual'
Dams/Ste dov�ms etc.
m
Pressure Laterals �
Hole Spacing �
o e i� ze
Pioe. Slesve
Required� Se�ac�
_ From� WeBs
�.:, From Propertv lines
Surface Waters
Public 1JVaier Suppiie;
Verticai Cuts (>2 ft)
Water Lines
Vehicle�Traffic �
Adjacent Systems �
�Easements/Righf of V'
Ot�er
Easements Recarded
e e perator o
'Tri-Partate Agreemen
1
Co�ramen�
pcf�d rev. 3113/01
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