Loading...
A23 533 " f5—b2 McutQc� �°i'i °`r (Oe�rrti•r'� �o F-----,—� /1%��s'. �ct1-P� �S ��� _�.�'J� �-�,2�h�_ � � Application Date: "� b '� Amount Paid: V RecEipt#: � �� ��� � � � q�. � d I ����.s� I�I�I�� �� - _- � � ���� �ffi�����,�.., m��.�.a ���.�.�� APPLICATION FOR SERVICES Tax Map #: ParCEI #: IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALS1FiED CHAFVGED, OR THE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZl�TION TO CORISTRI�CT SH�4LL BFCOl11lE IN�lA�Ll�. 1) Permit requested by: (Ownedagent/prospective owner): G�4191Z�b�ti G- -%.�.n C= t..c�� cY�TE - K� t N C Home Phone: 3'� - 3`i�i -`I �S � � Address: �I o Q� � p�,•� �,.,- f 5� .�4 t�T, 3 BusinessPhone:'��C,-3Hg-11$S 2E�o5v1�.t,E �.�'�-3��% 2) Name and address of current owner. �1qrv� �� C�l NN I N(Y N'Y}YV�. �5�1�1 N C�. �T� (ZE.E�-L 3) Property Description: Lot size: 1�, ��3Township: Subdivision: F�,Z,v� .L-ot#���-r�_ Directions to the prvperty (Including road names and numbers): q'u 1�. -Fw� 'S� v�no R-v� - •A;�r,� �. Cc,�.n�;...�.�.,,.r,. _'��tiv..�- o.�- Tew-�i1 ���„� 1��.. Qe.�,- �.e{�- c�.�- \y �v/1� �r.��o �Pr�"vc�-� Dr. - Wtnw�v. �C-a- o�r- v���- �v�a-ev�9cc:liu-� . ►--�-F�- �- r,�e..aYa�r.u� C�*� �4wei \a�e� �-r.,�- c�. ��rc,per �,-i� bv-�- c�e,-. �wi�l �e.e, SC�v�S, 4) Proposed Use and $tructure Description: answer each of the following questions: a) Proposed �,, Existing , Type of Structure: QR�vY�Tc l-�v�n �� Width: Depth: b) Number bf Bedrooms: �_ Number of occupants or people to be served: � c) Basement: Yes , No � Will there be plumbing in the basement? d) �arbage Disposal: Yes , No � 5) Water Supply Type: Private �(new � or existing�, Public , Community , Spring _ Are any wells on adjoining property? Yes_ No ZC If yes, please indicate approximate location on the 'site plan. fi) Does your property contain previously identified jurisdictional wetlands? Yes_ No,�C PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LlNES AND CORNERS MUST BE CLEARLY MARKED. �, ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR �LAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEiVT 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 Legai Representative l U l Dat PCND, 2v. 06/27/02 •` 1 4 ��� ��' �.I:S..Li �� �� ��� *�� � � � ���� 1-�." an.-m-n.a-��+ �*-�-n <ea�..�.�.I1 �L �aa.]1zE1�. T�x Ma�� � �rc�ei � Su�bd�ivis�iar�� P�ha;s�e�Sect�iam:'Lo�t +� P�r�nit Valid for �/ �'ive 3�f Type of Facility: �.�,;, V c�-�-e. # of Oc�upants m� # of Proposed Wastewater System: Proposed Re�air: �.�{� Permit ][�praveinent.�'ermit l�To ��piraiion / ����� ��^�- � New VAddition _ � �Vater SnPP�Y '� � L_ rooms 3 Projected Dail Flow �( _ g.p.d. -�- Z � m � Type: �L!_� `2.. - C.'l,� : 'I�pe: �—. e Owner or Legal Represen 'gnature: � Date• Autiiorized State A � '� � ' Date: 2- '1-0 �, The issuance of tlris permit by the Hea1t3� Department in does not guax�tes the ;s�,a*+��-"of other permrts. It is the responsib�ity of the aPPlica�t/praPert}' owner to in sure tha# all Person Couniy P3anning and Zomng and Bu�7ding insPections requaements are met This Improvement Permit is snbject to revocation if ttie site plan;�pla#`'ur'the intended use changes. The Impravement Permit is not a$ected by a ciiange in owner"ship of the propertp. This permit was issued in complianca with the provisions of the North Carolina, . 'Laws and Rules for 5ewage Treat�nent and Disoosal Svstems' {�5A NCAC 18A .1900). Neither Person �onnty:nor�°rt�ie-`'� � Environmental Healih Specialist warrants that the septic tank �ystem w�71 cantinue to fnaction satisfactorily in the fntnre`or:t�t. the-water saPP1Y wi71 remain potable. • • • Authorization to Construct Wastewater System (�2equired for Building Permit) � * See site plan and additional attachments (_,. . . . -• l ^_ . Proposed astewater System:� ��`L -�cw �cr %�w;nt,��� T��pe._J1�.L Wastewater Flow ��.p.d. New � Repair Ex�a�sion! .• Soil L�A�: •� g.p.d1 ft 2 � Type of Fac�ity: �ri ✓�� �e5 rc���� � � � Basement _ Yes�N�o� �'Vastewater �yst�m Req�rements Tank Size: 5eptic '�ank:'� gal PumP Tank: gai Grease Trap: -------gal d�c� 5��� e. Drainfield: Total Area: � OD sq ft Total Length �Ot� ft '�mam Trench Depth �_ in S� d e p, C, Trench �Vidth 3 MCinimnm Soi� Cover. �_ in 11d'inimuxn �'remci� Separation: �_ #t IDist� ibntion: Y i)istri`bution �oz Serial Distribntion spe�ificatiuns: state A� Permit �a lOs.wifold . P � ,r � d' � D�: � —7--0' The type of system permitte� is Conventional '✓ Acc�ted Alternative. I acc�t the specifications of the P��- � i�e�/�agal �ta���s�nt�tive: Date: � pCffi� rev.11/10/Q5._ ,� .. . . � - r� 0 ::{+v • � . .. . `•�'•'„'�.!'i. �i.•.'•.:.'�••<; �•,' '' �� :�:: � �� �.:��... .�.• •• :: �,•' . . � : V �J:': �'..: . . . .. ' ' : .. :.....�� .,�y:v.. : . y .. ,,�.;. :..: ... . :�•.��� •. `�r:.'' . . ... � . . / V45.: +..: :�: ' . �:+.�v.'v:'v.: ,.. . , � i�:'.�' � ��'.'.� �� . {....:..: ,':,N.y:i::,.., .';•. -�L3:�J�ic'S,]�.'.71i:]L�.4� �7?'.��r. n�.�.9l�7]W9:�.'�$1, ,.•'�h :� .. y . �'`�:°B•d�1-.Ill.'ii� ', � . �ELi, PERN9IT . PLTAS]E SEE� ATTA�ID Pg..e�N �pga yyEI.L S� I�AAY'OYJ�' Tax Map � Parcel # �� .. Touinship: Applicanf• _ G�,c� �a� t l„�� I(�, �.ca��-z— �fe�.,�o Subdivision: r „+ � 'Pype of Vi�ater,5upply: ✓Individual _ Communi Public tY Itequirements: Sita Approved By: Grouting ApProved By: � Well Log: � Pump Tag: . Well Tag• ' • Air Vent:. ` � � Hose Bib: � � Casing Height: ' Concrete Slab: • � � � ' � � Well Driller: Well Approved by: ****See.tlttached Site Sketch**** I,iner: 7nsta1led by: � Depth set: Grouted• Date: . Water Satnple: Wells must be 10 feet from property lines. Wella muat be 100 feet from s�ptic systems, Wells must be at least 25 feet from any building foundation. , Other conditions: Date:, � PCT3D rev 01!27/0� .���,�f ������ . `.... �. � ' � � �� �y.7�1�T7C�" �Y3'v'17CO,...,......MD33�.i ��C��L. N�me _ l�h r) �fFe, � u d I I a �a�-e -�e�n�, Sub � . Autho�ized State Agent r �►/ a � Ta.z Ma.p # %�" 23 � P�tcel # � Sectian/Lot# -- Z`� Z' D'� • Date System cvmponent.r s�epr,erent ajiproximate �contours only: The contractor must fCag the system prior to . beginning the installcdion to i�sure thatpropsrgrnde is marnt�ned ' .S' - � �Ff •�J' f •W _ „ _ . ,. _ � t�. . . � .�.. u � . � �,�. r � r. =�r '` �.,; - .� _ _. �, .-�--- ��y.�-._.. �� �' .� �- . �r'y . J��r �� �'� � " � ��°�� � � � � .. ...._.. ...... ... ..... . . —..... ...•+i � 11� �r . �._.��_._. , r ��D � ��d �{� c�a I (,,� �,�° � R e�a� ��-� � � 1 �.�`(Q,a ,.. �Cl i. v � �......� I. �' � ;`....... �� »� ,.,' y�f 1.,.+. �� � � t . / ,,�. .. . tlL.� � � ... � ! �•' '-----, � z �--l� •4 � .... ..�. . w. , ,Mow„ ` ..r•►"r ��� ����c ./ _____9 °`°r�\\ S:�` � �� , ' �a� � �° � i � �� , � �� �` ..,,,, _ � 6 J`i�J ti�% ,I' ��� ���'i _.. � � ��,�1� � e� . , � '� . �`�... _. . `y�,�' ,�� `�,r,{�,. . . ..... a �� �i .� � '' � � ` ' �,_.,._�-'`"' G"�1r't�I���' ,�'r�����` . ����� � ,.._.._... ' � r� � �r�r� ���,� � ,� . �. `- ✓ �+� � �..� �.��C..,��'� �,,� •...�,, � �� � , . a . � � 1 t d� � �� r ,,r �„+"���� �� j,p '� V' / �''"'rl • �� d ���� a � �,�. r+� '� � � J � .f� � ,"%°. � ..r�'"./. 1 R' ' � o„' � � �. _„� �� Y '�y �� � r I �,�� �,�1'�' , 4 ����� t ..,�y,. � ;� f_' /V��.��I �► �'Q,�1f15�Q��aT��� a n a�� � � �