A23 66 & 154D �'
Amount paid %��-
R'eceipt /� ' d7
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S' � {�. t'(ctu — �{ —19 — 9 �j
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v Date
Im�rovements Pecmit.(Established/Recorded I.at) �_ Reinspection of Existing System (Loan Closing)
Imt�ovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
_ Improvements Permit (Addition)
_ Bacteria � _ Chemical
RepaidReplace existin
_ Permi[ for New Well
I_ Replace Existing Well
S`�-O�io —1
iuiple to�tie:Colleciecis =� �fSy ''
� � ...� �../�c�...:a.�i•rr.�.r .... .� � +;k/�yl i � i��.
_ Petroleurt�j �$�� estici
ic System
I Lead
.=�e z Csr's�c r
l. Permi[ requested by: . �`�� � 7. Dimensions or Proposed Structure: /�—
owner/prospective owner/agent: Width:��� co, �� t�' �
Address: �p-�"����5. l � �Krn�����_ Depth:��'� Me�
^--�.r �.�r� y
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V Home Phone #:
� usiness Phone . �^ /
a
z
. Name and ddre�s of,current owner: _
_ l � �;1�s�-►.rk_�
. Prope�ty Description: Lot size: �-��
. Tax Map#: �1 � J
Parcel#: �
Township:�'c�a.�,,�.�. �.,�.���a�� �
Directions to property: State Road #& Road
Names,�tc.
���'Ltr4Sv5 �-�1vX�� �c�-
. /K� �- / -S L� FR �.%1 � �/C �--
C t� � x.�- t-�
6. I�Iumber of occupants or
,
S�
to be served:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facili[y
that this se�vage disposal system is intended to serve?
9. Watec supply t}'pe:
privat�. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No j�.
If so, identify location:
10. Type of structurelfacility: Proposed: �Exis[ing: Q
Type of dwelling:
House:� Mobile Home� Business: ❑
Type of business:�>�
Number of Employees:
Number of bedrooms:
Garbage Disposal? Yes ❑ No 0
Basement? Yes f� No�I If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTUR�S.
I hereby make application to the Pet'Son COuniy I�ealth Department for a site evaluation for the on-site
sewage disposal system for the above deseribed property. I agree that tlie 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. I understand that before an Improvements Permit can be
issued, I must present a survey pla[ of the propercy to the Health Dept. I understand [hat in the event I have not
delivered a survey plac of the property to the Health Dept, within GO DAYS aftec the date of ttie evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signce� Owner c�ir Auttiorized Agenl
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B 2897•
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 # � Z� Parcel #
Zonin� _ Township
Owner/Contractor
Location/Address
d
� . ,.-. r._ , , �
ivision Name
�
SEWAGE SYSTEM SPECIFICATIONS
�ir Lot Area`o( .'-t`1�L.
� v Mobile Home ✓'
ness # of Bedrooms �
Permits may be voided if s
Well and Septi Layou4 by�
Comments: �
. . _,_ �_ ._
Date
ell Permit Paid
Installed by,
altered or
�
S.R.#
Size of Tank � '" �¢�
Size of Pump Tank
Nitrification Line �' �C3 �
Max Depth Trenches �o'� `�
� `�� ��I►"-S
n�y�Qj�d use change .
,\/( 0 A/\VYIV\ � �� �
WELL SYSTEM SPECIFICATIONS
ridual �1/ Semi-Public Required Slab "
ic Replacement Air Vent �
Approved Required Well Log �
I Head Approved � Well Tag �
.�ting Approved � o f � � �D " �J' i�bc � .
Date Installed by � v[�Nt11 Approved by
This report is based in part on information provided the homeowner 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 warrants 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.1
R � ,
AUTHORIZA.TION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
� • � � � � �' ' � � ' �' � �i1
TAX MAP #: Z� PARCEL #:
OWNER/OWNER'S REPRESENTATIVE: �e �� c� �� C'�b+�
LOCATION/ADDRESS:
SUBDIVISION NA��:
SECTION OR BLOCK:
TION FOR CONSTRUC
AUTHORIZATION
SIJED
LOT #:
1. The Wastewater system construction and installation must meet all of the conditians of the
attached site plan and specifications as set forth in Improvements Pennit ��. The
construction and installation must also meet all applicable rules and laws.
2. No portion ofthe Wastewater system shall be covered or placed 'urto use i,mtil inspected and
approved by the Person Coumy Health Departmeirt.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified 'm the associated
. improvemern permit and application, may void this authorization and associated perniits.
4. Canditions:
prapertv line 15 feet from basemeut wall S feet from any vart of the house. Keep well at
least 25 feet from an� foundation and 10 feet from any vropertv line -
' Person Requesting:
:� i�i;asuN cui��•rti� i:�vv.i.itc�Nr;::N�ci�i, � � • ;:;�,ti.�i
iu.ni,rr� �:.�
• ~��:r.
,. ,
' ' IJI:I.I. I.U(� - .
`Y i . . . �
� Da te: �.�- _�._. • ,
Owner: ��„ � �]'
. �..
l l Y) L �d /��
L,ocation/D�rec[ions: _�� h.-s K.s Gl�wr�l�.. �� ----- S�#�� .
�
. `_...._. . ^
..
�u���'_V1S1011 N�lll"1L: ..._ _'_ •
------� ..
�.Cl �.� 1 ]7 . ..... .... . . .._ ---- '�`'O
g COn t�'�1CtOr' . . — . .
. • --�,�.�y-s__.Lt%ll...__iQ r__��.�_'. _.,�_�_ �.y h � t
� V�1;1.( C:ONti,('ltl1Cl�(nN . �.;.
Distance fxom Ncr.u-cst l��-o��c,��y z..,i,�c..._,-�S�pJ� llatii;ij��� ,troin Source of
Pollution . a v c�.c '
Total.�Depth: a- . � Ft. �'ic1c1: � •
� ....�__.._.__ C�1 M Strilic Water Level
Water $earing ;�Lones: Deptli.__�� j� (-'t. � � ��FG�
� _�t.
Casin _ ..._.. ----.__�' c. F[.
�: �ep�l: � From____t�____i<,---- -�� _..__I'�• Di.11llClCt': 6 �
TXPE: Steel � _____.G,i�v,ini�ul Stccl ,_ ��hes
X.f Steel, does owncr approv�.:: a'c;- No
. . � Weigtit:_� T1lickncs�:��.I-lci �A, . � . .
Di-ive ght l�o c Ground;_-�iZnches.:�;.
Shoc: Xes__` ��No - .
Werc Problems ��icountcrccl.ii�i S�:1ti�Tt; t11c Cs,sin��7 Xes �� ��j'o
zc �� �� . ..
ycs �;lve rcasou: ,..�j.:
Grout: .Type: Neat � � S:,`--- �... _ ------ . . . : :%::ia�:<
ncJ/Ccmciz� � Coricrete . .'r �.�
.
•.;
Ar�nular:$pacc Wzelct� ,3 . ._ r___. � •�
_""'_"' '__..__IIIC]]c:J .• •"R?,.',
Water in �A,nniil�u- Spac�: ' � ,� � � ..
� �::; �
Metlioci:� I'wnlx:c�c�_._._ 1'rc' -::u ----- .--_.,. _____ .
. _ :, r�: l c, �.irc.cl � . . . � � • • .�; �
Dcpt}I: I=rom .._____.. _._.__. � ' .. .
---�---- --- <<� a-a I�t. � . , . .:....
Materials Uscd:v No. �j,i�s ,�'c�rtl�u�d Ccincn[ �._� `;;'�
Wcight of .l�tia' �` t �
Zfmz�;tuirc (sZnd, grrivc;l; cuttii��;�ti) - Ratic�: _._-i � � �—� lb�,�
��7J Pl;ites: Xes � ., ..�- o .;�,�.;:<��y
� .— Nc�_...__ _ --- � •• . �' � '
x �� ;lab Xcs `l No :=:L?
- __._..___.__ .. ;
- -----..__.....- --.-.l�i:l.�.a .i �vc� � .cx� � :.
De tl� -----._
Fram T —I------�--...._..-----�-� : _ :,;>;�;
� ° �� .�__ l��iirrnation Dcscription . �''''�;�
; � .;;.
�
C�
� - _.T�-7 .�..
- -�rn_�__ ...c�',�., �.
�— --- �..r� �ct . ,�a ��.. _-____..
� --� �t'tt_ � � _
�
Z HEREBX CERTIFY T�-I�1T `l'I-IE �A,I3UVL �NFUIZMt1'1'�ON ZS CORRECT AND.T;
�. T�S WELL WAS CONS"1'RUC"1'LI) .t[� �,CCORllA,NCE WITH REGULATZONS�
� FORTH �X�TkI� P�RSON C:nU.N�'l' I�II;AI,TI-I DLP�11�'I'M •"' � �'
., .•
EN I .
. .��'��. �� �. .� _.._--__
.�IUlI�IIUCC Oi C011li;i�:IU1' '
�
. r�.'�':
�r 1�alc 'f'r
► <.'
'" � �l�
. �
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #:�Z� Pareel #�,� 15�1
Zoning _ Township ��� ��Y �� ��
Applica
LncaGo
Subdivision: SecUon• Lot:
N�v ���s � ,
lW I / �'
Improvement Permit
A buiidinq permit cannot be issued with onlv an Imarovement Permit
New ✓ Repair _ Addition _ Type of Structure{�h Water SupplyQ}' ( U(L,(�tl7Gt�i
!-
# of Occu ants # of Sedrooms � Other
Basement �Basement Fixtures? �_
Projected Daily Flow: � g.p.d. Permit Valid For: ive Years ❑ No Expiration
Proposed Wastewater System Type:,� V) V%D �Li�I �IP( Z'J�% %� ����(Q,� �Lj
Pump Required? Yes ✓ No . ��
Permit Conditions:�� I�' �Lc �l I� ���f,�,� r� �1�. �/Q U1 �LC% e l �
- - . . . � J
c�wner or �egai rcepresen�au�C ��y��a����•
Authorized StateAgent:,,������ .��� ����1��� Date: �—� —
��-O
The is�uance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit
holder is responsibie for chedcing with appropriate goveming bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This pertnit is subject to compiiance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Autho�ization To Construct Wastewater Svsiem (Required for Buildina Permit)
Type of Wastewater Syste�ri Wastewater Flow:�Q�g.p.d.
Facility Type:� �_ New L�' Repair OExpansion ❑
Basement? O Yes —���No Basement Fixtures? 0 Yes �lo
Wastewater Svstem Requirements
Septic Tank Size: ��DO , 9allons Pum,p Tank Size: �_ 9allons
��fo ��a11rW11 `lt�')
Total Trench Length: _ eet Maximum Trench Depth: � inches Aggregate Depth: �zin.
'�o I Cover: i_ inches Trench Separation: ��' . Feet on Center
Other: � W �Jv '
Permit Expiration Date: (/���� �b
Authorized State Agent: ��� i��✓f �IIJ(/t/Y � Date:�(�—/S �
The type of system pennitted 0 doss Q does not differ from the type specified on the application. I accept
the specifications of this permit.
Owner/Legal Representative Signature: Date:
PCHD, rev/ 10/12/99
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Person County Health Department
2 Environmental Health Section
Tax Map #: � � J Parcel #:
Zoning: Township: ' U /1 �
Subdivision: Section: Lot:
Applicant• �� �
Location• �
Operation Permi�
System Type (In Accordance With Table Va): �G�
THIS SYSTEM HAS BEEN iNSTALLED IN COMPUANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULE5 FOR SEWAGE TREATMENT AND DI$POSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
� . l 6
Authorized State Agent Date
Tax Map #: Parcei #:
/
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ST
� v 7���00 0
ST,g- a��
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PCHD, rev. 10/12/99