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A23 68. • � - �� z ' �,�� `'- (�$ ''�' ` � Nerson Cour�ty aHealth Department � Sewage System Improvements Permit �.�bThiS�Permit Vo'id After 5 Ye�ars .� Owner: � z Subdivision Name: _ Lot Sizc: Water Supply: Private: Bedrooms: Basement ,-�► ,^ REPAIR: Type of Dwelling: Public: Garbage Disposal Basement Fixtures.,� . REEVALUATION: ��_� - T Size of Septic Tank: l ►L Nitriiication Line: Depth of Stone: 12 inches � Max Depth of Trenches: Altemative System: Conv. Pump Remarks: SR# � I � Lot # Community: A � — ��-..�c �. repieseatat� � (.2-. Size of Pump Tank: _ f,/-� �F � _ ► • LPP Pump Date Well Approved: Well should be 100 f� from any sewer system BY anitarian ^ � Date Sewage System Approved: �� gy Sanitari — — - —��TE OF COMPLETION— — — — — — — Contractor. �,�✓� � � Sewage System location, installation, and protection must meet state and local � regulations. Septic tanlc should be pumped out every 3 to 5 yeazs and shall be maintained ►��- by owner in such manner as not to create a public health hazard. Septic tank and'd nitrif'ication line must be inspected and approved by a member of the Person County � Health Depaztment before any portion of the installation is covered and put into use. If the site plans or intended use change this pemvt is subject to revocation. (G.S.130 A-335F) I,ocation of sewage disposai sewage system sketched on back. (OVER) NOTE: Make sketch oi installation showing lot size and shape, location of house, septic tanks, privies, water ,, supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located � at later date: Note location of water supplies on adjacent lots. . �� ■■��.■■■■■�.■■■■■■■■ ■■ ■■■■■■■.■■■■■�.■■■■■��■■■■. ■�■■■■■■■■�■■. ■■■■■■■■■■■.■ ■■■■■.■■■■■■■■ ...■■■■■...■■ ■��r'��■ ■■��■ ��'11l��1��1��■ ■��■ ■�iririi.:��!I��■ ��■��■ e��r��■ ■��■ ��i�re��■ ■��■�■��■ ■��■��■ ■��■ ■��►�.,��■ ■a��n■■ ■��e�■��■■��■ .. ` �#ion Date• 3`026-60 �;mou�t Pai�d� � � ' Recet t #: Tax Map #: �� Parcel #: � b (� Person Countv Heaith Department Environmental Heaith Section . APPLICATION FOR SERVICES . �F THE INFORMATtON IN THE APPLICATION FaR�AN IMPROVEMENT PERMIT IS FALSIFIED. CNANGED. OR THE SiTE IS ALTERED. THEN'THE iMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. i) Permit requested by: (OwnedagenUprospective owne�: r� ' ��^ �� Home Phone: 33G -s`49��r P.3 � qddress: �f u�ti�s k�Ls �..k �/�a� c� IJ Business Phone: I-S�On- S�r4 �-?ao� C'� nt c t- cz ��VL �% 3 JQ,_ � � 2) Name and add�ess oi current owner. S� rn-� /�C. 3) Ptoperty Description: lot sfre: � Townst�t� 1 Directions to the prope In du�g road names and umbezs}: 3�� l� a�-5� ��eS c�c ( G, u.�� l�� + r, �� s�`�� b S � �-�S�I�a TL 4) Proposed Use and Structure Descrip8on: answer eac� of the foll�owing questi�ons: a) Proposed Q E�as�ng b) S�ck Bu�7t Q Modular�ingie V►fide Q Doubie Wtde c) Number of Bedrooms: � � Nw�of occupants or people to be senred: e) 8asemen� Yes q No�ffi,if yes, � of basement fixtures: � fl Garbage Oisposal: Yes Q Noj�1 g) OUnensions� oi Proposed Struc�ure. Width: a,�, Oepth: � � Water SuPP�Y TYPe: Private�(new a oc exis�n9 �� Pubiicc 4 CommundY 4 Sprin9 � Are arry�weUs on adjoining property? Yes Q No O lf yes, bca�on 6� Please Indicate Oesired System Type: (systems can be ranked tn order of you� preference) �Co�ve�tIonal Modified Corne�tional _ Altemative Innovative Ottter (specifyj: -% � CLEARIY STAKE ALL CORNERS AND LJNES OF THE PROPERTY. 3TAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY P�AT OR SRE PLAN TO THIS APPLICA►TiON �t� t F'�o�tir �— Y I hereby rtiake appficaUo� to the Person County Health Department tor a site evalua�on for the ao-site sewa9e d�sP°sal sy�te� f°� the above-descnbed property. ! agree that the contents of this a�ppBcation are true and represe�t the ma�dmum iac�itles to be piaced on the prope�ty. I understand if the site is alte�ed ar the intended use changes, the peimit shau beccme invaiid I understand that as apQGcant. 1 am respons�ble foc idenWying and maritin9 ProP�hl lines, comers and making the site aa��ble for the perso�nel of the Person Ccurtty Heafth Departrnent to conduct theic evaluatioas. l undecstand that 1 am tespons�'ble to� notifilM9 the Heai Dep PenY anY wetlands as designated by the Army Corps cf Es�gQteers. at \ �� Il26(6�" Qv Ovmer or Legal R tive _ Date ' � � . _. PERSO� UNTY ENVIRONMENTAL MEALTH _. PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND Si(STEM LAYOUT Tax Map #: rl 2� Pucd i_�PT � Zoni�g Appiica LocaUo Subdlvta.�... ,�pon: ��. Improvement Permit A buildinct aermit cannot be issued with oniy an Imarovement Permit New Repair� Additio� Type of Strudure3{2�YIM Water Supply�j_C� �0(R� G(�Q # of Occupants #•of Bedrooms � Other Basement? Basement Fudures? �Q_ . Projeded Daily Flow: �(�, g.p.d. Pertnit Valld For. roe Yea�s 0 No Expiration Proposed Wastewater System Ty :Gf�l/1 V{,(iL$l�Vl� �I�(X, ) Pump Required? Yes �o Proposed Repair : /U PermitConditions:,si , r�,u� �,��.�c��r6 int�tl� as lit�lr� �(��ia.vl��r, v , rv v �IvIL . ,�, ^ Owlner or l gal R"epr�ta ve iga�re � 5 l� .� �� ( Date: GO �V � ` fi I e[�� cUv, Authorized State Agen� Date: "— �� e(�1. �Ll/1Gp/1 � . �'/�1,�1�/I 12 ? DD — p� [�s�Cft The issuance of this peRnit by the Heaith Department in no way guarantees the issuance of other permits. The permit holder is respo�sible for chec*ing with appropriate goveming bodies in meeting thelr requirements. This site is subject to revocation if the site pian, plat, or the intended use changes. The Imp�ovement Pertnit shall not be affected by a cha�ge in ownership of the site. Thls pertnit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Ccde. Autho�ization To Construct Wastewate� Svstem (Required for Buildinq Permitl Type of Wastewater SystemC�G UUif,L��l OG�Cl�%Q,� Wastewater Flaw: �-�g.p.d. Faality Type: � �Y� IM DIM,C' Basement? 0 Yes �IVo Wastewater Svstem Recuirements New ❑ Repair �xpansion ❑ Basement F'uctures? 0 Yes Cid4o .Septic Tank Size: I� Ql�� gallons Pump Tank Size: NA � gailons Total Trench Length: � feet Maximum Trench Depth: � I Z inches Aggregate Depth:l2 in. �'�� Soil Cover. � inches Trench Separation: � Feet on Center : Other. G � �" �2K15f"l V 1Gi ve�Qf"l C�'-z� e�1 P�a,U o a �� J it ExpiraUon a � � - _ _ C� . Authorized State Agent: c�� D •�'�IV� I/l �/.��/I Date•��,2 . The type of system permitted Cl does ❑ does not differ from the type specifled on the application. I accept the specifications of this pertnit OwnedLegal Representadve Signature: Date• PCHD, rev. 11/18/99 Apptication #: - Tax Map #: � Parcel #: Person County Health Department Environmentai Health Section .� SITE SKETCH �C.v �� LlneSr,c.� C,�,�,cy�,J� , � . _ Applicant' Name Subdivision/Section/Lot# �� A °� �r1 � 1?��?�U� Authorized State gent Date System components represent approzimate contours only. The contractor mustJlag the system to be�2innin� the installation to insure that proper gra�te �.r mainta�ner� � n� tc�.v� . - �,i� r •.� ..� � � �-- 9 �a�l e Zp� Gt�(/��"Df�(.,� � j�� bbcl c�tl�� (St�tM � l o' vv� i v�r vHuwr af� �y'p�ej�'fi! I I w�.: �5b' IM,( Vt I lM(�f/VI D� �v'e�� C(,UDIGt l�(SitiCYIo1V1 �ccs� �{�e� � PCHD, rev. 10/12/99 � � Perso�ty Health Department � Environmental Health Section Tax Map #: �2� _ Parcel #: � Zoning: Subdivision: Tawnship: � Section: Lot• � • � .��.�,Sr�,rr►�ri.�r.►.��n�nir��r��nRr,{ . . �/ I� ' . �I, (I � ./.� / / r � � � % ; � s � • . � � � System Type (In Accordance With Table Va): �� THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPUCABLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION AUTHORIZATION. �/i�I ,/.:I � L.JI�%!I.►��ll .. Ii r. -. - •.- ._ - P� 5�( �, ��,u� [� ' � � �o' 2 =�o� � 3 = �5' � =�7' �� ',' � �� 'rC�� y !�v�e Tax Map #: �"� � Parcel #• ((i� PCHD, rev. 10/12/99