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A24 149
A IicationDate: ������b Amcfunt Paiii: Receipt #: 1 � q Tax Map #: ��? Parcel #: � �T ���_s� I�I�II����T - - _ � � ��-�� zc����-��,.�.-..m���,.0 s��m.m.n��� APPLICATION FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED, CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: (Ownedagentlprospective owner): J�RR.H ✓• S},�„Psoa Home Phone: q rR- �7i-9Zb� Address: �h� � Rrcc-rti- Ofcac�o_ Business Phone:c��A- �7/� 71�J5-O q�q_ qyq.zig�_e 7���..-, �i e Z��i Z 2) Name and address of current owner: e A QOl 5�l �3Y SS32 , 1�iARgoo �Rr1,� �'ru,�l-t �,,._�. nr�2 k �P � ��3 r /SZ> C � 3) Property Description: Lotsize: la•56 Township: Gv�a.�tiR�, Subdivision: �k Po. N� Lot#� Directions to the property (Including road names and numbers): N� GH�s n,,« -� ,O/,��,�n��, .�rt+r.Q (1�t-� L��r va n�eaF���� «,� 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed �, Existing _, Type of Structure: S�a /e ��� � � n, Width: �� � Depth: �o' b) Number of Bedrooms: �� Number of occupants or peop e to be served: c) Basement: Yes , No �/ Will there be plumbing in the basement? d) Garbage Disposal: Yes _, No _ 5) Water Supply Type: Private ✓(new � or existing�, Public , Community , Spring _ Are any wells on adjaning property? 'Yes No ✓If yes, please indicate approximate location on the site plan. 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No ✓ PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY 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 STAKED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT 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 J (�gC �(�-�b�1/ ZQ6lo Date PCHD, rev. 06/27/02 �����1•� � �11.fJ �� ��. V �..� � � � � � � 1L 1�,aav�-n.�c-�arn�rnrna��cn�r�n.7l ��.m.71�7la Slopad To Shed Water NEMA 4X Simplex Contzol Panel 4" X 4" Pr�ssnre Treated Post 12' Sep+ratioa Electrical Co�uit ; i . . •. .: • ' •' . �. , , � • • b" Cov.x •� � � Acce�� Cover• ' , ' . ; 1 . ' � • . � � r • � � •�• � ,� � t� �' `� , ••�' • ^ I ', i,. �Penin= Filled With ` . Anti Siphon Hok� \ Ixdet Fmm Saptic Taak Portla�ud Cemenf Crmut �� g� A" SCii 40 PVC Pipe '� � � � ' ��� T�x M��i��� ; P��rr:-E�1 # ' Su,l�ciivi�sioi,i / � , �, I'h��i�;�e Sc�ct,i�n L�t i� : Duct Saal Both Cox�+eta Riser Endi Of Tha Co�duit � 24" Miziiztium '' '� ' ��' -- 6"S�paration Tlue�dad Gate Yalme ; Union ' • • • ; •r..tCG� - 4,r;,_...rPoztland Concreta Grout • • � i� �ift]C • ' � ..� � � , Zip Cvid � � op.ning Filled Wiik T� SupplY • Portland Cenunt Grout � LinA ' • ' 4utlat To Dutnbution N � �" SCH40PVC Pip. . •4- Y n . ' • Valv� �De ' Float Wiz�f .� � � s�xw�t� s� L.�i � ' : � . , (6" Separation� Hiah Lewl - Pump On • i. ' . ' �,: � rVapoxLock P7oat� .�: • '. Hole • . . . . . � g Dravvdnwn �Up H�71). E-l�.emov�bk ���. • , � .� E1oat Ttae , • Law Lavel -Pump Ofi . • . . puntp • ,'„ t .. '�.; ' Pieca�t Concrete Tank ' 4" Concsete ���,• � ' �' Matezial S h>3500 P H1ock � 1 ••• . ,; _ . .�. �,�,... , • . . 3 .� , ,:� -,.�,� •. •�:• • : ' • • • ' - - � 1 . � Od� GALLUN' PIJ1�11P TA1�K ; . . � . . . . �... � � . u 3Z ��� � 3s' o�/�e� 0 ���, s f I�I�I�.� ��T ----= � ������ 1[ :a.n-vnn-•caaaa�cn.�xa�E.cn.11' 1HL�.en.1L+E1La Owner: Ta�c Map: � Parcel #: /�{9 Date: Line Tap Tap (Sch) Tap Flow Line Length Flow / foot # Diameter(in) ( m) (ft) 1 b •d 2 0 3 • �� � 4 a 5 . 6 7 8 - 9 � � 10 � ft of line x 65 gal. per 100 ft= " 100 =� gal 75% x gal =�(� gal per dose gal per minute (gpm) = Flow Rate Frictior� I�, d - :--:.: � Loss: 1. 1� ft per 100 ft f supply line x� ft of supply line = 100 =�_ft ft x 1.2 =� ft of friction head .� NIanifold Size: 3' " Force Main Size: 2 " PVC Total Dynamic Head —�ft of Elevation head +_�ft of Pressure head + 3 ft of Friction Head = ____��TDH Pump Requirement: 3Z GPM @ 3� � ft of Head. Drawdown: ���c gal per dose ,—` 21 gal per inch =�_ inch drawdown per dose ��� �� �� � � ��.��� � � .,. . � . . — =�r������i � . � : _., �� �,� �!■ � . . � � '����' �[t�)1�0000 ,. �I 1�1 (�► 1�1 iiiiaiiiiii�iiiiiiiiii:iiii+iiii ��:�i�.���ii�:������i�i��a��:���:+�:� � 1 1 I � - :+ :� : �- . �__._ �� ���� �xF„��c.�.^^.�.t r.r � � `,..� �:� � , � � �� ��� � 2» mia Schedale 40 PVC � , 9 moamz 3" 4" 'r4" ta s '/." ta a 1" t� 4 ? 9 5 3 40+ 2l � 12 1 .. . � �lo� er Ta �- Size iLfcuerial Flotiv GP�%1 ;: " Sched 80 �.� � ; . " Scherl4U i.l �/," Sclred80 1Q.1 3�, .. Sched 40 1=•� F 0 ..�'�.:.. : . ..'. ..`� �;.�'.: '�:�.;: .::.: . ���:.;_. :..V:`.. , .� ..�'�•� • . y.l;..:,.,a:. . ,.: �. � ; ..;; . .,. �: . . �.:...•., � . 'q' , •. ��,.' � .. . • . . �.. �•:.,::: . w . ?'i� :�.',�1J �.�.'.� '�.� �� ' . ... .......�..v::,..,::: �,,:..v. :.c:;.v..�.•,:;•: :;;.., . . .�:. .,�;.,.�:.... .;:.:......, . . ;....... . . .:. . ..... . '. . . � . .:.: •. � 7��- 7��1�� � � ,., •..]A1;.t9'71i�SVti`�e''rt'�*�r.'n':R�3k7L�...i�ll:' . . . . : :• . ,..:: .. .. �.:....:.,:,;�,;-� ,�^,:'.^ ..r.. •..... ..:_ .:,.��::� 1i.;;�;:t�.�.�qS1-�1,11r]L71:'. 'Yi 1�.fi../� S.3�SV.71LL 1 . �9.��� ��� �1 1t��3Y �a •ra'l ��Il� VYL' JV.9J ��. e 't+a 3 �Y.! � T� n� � Applicanf: _ Subdivision: Location: � n� . -- Parcel # /y9 To�vnship: , _, . _ Lot # �3�e of �atea��5up�a�y: Individual _ Community Public �.tequirements: Site Approved By: Liner: Grouting Approveti BY: � � 'Installed by: _ Well Lug. � � Depth set: _ P�P T�' ' Grouted: Well Tag: • � ' Date• Air Vent: � . . Hose Bib: � Water Sample: _ � Caeing F%igh� � Concrete Slab: � � � ' � � Well Dn71er: Weil Approved by: ****See Attached Site Sketch**** Wells must be 10 feet from property Iines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building founda,tion. Other conditions: Date:, � PCAD r�v 01!27I0� .�1���.)� ���� �� � ' ����� 7E�.�y-�� �-- ��.�.g ]HC�.m.g�Ila. � . SITE S�TC� �� . Name �'c,K Taz Map #�?-� . Pa:t_cel # I�9 Subdivi . � Section/Lot#_ (3 . . , . r,—,$-�S-� � . uthv�ized State Agent . � Date System camponents s�e�re.rent upproaaimate�contours only: The conimttor must, fTag the system prior to . beginning the installation to i�sure thatprojbergr�ade is marntained � � ,..1—r►+fia� S Sfem � � -- 3�d . �. � � 3 b� �P �' 3G�0' ,� � � � =� � � � a�� , �I c�e� ��, c� �n �� :�.. �{�n�h 1� and ��ur ' �� �� �Y'�nC %� ' ---� � � � ► :1� � Pl ac� f�''- 8'� Q���4'o Q�'�? Soi� Cove� ovCr S S`�Wl�� -�'��:� �. ; _...- .._.... .,....... ...,.,._,. _,_,_ � ,.. —�-. � �.:, �- o ," i"' n. �� "�-� • -Y--• � _o._,�,r i � — � \ , �_ '�. ^,�.. �,. � .� �, ?o' ( � � @ g�' ��_.. �. .-�., . �I � '-���' i i • l� t �a �� �. �� ; ��:.:.�>...,�.�.�.�,�:.....,.� ���.z:.. .�:.:, �,xa.�w" , ��� � -r� %� i� ,_.: . � � _,..� � � o'� � . C, s � ► � 0 ' � _3 , �'f �.r �,� ��- ';' '��J � 1 . .,� .��.� ��...���`" � � , � �. �: � � �� � - '" �, ��. I C� � U r`��'� � / �.� �� , � .,..�,.�,�..�.��� � '----.. � c.vi _ I V O r �' ..� � I �. •( u �' ! \ � , ------...� j �.�.-�....... ". `_ ^----.--_._._. _._._ __ �, � , �r•- , �.• C�J ` ,. �---�----._.___. .�. -'-' �.,---���; __.___.__ _.. --__.__-------___._-_.._._. \ �I , -- _..____�_.,___-___ � � ..--- �. _.... ____._.._. ,- _ __. ._ . , _ .__-�___..__ �J ' '_" -.... .: ' .. . ..... . ` , . _ ... ....... S��V.. ����-�'V J�J� _.....___..'"" •` a . I ���� ��, �J9.L! ��1J �� �� �p . y�� y j 1� �\ � � � � ���� 1��.�.s�� � ���.�.Il I�3L��.71� T�x Nla,� � � �rcel � � Su�bd�ivisiar�� 1 e . � � � P•has•e: Secti�om.'Let � i Psr�t Valid for Type of Facility: , # of Oc�ants � Proposed Wastea Proposed Re�air: Permit Conditions: / Impravement �'srmit e 'Y lYo ��iration / � esiau,�P: � New ✓ Additian # of Becirooms ��_ �rojected Daily_�'low, �l� � _� e �Vater Snpp�Y � g.p.d. Type: TYPe' � . Owner or Legal Representativ e: � ' t�ate: Autiiorized State Ageai: ` � Date• R- /T�"-_o7 .. The issuanc� of this permit by Health Departmeut in does not guaz�ntee the s��*+�a of other permdts. It is the �esponsib�7ity of the �Qpli�au�proPertY owner to in sure ti�at all Person Co�mty Planning and Zoning and Bu�iding Inspections requiremcnts are met. This �mprovement Permit is snbject to revocation if the site plan; �pla#''�i'the intended use changes. The Improvement Permit is not a�ected liy a c�ange in owner"ship of the property. This permitwas issued in compliance with the prnvisions of the North Carolina, .�� `Laws and Ruies for Sewaee Treadnerrt and Drsnosal Sestems' (X5A NCAC 18A .19U0). Neither Person �nnnty�:nor��ltiie-`'�� Environmental $ealth 5pecialist warrants that the septic tank �ystem w�71 continue to f�ncbon satisfactorily in the futnre�or:fliat. the-water supplq wiil remain potable. • � � Anthor9zation to Construct'GVastewxter System (�equired fur Bnilding Permit) � * See site plan and additional attachments (�. . � .-. � . , � � �cul � w�p�i'�pe Wastewater Flow �g.p.d. . Proposed,R�'astewater System:� , . . - New �� Repair E�p�o .• Soil LT , ZS g.p.d.! ft 2 Type of Fac�7ity: � �e R �Si'.�r�ce � _ � Basement _ Ye—�No . �Vastewater �ystem Req�rements 'iank Size: Septic Tank:' J6� gai Pump Tank: /�o a gal Grease Trap: gai . Drainfieid: Total Area: ��id sq ii Total Length �v fi ' Ma�ma�n Treach Depth �in Trenci► Width � ft 1VYinimnm Soii Cover: �_ in 1�'wimnm'Prenc� Separation: G� c � � DistPibntion: I)isln'bution �oz Serial �DistYibntaon �Pressnre 19?anifold . � _ Specifications: Date: 8'/� 67 The type of �ystem permitted is Conventional / Acc�ted �� u� te�rnative. I accspt the specifications of the P��- i�erl��al �a�a��se�t�#ave: Date: pCHI� rey.11/10/05-- � .. . . b