A24A 4_q_� ,� ��� �
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A iication Date: � 3 Q'� Tax ll�aa �: �ot�' �
Amount �aid• a' il
Rec�ipt #: 3� l Parcai �: `T
' ���_�� IL�'I�IE�.��I�
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���ia-.maa��-•--�• .e���.71. 1�Zoa.I1�11-a.
APPLICATION F-0R SERVlC�S �
IF THE INFORMATIOM IN i'HE APP�ICATION F�R AN IAAPROVEMENT PERMIT 1S INC�ORREC'T',_F�1LSI�iED.
C4�IANGED OR THE SfTE IS AL'i�RED i!-fE�! i'HE lAAP4iOVEflIIENT PERMIT AND AUTHORIZAilO(d TO .
CONSTRUCT SHALL BECOME INVALlD.
1j Permit requested by: (Owner age rospective owner)• t�
Home Phone: ' ` S �'� Address: a� - �
Business Phone: Ss�1rn� ������/L��,�t'/� _�7-�/0
2) idame and �dclress of current owne� P�rR c �, Tstn
. //�
�/ /a � � ��'2-��
3) Property Description: Lot size: /��- Tawnshlp:�� � ubdivision:l�/n'v
Directions to the property (Including road names�and numbe�). �st1��
. . . . ,��,�_ A • .� �, � � . .,
�{
Lot ��,
��
�u U�.�- r� �.. lJ � U . v
4) Proposed Use ag��ure Descn�n: answer each af o g ques ' :��� "` � �
a) Proposed ✓, Existing . Type of Structure: Width:� Depth: �
b) Number of Bedrooms• .:3 Number of occupants ar people to be served: / �
c) Basement Yes�o _ Will there be plumbing in the�basement? �
d) 6arbage Disposal: Yes , No ,� _
5) Water Sup�ly Type: Private ✓new _ or existin PuBlic_, Community� , Spring
Are any wells on adjaining property? Yes�o _ If yes, please indicate approximate lacatiori on the
� site pian.
6) Does your properly cantain_previously identified �urisdictional wetlands? Yes_ No �
PLEASE NOTE THE FOLI..OWING:
➢ A P�LAT OF THE PROPERTY OR SIT� PLAiV NIUST 8E SUBMIT�E� WRH T6-I1S APPt.1CA'iION.
➢ PROPERTY UNES ;4ND CORNERS MUST BE CLEARLY MAR�ED. �,
9 THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR F�AGGED.
9 THE SiTE MUST �E 4iE�►DILY ACCESSIBLE FOR AN EVALUATION �Y THE HF�4i,.TH DEPARTMENT
STAFF.
f hereby make appiication ta 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 cantents of this applicatian are true and represe.nt the maximum
faciiiiies to be piaced on the property. 1 understand ifi the site is aitered or the intended use changes, the permii shali
become irnalid..
Cwner o�L�gal Representative
i q �
ate
PC3iD, tev. �6127/02
A fication Date:�o�� ��03
�.mount Paid: "�
Receipt #: ,� 'l�„_'��_
Tax Nlap #:�2-=t�
Parce! #: 4. .
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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 AiVD AUTHORIZATION TO
CONST9�UCT SH�►LL BECOME INVALID.
1) Permit requested by: (Owne agen prospective owner):`�.�' �:�sT:�v�-cs�a�
Home Phone: 'X Address: �t C32SC�4�TWOS7flGr\.1Z.A-
Business Phone: �-3tQ-4��-1\�t�t . c��a.��r�•rs.�E ^►�►,_L . Z,�z.4�
2) Name and address of.current owner: ScaS��..21�- '�Zo��Z�E.S
��fj jQl�GliTw�o�LLa-�:1 -
C�-�cz-� ,�.� �.� , N G Z� � q-�
t�-�N�.:,3a^.c��-`�
3) Property Description: Lot size: _\ c�A�--.Township: c,�,n,nrr.�c:�..+,�Subdivision: Es�s�t� Lot #�
Directions to the property (including road names and numbers): �,,�•� S`► -�n o� �.-�N l_r.�c,� �
C\iuZU.L 1Z D '� iZ0?EiZT� O N R't �\�GC' —
4) Proposec� Use and Structure Description: answer each of the following questions:
a) Proposed �, Existing , Type of Structure: SF D Width:�o _ Depth: 3�
b) Number of Bedrooms: � Number of occupants or people�to be served: Z
c) Basement: Yes�, No Will there be plumbing in the basement? `Yc�
d) Garbage Disposal: Yes No �
5) Water Supply Type: Private �(new � or existing�, Public , Community_, Spring _
. Are any wells on adjoining 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 FOLLOVVING:
➢ A PLAT OF THE PROPERTY OR SITE PLAiV MUST BE SUBMITTED IA/ITH THIS APPLICP.TION.
➢ PROPERTY LlIdES AMD CORNERS MUST BE CLEARLY MARFCED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AiV EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make app(ication 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. 1 understand if the site is altered or the intended use changes, the permit shall
become inv�lid. . , , �
�
Owner or Legal Representative
�9 - � -% - �"�
Date
PCHD, rev. 06127/02
`--��, ; ��f ���� ��
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I���aa-��.�•-„-n ����.]L IHL��.Il¢l�
Applicant:
Location:
SS e Ir �Y'0
T��x M��,� � ' � P�rcel # r� '
S�uhcl:ivi•s�ioio � !.� � •
, ,.
Fh•a�s�e Sect�ion Lot #
Improvement Permit
Permit Valid for � Five Years No Ezpiration
Type of Facility: L a.mi t �W c. I i New � Addition _ Water Supply ri U�s.wc [(
# of Occu pants # of Bedrooms �_ Pro jected Dail y Flow �� g. p.d.
Proposed Wastewater System: r,�no�cc� r v c, Ca S ia k td uch'on ) . Type: G,
Proposed Repair: �Xt,�„� Type:
PermitConditions: �n�5fscl( SySfcw� C�5 1�(c�,�c.d or► ���lo� Effs, liCtD cS�/SEt�r� o•-�
�'.,n.�.,�.� �„a �`.. .�n��il='�r.� �l�rt0.z K�rn �►orY.L in a�c�. Sl1o�.�n, `B�z.Sc.-r►�.n�
Co vt �
Owner or Legal Represe
Authorized State Agent:
Date:
0
The issuance of this permit by th� Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are 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
Rules for 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.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (�.
Propos Wastewater System: �r1✓1pVcti`�i V c- Type �� Wastewater Flow �og.p.d.
New � Repair Expansion _ Soil LTAR: .� g.p.d./ ft 2
Type of Facility: ,� i nq jL Fam i fy ,QW�,� � i' n, Basement _ Yes _ No
Wastewater System Requirements �
Size: Septic Tank: � gal Pump Tank: IJ ��, gal Grease Trap: I� ��i gal �,��S�OP�
,.� ���,c.
field: Tota1 Area: � sq ft Total Length c3C� ft Mazimum Trench Depth �� in
�h Width J� ft Minimum Soil Cover: �.0 in Minimum Trench Sepazation: -1 ft
ibution: Distribution Box V Serial Distribution Pressure Manifold
Specifications:
�cn-f-6,, a,
Authorized State Agent:
Permit Exx
ouc
c.
Date: .� - tt� -
:.r1'' ). Uepc�cl �n
i.
crn c�.t
Date: � --1 � - O�
The type of system permitted is Conventional �/ Innovative Alternative. I accept the specifications of
the permit. /�
Owner/Legal Representative: � Date: �
C 7/30/2002
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�.ccSs�r- 'P�r-o � - SI'I'E SKETCH
Name �r--� ` � y
Sub iv sion �`��c bercu ti ES «C�s
�
ti
uthorized State Agent
'Tax Map # �a9'fi� Parcel # cyc%4
Section/Lot#
�' I u-- G3
Date
Syste�n co�nponents represent appstixi�nate contours only. Tlae contractor lnust flag the systena prior to
beginning the installation to insure thatprr�pergrade is maintained.
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K� �� 2�� In �+� I mu ��
� ScPtic,
PCHD, rev. 09/12/01
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Applicant:
Location:
T�}x M�p '�, F�rc�el r �=�
S�ubd!ivis�ion ��- -� � .: •� % -
Ph�s�e;�Sec�t�ior��'Lo�t �
Operation Perrnit
System Type (In Accordance With Table Va): a-
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NQRTH
CAROLINA GENERAL STATUTES,. RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AIVD ALL CONDITIOIdS OF T�IE [MPROVEME[dT PERMIT AND. CONS�RUCTION
AUTHORIZATIO.N. �
��%�z� �,��
—�thorized State Agent -
lnstalled By: �. �� -S �
�%/�'-� ; . .
Date
Date: �/- / � � ��
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` �� �" �PCHD, rev. 07/29/02
SE�TIC Ti4N� 1NSPfE�CT1ON CHE��fLlST (Type 11-1�
Tax MaQ #�a��%� Parcei # 4'D � System Type (Table Va) a`
OwnerlAppiicant Subdivision ' �s�•
Address/Location SeclPt�ase Lot "
State ID/date �'(3 • �
Tee and Fiiter - .
Baffle ✓ .
Sealant �
Riser (if applicable) �✓
Tank Outlet�.Seai �
Permanerrt Marker �/,
Pump Tank
,
Wate roof /Sealant
Riser
Pump -
; Checic Valve/Gate Vaive
t�-s� on o e
FioatslSwitches � � .. . . � .
Alarm visabie and audible
Etectrical Com onents
Rate (aam)
Approved Pump Modei
Bloc� Under Pump
Pump Removal RopelChain �
Distribution System
Serial Distribution � ' �
ressure an o
Low Pressure Pipe �
Appr. Pipe Materiai and Grade
Valves .
Trench Width 3 , ft.
Trench. Depth �- � �� in.
Trench Length � ft
Trench Grade �
Trench Spac9ng ��
Rock Depth and Quality �
Dams/Stepdowns etc. v
Pressure Laterals
Hole Spacin
o e �ze
Pipe Sieeve
� um-ups�rrotectors
' Required Se�Ebac�cs
From Welis �: .
Fr.om Property lines �
Public Water Suppl
Vertical Cuts (>2 ft.
Water�Lines
Vehicfe Traffic ,
EasementslRight of W�
Other
i c�- o�f- Easements Recorded .
Comments�
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�C //-/� �
pcf�d rev. 3113101
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WEI�I. Z'E�2MI'I'
Pi.EASE SEE �.'1'I'I'A,CH� PI.AN F�R'WEI.I. SITE LAYOUT
Tax Map #: � 4�' Pazcel # �� Township
` ' �as ��r Pro p ,
�P�� y
Subaioision: `Pincs6pro��il.�, E�-�C1�ts secrioa: Lo�
Location:
'��e of Water Sun�lv: V Individual Communitp Public
�2es�uireffients•
Site. Approved bp � �+ �'3 �v 3
Grouting Appzoved by�� 3 "�
Well Log ✓ � N �i'h � O�
Well Tag. � �
Air Ve�t V'
Hose Bib
Concrete Slab
r-
Well Dri�ler. `r Ua'�t S �
Well Apgroved By: � 1�ate• ����° �
'�See Attached Site Sketch'k*
Wells must he 10 feet from property lines.
Wells must be 100 feet from septic systems. �
Wells must be ax least 25 feet from anp biu7ding foundation.
Other conditions: �n Sfq (I W�/ I GzS S� et.J n,
PCE�, rev. 09/07/Ol
��� � 11.� � ��'- �1�.� �U�.� ��. . .:�� _�-� �-, .
�,r., _ ` ' � _ ) � 1�r �.: ;):�Gtl1J �u�(NiIU ��1.2-c ',(.�c I � %��r ; l, n
-- t� cC> ZCI_�l� �1C �:. �, 5
If~ x�n•,r�in-.c� zcs�.����:n.�v-,rn.,L..:,�. l'i. 7.C�.r�c.:n.11 �c:�l:n. ' `���"' " �iU��� �1- �- �o��
. .. . .. � �'y(;� �..Ob
Owner: �, � �
Location: ,� h,, �.�-
Subdivision: _ _
'1':L� tY(ap �.�. 1'u•ccl i�- �j�
LoclF��
l���cll Cozistz•uctiozi
Distancc Proui nc:u'cs[ Propc:t'ty Linc: (Nlinimt�in !(; �fee:t) r`� .�M_,__._._
Distancc fironx Scplic Systcm (Iviiniuzum G� icct) �__
ToEal Deptl�: Ov ft Yicld: `�+ Gl'M SCatic Wacer L�v�L• ? S._. C�
Wacer IIcarinb Zoncs: Dcpth � t't �� li _.c _ l't
Casiub: .
Dcp[h: rrom l') to _� �- Q� Et. Diamcccr: _(� i��
V G� �
Type: Galvanized Stcel
Wei�ht: % � . �.(�l�ickncss: �� � I-Ie:ivl�t abovc Gcouncl: __/ >� ii�
Drivc Shoc: ./ �'c:s No hlny problcn» eucoui�ccrcci wliilc: sc:ttin�; ca�iu�? __ Y�s �No
(f'j�es" give reason: � — —�.__
GXout:
I�ie;at: Sand/Cement ✓" Concrcic Grav�llCcme��c
�.nnular Spacc Widt!a �_ lilCilt:S V1�.tl'CC 111 �.,1111U1J.1 SnaC� Yes '—" No
Mclhod of Grout: Pumpcd i'rc:ssure: '�'oured `�' Dc���li '�.to Ft.
YJ[acczials Usca:
� No. }3a,r,s Portlai�d ccmcn[ _. Wci�;hc a�P 1 13a;; _Y______ 1'ouiids
It tnixluz'e (sznd, sravc:l, ctiltinb�) — Racio ��o �
ID platcs: �Yc� No �� x�� �laU J1'c� r� No
1Jrilliu� J.c��; 1,oc:iCioi� 1Jrawiub
( b,ezeby ceriii'y that dic �.Uovc ii�.�on��a�ion is cone:ct si�cl tllat ct�is wcl! tivas constructed in accorclance with regulations
� Fotth by �hc P�rso�� Counry 1-��stcl� ��nartmcnt.
�� ��)1� ��atc � ��,��� ' '
,�uzc of Cox�tracto� �- �-�-� � �rFan «u �111.��►12