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A25 161,: z `� Person County Health Department � ` Sewage System Improvements Permit Date: z�'9Z This Permit Void After 5 Years Permit # Owner: nnv f�Q �cL,,. �s� SR# /3y0 I.00ati0I1/D1tECU0iLS: S 7 /1/ /�71 Q� �o: � ei �r/ , La f� Subdivision Name: N�� Lot # ^��� Lot Size: /. Ud Ac Type of Dwelling: Mod%/s i�ior�z. Water Supply: Private: ✓ Pablic: Community: Bedrooms: 3 Gazbage Disposal /�o Basement No Basement ixtures Nc INFORMATION CER'I�IED BY � a^�"'�-� � SBllitffi18[l: �ak.,.R� B r vr.e.�, own� or re�esentative REPAIR: VALUATION: ------------------------- Size of Septic Tank: �v�� gallons Size of Pump Tank: Nitrification Line: __ 6/ad � X 3� Depth of Stone: 12 inches Max Depth of Trenches:_ _ 2y Altemative System: Conv. Pump LPP Pump Remarks: __Z'� ji o.� �in s �� ct n f�c ��L d i�,�rrr s�.1. 1 B1C � f r ,_. . . . �' n . � � � � � � � � � � � � � � � � � � � � � � � � � Date Well Approved: Well should be 100 ft� from any sewer system BY Sanitarian Date Sewage Syste Approved: �— g' 92 BY ��+-� ��-•- Sanitarian CERTIFTCATE OF COMPLETION ,.� Contractor. /vQ v,�,� .�1.a..�ersoN � S�pf%c fia�•E ao�.c�,cd „po.., i�,r,c�.c�.'o� ,/ ------------------------- �-�, Sewage System location, installation, and protection must meet state and lceal � reguladons. Septic tanlc should be pumped out every 3 to 5 years and shall be maintained by owner in such msnner as not to create a public health hazard. Septic tank and nitrification line must be inspected and approved by a member of the Person Counry Health Department before any portion of the installation is covered and put into use. If � the site plans or intended use change this permit is subject to revocation. � /R (G.S. 130 A-335F) _ `� ` t Location of sewage disposal sewage system sketched on back. � (OVER) � 1. "� MiGa�c� �(�(1�ETTC, G�Ji ��02 � Person County He�ith Department � Well PE�rmit . � �y�;,: Z 28_q�This Pezmit Void Afte� � Years � . o�: ��; iy �. �� � -��. sR# /3yo �.00dIlOT1�1TCCil0I1S: ,,,5 7 N, ' Q� ,_ d� GCC.,�4tr� ^% „� c� . LoI� o�+ 1Q'�,,tt� : �4'A ,��� . C�.��G � Subdivision Naine: " , ��: .. . . _X.�o�# : : N/Ar Dt�ling Contractor: �V WELL CONS'''R(iCTION , ►� Dis'.ance from Nearest Pcoperty Linel._,__,,, Distsnce _trom Sou�ce of `: �� PoL��don � ~ � _ : . ';�. Toul Depth.� t Yeid:,.� GPM Staric Wata Level. _� Ft W�-.:BesringZones: ----�f�, Ft Ft�.J�F-..'�';. . . - C�sin� . Depth; �rom� w Z�L Ft � Diur�c� V�- � Incha 7'YPF.: Stoel ' Galva�uzed Stcei if Steel. dxs owna spprovr. �� No . � - ..-. WeighC _ Thiclrnesx � . Height Above Gtotmc:— Inches '.' Dcive S:�oe: Ya� No _.: • � : `�' Wae r'noblans F.nco�a►taed ia Su�mg the Casing? � Yes _ � � `�' ': ' No ' ` �� lf "yes" give rason: ' -''C Grou� � 1j�pe? Neat �_ a:,au ` Conezace � • AnnWar Spax Width 7ncha ' . �. - - :�w.� �, �:.�w s,�:,�: :� _ � rr� , � Mcttwd:: P�npod Pns: Po�aed � _ Z7c,��Frot� � ,to _. Ft , ;� •�F ��'-'�'�`����ul'a�en �`°Used: : No. Bags Poitlan3 Canrnt ' ag t of , . � Ibs. . - , If r.uxture fsand, gra� cuttings� • Rano: to � ID Platex Yes'_�,� ._ No_ �` ►d 4 x 4 slab Yes . No_. � , I HEREBY CER'I'�Y 1'}iAT THE ABO`� E INFORMATIOri IS CORR�: � I' AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH RE ULATIONS SEf PORTH BY THE PERSON COUN'I'Y ' P ' ` ,�S• � 1� QZ Q 1 �° �. - -,t?� 1� �L �So Si,�ature of Conora�.-�or Dau � ! • � �,�� _; � .-�...� Z- 2� -'�'Z ��;,� �� Sanitarians Si anae Date Issued � 5�5 ,. � _ ��o: C , Sanitarians Signaure Dat, Completed S'sctch we'1 location on reverse side. ' � r � . . ������rl� r ',���'��....����i����,. ��1 ���� � ������ ■�a��■ ■������������■ �������o�������� ��oe������e�■ ■��o�������������ee��■ ■�����■ ■�����e����s,�������■ ■ o����■ ■��o� ��.����s���� ■■ ■����� ■���� ��: :��o���■ ■��� �■����� �����c==���r���� ■��■ A�����■ ������-����aa��� �����������■ ������������t��� ■�e��������� ■o�::=�:��� �� ■����■ ■�� ����Q����■ �� ■ � o,�►ra,a: ��: � 0 _� � �_ . � '� n�,..,,... r R Apalication Date: �oc. `� '� `f � Tax Map #: /Z�` � Amount Paid: �j O_OC� Receiat #• � 7 � �,,,,�,„ Parcel #• � � C.�� �����5� ���� �� i 3 I� - <C � iL��T�"�Y -�' �a�a.a-��a�-�--�- maa.��.Il 7���m.71�1la 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: (Owner/agent/prospective owner): �q�Ry ���'�-�'ti-�� Home Phone: 3-��- �> �-� S� 3 Address: l �`� a- � ti eo G�Fw r2.� Business Phone: 9' 19-�sa -Cc� � C��� � �x bd � � � e a-� S?'y 2) Name and address of current owner: _�����. � 3) Property Description: Lot size: �� � 4r Township: Subdivision: Lot # Directions to the property (Including road names and numbers): O�� C� �J C CLr 4) Proposed Use an Structure Description: answer each of the following questions: ' i a) Proposed _, Existing _, Type of Stn�cture: Co� r�o rt% Width:� Depth: 3 4" b) Number of Bedrooms: � Number of occupants or people to be served: CeM�� Q�� v c) Basement: Yes , No _ Will there be plumbing in the basement? P d) Garbage Disposal: Yes � No ✓ /5 ' X�� � 5) Water Supply Type: Private 1� (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 FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITrED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �, ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAI(ED 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. `�� � c^—,� // D -3 Owner or Legal Representative ate PCHD, rev. 06127102 �lY t�1A3 �'�E C�iwSERi1 ra�n , _ ���� � � 11l� liFl�S� �.�1. DEfl�tCATC; �t14 -AtlEYS 1i�LK5 EASE.�+� � ., � ` , S O1t�R tl�Et�. '�CE& i6 :PLs,.ie �'���,�T�s s�o'�u � ' � ���� 1t3�t,:F�E���, t�,Atl;FY, Tiih'ty _ , - " . g 61�THtT�t �����ROI �h EGUt7�tltlr� )t�iiiBU�Ci16Si t+F . . ���� t, to��� , r k�,p Gi��M TWP• � � �q=- s : � 3.;. '' r [„�1`�1`� � � b�n�s, � vARY ���2� H�L� ��� f 7!�'`5�k�t1t41�tOh1 Pi1�t: �� 0��� YEi1 F��� [��t `.1 E�Jh! I N� `� � Tt� ,� '�. ' C�EATIF`t iHA Apr�f}pVAI fkfR��%hNr �g�g g�t� fiSi?+k�1Ed . �3�;,��lti.. , . r , ,� �� � • J • ��N COIINYV SE!li1� SdN GULFtibt44� , a r ' p����, -y�*�+ui'�." i�����r, ,,�.• RI �a O+i ' �r ` t: , dr ��'E!� r�Nl.�{� . �i0!71 1 �, ', ` . Y . , ', � L�'��.�.- �-- �� zo � >: .. . ptx,a���t�., N�` � _ !� ' � ( ` ` '° SCAIE 1 IPbC `,�� � ,. f �. ; , _ �� �� , . 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S� ' � ,���Enatcd is ce��feni d for �g� tre t311 his Plat was pt�- 3nd record�d in thls ofilc at �1 , T� . cabinet �--+ Pege �tL-`� cloc� %0 . . �-,� . lhis_.�--� .. � . � � ,.. �� - �. _ _ C�..a-� . �. a� �� � �ta8�ie� at d�� �