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,�mourrtPaid: � . . � � � P�rcEi�� �� � '
��E�pt�: � � � j� . .
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- � APPLlCJtTiON FOR SEit1RIC�S •
1) PenNt requested by: (Ownerlagentlprospec�ive ownery: �A�v�4R✓3�.� aAyit]
Home Phone: �� 9- �7 � Address: � L Fv g
Business Phorte: Zo � z7
2' Name and address �f cament owner. �of �`�2T ��SAy GtJ�/1c�2
�//( 3 �'fa.� Go2 D -G �F"�O ,P4�
/eOX�D�b�, /� �r �.%_��
3) Properiy �escription: Lot size: Z��.sTownship: u�i A_Subdivision:
Directions to th� pr�operty (Induding r+oad. names and numbers�: - C =
�--.� i ��.,��,��i��n i-,/�.�=',7a�4r .6 t?/. S
4)
�
6)
Lot# % ?
�?C�",
�•
Proposed Use an �ructure DesepipHon: answer eact� of the following questions: , -_
a) Proposed _, Existin9 _, TYPe of Struc�ure: �a�SE' Wdth: � Depth: .S o r _
b) Number of 8edroom� •.'� Number of oa�pants o� peopie fio be served: , •
c) Basement Yes � No _ WiII there be plumbing in the basemenY? �?'c�'S ,
d) Garbage Disposat Yes J No �
Waber Supp(y Type: Private _�new _ o� eads�rlg �, PubGcJ Cammunity � Spring _ .
Are any wel� on adjoining property? Yes ��Na _ If yes, ptease indica�e appro�dmate loc�ion on the siie ptan. l.�o,�o'�
—' � �C!x?oc�I
Do� the pr+opsrty contain previousiy ddentifled jurisdictional w�lands? Yes _ No � �oc�TTo•�
PLEASE NOTE TNE FOLLOWING:
' 9 A PlAT OF ilE PROPERTY OR S1TE PLAPI NUST BE SUBlI�1TiE�D Wi1'Es THIS �►PPLlCATtON:
9 PR�PERTY L1NES AND CORNERS MUST BE Cl.FARLY NAR�.
➢ THE PROPOS� LOCATiON OF ALL STRUCTURES NUST BE STAI� OR �LAGGED. •
� T9�iiE SiTE MUST BE 9i�ADILY ACC�SSIBLE !FOR API E1/ALUATION BY THE HEd�LTi1 DEP!►RT�AE�iT STAFF.
1• hereby make a�plication to the Person County Heaith Departmerrt foc a siie evaivation far the an-site sewage dis�osal
systern for the above-descn'bed properiy. I agres that the conte�ts of this aQplic�tion are true and represe�rt the maximum
fiaa7i�es to be placed on the properiy. I understand ii the siie is a�e�d ar the intended use changes, the permit shalt
became invalid. �7 � //%
or
Pc�o. �ev. �an7ro�
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Duke IIniv. Federal Credit
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Ta�x M�� � P�rc�el # i �
Suhci'ivi.s�ion •
'Fh��s�e Sect�ion Lot �
Applicant: �ano� Qen �q..V 1 d
Location: 7 i�J P �a�1Ct�r'o� - C.zFFD K,aa.d Q.� /at bcSicl c '�l Fa VolurtEc�tr'
Fi rc Ocoa rt�r, c.,1rt
Permit Valid for '✓Five Years
Type of Facility: 1 c aa
# of Occupants c+. ,# of Bec
Proposed Wastewater System: �
Proposed Repair: L, P, �� ui
aFf,cr (ni�a( SyS�cm ►n,SEa/
Permit Conditions: �lG+.� Sv�St
S ldc 1 i nS� c� �.i,e �o Sb'
arL (o�e�td t� a.c �fe
Owner or Legal Represe ati e S
Authorized State Agent:
. Improvement Permit
No Ezpiration
� i l d W� Il i� New �Addition _
rooms 3 Projected Daily Flow 3(po
tm Z' a-�i v c C�.S � 2cduc�h'an
[cs .SuFFicici�e Spacc ,`s ct�a�la6(c �c�r Z�
Water Supply i vai� W�(�
g.p.d.
Type: I1I�bi
c��, Type: _�
t� arld ���t d�-! !� Gu- ct Ftc-r' I�t iS C,ft� rr.� . Con�b"�c{�r
z s nrsc t� d r`,�{,�,c.rb �h c- � i I� c t� SyS-eun (o a' p FIC'
. ... . � _ � -- �_ . . . _ . • . . _ . �-t o- e � e i�
hzScmcrtt plu � a(ar cr 4,
�"��� - 9 _
Puvr�p W � u 6 c r-e�'d �
Date: -- � - �
Date: �,.0 -�l -p�
The issuance of this permit by �e 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 slte plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was isaued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900).
Authorization to Construct Wastewater System �Required for Building Permit)
* See�siteplan and additional attachments (�. � C�v:Qi.�c�o�- � �- l 3-C�
c� ���-�
Propose Wastewater System: U rr10 Si'�r1av�-��V e- Type��i Wastewater Flow ��.p.d.
New � Repair Expansion Soil LTAR: . daS g.p.d./ ft 2
Type of Facility: f i nq(� Fam r 1+� �W t,j (��n�i Basement _ Yes _ No
Wastewater System Requirements
Size: Septic Tank: �,�Op gal Pump Tank: � gal r e Trap: ���i gal E
S�' Cs�u� �, u�s� 5 d t
field: Total Area: �� sq ft Tots�l Length t Magimu ench Depth �S in
zh Width 3 ft Minimum Soil �over: � in Minimum Trench Separation: -( ft
Distribution: Distribution Box Serial Distribution � Pressure Manifold
: �nc
� r��,
Authorized State Agent: _
Permit Expi
c �4r'c.a�,
0
� I Cc�l e� t�+� i I l ha u c.
Date: Lo 3p—O'1
Date: l.� � - c7�
The type of system pemutted is Conve�t' nal Innovative Alternative. I accept the specifications of
the peimit. �
Owner/I.egal Representative: " r Date: - � �
:,
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Undergrua�d Cable In Cond�sit
pith Se:ita6le Sealer In Boch
Fs�ds Of Conduit
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3/16" Syp� Hre�lces Fiole
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---�— � ALacm Float {el.evation)
. "pu� on,� Float (elevation)
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y' a r
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, � PUHP EtATING
p��[�lust Be Rated To Deiiver
GalLons Pet Hinute
Against �,S Feet OE Tota
Dynamic Head (TDH)•
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PUMP SYSTEM DETAIL SHEET
See FolLowieg Sheet For
AdditionaL Specifieatioas,
Noces, And Explanatioas.
� -1'Elcvc��on �I'S'Tan K
zz' C3 x ���) =a�.3� �zat�
?j�.� 1 '�' Z� I�'1an � FaIA =3`�.$1
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