A25 35AAuciication Date: 1' �v.J
�,mourrt ;'aid•
Re�a� �:
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CaP15TRUCT SHALi. BE�1�ME 1P1VAL]D. . --- �
'i) �ermii re�uested by; (Owne � � � l 'Q S
dager�ilprospeciive ownerj: �`� . ` �lJ i /1 � �J�i
Home Pfione: • � . � Address: 4(>.37 �qt��-�p,��.— �lr�.��.. (aYJ
eusiness Pfione: 9 � sa�, � �, � �-, �'. ( � i e .
�) Nam� and address of cs�rrent ovun�r. �� ;�5 �'
. �
) Propesiy Descripti�n: l�t size: Townshtp: Svbdivision: l.ot # .
, Dir�tions to the prope lnduding road names and numbers : � � S�
� . _ � C� � , �
d) proposed lls� �d Struc�ure a�s�ri�ation: answer eacfi of the foltflwin,9 questions: � � �..
a) Propas� _, Existing �Type af Strudure: Wldth: � De}�th:
b) Number of Bedrooms: � Num�er of ocr.vparrts or people to be ser.ve�1:� .
c) Basemer� Yes . No ,�Wiit tfie �mbing in the basemer�t?.
d) 6arbage Dispa5al: Yss , Na .� �
�) Wa�r SuQ�1y TJpe: Privaie �new _ or e�stin , Pubiic_, Cammuniiy ., Spring
Are any wells on adjoining proQerfy? Yes_ (�lo _ tf yes, please indic�te appraximat� location on the
� ": 'si6e pian_ : . . •
6) �oes yau� prepe€iy cantain �a�eviousiy icden 't�i"a�d jueisdictionai we#far�ds? Yes_ i�o l/
Pt�SiE iVOTE THE FaL.LOWING:
� A P�T OF TI-dE PRflP�'d'Y a� Sa'fE P.9�td flflllST BE SUBMI7TE� WI'�i 'T�l5 APQl�CAilOAi.
� PftOP�iTY L.l11�1E� �41�lD CaRAI�S MUST HE CL�.'�RLY NIAR4CE�. �,
s THE �ROPOSE� LDCATiOId OF �LL STD�UCTURES 1lflUST BE ST�i! OR �AG��i3.
y i}iE Sl'iE �UST 8E R�D1LY �►C��SiBi� �aR AN �1/Al.lJAi70�1 H�l T�-ilE f�]F�Li'�i 3�Ea�RTM�lT
STAF�. • �
I hei�by mak� apglicafion tfl tfie Persan Courriy Healti� .Departrnent far a siie evaluation far the on-site sewage disposal
system for the abwe-describe� property. i agre� ti�at tfie caMents of this appiicaiibn are true and re�reserrt the m�imum
�ciii�es tn be pla��f on the property. I understand R ih� siie is aliered or ti�e intended use cnanges, the pemzi� snall
be�ame ir�vaiid. , ,
Cwner or Le�al
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�aie
PC:�O. ��ev. 061Ti102
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Applicant:
T�x Nl�� % - P�rcel + �
S�u�hcilivi�s�ioia
Ph�s�e Section Lot �
Improveanent Permit
Permit Valid o_ Five Years _ No �zpiration
Type of Facility: \
# of Occupants # of
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Owner or Legal.
Authorized Stat�
Signature:
New Addition Water Supply
Projected Daily Flow g.p.d.
�
Type:
Type:
Date:
Date:
The is��of this peimit by the Health Department in does not guarantee the issuance of othe ermits. It is the responsibility of the
applic t/property owner to in sure that all Person County Planning and Zoning and Building.Inspe � ns requirements aze met. Thi�
Improvement P.ermit is subject to revocation if the site plan, plat or the intended use changes. The Impr ment Permit is not affected
by a change in ownerslup of the property. This permit was issued in compliance with the provisions of the rth Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the nvironmental Heaith
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 Const�uct �astewater System (Required for Building Permit)
* See site plan and additional attachments (_).
Proposed Wastewater S stem: ���ul��wdi.csi � Type�t' � Wastewater Flow ��� g.p.d.
New Repair� Expansion Soil LTAR: .� g.p.d./ ft 2
Type of Facility: ����e4 . Basement _ Yes X No
r Wastewater System Requirements
��t �
Tank Size: Septic Tank: Pump Tank: gal Grease Trap: ga1
/�'iaD� r r
Drainfield: Total Area:'„ �Pm � sq ft Total Length ft Mazimum Trench Depth in��i p�
Trench Width � ft Minimum Soil Cover: in Minimum Trench Separation: � ft �•C •
Distribution: Distribution Box � Serial Distribution Pressure Manifold
Specifications• l � � � 6rt– � � � �„P,�� S , 1' [�!'��2 t�� � �D �� ����' �a �� S �
Authorized State Agent: �� �"'✓��� Date: ���� 5
Permit Expira o Date: — –1 �
The type of system permitted is �Conventional Innovative
the permit:
Owner/Legal Representative:
Alternative. I acc�pt the specifications of
Date:
PCHD7/30/2002
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Name
<< `�� � , V`ar �� �S � — ` Taa Map #/'��� Parcel # �S�
Sub . . . � Section/ Lt '
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Authorized Stau Ageat Date �
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ino•«• dzatpmpetgnde is mziataived �
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Appiica
Locatio
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ax M�p � P�,rc
� u�bcilivisiom
Ph�se Sect,io���Lot
# of Bedirooms
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System Type (In Accordance Wiih Table Va): �� G�
TNIS SYSTEflfl HAS BEEN 1(VSTALLED IN COMPLIANCE Wli}i APPLICABLE iVORTH
C;4ROLlY�i�4 GENERAL STArTUTES, RULES FOR SEWAGE TREATME�lT AND DISPOSAL,
AND ALL CONDITiONS OF THE IMPROVIEIi�ElVT PERNIIT AND CONSTRUCTION
AUTHORIZr4T10iV. �
� w, �w►-e✓ �( � I`l ��S -
Authorized tate Agerrt Date
instalied By: � mrYiie �w�S
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Date: � 1 �����
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PCHD, rev. 07/29/04
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���'�'iG �'�6C �N�����'�06� ��E���lS�' �'y�e a� - i�
Tax Map #�� Parce! #� Sysiem Type (Table Va) _ 0�-
OwnerJA�plicant I�tillie iK4.0 l�Ui��d Subdivision
Address/Location Sec/Phase Lot #
r��,he� M;i► ��I -� ��..�q �ur�t,,�c�.� �2d � � -
Se��c Tan6t ni#�a �ate i� �cata�n anes na�aa ate
State �ID/date
Capacity gai.
Tee and Fiiter
Baffle -
Sealant
Riser (if applicabie)
Tank Outlet Seai
Permanent Marker
Purnp T�nk
Capacity gal.
Waterproof /Sealant
Riser
Water Tight �
� Putt�p
Checic Valve/Gate Valve.
Ant�-sip on o e
Fioats/Switches
�larm (visable and audible)
Electrical Components
Rate (gpm)
Approved Pump iVlode!
Bloc� Under Pump
Pump Removal Rope/Chain
. � Distribution. Sys#em
Serial Distribution
ressure an o
Low Fressure Pipe
Appr. Pipe I�lateriai and Grade
Valves
0
rench �dth
Grade
Rocic Depth and Quali
Dams/Stepdowns etc.
Pressure Laterals �
Hole Spacinq �
Pipe. Sieeve
Turn-ups/Protectors
Fte�ui�ec9� Setbacks
From Welis
From Proaertv lines
SurFace Waters
Public Vllater Supplies
Vertical Cuts (>2 fi.)
Water Lines
Ve(�icle �Traffic �
EasementslRight of V�
Other
Easements Recorded
e e oerator oi
Camav�ents
pc�d rev. 31'13/0'1
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Applican
Location
6r
Ru�
3s�
Tax M�p : P�rcel #
Su�bcfivision
Ph�se Section Lot #
# of Bedrooms
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System Type (In Accordance With Tabie Va): �A
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE iVORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND COiVSTRUCTION
Rf- TION.
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����✓„ . �- l�-OS
Authorized State Agent Date
, , .
Installed By: „ .� ��� Date: ��/4�-D� �
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1�3' °� new Line,
PCHD, rev. 07/29/04
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SEPTiC YA�NaC INSPE��IOR� C�IECKLlST (Type II - IV)
Tax Map #�_ Parcel # 35� Sysfiem Type (Table Va) ��,
OwnerlApplicant I�iQ; o, fi'a� G�iir►sf�a Subdivision
Address/Location /V�r�,�rh�.�� n1,`1 f R�1.=7 Sec/Phase Lot #
Septic 7'ank nitia / ate itr� �cation �nes Init�a ate
State ID/date Trench Width ft. - y-
Ca aci al. � � T'rench De th in.
Tee and Filter Trench Len th ft. �/
Baffle � Trench Grade i/
Sealant � Trench S acin
Riser if a licable Rock De th and Quali a� �
Tank Outlet Seal Dams/Ste downs etc.
Permanent Marker Pressure Laterals
Pump Tank Hole Spacing
tate ate o e ize
Ca aci al. Pi e. Sleeve
Wate roof /Sealant Turn-u s/P.rotectors
Riser Required Setbacks
Water Ti ht From Wells � -1 D
Pump From Property lines
Check Valve/Gate Valve Struetures/Basements
Anti-si on o e �tc es raina e a s
Floats/Switches Surface Waters
Alarm visable and audible Public UVater Su lies �
Electrical Com onents � Vertical Cuts >2 ft. ✓
Rate m Water Lines
A roved Pum Model Vehicle Traffic
Block Under Pum Ad'acent S stems
Pum Removal Ro e/Chain � Easements/Ri ht of Wa s
�Distribution. System Other
Serial Disiribution s-- Easements Recorded
ressure ani o erti te erator ontract
Low Pressure Pi e Tri-Partate A reement
A r. Pi e Material and Grade
Valves
Comments
pct�d rev. 3/13/01