A25 46Apqlication Date: ��� ���
Amount Paid: 2� .��
Receipt#: �12q�
�� 10�3�
Tax Map #:
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APPLICATION FOR SERVICES
(Recorded Lot) - $200.00
ments Pertnit - $150.00
Home Repiacement/Addition)
System Pertnit
Parcel �l:
(NewlReplacament) - $225.00
0 ConstrucUon Authorization for Septic
$150.00/$200.00
Revision Fee - $75.00
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:. (O'wn agen rospective owner : v�"'l 'v '�6 (��� ���
Home Phone: `�a �l' '-tlo�O7� Address: � (�.� ( n '
Business Phone: �- 3 0 1�T a-�l "1 �{-
5a �- g o 0 o r � � J(/l�� � V \
2) Name and address of current owner: \ _
— Y`"' � - � �5 y(�
3) Property Description: Lot size: C�� ownship:�-�h � division: Lot #
Directions to the prope (In luding road names and numbers).
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�l'�,o o�. l,. ,1,, .-. 1 v�n v�n� �1 �-.�,- r� 1 C� .UnP_ i�l
4) Proposed Use an �tructure Description: answer each of the following questions: �
a) Proposed Existing Type of Structure: �c�"t-�Se- Wi�th: �� Depth:Z-g
b) Number of Bedrooms: ,� Number of occupants or people to be served: �f�
c) Basement: Yes No _✓Wiil th�re be plumbing in the basement?
d) Garbage Disposal: Yes _, Not/
5) Water Supply Type: Private _(new or existing�, Public_, Community_, Spring _
Are any wells on adjoining prope�y? Yes ✓ No _ If yes, please in icate approximate location nq the
'site plan. _ ' �ld �1 ou� G ►'� (�'"v�c-� — �i-- cS�-e C,v�...�SL
6) Does your property contain previousiy identified jurisdictional wetlands? Yes_ No �/
�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LlNES 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 ir?ualid. /% ,t� � „
Legal Representative
PCHD, rev. O6I27/02
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1��rn.�-n.��-�-n,�-�-,��aa�.�.11. ���.31.�.
Applicant:
I'�rmat Valid �or �+'ave �e
Type of Facility: t
# of Oc�upants j�,��x � # of
Proposed Wastewater Systeia:
Proposed Repair: �C on��
.� ,
T�x Ma� � ' �.rcei �
Suibcf,ivisian
P'ha.se Sect,iam.�Lo�t +�
][a�nprar�e�ent �ermit
_ 1�To �giira9ion /
�o . New ✓ Addition _ - �Vater SuPp�Y �? i �
�ooms 3 Proje�ted Daily Flow 3G D g.p.d.
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u • �pe: �
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Owner or Legal ]
Authorized State
Date: Z - � - a 7
. �
The issuancs of this permit Yry the Health Department in does not guaza�ee the issuancs of other pe�its. It is the responsibi7ity of the .
applicantfproperty owner to in sure that all Person Coimty Planning and Zonmg and Bu�g inspections requsements are me� This
Ymprovement Permit is snbject to revocatlon if the site plan; �pl��`or� the intended use changes. 'The Improvement Permit is no�
a�ected liy a change in owner'siup of the property. This permit was issued in compliance with the provisions of the North Carolina, ..
`Laws asd Rules for 5ewa�e Treudnent and D�snosd Svstems' (15A NCAC 18A .1900). Neither Person �ouaty�: uor'�tlie.' '� �
Environmental Health 5per.ialist warrants that the septic tank system w�11 cnntinue to fnnction satisfactorily in the future�ar:iliat.
the-water supply wi71 remain potable. • �
� Authorization to Constrnci Wastewater System (Required for B�ding Permit) �
* See .rite plan cmd additional attachments (_�. . � . : •
PTOj)OS�aStBF/StCf Sj�3�: l. a n v. n'Tl d n n �' t.)�' /1 i4 wt✓J •, �r'ge 11l � �%�W2�Cf �OW J�.�.d.
New air a�nsion � ' .� Soil LTAR: � g.p.d1 ft 2
Type ofFacility: �r;��n-�� �etE�pn'c2 � � Basement_Yes_No ,
WVa�tewater Sysiem Reqiairements
'T�nk Size: 5eptic'Tank:'�voo gal � Pnmp Tank: /ooc� gal Grease Trap: — gai _� .
Drain,field: Total Area: 2 0 o sq it Tatal Length �,p�_ fi " Ma�mam Trench Depi� _� in �.
o� ,
Treac�► Width .3 ff lYTnminm Soi1 iovea : � in M'in'imnm Trench Sepatation: �
Dist�ibntion: I3istriibu�ion �oa Serial �ist�ibntaon ✓Pressare 19�Sanifold . � _
SUe�i$catioIIS: �' �'P in5fa��Q71L�►n tvl��1'�t��lQ ,vt(�n�hfl�/N • ' . . . ". .'
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�J01
State Age�t ...� G-
Permit Expir 'on Date:2- (s,,=
Date: 2 -! -n'
The type of system permitted i� �onventionai ��� Ac��ted Alternative. I accspt the spe�ifications of the
P�• -
�e�/.���1 �ta�r�s�a�tatiye: Date:
' PCHD r�y. l l/10/05...
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Name r,� v� s N n� �'h � Taz Ma.p # A 2� . P�tcel # 4�
Sub . � Section/Lot#
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A thorized State Agent . � Date .
System cn»�ponents �sprerent u� pproaaimata �contours only: The confirutor must flag fhe syste»� prior to ;
beginning the instaAa�'ion to i�sure thatproperg�ade is maintai�ed
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JL+I[A`S riT�KD7[aIIh71�7CLL1E.t4Jl Il �Lrt'_+d�1.JL+EIla pwner.
Tak Map: � Parcel #: Date:
Line Tap Tap (Sch) Tap Flow Line Length Flow / foot
# Diameter(in) ( m) (ft)
1 2 � ( �v
2 •
3 � �
4
5
6
7
8
9
10
0o ft of line x 65 gal. per 100 ft =_
75% x gal =�� gal per dose
_ '100=�(�gal
� gal per minnte (gpm) = Flow Rate
3(
Friction H ad - __ �
Loss: �ft per 100 ft of supply line x"'�6 ft of supply line = 100 =�� � ft
ft x 1.2 = 7. S ft of friction head
Ntanifold Size: �_" Force Main Size: 2 " PVC
Total Dynamic Head =�ft of Elevation head + 2 ft of Pressure head +�.i ft of
Friction Head = �TDH
Pump Requirement: �1 GPM @ �d � ft of He d.
Drawdown: �al per dose = 2l gal per inch =� inch drawdown per dose
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Scptedale 40
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4"
6"
ufold Size / # Taps
Mas No. Taps off one side
luce b 1/: for ta in both ;
tg S 3/a� ta S 1»
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16 9 '`
40+ 2t 72
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Size itlnterial Floti�• GP.1�I
;: " Sched 80 5.5
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3/, „ Sched 80 1 �.1
?�, .. Sched 40 1 �. �
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I��a<e�-aac-�u�rn.�.-ncn��rn�.r�.�L 7F�L�.a►.71�IIg
Slopad To S�ed Watar
6" Cov.r �
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I�lat From Saptic Tank �
4" SCH 40 PVC Pipa �
NEMA 4X Simplex Contml Panel
4" X 4" Pre�sura Treated Post
12` Seppxation
Electrical Conduit �
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�• � ` Acce�i Cover• .• , ' , ;, � .1 ;
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I �� � r� '~_ _ � ' � ' r_ �
�., Openin� Filled With . �{i Siphon Hok� \
Portland Cement Gtrnit �� ���
� Check
� Val
T�x M��i�� � P�rc��.I #
5lL`]C�fVISI011
F'h��s�e Sc�ct,ion`Lot #
Duct SealHoth
Ends Of Tha Conduit
-'- 24" Mininaun -
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T�weaded Gata Valre •
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Hig2�. Water Alaisn Level
. (6" Separation)
: ..:,,.., High Lav�l - Pump On
� ,': fiVaporLock � i ��
' ' Hok � f :
. � �Draiudawn �Up ii�11). �
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, Law Lavel -Pump Ofi
. • . . . $uzttp
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' Preca�t Concretg Tank 4' Co�useta
��;.; Material Stre h y3500 PSIj $lock
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Concreia Ritex
5" Separation
Float Wiza� ' �
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Float� +..:
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F7oat Trea , ,
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��a co��ta crout •
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� Opaning Filled With
, Portland Cament Graut �
Outkt To D'utnbutiox
�} 2" SCH40PVC Pipa
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3/ �PM � ' �{a` � ���1
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Tax Map � Parcel # Tovr�nship:
Applicanf: � ,.QutS I �ara,�
5ubdivision: � Lot # -
Location: ('� ,��o,�a �e �� �,,, v�iC itees ►�l r ll —� L�t- o,�
Type of �ater�5upply: �individual
�equirements:
Sita Approved By:
Grouting Approved By: �
Well Log: �
Pump Tag: � �
Well Tag � �
Air Vent: � '
Hose Bib: �
Casing Height: '
Concrete Slab: � � � � ' �
Well Driller:
Well Approved by:
*�**See.Attached 5ite Sketch****
Community Public
Liner:
'Installed by:
Depth set: _
Grouted•
Date:
Water Sample:
Wells must be 10 feet from property lines.
Wells muat be 100 feet from septic systems.
Wells must be at least 2S feet from any building foundation.
Other conditions:
Date:
PCHD rev 01/27/0�