A25 50� `o�.S �Q � � . . Tax Maa#: ,� ��
AQalicaiion� Date- .. . . .
kmaunt Paid: . . - � � � �
�ECElptr�.' � � � . . �3�CE��r'�.
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� APPLlCAcT10N FOR� SERV�IC�S •
SHALL BECOME INVALID. �
1 r Permit requested by: (Ovmerlagent/prospecWe owne�: �� o b�� �-- � a 11 �.�
HomePhone: `� �`�'���72 Address: l/ 9 ,�.vCe2J -�G 1� • ,
Business Phone: fZb x �Pd , �CJ �r
2) Idame and address of carrent owner. �I.�o.�°�! � S4�SAaJ �(%�l4'YZ
l
3) Properly D�escription: Lot size: iZ � Township:C�lNv��'� S�bdivisian: Lot#:
Directions to the property (Induding r+oad. names and numbers): '
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed _, F�dstin9 � TYPe of Strudure: � uS�' Width: Depth:
b) Numberof Bedrooms: Number of oxupants or people to be served: _.� ,
c) Basemen� Yes _, No�iil there be plumbing in the basement?
d) Garbage Disposal: Yes _, No �/
� Water Supp(y Type: Private _(new _ or existing �, Pubiic_, Community _, Spring _
Ar+e any wells an �joiniRg property? Yes _ No _ If yes, piease indicate approximat,ee loca�on an the siie plan.
6) Does the property cantatn previously identiflsd jurisdictionaf wetlands� Yes _ No _
PLEASE NOTE TNE FOLLOWING:
'➢ A PLAT OF THE PROPERTY OR StTE PLAAt MUST BE SUBMfrfED WfTH THlS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARI�D.
➢ THE PROPOSID LOCA770N OF ALL STRUCTURES MUST 9E STAKED OR FlAGGED. �
9 THE SRE MUST BE READILY ACCESSIBLE FOR AN ENALUATION BY THE HEALTH DE�ARTIIIAEAIT STAFF.
I• hereb� make appl'�cation to the Pefson County Health Department foG a si� evaivation for the on-site sewage disposal
system for the above-described properiy. 1 agree that the contents of this application are true and represent the ma�dmum
facili�es to be piaced on e property. I understand ifi the site is aitered or the intended use changes, the permit shall
became invalid. Z �
Owner or Leaai Reoresentative � ��
PCi;D. rev.10h7ro'I
i�,�, • � 15 �
PERSON C EALTH DEPARTMENT
e'
�' � WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map #_��s Parcel # �C�
,
Zoning Tnownship�— � f�
^---___ir.__.___.__ ' n..... .� 1 i /.0 /�� /,r/o LJ Tlata %• .� _ .
Location/
Subdivision Name Lot#.
I.ayout
���— Wv� �,� �o �cJ
�yn� �
Co✓LV�►'sr���Ye����
�-F �1� s��-e <<,� �
� � ��G� �es� �eN �-e
W�d'� hJ p �1��y�, o r ,
c Y �.
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<�,�,;_ ���/�.ri _ �
S.R.#
As Installed
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f-� �
Q ��
�a��f3�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area
SFD Mobile Home
��s— # of Bedrooms�_
S.ee ���c
Size of Tank_
Size of Pump T
Nitri�cation Li�
Max Depth Tre
�
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or inte d c anged. ,
Well and Septic Layout by U'��
., ..
T'his report is based in part on information provided the homeown�r or his/her representative in the application submitted for this pertnit. The
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or
misleading statements provided to him in the application. 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. c:�amipro\permit.sam Ol/95 rev.1.0
�
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��n.wn�-��n�rnnti��.tn,� ����n.�.��
Applicant:
Location:
Permit V
�� r
Five Years
Type of Facility:
# of Occupants f
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
,�v
Ta�x M�F� ' . P�rc�el # �
S�ihciivis�ioii
Pha�s�e Sec�t�ion Lot �
� � I
Improvement Permit
No Ezpiration •
Bedrooms
Owner or Legal Representative
Authorized State Agent: �
�'rl�ecs /%/-;
New Addition _ Water
Projected Daily Flow g.p.d. /
Type:
Type:
Date:
Date:
The issuance of th' ermit by the Health Department in does not guarantee the issuance of other permits. It ' he responsibility of the
applicandpr owner to in sure that all Person County Planning and Zoning and Building Inspections require are met. This
Imp ment Permit Is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permi ot affected
a change in ownership of the property. This permit was issued in compllance with the provisions of the North Carolina ` and
Rules for Sewage Treatment and Disposal Systems' (15A NCAC 18A .1900).
�' Authorization to Construct Wastewater System �Required for Bnilding Permit)
* See site plan and additional attachments (�).
Proposed Wastewater System: ('�,��,;�o.�c �7�y�-� Type � Wastewater Flow ��fD g.p.d.
New Repair�/ Expansion _ Soil LTAR: .3 g.p.d./ ft 2
Type of Facility: � ,t� �,t„� / ,�,,� %�s,�,�i� _ Basement _ Yes ✓No
Wastewater System Requirements
Tank Size: Septic Tank: pOc� gal Pump Tank: ..-�, gal Grease Trap: -- gal
Drainfield: Total Area: �Do sq ft Total Length �Z ft Magimum Trench Depth � in
Trench Width _�� ft Minimum Soil Cover: in
,Distribution: �/Distribution B�x � Se�nal Distribution
!, _ , , �Gi► s'1/"��/ �!t_ . ,
Authorized State Agent: ������, �
Permit Expiration Date: 3- /� -
The type of system permitted is ✓Conventional Innovative
the permit.
Owner/Legal Representative:
Minimum Trench Sepazation: � ft
Pressure Manifold
i�
Date: � %a�Od2
Alternative. I accept the specifications of
Date:
i
�,�,�;5�' �I��.���
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�:mi.�nma�n-aynrn.��-n.tb.ml� �H�¢��.1�tEll-n
Name �c��•7" �����''-
Subdivision `
/� ^yl /�'� •
Authorized Sta.te Agent
SITE SKETCH
Tax Map #�e2�� Parcel # ��13
Section/Lot#
.3�/�- c�:Z
Date
r cornponents represent approximate contours only. The contmctor tnust flag the system prior to
�ing_the installation to insure tTiat propergrade is maintained
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Applican
Locatio n
T��x M�p . P�rc�el :
S�ubdlivis�ion
Ph��s�e Sec�t�ior�� Lot �
Operation Permit
System Type (In Accordance With Table Va): .�'�
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NQRTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF T�IE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
� �� $��� � o�
Authorized State Agent � Date
Installed By: �\ • UC��'>2�/'I Date: �-026 - O�—
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PCHD, rev. 07/29/02
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S�E��IC TANK 1NSPE�TION CNE+��(LlSZ (Yype 11- IV)
Tax Ma� # �2� Parcel # System Type (Tabie Va) ?S-�.
OwnerlApplicant � Subdivision �---
Address/Location -- , ec/Phase G Lot # --
State ID/date
Lapac�tX /�1S- /��c7.
Tee and Fiiter .�
Ba�fle �
Sealant �
Riser (if applicable) �
Tank Outlet.Seal �
Permanent Maricer
Pump Tank
Ca
roof /Sealant
Riser
Water Tight
Pump
Check Valve/Gate Valve
Anti-sip on o e
Floats/Switches � �
Alarm (visable and audible)
Electrical Components
Rate (gpm)
Approved Pump Model
Blocic Under Pump
Pump Removal Rope/Chain
Distribution System
Serial Distribution ✓ '
nes
5^�'�- Trench Width ,�
Trench. Depth < c
Trench Length r '
Trench Grade
Trench S acing '
Rock Depth and Quali
Dams/Stewdowns etc.
Low Pressure Pipe •
Appr. Pipe Material and Grade
���
Pressure Laterals
Hole Soacina
Sleeve
Tum-ups/Protectors
Required Setbacks
From Welis :
Fcom Property lines
Structures/Basements
SurFace Waters .
Pubtic Water Supplies
Vertical Cuts (>2 fi�.)
Water Lines �
Vehicte Traffic
Adjacent Systems
Easements/Right of W�
Other
Easements Recorded .
Tri-Partate
� ,
Comments�
ft.
in.
ft.
�
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pcf�d rev. 3l13101
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