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Improvements Permit.(EstablishedlRecorded Lot)
mpFovements Permit (Unrecorded Lot)
of Existing Sys[em (Loan Closing)
,_ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) ._ Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
: _ : �, �
�. �� � r � ,� ` z �5 : F ,� r �.x� fi d'£� s .� �i�rater Sam�e��o }be`Co1lecEec�: � � ., s. � � ��=z�
: x a . �a `ti��u,....£.;�?� �:t�.a .<�'�.:..�.�. .�.s�<..`�x..
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Bacteria Chemical Petroleum _ Pesticide
: Permit requested by: . ,
wner/prospective owner/agent. urvuR
�ddress: • � d � " � �
1.
iome Phone #:�/G`:���'Us/�
3usiness Phone #:.��1.,� -3�. y-�?YZ �l
7. Dimensions or Proposed Structure:
" Width:
_ Lead
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility .
that this sewage disposal system is intended to serve?
. Name and addre�s of.current owner: 9. Water su y tSPe:
(�-1ra.V'e.. S . �� �+. ���- private . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
If so„identify location:
. Property Description: Lot size: ,�,9�`�l
. Tax Map#: �
Parcel#: ,
Township: A-�a � �
�. Directions to property: State Road #& Road
��J
Number of occupants or people to be served:
�
�
d0. Type of structure/facility: Proposed: DExisting: Q I
Type of dwelli . ,
House: obile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �,�.�,,, /
Garbage Disposal? Yes ❑ No L�
Basement? Yes ❑ No�f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PersOn COunty Health Depal'tment 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 tcue
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. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
�
Signcc� Owner or Authorized Agent
Permit Issued ❑
,�e�mit Denied ❑
���i�t Observed ❑
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_ , . .. ... .
1. SLOPE (%) S S S S
PS PS PS
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2. SOILTEX�'IJRE(12-361NJ S S S S
(SANDY. LOAMY. CLAYEY. NOTE 2:1 CLA17 . S /' 1,� PS PS PS
(T'V� U U U
3. SOILS77tUCIVRE(12-36IN.) S S S S
(QAYEY SOiLS) �( PS PS PS
U ��_''J U U U ,
S S S S
3. SOII,DEP7'F{(IN.) S �� i� PS ps PS
U U U
S. RESi'RICTIVE HORIZONS (iNJ S ` ' S S S
(IMPERViOUS S7RATA. ROCK) S� t V b PS � ps
U U U U
6. SOILDRAINAGFJGROUNDWAIER S S S S
(DCfERNALRUfiERNAL) S /� b PS PS PS
� U U U
7. SOII,PERMFABILTiY S S S
(PERCO[AATION RA7� a 2 S�n PS PS PS
U U U U
E. AVA1[,AB(.E SPACE S S S S.
PS PS PS PS
6 � U U U
9. STIECU1SSiFICATION(SEEBELOW) C
J
SOtL SERIES
S•SUITAIILE PS-PROVISIONALLY SUITABI,E U•UNSUITABLE
RECOMMEND ATI ONS/COMMENTS :
�
SITE CLASSIFICATION DIAGRAM (Include: Soil azeas, property lines, roads, streams, gullies, wet areas, �11
areas, wells, water bodies, slope patterns, etc.) C:�AMfPRO�DOCSAPPSEC.ST1 FWANCE.PC
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B 1659
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlvIPROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shatt be issued until Authorization for waste water system construction
has been issued.
Tax Map # �� Parcel #_
Zoning Township
Owner/Contractor C V 1� r+ 2 i� a Vn �
Location/Address �'�.� i�� y h�� �
Subdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Lot Area f,� c�cy� Size of Tank UUU �''�
Mobile Home Size of Pump Tank Nc
# of Bedrooms 3 N'itrification Line Sf70 �7C 3 �
Max Depth Trenches_� �; � �
Permits may be voided if site is altered
Well and Septic Layout by �
Comments:
use changed.
Date Installed by Approved by
ell Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
dividual �� Semi-Public Required Slab
�blic Replacement Air Vent
te Approved Required We�l Log
ell Head Approved Well Tag '
Comments:
Date Installed by Approved by
This report is based in part nn information provided the homeowaer or his/her
representative in the application submitted for this permit. 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\permi�sam O1/95 rev.l.l
�
S87'39'00"F
,__.s _... '' • . .__... _.
Annlication Date• � �=Z d��
Amount Paid• ^ �
�eceipt #•
- t:
Tax Map #- � � �
Parcel #: . l � �
"�6 �� ���.5� I�'I�I�.� ��
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,�PPUCATION FOR 8fRVICES
�
1) Permi# requested by: (�wnerlagentlprospecttve awner): �on�qs ��x�'�Ie7�F
Hame Phone; _:5�79� y�36 � Address: ti�3" rn�/� o-�� �'T
Business Phone:,9�9�59�,.�sQsa. . /�oxlx�r� �v� d�s�3 ,
2) �lame and address of.carrent awner. �rn�►1 C/_3a �n e.��
• �la� �ro�uAn sT
/kt,r.bord NC o27t'�3
CUh111�,'" �
3) Property �esaription: Lot size: er Township: Subdivlsic
Directtons to the�property (Inctuding road names and numbers): B Ga �
1...e �+ n n (`.i i-�n \ A t( e �0 , i�;� 1.`t �
4)
v)
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�� �e��
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Lot #
(�p
Proposed Usa and Structure Descripti�n: answer each of the foliowing questions: .
a) Proposed ✓. Existing Type of Structure: Wtdth: � Depth:
b) Number of Bedrooms: . Number of occupants or people�to be senred: .
c) Basemen� Yes , No _ Will there be plumbing (n the basement?�_
d) Garbaga Dfsposal: Yes . No J� � •
Vllate�r Supply Type: rivate _(new _ or existing___), Pubiic . Community , Spring _ � -
� Are any weiis an adjoining property? Yes No ,_ !fi yes, please indicate approximate lacation on the
• site plan. � . ..
6� 17oes yQur prop�rty contain previausty identifled jurisdictionaf wetlands? Yes� No v
PLEASE N�TE THE Fatt'.�WIPIG:
A A PLAT OF THE PROPERTlf OR SRE PLAIY MUST BE SUBWITTED WiTH THiS APPL.ICATI�N.
➢� PROPERTY L1NES ANO CORNERS MUST BE CLEARLY AAARI��.
➢� THE PROP�SEI] LCICATION OF ALL STR,UCTURES MIJST BE_ S'�Af�D OR FLAGGED,
A THE S1TE MUST BE READILY ACCESS18l.E F�R AN EVALUATI�N BY THE. HEALTH�DEPARTMENT
STAFF. � •
1 hereby make application to the Person County Health Department for a site avaluation for the on-site sewage disposal
system for. the above-described property. l agree that the cantents'of this applica�on are trve and represent the maximum
faciliiies to be placed on the property. i understand ifi the site is altered or the intended use changes, tfie perrnit st�aU
become invalid. � �
��rr � � ��..�'
Owner or Legal Representative
/d �zd -03
❑atB
PCtiD, rev. O6I27lo2
������� ���� ��
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I���aa-��.,.-„-r ����.71 IFIL��.11�]�
Applicant: �tYp1�.S C� �rr1C��E�-
Location: C�►u.b �� Kc, 2oc�d L ►�y LaK�
c.�t on
rUL i7C5��G bbX,
T��x Ma�� %— � P�rcel # �
S�uhefivi•sion
Ph��•se Section Lot #
Improvement Permit
Permit Valid for � Five Years _ No Ezpiration
Type of Facility: �j � ny �t, Fq,m i� � y O W�.! �i`n q New � Addition _ Water Supply �iva�6c- w� l I
# o f Occupants ( p m a�, # o f Be d rooms �_ Projec te d D a i ly F low � Q_ g.p.d.
Proposed Wastewate,� System: ��{�S� ►�1 oJQ•Ei uc, � . Type:
Proposed Repair:
Pernut Conditions: T
�O[_c,i �i Cc�.tl on S [
r« drai
Owner or Legal Represe
Authorized State Agent:
L
��,
Type: T � Cx
d-mCniFol�
Date:
Date: � "I �''O�
The issuance of this permit by the�Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property 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 site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rule�or Sewage Treatment and Duposal Systems' (15A NCAC 18A .1900). 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.
Autho.rization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�.
Proposed Wastewater System: �l.c rvl,p Trl rlp va.-E i U�- Type ura, G Wastewater Flow �O g.p.d.
New � Repair Expansion Soil LTAR: • 30 g.p.d./ ft 2
Type of Facility: � i nc rc, Fa•�, � �v dW �-� ���n� Basement _ Yes �/ No
Wastewater System Requirements
Tank Size: Septic Tank: 1, 000 gal Pump Tank: 1, OOb gal Grease Trap: 1�1� 1� , g uPs��P�
�' S►ai
Drainfield: Total Area: � 0 0 sq ft Total Length � ft Mazimum Trench Depth �� P in
Trench Width 3 ft Minimum Soil Cover: �0 in Minimum Trench Sepazation: �' _ ft
Distribution: Distribution Box Serial Distribution � Pressure Manifold
Specifications: �l,�c, �A SIoP�- �55/Sttnn W i l l iJt I'�T- C�re�c pn Ioc.�S►dc � W� �� t'Ly�t�.r`rc.
rl m i n i.,�. ��...,,. .. G r�'� n n n �r��t a�n i l.c r�.o. i.)n„ 1 a rr f C�rv� ✓V�� r'1�I �—� 1`:
Authorized State Agent:
Permit Exx
idn Date: 1—
The type of system permitted is
the perniit.
Owner/Legal Representative: _
Date: �"' �q�a4
Conventional V Innovative Alternative. I accept the specifications of
Date:
PCHD7/30/2002
�.��.�� I�I��.����
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�E;�.-���..-, --� ��¢�.�t :t--��.�.,��. pwner: / n �m AS `!�a �n c�fc
Tax lY1ap: Parcel #: �ss Date: 1-1 q-04
�.ane Tap �a� (�c�) T�p �'low �.�ae �e�gt�a ��ow / ��ot
# Diameter(�) ( in) . (ft)
1 2 O '1. I . p
2 �p�� I .
3 3 O .I Iov .10
4
� —
6
� a.
$
9
10
� ft of line x 65 gal. per 100 ft= I�, 5t7� �,500 ; 100 = � qs gal
75% x Iq5 ga1= �(� ga1 per aiose �'7 ga1 per minute (gpm) = I'!ow �te
�'riction �e�d
a.oss: �8 ft per 100 ft of supply line x � Q 7 .. ft of supply. line = 100 = �•�18 ft
."I ft x 1.2 =. � 4 ft of friction head
Manifold Size:, �31 �i _" �+'orce 1Vlain Size: ca� " PVC
�'ot:al DynaYnic �eaci = l�ft of Elevation head +��ft of Pressure head +07� la ft of
Friction Head = � � TDH
-�2GPR1 F�r Rn�.is�Ptian h��c
Pump �tequirement• 31.1 GPM @�� � 4� ft of Head
Drawdown: ((��a • per dose � 21 gal per inch =�(o inch drawdown per dose
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pr EQu�valcn�
� l�iani%ld 5ize! � Ta s
t�ifold Max No. Ta�s off one side
gize (a{{esiuce b 1/a :or tap in �oth;
�» t3 3 3/�» t3PS ���
2" 4 �
3" � �
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� 2i � 12 I
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�u,e :Ljait¢ricil r�aw G?�!
=. " Sclied 30 �•�
!, " ` :;ct�ed 10 �•_
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' Sp�ecificatiaas
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lil - ��i = nt =
/� Ip = I 11 =. I 11 _
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lh�dergto�md Cable In Canduit
Wi[h Sc:i,table SeaLer In Both
F:,ria Of Ca�dCsic
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Block
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�.Supply L.is�e 'fo •� � _ �
< . Diane[er S�eduTe 40 PNC
� a pi�
� lill Pucrp Re� �
.. .
� . Gate Valve
� 'Ihceaded Unian
• Q�eck Valve
3/16" Syp�n Br�� ��ole
' ' Iod�rg St�s Ar,aar.i Ail �
� Ala=m Float lelevation)
•'p�� On" Float (elevation)
• ` •'pu� Of£' Flaat ����n�
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�'11 R ��s� �ill be c� a St� � �� '�t �'
�1 a�3 ssll be I.e�c �s-h�3 ar&i-t� .
pUMP RATING
pump Hu Rated To Deliver
�_ Gallons Per ltinute
Against �Feet Of Tota
Dyaamic Head (TDH).
See Follovi�g Sheet For
Additiona! Specifications,
Noces, And Esplanations.
1
PUMP SYSTEM DETAIL SHEET � �
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a� ��� #: Fl �� ��� # Iss ��„��
�PP1i.c�a� / I'bma.s � �-'n c-�-£c.
Subdivisaon: N � � Secsaon: ��
j,ocation; bc c iC �" n'1 i�E � .
'I'�Se of Wat�r �u�wllv:
��.ig�effi�n�.
Site Approved bp
GmutYng Appmved bp
Well Log
�rell Tag;
Air Vent
Hose Bib
Concxete Slab
,a�� - �, �. , , ; ,
� Individual Cornmunitp Public.
w�.��80Qi�. ��: �3$�'
�See Attac�esi Sate S�s�x�
Wells must be 10 feet from propertp liaes.
�ells must be 100 feet from sepric systiems. �
Wells must be at least 25 feet from anp btulding foundaiion.
i.3 C.
II�W"I4��n4 Gl�tp-. as��f' Fr�M
Homc,� (�o' �- From � o�i� � �
PCf�, sev. 09/07/01
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