A26 1571/l0/1998 15:59
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9165990678
TONY WESLEY
PERSON COUNTY H,EAL`�':�-I DEPART�VIENT
WELL t�ND SEwA,GE SITE, LOCATION Il�E'ROVEMENT k'ERN�T'r
PAGE 62
Not for wast� wgter system construction. No �er�nit(s) f'or Canstruction �ocation or
Relocation Activity shall be issued until Authorization for waste water system construction
bxs bee�n issued. �
Tax Nfag # ('� �d Parcel # � � �
Zonaz� Township � 1+�-�
wn Contractor ��/ �.����� Date D---�
LocativrJAddxess ��-�-���ti �� ���'' �'`'� �� `�'�''���' --
1 fl� Vw�� .S' � G�'� ..S .�, t 3 4� - S.R.� �
Subdivision Name
�.ot�
SEWAG� SYSTEl►'� S�'�CI�'XC,ATIdNS
Rcpau „_, Lot Ace� / �c�- _
SFI� � ' Mobiie �iame,��
Buszz�ess� # of �edrooms�,�
Size ofTank /� O _—
Size of Pum� Tank N//�
Nitrification Line �-Do 'X �3 �
Max I7epth Trenches ��
�ermits muy be voxded if site is altered ar inter�ded iise changed.
Wel� and Septic S.ayout by lN _,��� �.-�� �--�-�- �
CommenCs:
Date
eil
�3 - 9__ Installed by T' Lew � S Approved by
n� Q''_�!_4,P
SYS'ITM SPECff'TCAT�ONS
dividua� V' Semi-Public�„�
�blic Replacement�
te Approved j��
ell Head Approved ✓
routing Apptoved ✓ �
Rec�u�ced Slab ✓
Air Vent �
Required Weli Log � .
Well Tag ✓
Comments:
Date �l-/G-- 9� Installed by �va,�s Approved by .�9 J*--
This repor# is based �n part an iafax�nation ��rov�ded the homeowner o�r his/t�er
represe�.tative in the application subm,ittec� �'oi- th�s permit. The envixon►me�tal
health specialist is not res�onsible for false o�- m�sleading information
contained iu the application. The environuac:nta� health spQcialist is also not
xesponsikle �'or concealed conditions on tk�e ��A•operty ox for statem�ents in this
report th.at may have resulted �xom �alse or misleading statements provided to
him ��a. the applicanon. Ne�ther Person Couraty �ao� the env�ronmental t�ealth
specialist warrants that the septic ta�.k system will cvntinue to fuuction
satis�'actozily ia the �'uture or that the water suPply wzll remain pota6ie.
c:lami�rolpermit.sam Ol./95 rev.1.1
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ERMA B. TIINSTEAD
NE]RS
p.Q. 53, P. 532
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Person Cauntv Health Department
Environmentai Heaith Sectton
APPtJCAT10N FOR SERVICES
Tax Mao #:
Parcel #:
1) Pertnit requested by: (OwneNage�prospective owne�: (
Home Phone: � — Address•
Business Phone: — , '
2) Name and address of carrer�t owner:
3) Property Description:
Diredions to the prope
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed I�Existing ❑
b) Stldt Buiit [�Modular ❑, Single Wide 0, Oouble Wide ❑
c) Number of Bedrooms: 3,_ - d) Number of occuparrts or people to
e) Basement Yes 4� No � If yes, # of basement fixtures:
� Garbage Disposal�es 0� No f� t �
g) Dimensions of Proposed Strudure: Width: 3U Depth: �0
be served: �
5� Wafier Supply Type: Private �(new 0 or exis�ng �, Public �, Community 0. Spring ❑
� Are any welis on adjoining pro rty? Yes �( No O If yes, location
.�
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
�Comrerrttonal l,Modifled Conventionai ^ Aitemative Innovative
-Other (sPecifll):
CIEARLY STAKE ALL CORNERS AND LINES OF THE AROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SlTE PLAN TO THI3 APPUCATION
I hereby make applicatlon to the Person County Health Department for a site evalua�on for the on-site sewage disposal system for
the above-desaibed property. I agree that the corrtents of this application are true and represent the maximum faalitiss to be
placed o� the property. I understand if the site is altered or the intended use changes. the permit shall become irnalid. I understand
that as applica 1 am responsible for identlfying and ma�idng property lines, comers and making the site accessible for the
personnel of Perso C urrty H th epartment to condud their evaluations. I understand tha I responsible for notifying the
Heaith De er�t if m p perty i s any wetlands as designated by the Army Corps of En ne rs.
�� 0
wner or Legal Representath+e . � te
PCHD, ►�. �a�zrss
� PERSON COUNTY ENVIRONMENTAL MEALTH
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SifSTEM LAYOUT
Tax Map ik: �#- � Se p�s� g 1��%
Zoning Townahip _Cfl 61/ e �'1 / ��
ApplicanG
LocaGon:.
vt
�S• �airy ��
L�"1 � � O"� VyL j _ '
Subdivtslon: S�ctlon: Lot
C��- o �
improvement Permit
A buildin4 aermit cannot be issued with onlv an Improvement Permit
New � Repair Addition Type of Strudur�s
# of Occupants #�of Bedrooms 3 Other
Basement? �_ Basement Fixtures? ,,,�0
Projeded Daily Flow: �O�g.
Proposed Wastewater System
Pump Required? Yes l
Proposed Repair : f'� �1 J�ri
Permit Canditions: l%h
Owner or Legal Representative
Authorized State Agent
Pertnit Valtd For.�Five Years
�: C.�D/t //c°'ii7bna �
Jo /
�/ 7Y'D i1t 1�L� r�'Gl �
. �.".41�1, G�,�? !n �,-� n�i1--
Water Supply �e�� .
0 No Expiration .
-�i ,f-+�GLh-ot'Gt,�]�jy� G!/�e+� f0 �
. �
Date: i � /G n,
Date: G- 3 Qa
The issuance of this permit by the HeaRh Departme�f in no way guacantees the issuance of other p�rmits. The permit
holder is �espansibte fo� chedcing with appropriate goveming bodies in meeUng their requirements. This site is
subject to revocation if the site plan, plat, ar the intended use changes. The Improvement Peimit shall not be
affected by a change in ownership of the slte. Thls pertnit is subJect to compliance with the provisions of the
Laws and Rules fo� Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Autho�ization To Construct Wastewater Svstem (Required for Buitding Permit�
� Type of Wastewater System �1 U�"►��-`� 1 Wastewater Flow: ��Qg.p.d.
Faaliiy Type: ���� �( NeW,� Repair DExpansion
Basement? 0 Yes �No Basement Fixtures? 0 Yes�No
Wastewater Svstem Requirements
Sepac Tank Size: l� o v gailons Pump Tank Size: � gailons
�
Total'�rench Length: a0 feet Maximum Trench Depth: inches Aggregate Depth: � in.
lMrh inrcl/K �
� Soil Cover. � inches Trench Separation: � Feet on Center
Other. �
Pertnit Expiration Date: a 3 6�
Authorized Siate Agent: Date: ��� �� GO •
The type of system pertnitted D does Cl doe ot di er from the type specifled on the appl[cation. I accept
the specifications of this pertnit
OwnedLegal RepresentaBve Signature: %( ���, ,��_ Date• %� � Zo�.� .
, PCHD, rev.11/18/99
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' AppUcation #: i�� `
Tax Map #: -
. Parcet �:
• Person County Health Department � � "
� Environmenta! Health Section
� SITE SKETCH
La�y W�s�� .
� Applicant's Name Subdivision/SectioNLot#
, �D l3 00
Authorized S a Agent Date
System componexts represent approximate cantours only. The contrucior murt f Iag tlse system
arior to be�nnin� the insfallation tv insure that proper grade is marntained
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Scale: � J Sd
.s �
PCHD, rev.1011Zl99
Person County Health Department
Environmental Health Section �'�
Zoning: Township: Q��ivP
Subdivisfon: Section: Lot:
Applfcant: �� �N W�� g"�'�`� , �
LOCBtIOt1' L� `� a ��' �`" ' -
� Operation Permit
1. LOCATION AND SEPARATION DiSTANCES QS
A) System meets .1950 setback requirements ,
B) Distance from system to any welts well r+a� r'b ye�
C) Distance from septic tank to foundation =
D) Distance from system to property lines y[o`
2. SEPTIC TANK p ye s
A) Visually inspect the exterior wafls and to of the tank
_ B) Visually inspect the interior walls, baffle, tee, filter, riser, lid.s, air vent,
bottom, and water tight outlet �_ '�-
C) Date of tank manufacture f-�-o� �
D) Tank seriai number S`T(S !�a
E) Liquid capacity of tank � /'eoo -� gallons �--
3. SUPPLY LINE TO T E�CHES
A) Grade See �raw ^g (1!8 inch per foot minim m
e) Material supply line is constructed from � I° �C
C) Diameter r
D) Length � ' S
E) Distance from tank to drainfi distribution device Sf
,
4. DISTRIBUTION DEVICE(S)
A) Type NR'
B) Is Device water tight_�_
C) Distance from the distribution device(s) to the trenches /�l �
D) Is the device on a level foundation �_
E) Does the device perform according to its desi�n�specifications %� �'
� Record the inlet and outlet elevations I\f
5. NITRIFICATION FIELD
A) Trench depth � inches
B) Trench width - 36 inches �
C) Distance between trenches =� o� ��
D) Number of trenches �
E) Length(s) of trenches .rn,� ft 99. 113 :� 1
F) Aggregate depth _� inches
G) Aggregate mate�ialand size � � �
H) Record septic tank outlet elevation ,�� a'
I) Trench grade See � (<_ 1/4" per 10')
J) Step downs �
a. Minimum of 2' of undisturbed ea 5�.,__
b. Proper rise over step down �
c. Soiid pipe used �� e. ,
d. Elevations of step downs �mw� (Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, �ev. 90/12/99
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� � ���snn ��tu�i� �� i3e�ardmera�t � -�` .
� �.�vir�nmeniai �ealth Section :. �, � .
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Zsaning: - Tcwnsi�t�x �I � �.' � 3 `� � �
Snbdivisio� Sectton: ,__ 1..� _ .
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�P� �"c�1 l�l N 37 ea . .
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L�on: S I il l( i�/,�ro a�-s f�Q � � y�c�. �a .-zl,�.¢ r�r � .
� Q e�ra�ti o n P�e �rn it ,�
� �� System Type (In Acxordance W�h Tabie Va): ��� �
THIS SYSTE�A HAS 8E�1 INSTALLE� !N GDMPLlNNC� WITH AP�LICABLE NORTH�
CAR�LINA GEi�IE�RAL STATUTES, RULES FaR S�AIAGE TREATNE�IT AND DISPOSAL,
-AND � ALL CANDlTIONS OF THE 1111PROYE3YIE�li' PE�MTf �� AND CaNSTRUCTiON
AUTH TI � '
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PC�ID, rev.I 10112199 . _