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A26 173� ' Application Date: L"`36-� � Amount Paid: 3 � � Recei�� 6 _� Jg�' �0�08� _: Improvements Permit - Person CountY Health Department Environmental Health Section APPLICATION FOR SERVICES ; :.�, �: ::8ervices Requeste . , :, : < :C Lot) - 5150A0 � �i�Well Pertnd (New/Replace� �tded Lot) - 5150.00 � ❑ Existing (Mobile Home ReplacemenUAddftion) onstrudion Authorization - $100.00 Tax Map #: �c�� Parcel #: - 5725.00 em Inspection - 5100.00 ce Existing System Pertnit Plan - 575.00 1) Permit requested by: (Owner/agent/prospective owner): c Home Phone: Address: Business Phone: 33G -Sa3—�a�7 � -3 2) Name and addres� of current owner: ,��,�� 3) Property Description: Lotsize: �.Q Township: � � Directions to the propert�(�cluding �ad�mes and /,�S/D 4) P�oposed Use and Structure Description: answer each of the foilowing questions: � a) Proposed �Existing 0 b) Stick Built �, Modular , Single Wide �, Double Wide G c) Number of Bedrooms: _„�, d) Number of occupants or people to be served: ,� e) Basement: Yes 0, No �f jres, # c�f basement fixtures: � Garbage Disposal: Yes �, No �� g) Dimensions of Proposed Structure: Width: � Depth: � . 5) Water Suppiy Type: Private new r existing 0), Public 0, Communiry 0, Spring ❑ Are any wells an adjoining property? Yes 0 No ��, location 6) Please Indicate Desired System Type: (systems can be ranked in order of your preference) _ onventional _Modified Conventional _ Altemative innovative Other (specify): CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACN SURVEY PLAT OR SITE PLAN TO THIS APPLICATION I he�eby make appiication 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 appiication are true and represent the maximum facilities to be placed on the property. i understand if the site is aitered or the intended use changes, the pertnit shall become invalid. I understand that as applicant, I am responsible, for identifying and marking property lines, comers and making the site accessible for the personnel of the Person County Heaith D�epartment to conduct their evaluations. 1 understand that I am responsible for notifying the Health D art nt if my property contains a wettands as designated by the Army Corps of Engineers. a� O r or L a epresentati Date PCHD, rev. 10l12199 � PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND S�(STEM LAYOUT Tax Map �1: �� 6 Parcel � ( / � Zoning Township �r�rl��it�.. ✓ " AppUcant: — O ��p> �ocaeon: 3 / .�..76 — O� � Subdivision: �" Sectlon: � LoL• "� Improvement Permit A buildina permit cannot be issued with onlv an Imnrovement Permit New ✓ Repair Addition Type of Structure 38R Water Supply e/ o� S�t S'�'cl�.r �, # of Occupants ?-� #�of 8edrooms 3 Other -- Basement? ,�/,Z Basement F'ixtures? No Projected Daily Flow: 6 o g.p.d. Permit Valid For. 0 Five Years ❑ No Expiration Proposed Wastewater System Type / ir/ o '.� S'� S�,(Q�, Pump Required? Yes r/ Np Proposed Repair : �'�.A.K. � Nn dl,�„� .- �'c�prc� /r� -�J � �� Permit Conditions: U _ � _ `` /D. /, i .�.. __ ,14 _ l, /, ,. _ . � _ � / i . Owner or Legai Representative Signature: � Authorized State Agent: Date: �7 01 � ' o 0 Date: � �?S - cs� The issuance of this permit by the Health Depattment in no way guarantees the issuance of other permits. The permit holder is responsibie for chedcing with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if the site plan� plat, or the intended use changes. The Improvement Permit shall not be affected by a change in ownership of the slte. This peRnit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Authorization To Construct Wastewater Svstem (Required for Buiiding Permitl Type of Wastewater System Wastewater Flow: �,�Qg.p.d. �� !� S� s a Facility Type: � v C !"E'�'� �� New ��epair DExpansion � Q 9 S� ��o�� y � � Basement? 0 Yes I7-t�S Basement F'�ctures? 0 Yes �iQo � � �/ /� � s .e / rS �2o�/cL �d- Wastewater Svstem Requi�ements ' - � G� �/ �v �su � 3�j Septic Tank Size: �' Poe gallons Pump Tank Size: �---- gailons Q��,�,� q�j� �n �;� � Total Trench Length: �S feet Maximum Trench Depth: 3d =�6 inches Aggregate Depth:�, in. ��D �l�i�, �?I�nr So�.r�- /Oltln- Mend�-Soil Cover. _� inches Trench Separation: Feet on Center / � '�eX�r� r0��e Other. � • Permit Expiration Date: _ �".�J ^ �S� Authorized State Agent: � . �� . Date: �-i�.��'Jc� The type of system pennitted 0 does �cl'does not differ from the type specified on the appiication. I accept the speciflcations of this permit OwnerlLegal Representative Signature:' \ �-./,-/1%�,f�-� (�t' ti�` �• �%-o�"� � PCHD, rev. 11/18/99 .._. .------_._... __.__...___...___--__..___ _.__ _. Person County Heaith. Departrnent Environmental Health Section d�^�r ' �ravPs �ay r�o•� SITE S14ETCH __ ..__ _ -�� .n�.>< , c.�� T�/o� 1 AppUcant's Nam � p��, �. _ Authorized State Agent Tax Map #: �6 Parcel #: 1. . Subdivlsion/Section/Lot# ? 1s-� Date System cnmponen�s represent appraadmate cnntours only. The contractor must Jlag the system prior to begin� the installation to insure that PraPe�' �''ade is maintained � o� // c` Aojof`'�,:•�. P.e�..' �o•�'��' �� /. S s{r,.w sl�.(�� ^6�lle�� 3D' �,p� 1� e�zsur� � (a � �.,�{ q��a �n /• �.es qrc i�e �� e • in � a�U,�'�r�* -��rn�� as �o.a��o�s� �er�y-�`'��L� � . . ��'i»✓ca/1J-- � � Q 3 �' / �nSmn C.or,��V, i�elz-/7!+ . � � .� S �, � � f,,.,�,�,� p.T �/� � � � �-2s'' �� .g��..��.'or � �� • � � Cu.rr�f �'/a9� 3 r"' �o J�ave ��' r.�O� \ M "�°1 � �� %1 � � � I � � �.,• � �a'e��l � � �, Sf: ��. �.ss. � � �, . . � �. � �' � �,� �—' � � ' � �; :� �y'"`r �� ` c� '� � � �� r�� fi P �-�. � ; � � � , �� .� K \ 3 � e �� 0 �QS r � � � �D�¢' ' �r �%�nGr °�' �N�� o lu- 11o�1�� gs'f�D,� reR� ,p_ U trT�' t:n.� • I Person County Health Department � ,��f Environmental Health Section I Tax Map #: /7"� Parcel #: / Zoning: r— Township: .+ n n�' � Subdivision: '—' Section: Lot: Applicant• rrc� S �,�Gc.�r fi�s� Location: ��r�n 1"�//�- �a/. _ O�eration Permit System Type (in Accordance With Table Va): � THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION AUTHORIZATION. _ , �2.S i.� -- /S-- � Authorized State Agent Date � � �� f'�, �� -- Ko-/, � � � � .---� � � -� � `� ��' r� � � � ,�$"S� Tax Map #: �� 6 Parcel #: 2- �-s /�� sTi3-�� PCHD, rev. 10/12/99 Per�ore Couni�/ Fiealth Depaetment Environmentai �9ealth Section Zoning: �� Township: ' Subdivision: '"�— �eciion: "r Lot �' �►�piicant: i Location: / � � �- �� 10� 9�erm�t 1. LOCATION .�►iUD SE9�ARATIIIiV DISTAIVCES A) System meets :1950 setback requirements � B) Distance from system to any wells ✓ , Cj Distance from septic tank to founda6on �� D) Distance from system to property lines _� /(�,' 2: SEPTIC TANK A) Visually inspect the exterior walls and top of the tank ✓ B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent, bottom, and water tight outlet � C) Date of tank manufacture -?-� D) Tank serial number Pf� /� Tf3-/�/-� E) Liquid capacity of tank 140� gallons 3. SUPPLY LiNE TO TRENCHES A) Grade ✓ (1/8 inch perfoot minimum B) Material supply li�e is constructed from ��V�— C) Diameter .`3 ` D) Length �l- ' E) Distance from tank to drainfield/distribution device T� 4. DIS BUTION DEVICE(S) A� �/�- B) Is Devic er tight C) Distance from ' ribution device(s) to the trenches D) Is the device on a leve tion E) Does the device perform accor i 'ts design specifications F) Record the inlet and outlet elevations 5. NITRIFICATION �IELD \ A) Trench depth 3� inches B) Trench width '� _ inches � C) Distance between trenches � ,� �� D} Number of trenches `7- � E) Length(s) of trenches �`�� F) Aggregate depth ��,_ inches G) Aggregate material and size �..7 %�S H) Record septic tank outlet elevation �4�' ccf � I) Trench grade OLc -� �(< 1/4" per 10') J) Step downs L� a. Minimum of 2' of undisturbed earth b. Proper rise over step do c. Solid pipe used � d. Efevations of step downs _� (Record elevations and show on as built) ��e "�s �uilt" �la�a �ra �t�ached s�eet. PCHD, rev. 10/12/99 r' • � Person Coun4y Heaith Department � ,�/� Environmental Fiealth Section Tax Map #: /1'� Parcel #: � 1 �3 Zoning: �—"' Township: ( 'a.� � v� ��r��.�n Subdivision: Section: Lot: Applicant• �-r��. S��Gc,� �s� / �` d►�I G-a b l e Location: ��r�r� �� /��- ��1. Operation Perrnit System Type (In Accordance With Table Va): � T9i1S SYSTE�11 FIAS �EEid INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH Cr4ROUNA GEfVERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT A(VD CONSTRUCTION AUTHORIZATION. �� -- /'j–�' �� Authorized State Agent Date � �,c�,�� K //�. ,� .–� � -� � "� '��" `�� > � .� � �i %�o�-- j i. � � �j'l� � � r� /'�C%C/�--. i S � '� � �� , � _� �' �� ' � /��'��` ,. Tax Map #: �� C� Parcel #: �- �-s = /�� ST13-�1�� PCHD, rev. 10/12/99 PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map tl: ��6 Parcel # � �� Zoning Township �hH�� Applicant: ��yk � Y/G.%`-Q.i" � �'"'Y'Gzf/'e`S l�l�/��1 (/ Location: �' h�U , �'' ��F-- Subdivision: Section: �^ Lot: —' Well Permit Tvpe of Water Supalv: �Individual Community Public Requirements• Site Approved by Grouting Appr d by �S� / o/ Well Log � 1 0 Well Tag Air Vent Hose Bib Concrete Slab ,� �.�1. Well Driller: �� f ` ' `"� � Well Approved By: , Date: �J v **See Attached Site Sketch** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: PCHD, rev. 11/29/99 1'�'FSbN COi:N'T'Y ENVZRONM�;NTAI. HLAI.Tfi WE1.T, LUG Uate° - - -- � ^ ��l��J�C� Owner:_ �Y,Z ��r� , — SR# Lacatior� irection�; ..__ �.�., . ,: StibdivisiGrt N�tm�:� - _. Lot # Dxillxng Contractor; Y�. lZ/ C_. � . _ WELL CONSTRUC7'TU l�ist��.nce frc�m Nearest Proper��.ine�� Distartce iram Sau;ce �f PQ1�L1I1011�, � Tot�l De�.th: Ft. Yicld:�, CiPM St�ztic VVatcr Level, �� FL Waief I3eat'uig ��ncs; Dept}��t. Ft. �'t. Ft. Casing: Dep[�i: �ram__�____to__��_Fc. Dlc'illl�tBI: s Inches TX�'$: Steel Gt�lvanixcd Steel �—� If Steel, does awncr approvc; Yes No� W�ight:� Thickness: , �� Height Above Graiuid:,,,�� Inches Drive $hoe: Ycs �'Vo . Wcre Problems Encotlntered in Setting the Casin�7 Yes No � ��,►�'S�� 'lVC I��OFI: Grout: Ty�: Ncat SandJCemcnt ��Concrc[e An,nular Spacc Widih �/ TnchcS Watcr in Annular Space: Y'es� No Method: Fum�ed Pressure Rotued .-�--"" Dcgth: From co_��Ft. � Matcrials Useci; No. Bags Portland Cement 3 Weig,ht of .1 bag_ �_Z--lbs. Yf mixture �sand, gravcl, cuttings) - Ratio:� to�_, � ID Plates: Xe� � No 4 x 4 slab Yes ��No I HEREBY C�RTIFY THAT T'HE A$QVE YNF�3�.MA'T'SON IS CQRR�CI' �1Nn THAT THIS WF.,LL WAS C:ONSTRUCTF_D TN ACCOR�ANCE, WiTH RECULATInNS SET FQR�'H ?3Y TI�IF P�R.SC�i�' � C)i�i�iTY HEAI,TH bEYARTMF.N�'. � , ' / S� 6 �� C�-�.�-- _ _. .. -- ��/� � g a ure o Con . Q, atL _ , � i0'd d55=£O LO-bQ-�QC �