A26 19r
.
" Amoun t paid � 50,00
. .
' �Receipt !I '
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�oxcoro, N.C. �; �;.�
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APPi,ICATI0�1 FnR SEFViCES
. >. = ., .... �� __��
_'" �----Ser�tce;`s�Requesteci� . . _. . ._ ��
�d'I � -��
Da te
�
Im�rovements Permit.(EstablishedlRecorded Lot) �._ Reinspection of Existing System (Loan C;osing)
Im�ovemer.ts Permit (Uncecorded Lot)
_ Irnerovemeats Permit (Mobile Home Replace)
_ improvements Pecmit (Addition)
�
_ E acteria � _ Chemical
�. Pet�.tit re�uested by: .
owne:/pros�ective owner/�
Address: ���
,�� ��a � a . �v. e
�
�
�
� Home Phone �: " 8`�
¢ usiness Phone n:
G
w
¢
z
ReYair/F�eolace existing Sepcic System
_ Pernit for Ne�.v Wei[
�_ Replace Existing Weil
im � Ie fo �be Collecte3 ` f�`-` i
_p �z
_ Pet;o?eum � w _ PesticiCe
�� 7. Dimensions or Procosed Structure:
,� �r ��1 idth: i �
���^'` �� Depth: _ .
_ i �ad
8. What tyoe (if any, acditions, expansions, c�
replacement is ancicipa[ed to the structure er :_cility
t�zt this sewa�e disYosai system is intendeu :� ser�e
,����"'
2. I�iane and addr of curren[ owner: 9. Water su�ply t5•pe:
' i%�— privace �....`�j�public ❑ community ❑ spring'!
/I7o.�i � J ��" Are any we11s on adjoinin� property?Yes ❑ Vo t�
0 0 0 •, 02 7.S 7�.3 If so, identiiy tocation:
. Prope: �y Description: Lot size:
Tax Mat�: H d .�
Parceln: „�� -
Townshio: _ . __ _-_
. Directions to property: Sta[e Road tt& Road
iames,gtc. ��-�� � �
�/.j�� 1�%,�ifi� ;.���L:i�r1�
�S Type of structurelfacility: Proposed: ME.:isting:
Type of dwelling:
House: C�obiie ome: Q Business: r
Type of business: �A-iz�l1 � .� �{
Number of Employees: _3
Number ot bedrooms: �_
Garbage Disposal? Yes ❑ No �'�
Ba.sement? Yes❑ No�f so, n of basemer�t fixtui
I6. Number of occupancs or people [o be served: �_ �
CLEARLY STA� ALL CORNERS OF THE PROPERTY AND THE CORNERS �F ALL
PROPOSED STRUCTURES.
I hereby make applica[ion to the PeL'SOri COunty Health Departmenf for a site evaluation for the on-
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 propecty. I understand if the si[e is altered or the
intended use changes, the pectnit shall become invalid. I understand [hat before an Improvements Pecmi[ car
issued, I must present a survey plat of the propercy to the Health Dept. I understand that in the event I have i
delivered a sucvey pIa[ of the propecty to the Health Dep[. wi[hin GO DAYS after [he date oE the evaivation o
the site by the Health Dep[., this application shall become void and al( fees paid forfeited.
S�gncc� Owner or Authorized Agenl
a
• �
. PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: � � 2� Parcel # � /
Zoning Township �/v�✓/�✓«'%�� _
Applicant:W�7/VC C�y�N
Location• �� �33CO
Subdivi&ion: 1 " �A Section: Lot:
Improvement Permit
A buildincl permit cannot be issued with onlv an Improvement Permit
(►qof�1 -
New �Repair _ Addition _ Type of StructureKOnL Water Supply �15PN 6
# of Occupants �� # of Bedrooms Z Other .
Basement? �_ Basement Fixtures? _�
Projected Daily FIow:2�� g.p.d. Permit Valid For: ive Years ❑ No Expiration
Proposed Wastewater System Type: L�����hG �`-�- �J
Pump Required? Yes �No
Permit Conditions: i�f/'�"�L G/� C�/�/�u� . /1�1�'/�1 �t� %7�4'✓Ci� ��� �a ��
s�� si�� s�G��H �� s src�► �1ou,-. ,Q�°r9i�e /L��X. T���l �'�ti ,8 J
Owner or Legal Representativ Signature: /-L �^ Date: " �r </
Authorized State Agent: �f Date: �� �j 7
S il.(3 aq
The issuance of this permit by the Health Department in n a guarant�es the issuance of other per ts. he permit
holder is responsible for checking with appropriate governing 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 site. This permit is subJect to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
To
d for
Type of Wastewater Syste� bN �o`N���,y- AJ Wastewater Flow: �g.p.d.
Facility Type: o6�I-� �(�'�� New �epair OExpansion ❑ ����,e�j �plr.u�NG'
Basement? 0 Yes L9�1 o Basement Fixtures? O Yes �-tdo
Wastewater Svstem Reauirements
Septic Tank Size: 1�u gallons Pump Tank Size: /" � gallons
--�Total Trench Len th: �`1Q� feet Maximum Trench Depth:�0��- inches Aggregate Depth: � in.
02�� � 9
M�imum Soil Cover: �, inches Trench Separation: � Feet on Center
� ��� �'� .�EI�cM n� �8�` ��ibO�N��r�F�fi�. Ure • --- �r�s�- o►� ��N��2.
Other:
Permit Expiration Date: /� �7
Authorized State Agenfi ��
The type of system permitted does
the specifications of this permit.
Owner/Legal Representative Signature:
C
/� Date: �� � C�
�$ ►l 13.�tT
from the type s eci �ed on the application. I accept
�t—`- �j , f Date/ / � �� �/
PCHD, rev/ 10/12/99
Application #: ���3
Tax Map #: '�
Parcel #: /�
Person County Health Department
Environmental Health Section
SITE SKETCH
�� �Yn�� �A�{ j�l� ,���
ApplicanYs Name Subdivision/Section/Lot#
�.,Q -�—� /r 3 �_
Authoriz d tate A t Date
System components represertt approximate contours only. Tlte contractor must flag tlte system
prior to beginnin� t/:e installation to insure tliat proper grade is maintained
� �EP µGL �oMP�N�r�iS p� S �P�1 � �ySt�
f�-r �SF'" �a0 � �°� ��/ d��LLS' .
0
��D� I�5 I
��' _�EP�.� � _ I
�
, 200 ��R
�{Do' rJi�aFrG�i'fuN LINE I
— — r�r�r��� —
1�40a1t� }�onn£
5�. 133(�
Scale: ND ��'��
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�N1� �A-L � •Z7s "� 7oN
y� �1��l�Ju�
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y,��[.L
� 5b� � ��w� h.a�
Mo1�1�N PuU,r� R�,� t 12. p. W.
PCHD, rev. 10/12/99
Person County Health Department
n 1� Environmental Health Section .
, Tax Map #: �"f �2 �.�1 Parcei #:
Zoning: Township: l.l.l.nYlr�rlAhC►'Yl _
Subdivision: Section: Lot:
Applicant: V V� Y1,P l. ��
Location • I`� �i� r-}-n n-- Qf ,t � �: Q,m [-�
Operation 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.
C:Q . I a ��-9�i
Authorized State Age Date
Tax Map #: �� Z� Parcel #: I q
PCHD, rev. 10/12/99
Person County Heaith Department
Environmental Health Section
Zoning: Township: � n � ��
Subdivision:
• . . . � . . � • ��..� c• �
. • . � i� � � �1. /i
Section: Lot:
Operatio,n Permit
1. LOCATION AND SEPARATION DISTANCES ✓
A) System meets .1950 setback requirements
B) Distance from system to any welis %a�'�"
C) Distance from septic tank to foundation / o�-t_
D) Distance from system to property lines iez�t.f- t
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank t/
B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet ��
C) Date of tank manufacture ��'�—`1 q
D) Tank serial number �t5-aaa-b �-/Uz
E) Liquid capacity of tank l aZ�'D gallons
3. SUPPLY LiNE TO TRENCHES
A) Grade ✓(1/8 inch per foot minimum)
B) Material supply line is constructed from Sc'-h, 4b PVr
C) Diameter 3''
D) Length ' k3'
E} Distance from tank to drainfield/distribution device '�'
4. DISTRIBUTION DEVICE(S)
A) Type
B) Is Device water tight _
C} Distance from the distribution device(s) to the trenches
D) Is the device on a level foundation
E) Does the device perform according to its design specifications
F) Reco�d #he inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth �� inches
B) Trench width r3 lo inches
C) Distance between trenches q l� _
D) Number of trenches �
E) Length(s) of trenches ?�`'�"
F) Aggregate depth ►Z inches
G) Aggregate material and size 5`�
H) Record septic tank outlet elevation t�•�. �/z
I) Trench grade �ce.c c�.1�}�°1 (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth Li
b. Proper rise over step dowy ✓
c. Solid pipe used ✓
d. Elevations of step downs �ecord elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/�2/99