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3) Progerty D'asr.�iptlon: Lot siza: Taw�hip: �e �^
Dir�tiona io th� [�P�Y ���9 raad. �� numbers): _
. � /h� �� i{D ��K-Tll �Cli'1 CI�JI�
�a� �,To-�
�. �uS� .
4) Propoaed tlae and �t�ctu�n D�ser�tlom ans�" �ch af tha foilowfig ques�on� •
a) Pro�msed _. � E�ing �✓TYpe af Strudur� � Widtt�. i�epit�:
b) Nurr�6er of fledcaom� ,� Numb� of accupanfs ar p�ple tio be servec� ?� ' , ._
c) Ba�nen� Yes _„ No 1NN thexe be p4unbing tn the basement?
d) Gerb�e ��t Yes ,� Na �, .
� w�' �'ijltta: Prfirabe _(t�► ._ ar ex�ng ✓�, Pub�c_, CorturuusitY _, SP�9 _.
Are•any urd� cn adjoinm9 P��1? Yes _ No _ tfyes, �e i�e aQ�e l�an cn Qre s�e �n.
Bj Does the proprcty � phevioc�y �d jut�ai �� Yes _ No �
PLEA9E NOTE THE FOLLOWING: . . , � -
'➢ A PI„I�T �'i't� PROP�TY OR Sif'E PL�1N �19'i' BE �lBYtl'iEfl WITEi THiS Ai'PLiCA►TiON:
� i�P�iiTY W�IE� AND CORII�RS �JST BE CLEI�RLYliAR�. .
➢. T'HE 2ROP09� LOCATlt�N OF ALL 9iTRUCTURES 9WST HE STAIt� OR PiAGG�. • �
� n� srrEerusr� �►nu.v ��et.� FORaAt Evaw�►-rroN e�r � t�►�n� D��►�Tee�r srar�,
t• h�re� m�ae a�plic�an to the PersoR Cau� H�Ifh Departrnent fioc a s�e �+►aivaticn t5r the oh-siie �rage dtspasal
sY�m ior the above-de�bed property. 1 agree that the conbents af this appQc�ttoa at�e true and repre�nt the ma�num
f�ities tc be on the prope . 1 under�and i� the s�e is ai�ered or the inbended u� changes, the permii shait
�� � � : �� -�� .
o� �e Datis
_ pC�.�p� tat►.1Qt17/01
\�t 1,,)..� ���� ��
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���.n�^�na��gn.�.m.� ����.Il��
Applicant:
Location:
Ta�x MaE� � � F�rcel �—,
Scihciivis�ion
Fh���s�e Sect�ion Lo# #'
L 1
�
Improvement Permit
Permit Valid for _ Five Years _ No Ezpiration
Type of ' '
# of Occupants of Bedrooms
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
New Addition Water Supply ��1�
Projected Daily Flow g.p.d.
Owner or Legal Representative Signature:
�� •� �
Authorized State Agent:
Type:
Type:
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit Is subject to revocatlon 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 compllance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900).
' Authorization to Construct Wastewater System �Required for Bnilding Permit)
* See site plan and additional attachments (�.
Proposed Wastewater Sys m: LL�'j �Cj��-,`anlLi Type � Wastewater Flow �.p.d.
New Repair� xpansion _ Soil LTAR: .� g.p.d./ ft 2
Type of Facility: ���� �i Basement _ Yes =-�Ido
Wastewater System Requirements
Tank Size: Septic Tank: �_ gal Pump Tank: N�A gal Grease Trap: �� gal
Drainfield: Total Area: � O sq ft Total Length a%J ft Maximum Trench Depth �� in
Width �_ ft Minimum Soil Cover: �_ in
ition: Distribution Box t/Serial Distribution
Specifications:
Authorized State Agent:
Permit Exnirat' Date:
The type of system permitted is _��"onventional
the permit.
Owner/Legal Representative: �
Innovative
Minimum Trench Separation: � ft
Operation Permit
Pressure Manifold
Date: c� c� �-{�Z
Alternative. I accept the specifications of
Date:
System Type (in accordance with Table Va) -�F •
The system has been installed in compliance with applicable North Carolina General Statute, Laws and Rules for Sewage Treatment and
Disposal, and all conditions of the Improvement Pertnit and Construction Authorization. Issuance of this permit does not guarantee that the
wastewater system will function properly for any ' e period of time.
Authorized State A ent: ��� Date: 3 a s�a
g
PCHD rev. O1/23/02
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SiTE. SKETCH:
Ta.x Map #� Parcel #��
Section/Lot#
3-��-az..
Date
System components represent approximate �contours only. The contractor must, flag the system j�rior to
beginning t��t�rr,stalla�n to i� e that pr+npergrade is maintained
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PGHD, iev. 09/12/Ol
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Tax Map #: 1"f �1 . Parcel #: ��o
Zoning: Townshlp: ���t� L �' �� /�
Subdivislon• � N % � Sectlon: Lot•
Applicant• I�O��Ii'� Z,`c.Ka-Foo�� _
Location: b���� iDac� �a�,q ����- n��
;
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
AUTHO TION. -
� ��-a� oa
A horized State Agent Date
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