A27 35400
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Apalication Date: � � 3'� �' 3.� 1 Tax Maa #: � �
Amount Paid: �
Receipt #: �'7 LF� 3'� Parcel #: 3��
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APPLICATION FOR SEIiVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHAiVGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AIVD AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. -
1) Permit requested by: (Owner/agent/prospective owner):�e A-�i1 Q ���� c���i»sc-
Home Phone:�33�1599- SFr9� Address: � � �.
BusinessPhone:t;��,1ss�-��(�� �o�!h�i0 �llc ��3�
2) iVame and address of current ownec ��t�� Q I,JC.t C e(1
�J�_o51�Rcc� N�
P ;,
3) Property Descr7ption: Lot size: � 5�'''"Township: U���Vc �-�'�\� Subdivision: Lot #
Directions to the property (Including road names and numbers): Nw-� S? �, 3 c�. . �}�i- u� = l�f�q �S
4) F�roposed Use and Structure Description: answer each of the foliowing questions:
a) Proposed �, Existing ___, Type of Structure:!��c,.. `n�,� �..�.c\ � Width: 5�_ Depth:�.
b) Number of Bedrooms: � Number of occupants or people to be served: _ L
c) Basement: Yes . No � Will there be plumbing in the basement?
d) �arbage Disposal: Yes � , No � �
5) Water Supply Type: Private �(new �, or existing�, Public_, Community� Spring _
Are any welis on adjoining property? Yes_ No � If yes, please indicate approximate location on the
'site plan. �
6) Does your prope�ty contain previously identifled jurisdictional wetlands? Yes_ No�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �, ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAICED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUA710N BY THE HEALTH DEPARTMENT
STAFF: �
I hereby make application 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 applicatio.n are true 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 shali
������
Date
PCI-ID, rev. 06127/02
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1��.�-�.a-�� � ���.�.Il IL 33L ��.11�.11�.
Applican�
Location:
�
T�x fV1a� � � �rcel �
Suibef,ivisiaro
Pha:s�e Sectian:'Lot �
P�z�it �alid #or V �+'ive 3�ears
Type of Facility: � �� P�
# of Oc�upants Mc X # of Be�
Proposed Waste System: �.
Proposed Re�air: � -
�prnveiaent_��rmit
I+To ��pira��on /
� New Y Addition � �1Vatea� S�ppdY _��
at
s Projected Daily Flow �_ g.p,d.
� ���o v� .�� � . � � Type• ���
• ,I�'Pe: �
Perrmit Conditions: l�la�;fn;�t a II S�it7c�S ' --- -
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. ��
The. issuance of t�is permit by the Health DeparGment in does not guaiantee the issuanc$ of other pe�ifs. It is the msponsibi7ity of the
aPPli��P�i' owner to in sure that all Person Co�mty Plaaaing and Zoniag and Bu�7ding inspections requsements are met. This
Tmprovement Permit is snbject to revocation if the site plan;�pl�t`'br'the intended use changes. The Improvement Permit is no#
a�'ected liy a c�ange 3n owner'siup of the property. This pernait was is�ued in compliance with the provisions of the North Carolina, ..
`Laws aad Rules far Sewac�e i`reabnent and Disnosad Svstems' (X5A NCAC 18A .1900). Neither Persun �ounty.:uor��tiic.` �� �
Environmental Health Specialist warrant� th�t the septic tank �yystem w�71 cantinue to function satisf�ctorily in the futare�or�#�t.
the-water supply wiil remain potable. - • �
� Anthorization to Constrnct W�siewater 5ystem (Required fur Building Permit) � �
* See site plan casd additional attachments (_,. .� � -.
, . . ,/ .
Proposerl%�astewater Syste�m:�J .;,va n� 6 tu�1 � �. "I�,'pe .�--� Wastewater Flow '1�� g.p.d. .
New v R�,p �'{_. ExPapsion .� Soil LTAR: •� 7 g.p.d1 ft 2
Type o f F a c� i t y: f�rt vr,�'P � c` u��'�,�•r� �. � B a s e m e n t _ Y e s _ N o .
� ��Vastewater �ystem Req�airements � .
'iank Size: Septic 'Pank:' i D U Dgal Pnmp T ai Grease Trap: gai � .
I�rainfield: Total Area: I%�i3 sq ft Totai Length �� 1 fi ' Ma�nnm irench Depi� �_ in �
. �� #tc,
Trenci� Width �j 1V�in�nnm Soil Cover: �_ in 11�inimnm'Y'renc3i Separation:
Dist�ibntion. I)�str�'bution �oa �rial �istribntion Pressnre 19�Ianifold . .
3tate �igea� �
Permit Expiration Date:
Date:
The type, of system permitted is . Co ventional Aca�ted Alternative. I ac��t the spe�ific�ians of the
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�e�J��al �tapa�s��t��ve: �iu�- �� � � Z 3
' pCHI� rev. l l/10/O5._.
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Name �¢cti�►p r� t c�„�.,�� Taz Ma. #✓�°2 7� P�tcel #�`��
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Section/Lot#
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. Autho�ized State Agent . � Date
�System camiionessts rre�r�aent approximata�contrours only: The coni�rxctor must, fTag the system prior to .
begi�ning tlis in,rtallai'ion to i�sure that properg�de is �rai�tained �
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Tax Map /
Applicant: _
Subdivi9ion;
� 7 Parcel # �� Township:
-Fi�n��r Zir.�.,-e�,�tcv
Lot # .
�� — � 1„�- ��
Type of �a#er�5npp�y: �✓Individual � Communi Public
: tY
ltequirements:
Site Approved By: �
Groutyng Approved By: � ,� , b,
Well Log: ___ _�ii/ `�
Pump Tag: �
Well Tag:
Air Vent: ` , -p'
Hose Bib: �
' Casing Height: '
Concrete Slab: , � � �
Liner:
7nstalled by: _
Depth set: `
Grouted:
Date:
Water �ample:
Well Driller• ` /��n f�P �
Well Approved by � � Date:, �—� d7
****See.At#ached Site Sketch**** �
Wella must be 10 feet from property lines.
Wells must be 100 feet from s�ptic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD rev 01.�27/0�
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.�✓�.'�3.� ��►'39z��,� ���.��.. 4:M1SRr7 LJYWRTSI �� 1(��. •; ..
Ocvner:
Locatio �
Subdivision:
Zi,
�'ii'OIIt I.Og
" Tax
# —�–�
� Pancei # �
- WeII Constractioa
Distance From n� Property L'me (Minimum IO feet) / fl�'
Distance from Septic System (Mmim� 60 feet) �OD
Total Depth: /(�fl. ft Yeld: _�_ GPM • St�tic Water I.eveL• -�r ft
Water Bearing Zones: Depth �� 5 ft t I o ft�� ft ft
� �m . D � 6 �. n���: ��m _
�: c�t�a s�i - .
Weigh� Thicirness: �_ Height above GrauntL• ��` in � ;
Drive Shoe: �Yes No Any problems enco� wh�e setting casing? Yes ✓ No
If `�es" give reason: . ' —
Groni: - ! � •
� Nea� Sand/Cemeat ✓ Concrete GrraveUCement
. -•. i�niular Space Width • mches Water m Ann Space Yes �No
Method of Grou� Pumr�ed Pr�re Poured � Depth �_ to �_ Ft
Materials IIse�L• - .
No. Bags Portland cem+e�t ' Weight o� 1 Bag Po�mds .
If �ue {sapd, gravel, cuttin&s) – Ratio to -
ID plat� ✓ Yes,_ No 4 x 4 slab �_ No
Liner: ' � - .�.
Depth: Daxe Instailed: Grout Installed by —
Drilling Log
Location Drawing
I+�-om To Bormaxion • . •
3 r. � ,�. .
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I h�ereby ce7tify that �e above� info�ation is coirect and drat this well was cons�ted in accordance wi$i regvlations set farth
by the Person CountyHeat#h Departm�t ' �
SSgaatare of Co�ctar
m#_�� n�. - •� 1• v�
Pump Insl�ilment
Pump Inst�llation Contractor_ .! L �� St�ie Registration Number: �
Pump Dep�: f�'t� $ Si�atic Water Lc.wel: ft
Pamp Make & M«ieL• � Pump Size and Ratin�- ��Z hP �_ gpm
I hereby certify ti�at this pwmp was installed and the well head completed according to the Person Cocmty Well Rnies in effed
on t�is date and thaf a copy of this has been �ovided to-t� well owner .
Pamp instaiIIer �e - :• - Datc: S%2� �'a 7 PCHD rev 0 U27/Q4
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