HB_03-033_Anderson

Sent by: NCR CORP 9194BB0706 03/25/03 5:22AM Job 495
Mar 24 03 11148a TOWN OF HOLDEN BERCH 9108429315
Page 3/4
Is.4
J1 F
focal GovatnmeM
CAMA
APR 1 1 2003 MINOR DEVELOPMENT
DIVISION OF PERMIT
COASTAL MANAGEMENT
as authorized by the State of North Carolina, Depanment of Environment
and Natural Rasouroas and the Coastal Resources Commission for development
in an area of environmental concern prasuard to Section 113A-1 to of the
/ 1 1 General Statutes, 'Coe al Area Marragement.`
;asuedtc K-ciA'�liwhlnuo i+►'►atkson1 authorizing development if% C. Y-
�[ 3,
Permit Nutnbn�
as requested in the permitloes application, dated --,:?—Cs G3
This permit, issued on "S—otU' U,� is subject to compliance with The application and site drawing iwhare consistent
with the perms), all applicable regulations and spacial conditions and notes satforth below, Any violation ofthese:arms may subject
patmPoea Ica tine, imprisonment or civil action, or may cause the permh to be null and void.
12. All construction shall meet all requirements of chaptcr.157.062 and Chapter 158.00 located
in the Town of Hoiden Beach Code of Ordinances and any other sections that apply to the
construction of the single family residence.
13, The concrete slab elevation for the proposed single family residence shall be at the elevation
of 10.0 above sea level or less_ The stormwamr system authorized with this permit must be
maintained for the life of the structure addressed.
15. Any enclosures below base flood elevation aball be for solely for parking of vehicles, or
sto rllge space. By signing this CAMA permit you as the owner agree that their shall be no
haWfable area allowed below but flood elevation. Only break a way walls are allowed
below base flood elevation.
16. THE APPROVED PLAN FOR THIS CAMA PERMIT SHOWS NO STRUCTURES, NO
DECKS, NO PILINGS, ECT. TO BE LOCATED WITHIN THE 60 FOOT SETBACK.
17. All pilings shall have be located at a minimum of five foet below sea level.
This permit action may be appealed by the permittee or other
qualified persons within twenty (20) days of the issuing date.
From the date of an appeal, any work conducted under this per-
mit rr.st cease until the appeal is resolved.
This permit must be on the project she and accessible to the
permit officer when the project is inspected for compliance.
Any maintenance work or project modifications not covered
tinder this permit requires further written permit approval.
Ap work n!u�.vl-�cepa�vrrten this permit expiros on December
31,_ O[[ll ��©©
in zsuing this parmil it is agreed that this project is consistent
with the local land Use Plan and all applicable ordinances.
i
ems. • YJ � • Lsila -� � f
e
Tnn permit may not be transferred to another party without pe- iItcr
the written approval of the Division of Coastal Me emem � 3signature r purr if special conditions above apply b permit::

Sent by: NCR CORP 9194880708
03/25/03 5:21AM Job 495 Pape 2/4
Mar 24 03 l l t 48a ��}}It��TOWHr OF HOLDEN BEACH 9108429315 P • 3
(ttit� ll v f5/J7�S-3'
''tYLLii''�jAa'' 1ST VV Permit Number
�Covernrnem LAMA
pPQ 2 MiNOR DEVELOPMENT
W41SION r, MENT PERMIT
COASTAI- s authorized by the Slate of North Carolina, Departmaltt of Environment
and Natural Resources and the Coastal tesoun as Commission for development
in an area of environmental concern pursuant io Section 113A-118 of the
_ Claneral Statutes,'Coasgai Area Management-*, f
lysved to
aut aiming
��)I,y` tC-•fLI R't�i1 Gil as requested In the permittae's application, dalnd
This pennh, issued On - - is subject to compliance with the application and site drawing (where consistent
With the permit), all applicable relfufatkms and special conditions and notes sat faith below. Any violation of these lermsmay subjaci
permia" tor, line, imprisonment or civa action, or may cause the perm;, to be null and void.
7- Any structure shall be relocated or dismantled when it becomes imminently threatened
by changes in shoreline configuration. The structure(s) shall be relocated or dismantled
withia 2 years of the time when it becomes imminently threatened, and in any case upon
its collapse or subsidence.
- -- 8. No impenneable surface shall be allowed over any functional part_ of the septic systern.
Septic sr. tom must he installed according to Brunswick County Health Deparhncii II
pilings must be located at least 5 feet from any pottirms orthe septic system. Waterline must
be located at least 10 feet from all portions of the septic system. All retention areas shall a
minimum of 25 feet soperation from all portions of the septic system_
9. All foundations and structures shall be designed to be stable during applicable fluctuations in
ground elevation and wave fume during a 100 year storm.
10. in accordance with T15A NCAC 714. 0308(a), no seawall or riprap revetments will the
allowed in the fuhim should any structure become threatened from erosion.
tt.'fhe structure must be elevated and bottom of lowest Horizordat Structural \4--mber
excluding pilings and must meet the 100-year flood level elevation. The current flood is
Vim+ and elevation of 18 feet
This parmil action maybe appealed by the permNtea or other
qualified persons within twenty (20) days of the issuing date.
?rom the date of an appeal, anywoM conducted under this.per-
ma m, st cease until the appaW Is resolved -
This permit must be on the project she and accessible to the
perm[ officer when the project is inapecied for compliance.
Any maintenance work or project modifications not covered
undet this permit requires further wdnen permit approval.
aticress
a work mustkea.Owhenthis permit emPires on December
In ensuing this permit n is agreed fhat the projecl's consistent
with the local Lad Use Plan and all appinable ordinances.
T�is permit may not be transferred to another party without Pormaie?
tie wrAw approval of the Division of Coastal Mane ,im(�o�t. tgnaturo equi I special eondaions above apDr 10 pawl+

,I Sent by: NCR CORP 9194680706 03/25/03 5:20AM Job 495 Pape 1
{l riae P4 03 11:48a TOWN OF HOLDEN BEACH 9108429315 P.2
L1_[�LYpICII'I� QGr 1 nit 3- ✓e
V Permit Nurnba:
Lucal Govemment CAM A
MINOR DEVELOPMENT
PERMIT
as authorized by the State of North Carolina. Department of Environment
and Natural Reswaoas and the Coastal Resources Commission for development
in an area of environmental coneem pursuant to Section 113A-11 Bat the
General Statutes, "Ca I Area Management.' ,
�asued to 1'-� tF ��n authorizing devaI nnenis r
1 a• ialnh(iitE31Y1 r�! e�]tYtSbYI ... ...
as requested in the permMee's application, dated
This Psrmc, issued an is subject to compliance with the application and site drawing twhern rxmaistant
Wit, 1jw permit), all applicable regulations and special conditions and notes set forth Wow. Any violation of these terms n:ay subject
uarmfeee to a tine, imprisonment or civil action, or may cause me permit to be null and void.
I NSTALLATION OF SEPTIC SYSTEK RETENTION AREAS, CONSTRUCT A
SINGLE FAMILY RESIDENCE, AND A CONCRETE DRIVEWAY.
All proposed development acid associated construction must be done in accordance with the
permitted work plat drawing(s).
1. No dune disturbance of a duties area will be allowed for this development because the dune',,
I protective value would be weakened or reduced. {
2. All construction must conform to the NC Building Code requirements and all other local.
State and Federal regulations and the local Rood damage prevention ordinance as rcquircd by
the National Flood Insurance Program.
3. Any change or changes in the plans for development, construction, or land use activities >vill j
require a re-evaluation and modification of this potmit.
4. Pursuant to 15 NCAC, Subchapter 71 0406 (b), this permit may not be iransfentd, or
omcrwise disposed of to a third party, except by the Division Director.
5. The structure must be set back 60 feet from the first line of stable natrual vegetation
(FLSNV). The permittee is required to contact the Local Permit Officer shortly before he j
plans to bran construction to arrange a setback measurement which will be eftective, for
sixtv(60) days barring a major shoreline change. Construction must begin within sixty (60)
days of the determination or the measurement is void and must be redone. j
6. The structure must be located entirely off of the frontal dune, and if a primary dune is present. `f
landward of the crest of the primary dune. l
This permit aotiun may be appealed by the permiaee or other
<Nr rtirre,•i persons within twenty (201 days of the issuing date.
=ron the date of an appeal, any work conducted. under this per-
mit rpm: cease until the appeal is resolved.
This uarmlt must be on the project site and accessible to the
permit officer when the project is Inspected for compliance.
Any maintenance work or project modifications not covered
,u,derthis permit regtrres further written permit approval.
All work mus' sa � In0 is permit aspires on December
p
It. testing this permit It is agreed that this project is consistent
with the local Land Use Plan and all app!icable ordinances.
:: its permit may nm be transferred to another party without
the w ition approval a, the Division of Coastal Meiagemert.
I
_ M
L; "I`�OTYI r
address
APR1120
DIVISION
COASTAL MANAGEMENT

Sent by: NCR CORP 9194680706 03/25/03 5tMlil Job 495 Page 414
Ma- 24 03 11:49a TOYM OF HOLDEN HERCH 8100429315 P.5
7 AEC HAZARD NOTICE
Project Is In An: Aef�oeean Erodible Area_ High Hazard Flood Area_ inlet Hazard Area
Date Lot WaS Platted:
11tis notice is intended to make you, the applicant, aware
of the special risks and conditions associated with
ievelopment in this area, which is subject to natural
hazards such as storms, erosion and currents. The rules of
the Coastal Resources Commission require that you
receive an ALC Hazard Notice and acknowledge That
notice in writing before a permit for development can be
Issued.
-fheCommission'srulesonbulldingsmndards, oceanfront
setbacks and dune alterationare designed to minimize, but
not eliminate, propertyy loss from hazards. By granting
permits, the Coastal Resources Commission dues not
gguarantee the safety of the develo ment and assumes no
I"iability I'm future damage to the development.
The best available information, as accepted by the Coastal
Resources Commission, indicates that the annual ocean
erosion rate for the area where your property is located is
feet per year.
The rate was established by careful analvsis of aerial.
Photographs of the coastline taken over the past 50 years.
Studiov; also indicate that the shoreline could move as
much as 330fect landward in a major storm.
Tine flood watersin amajor storm are predicted to be alxwut
_)I— feet deep in this area-
Creferred oceanfront protection measures are beach
nourishment and relocation of threatened structures.
I ard erosion control structures such as bulkheads,
seawalls, revetments, groins, jets and breakwaters are
prohibited. Temporary devices, inch uding sand bags, may
be allowed under certain conditions.
This structure shall be relocated or dismantled within two
pairs of becoming imminently threatened.
The applicant must ackrnowledge this information and
requirements by signing this notice int1te
below spate.
Withoyjrthe proper signatu the on will not be
SPECIAL NOTE: This heard notice is required for
development in areas subject to sudden and massive
stc)nnsand erosion. Permitstssued for cievelopmeillin thf>
area expire on December 31 of the third year I ollowing the
War in which the permit was issued. Shortly before work
begins on the project site, the Local Permit Officer will
determine the vegetation line and setback distanceat you r
site. if theproperty has seen fittlechange and the proposed
development can still meet the setback requirement, the
LPOwillinform you thatyoumay begin work. Itisimpur-
tant that you chedk with the LPObefore thepermit expires
for official approval to continue the work after the permii
has aired. Generally, if foundation pilings have beet)
placed and substantial progress is continuing, permit
renewal may not be necessary- ff substantial progress has
not been made, the permit must be renewed and a ne%%
setback line established. It is unlawful to continue work
after permit expiration without this approval..
For enure information, contact:
Local Per it Officer ---._._...
F ��'
PQO J\�eOP p ��(`
PS�P�
00
Rewsed r 1:94:r

a CAMA PERMIT NOTICE
Pursuant to NCGS 113-119(b), the Muni-
cipality of Town of Holden Beach, a locali-
ty authorized to issue CAMA permits in
the areas ofenvironmental concern, hero -
by gives NOTICE that on March 3, 2003, ap-
plicant Ed and Debbie Anderson, applied
for a CAMA minor development permit to
construct a single family residence, septic
sytem, landscape at 467 Ocean Blvd. West.
The application may be inspected at the
below address. Public comments received
by March 14, 2063, will be considered. la-
ter comments will be accepted and consid-
ered up to the time of permit decision. Pro -
jeer modifications may occur based on fur-
ther review and comments. Notice of the
permit decision in this matter will be pro-
vided upon written request.
Local CAMA Permit Officer
110 Rothschild Street
Holden Beach, NC 29962
(910)842.64M
Mar.6
VECEHVEs
APR 1 1 M
DIVISION OF
COASTAL MANAGEM
o2oo3- o Z-)3
STATE OF NORTH CAROLINA
COUNTY OF BRUNSWICK
AFFIDAVIT OF PUBLICATION
Before the undersigned, a Notary Public of said County and State,
duly commissioned, qualified, and authorized by law to administer
oaths, personally appeared
Carolyn H. Sweatt
who, being first duly swom, deposes and says: that she is
Publisher
(Owner, partner, publisher, or other officer or employee
authorized to make this affidavit)
of The Brunswick Beacon, a newspaper published, issued, and en-
tered as periodical mail in the Town of Shallotte in the said County
and State; that she is authorized to make this affidavit and swom
statement; that the notice or other legal advertisement, a true copy of
which is attached hereto, was published in The Brunswick Beacon on
the following date(s):
March 6, 2003
and that the said newspaper in which such notice, paper document or
legal advertisement was published, was at the time of each and every
such publication, a newspaper meeting all the requirements and qual-
ifications of Section 1-597 of the General Statutes of North Carolina
and was a qualified newspaper within the meaning of Section 1-597
of the General Statutes of North Carolina.
This the 6th day of March, 2003.
(Signa of person making affidavit)
Sworn to and subscribed before me this 6th day of
March, 2003.
(Notary Public) G'Ld,+., �BL1C' r ••............. ,.
My commission expires: December 29, 2004. �'"';"11 COIN
.......tu)V

LocalityO'�'�—
GENERAL INFORMATION
LAND OWNER
Name
1rin, 6 n
Addr
city
Permit Number 'Zbd 3"0-3
AUTHORIZED AGENT
Name �1ks & )►Gi'
Address fia /3� M
City r
o&bAe.X state "-I ZfpeWV
LOCATION OF PROJE�(,T `�' 4 7 0� k)
l r4- 12 �%X /NS
(If not oceanfront, is waterbody natural or manmade?) 0-4
.7 ti RIP1� Jrv57'AlI �4pT/
�
DESCTION OF PROJECT .Slnyh- T,a/11!% 1/L/
v
AREAS OF ENVIRONMENTAL CONCERN (AEC) CLASSIFICATION
(4 b filled in by the Local Permit Officer prior to completing application)
Ocean Hazard _/ Estuarine Shoreline _ORW Shoreline _
PROPOSED USE
Residential _ Commercial/industrial _ Other
fly
other hi MAR t
DIVISI("' �;MENT
COASTAL MAIN'
SQUARE FOOTAGE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR
BUILT -UPON SURFACES (/such as driveways, etc.) within 75 feet of the shoreline (575 feet
of an ORW shoreline)
SQUARE FOOTAGE OF TOTAL FLOOR AREA OF BUILDING 4-3% y
SQUARE FOOTAGE OF SITE
OTHER PERMITS. MAY BE REQUIRED:
The activity you are planning may require
permits other than the CAMA minor
development permit. As a service we have
compiled a listing of the kinds of permits that
might be required. We suggest you check
over the list with your LPO to determine if
Zoning, Drinking Water Well, Septic Tank
(or other sanitary waste treatment system),
Burning, Electrical, Plumbing, Heating and
Air Conditioning, Insulation anral,
I
Conservation, FIA Certification
Sediment Control, SubdivisionMobile Home Park Approval, H32003
Connection, and others.f'*
any of these apply to your project. I I BEACH

STATEMENT OF OWNERSHIP
1, the undersigned, an applicant for a CAMA minor development permit, being either the owner of property in
an AEC or a person authorized to act as an agent for purposes of applying for a CAMA minor development
permit, certify that the person listed as landowner on this application has a significant interest in the real
property described therein. This interest can be described as: (check one)
an owner or record title, Title is vested in see Deed Book
page in the County Registry o Dee
an owner by virtue of inheritance. Applicant is an heir to the estate of
probate was in County.
if other interest, such as written contact or lease, explain below or use a separate sheet and attach to this
application.
NOTIFICATION OF ADJACENT PROPERTY OWNERS
I furthermore certify that the following persons are owners of properties adjoining this property. I affirm that I
have given ACTUAL NOTICE to each of them concerning my intent to develop this property and to apply for
a CAMA permit.
(Name) (Address)
y(2) 7
(3)
a
n
a
r
O
n
a
r_
(4)
FOR DEVELOPERS IN OCEAN HAZARD AND ESTUARINE HAZARD AREAS: 7` y
I acknowledge that the land owner is aware that the proposed development is planned for an area wh ch may V «
be susceptible to erosion and/or flooding. I acknowledge that the local permit officer has explained tome the
particular hazard problems associated with this lot This explanation was accompanied by reco -dations J �Qg3
concerning stabilization and floodproofing techniques.
PERMISSION TO ENTER ON LAND ,� GEI�EI
I furthermore -certify that I am authorized to grant and do in fact grant permission to the local permit offi"� , `Vi
and his agents to enter on the aforementioned lands in connection with evaluating information rela�e�l#b fliis
permit application.
This application includes: general information (this form), a site drawing as described on the back of this ap-
plication, the ownership statement, the AEC hazard notice where necessary, a check for $50.00 made payable to
the locality, and any mformation as may be provided orally by the applicant. The details of the application as
described by these sources are incorporated without reference in any permit which may be issued. Deviation
from these details will constitute a violation of any permit. Any person developing in an AEC without a per-
mit is subject to civil, criminal and administrative action.
This the _day of /� /A 20o3
Land owner or-perswn authorized to act as his agent
for purposes of filing a CAMA permit application.

DATE. 3 3 - 0 3
To: _Q%1!(ALD 0. 13fYiAi
// ZZ )t? �1 - rpi-AusA ow.
&no r , PA. /?077
DEAF: ADJACENT PROPERTY OWNER
I ��t
letter is to inform you that I have applied f�or/a CAMA Permit on the property
owned by fa ' _ i4. /�Y f Aso, at Y107 06 ►'V
(Met address)
Holder Beach, NC. I have enclosed a copy of permit application and a copy of the
drav n;ofproposedproject.
lfyouhave any comments on the proposed project, please contact
Plonda Phillips, Local CAMA Officc*, Town of?iolden Beach, 1 i 0 Rothschild St.
Hoiden Beach, NC 28462 - Telephone -[phone].
Sincerely,
U.S. Postal Service
CERTIFIED MAIL RECEIPT
A ent) -q(Domestic Mail Only: No Ins"rance Coverage Provided)
(Owneror
TELEPHONE NUMBER: 3'VI-3Nr ru
" rn Postage $ 13D:�P070��
ORetum Recelpt F � (Fsdorsemeat Requl Co Reetrest OeltryF> �`,p (Entlorsere Required) Totel Poe 9pe 6 Faa,
MpR 13 2 3
�G\'O pSOlvlg\tOFIPOBlWilio.
o
. Apt
. N- a0.Y)
VPN
�rr.,nP.fIe YOA n�(City,
�U
�.
19077
300, April 20L

DATE: 3 3 -6�
'
• r
To:1111-D "J:5 lot
gill YGSAN QJVD
}�r�4N Bch. NG
DEAR ADIACENT PROPERTY OVTNER:
This letter is'to in form yonu that I have applied for a CAMA Permit on the property
owned by inat A % d.6
(sweet address)
Holder Beach, NC. Ihave enclosed a copy of permit application and a copy of the
drawing of proposed project.
If you have any comments on the proposed proj act, please contact
Rhonda Phillips, Local CAMA Office-, To-cvn of Hoiden Beach, 110 Rothschild 5t.
Holden Beach, NC 28462 - Telephone -[phone].
Sincerely,
�01 U.S. Postal Service
.n ■
MAIL RECEIPT
M Domestic Mail Only; No Insurance Coverage Provided)
r=l
TELEPHONE NUMBER: C7y3 �yn `37yS m
-°Ln
i
,f
mlie Pos e9td a cenidadfea
1�� Po-et`inwk
Retum Recalpt�Fee
•' (Entlorsement Reg7oad)
Restrictatl Dallvery Feq
2f1(Ertl Hot%Dt R.ery
i! 2003
It ru, Total Postage 6 Feas 'J L
N 0 _... _
Street, Apt No.; /1/ t
GONS"p orpoBoxNo. /'11 J 61VO
gym: st.�..L�«.fbLnr�t/ Pit N , i✓� �PN6'y

File No.:_2000.054229A
-
BRUNSWICK COUNTY HEALTH DEPARTMENT Type _ �alt r
P.O. BOX 9 BOLIVIA, N.C. 28422 [phone]
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE
An Authorization for Wastewater Construction must be attached to the Improvement Permit before any other
permit can be issued and before a wastewater system can be installed.
Supporting documents such as the completed application form, site evaluation form, fill plan, etc., are considered a part
of this Improvement Permit
Owner/Authorized Agent: CHEEK LAWRENCE H ET CHERYLE G Tax Parcel : 246DB00801
Lot 78 Block Section: EASTERN EXT Subdivision: ROBINSON BEACH
Residential: XX Water Suppy. XX Public Private (well)
No. of units: 1 No. of bedrooms: 4 No. of occupants: 8
Commercial: 0 1 A Number of employees: Number of seats:
Type of business:
Size of septic tank: /oo o LTAR: t o gpc/sq. ft. Drainfield sq. feet 17A o
No. of Lines: I L Length ea.: �70 Trench widthQ ct 9 .ia Bed: +t L Design Flow gpd: �8 a
Trench/Bed bottom depth no deeper than:Iq inches Pumptankvolume:
n O-1 (if applicable)
If applicable, the following conditions must be met prior to issuance of an Authorization for Wastewater Construction
and prior to wastewater system installation.
X
X
X
Keep 100 feet from all water supplies (minimum of 50 feet must be maintained). 11(
Keep 10 feet from all water lines.
Keep 10 feet from any property lines (no less than 5 feet for lots recorded prior to 7/1/77)
Do not drive over, park, pave, or build any structure over the area for the septic tank system , Dr
and the repair area if applicable.
Do not install the septic system during wet conditions. COAS(HL fJiN�VHG�MEN
Maintain Gravity Flow for septic system.
Drainage Maintenance Required.
Suitable Fill material must be installed exactly per the Health Department approved fill plan. Fill check plan.
Fill check must be completed by the Health Dept. prior to issue of Authorization for Wastewater Construction.
Approved for use of Altemative/Innovalive Wastewater System (Specify)
Submit Wastewater plans to the Health Department for review/approval
_ If Septic System Uses Rock Aggregate/Approved Fitter Fabric Covering Required
.Sx jai
on Permit)
DATE: ,2-.19_09
ACTIONS OF BRUNSWICK COUNTY HEALTH DEPARTMENT REPRESENTATIVES ENGAGED IN THE EVALUATION AND
DETTR)INATTON OF MEASURES REQUIRED TO EFFECT COMPLIANCE WITH THE APPLICABLE LAWS AND RULES SHALL IN NO WAY
BE TAKEN AS A WARRANTY THAT SEWAGE TREATMENT AND DISPOSAL SYSTEMS APPROVED AND PERMITTED WILL FUNCTION IN
A SATISFACTORY MANNER FOR ANY GIVEN PERIOD OF TIME. PERMIT IS SUBJECT TO REVOCATION IF THE NFT6 PLAN OR FIAT
WHICHEVER IS APPLICABLE, OR THE INTENDED USE CHANGES.
The issuance of this permit does not preclude the Permittee from complying with any and all statutes, rules, regulations,
or ordinances which may be imposed by other government agencies (local, state, and federal) which have jurisdiction.
.4EPYYCTANBS89ALL HAFEANAPPROFEDEPPL77ENTMTEB NACCEAVDEF/CEV
IP0398
Updated 09125/02

we
TOW WCTY1AREW
DRUNSWICK COUNTY HEALTH DEPARTMENT ®683
P.I.N.: FILENO] 200304 22g2
100 246DB00801 OO, .54'SU9
AMT. PD. TAX PARCEL
SUPPLY NC 28462- ($10h 842-72.`
CITY ST ZIP PHONE
YLE / ROBINSON BEACH / 7� /
SUBDIVISION LOT BLK SEC
DIRECTIONS TO PROPERTY: NO n )DR 7: S S n c C T r`_TTPTS
REVISION RELOCATION UPGRADE REPAIR
a gpd. Septic tank size: gal. Type: ( I
f Nooccupantsl"Voyeesf� Max. Trench/Bed Bottom Depth: ches
_ Length each: _721_ Bed dimensions:
Approved:
Authorized Agent
21 3 Permit expires 60 months from date of Issue unless otherwise specified
❑ 30 days from date of issue
❑ Other (date)
e: Registration: 134!?-
IECT TO R OCATION IF SITE PLANS OR THE INTENDED USE CHANGES.
PERMIT CONDITIQNS MUST Bt MET
'1a11M Installer:
(tW'a i0�e er approved)
Date:
PERMIT:
b,w
- - Date:
NOTES:
1.Septic Tank shall
have an approved
effluent filter and
access devices as
applicable.
2Maintain all set-
back distances for
septic tank sys-
tems and wells.
3.AII componentsof
the septic systems
shall be located
100 feet if possible
but not less than
50 feet to all
existing and future
wells on this parcel
and adjacent par-
cels.
Authorized Agent Signature
3ntatives or the State engaged in the evaluation and determination of measures required to effect compliance with the
ry be taken as a warranty that sewage treatment and disposal systems approved and permitted will function in a
Of time. The issuance of this permit does not preclude the Permttee from complying with any and all statues, rules,
mPcsed by other government agencies (local, state, and federal) which have jurisdiction.

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