A36 23-.- � � z
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'�Person County Heaith Department �
Sewage System Improvements Permit
Date:�Z-7- �1 Q This ermit Void After 5 Y s
Owner: '� SR#
Location/Directions:
Sulxiivision Name: Lot # �_ '� �
�
Lot Size: �f DJ e� g:� . ,
Water Supply: Privatc: � ° ��S"` ommunity:
Bedrooms: � Garbage Disposal
Basement Basement Fixtures
INFORMA C T BY -
$�i11t�Ran: oH�ner or representative
REPAIR: ON:
Size of Septic Tank: __�� gallon� Size of Pump Tank:
Nitrification Line: �,�� �
Depih of Stone: 12 inches
Max Depth of Trcnches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------,------------------
Date Well Approved: -��� Well should be 100 f� from any sewer system
BY /� _ �i�i'� � Sanitarian , , _
. Sanitarian ` �
T& OF COMPLE'I'ION
------------------------- �
Sewage System location, installation, and protection must meet state and local '�
regulations. Septic tank shouid be pumped out every 3 to 5 yeazs and shall be maintained �
by owner in such manner as not to create a public health hazazd. Septic tank and'd
nitrif'icadon line must be inspected and approved by a member of the Person Counry �
Heaith Depaztment before any potYion of the installation is covered and put into use. If
the site plans or intended use change this pecmi[ is subject to revocauon.
(G.S.130 A-335F)
Location of sewage disposal sewage system sketched on back.
(OVER)
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Amount paid )00,
Receipt /� '
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Pers�n C�urny Haalth Lcp:
00 �?� S. Morgzn S�re�:t �_a,�_q �
Aox�oro, N.C. 2?5?�
Cqur'er un2.�3•�s D a t e
l. Permit requested by: .
�wner/prospective owner
ome Phone �: ,55 7— S
usiness Phone #:�
7. Dimensions or Proposed Structure:
widch: �4 X 624 ��-+o i''
Depth: � 1 aC I 6 _ po rC�
�-J 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
��, that this sewage disposal system is intended to serve?
Name and address of current owner:
. Property Description: Lot size:
. Tax Map#: �
Parcel#: �
Townshin: u � rr�` .
S��
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¢ 5. Directions to property: State Road #& Road
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9. Water supply type:
private Q. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
10. Type of structurelfacility: Proposed: DExisting: Q
Type of dwelling:
House: ❑ Mobile Home: C1 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: _ �
Garbage Disposal? Yes ❑ No �l
Basement? Yes ❑ NoII If so, # of basement fixtures:
6. Number of occupan[s or people to be served: I �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORrIERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Person COunfy Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the concents of this applica[ion 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 pecmit shall become invaIid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of [he property to the Health Dept. within 6 DAYS af[er the date oE the evaluation of
the site by the Health Dept., this application shall become void all fees paid forfeited. �
_ i _ � �
Owner or
;.�.____. _ ,._ ...__---___�__.._.__ _ _.__.------------•---._.._ . ...
Agent
Person County Health Department
Existing Sewaqe System Report For: Hobile Home ltepiacement
_L/ Addition —,�%�a��Pp�C�—.
Requestee: i � ' Home Phone# � y-3�J �
�Q ` Gi. Business� 599'�3�{y
� DX.1�o ro .��1� 27s'3 �rax Map# 3b -`�
Location/Uirections: 5`� �V 7��. fYl�c--I�n -' ���'QrY1 K�`. ��/--
�� Qrn%r� c�. � -� t 3��
Original Per3�t Located V
Septic Syste:a Ues�rgned For: _ .
/
Etesidentiai ��� E3usiness
# 8edrooms
�_ #
llate '1'nstalled l(�-��~ ��
Other (specify)
�:mployees Other
Type ot System
Water supply
Nitrification Line �1"���1�'�� =
Tank Size
, Certified Operator Required ��
On site Hastewater disposaI. system showes no visually apparent
malfunction on `5ro72S 1 9�
Yermission is granted to: � t�
According to the attached site plan.
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83°17'28'E
8.03' TOTA
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� 16' GRAVE� DRIVE
ECK------__.—�._-
�.OL 14 ' 'c 3J'
+ y� W 123.9•
1 � i W �<c"�, a
o � s� 9.7' ,� �
m r . \v SEPTIC TANK Q_ v � "' LOT 3 OF
Y 0
� e � ' � � 5� ��� "W. �AWRENCE CL
' O � UNOG y �
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r Z� r - �Y m o in
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n �'�c A
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p,gl AC. EXCLUDING R/ W ��,ti ss.e•
Fj
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N83•1S'S2"W
250.66' TOTAL
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RILEY A. THOMAS
D.B. 186, P. 5�7
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LEGEND
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