A40 187�
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AUTHORIZATION PERMIT �: S 1-�' '+r1 i
PERSON COUNTY HEALTH DEPARTMENT
AUTHORIZATION FOR ZONING & BUILDING PERMITS TO BE ISSUED
.S. 130A - 338)
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ADDRESS: �'y u-
. �'73G
LOCATION OF PftOPERTY : x - � t - � ��� '
LOT S I ZE : � • � 9 Q��� TAX MAP � : � '� � � � %
TOWNSHIP:
SUBDIVISION NAME: n�, ti' � u �4-c��,,�"���►''-� LOT �:
ry"��yx�- ( � /�eciYoon.�s)
'��" ' HOUSE [ ] MODULAR HOME [ ] MANUFACTURED _HOME [ �
OTHER [ ] SPECIFY:
DATE: 4"�`� _ � � -
NEW SEWER SYSTEM [✓1 EXISTING SEWEft SYSTEM [�
MUNICIPAL SEWEft SYSTEM [ �
Environmental• Health Specialist
****�*******************************�**********�*****�***********
Certificate of completion or operations permit issued:
and compliance with local well rules where applicable.
DATE:
(130A-337)
(130A-39)
Environmental Health Specialist
****************************************�************************
YOU MUST OBTAIN PEBMITS REQUIftED BY THE PEitSON COUNTY ZONING AND
BUILDING CODES BEFORE ANY CONSTR,IICTION ACTIVITY IS STARTED.
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Person County Health Department
Sewage System Improvements Permit
Date:g� ermit Voi After 5 Y P rmit # �
Ownel: v I '.� �+" �' .+.' � SR# 1 S?
L.ocaaon/Directions: � ' ^ c=' .�_�„y-�, ��
Subdivision N me: �' � ��Y � r.l. I�r #� �'
Lot Size: � Type of Dwelling:
Water Supply: Private: _� p�blic: Communiry:
Bedrooms: 3 Garbage Disposal
Basement Basement Fi� s .
iNFORM OI�� D BY
Sanitari �) o o resentative
�_..
REPAIR: _ _ — REEVALUATION:
Size of Septic Tank: gallons Size of Pump Tank:
Nitrification Line: � ? �
Depth of Swne: 12 inches
Max Depth of Trenches:
Altemadve System: Conv. Pump LPP Pump
Remazks: __
Date Well Approved: Well should be i00 ft from any sewer system
BY - anitarian
I�te w e s roved: -- - ' .
BY $2nit3tiN1
c ' , 'ITFI TE OF �LETIOI?�
Convactor. , n �r : 0 Un 1\� L.
���.�����LL����L���������������
Sewage Sys[em location, installadon, and prote�tion must meet state and local
reguladons. Septic tank should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrificaaon line must be inspected and approved by a member of the Person County
Health Departrnent before any portion of the installation is covered and put into use. If
the site plans ar intended use change this permit is subject to revocation.
(G.S.130 A-335F)
Location of sewagc disposal sewage system sketched on back.
(OVER)
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Improvements Permit (Established/Recorded Lot) _ Keinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot) ,_._ Repair/Replace existing Septic System
mnrovements Permi[ (Mobile Home Replace) _ Permit for New Well
� Improvements Permit (Addition) I_ Replace Existing Well �
1. Permit ted by: 7. Dimensions or Proposed Structure:
owner/ rospective wner/agent: Width: ( 4 X gU M t�
Address: N i c_�., o I e �3 �rc�.c1 � t� Depth:
1� � 0 E3 o x 1 a 4 3 g. What type (if any, additions, expansions, or
{�� k b a,� o �v C- �`7.5 �7 3 - replacemen[ is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
ome Phone #: �`� q- 7 oa 6
usiness Phone #:
Name and address of current owner:
Ger�d �;►.,� �- o�v;� C�
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�.�,,,�a �P ��; �� � � � a
Description: Lot size: i, I`�
, Tax Map##: � 4 �
Parcel#: I g 7 ��
Township: r 1 a� �R � V e1r
. Directions to property: State Road #& Road
ames, etc.
���7-S � 1 a�- IR� v er �' 1a►���.�;
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Number of occupants or people to t�e served:
9. Water supply ty pe:
private� public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
10. Type of structurelfacility: Proposed: DExisting: ❑
Type of dwelling:
House: ❑ Mobile Home: C�'�usiness: ❑
Type of business:
Number of Employees:
.�Iumber of bedrooms: �_
Garbage Disposal? Yes ❑ No ❑
Basement? Yes ❑ No � If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
'PROPOSED STRUCTURES.
I hereby make application to the Pet'son COunty Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree tha[ the contents of this application 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 shall become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the proper[y to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
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permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
Date
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9. SITECLASSIFICATION(SEEBELOV.�
SOII, SERIES
SSUITABLE PSFROYLSIONAl1.YSUITABLE U-UNSU[TASLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
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B 0�49
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # /q �/v Parcel # /8 7
Zoning Township r�.4 TRiu�
Owner/Contractor /1//GI�/OLC �it's¢DSHEt? Date y-3o-9L
Location/Address_�Y is � To f� � T i�/ 1/c � Pc .d nlT�+TI v�
S.R.# /6'7
Subdivision Namel=�,qT�/vc�' ,,��A�/Tf�T�o/�! Lot# �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area f. /� R G Size of Tank �,�is7-�,vlr /ao�� GA �
SFD Mobile Home Size of Pump Tank J�//a
Business # of Bedrooms�_ Nitrification Line F�r /s T ��/G yvo 'x3
Max Depth Trenches '—
Permits may be voided if site
Well and Septic Layout by�
Comments:
or intended use cha
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�c% c�a�ls'� rr� sE�i /c �' YS i � Nl
Date�-3� - 9� Installed by L X i 5 T ��� U"' Approved by
L"dLC 111J1C111GLL V�' •,yY• �• �� ��
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l