A27 67r '` �
Person County Health Department �
Sewage System Improvements Permit
Date:�� is Permit Void After 5 Years �.���
Owner: 'Y �� SR#
Location/Direcdons: � . . �
SubdivisionName: �:c,{�L�:v��r: � �1I/y �/7) �t#��
Lot Sizc: Type. of Dwelling: .
Water Supply: Private: Public: Community:
Bedrooms: � Garbage Disposal
Basement ' Basement Fixtures
INFORMA �R D B
$BIlli3tla11: � � ner rep entative
REPAIR: � REEVALUATION�
Size of Septic Tank: _��� gallons Size olPump Tank:
Nitri�cation Line: �o � 3
Depth of Stone: 12 inches
Max Dep[h of Trenches:
Altemative System: Conv. Pump LPP Pump ,
Remarks:
-------------------------
Date Well A mved: - i- U Well should be 100 f� from any sewer system
BY��,%� Sani 'an
Date Se e S ste A roved:
BY Sanitarian
RTIFICATE OF COMPLETION
Contractor. ��d l �E CD� � �
------------------------- � �
Sewage System location, installation, and protection must meet state and local '�
reguladons. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained ��
by owner in such manner as not to create a public health hazard. Septic tank and'd �
nitrification line must be inspected and approved by a member of the Person County �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemut is subject to revocadon.
(G.S.130 A-335F)
Location of sewage disposal sewage system sketched on back.
(OVER) �
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NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
� at later date: Note location of water supplies on adjacent lots.
�i� eAI Q � A� (2)
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Apniicaiion �ate: �-1--�' `6 j
'Amourat Paid: __,�[�
�ec�iot �:
��rson Cauniv Health Department
. -_;�nvironr��ntal Health Section
Ta� Ma a �: � /
Parc21 #: � �
`:. APPCICATION FOR SERVICES �
IF THE 1NFORMATION IN THE APPL1CATfON FOR AN IMPROVEMEiVT PERMIT IS FALSIFIED, CHANGED. OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATfON TO CONSTRUCT SHALL BEC011AE INVALID.
7) Permit requesied�y; ��e�r/a,�ge tJprospective ownerj: �►'U �M� J� �� ��t �
Home Phone: �� �`t '/� Addres� (rG'�a_ � � I" � �
Business Phone: � v2 `�� �
2) Name and address af current oHmer. � �
3) Property Description: �ct s�ze: Township:
Direections to the property (Induding road names and numbers):
4) Proposed Use and Structure Descriptlon: answer each of the following questions:
a) Proposed �. Existing ❑
b) Stidc Built �, Modular q Single Wide �, Double Wde ❑
c) Number of Bedrooms: � � d) Number of occvparrts or peopie to be served
e). Basement . Yes �, No �7 !f yes, # of basement fixtures: � ' - � ' ' � '
� � Garbage. Dispcsaf: Yes �, �;:. 0- >_ _ _ .�_ . - . _ .. . _ . , . . J
g) Dimensions of Proposed Strudure: Wdth: Depth:
37 Water Suppiy Type: Private �(new ❑ or existing �j, Public 0, Cammunity �, Spring �
. � Are any wells on adjoining property? Yes � No � If yes, locafion
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
Conventio�al _Modifled Conventional _ Altemative_ _Innovative
Other (specify):
CLEd1RLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLiCATiON
�
1 hereby make appliption 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 appiication are true �nd represenY the maximum faai'�ies to be
placed on the property. I understand if the site is altered or the intended use ct�anges, the pertnit shail become invalid. I understand
that as appiicarrt, 1 am respon 'ble for identifying and marfcing property lines, comers and making the site acc�ssible for the
personnei of the Pesson C H aith Department to condud their evaluations. I understand that I am responsible for notifying the
Heaith ent ifi m rope cont ns any wetlands as designated by the Army Corps of Engineers.
. - �- ���
er or Legal epresentative • Date
PCND, rev. 10M2199
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LOT 18 OF
"ROCKWOOU HI�LS"
PLAT B001< I I P. 5
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129. 45'
cur�rr�o�
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