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Permit (Established/Recorded Lot)
Improvements Pernut (Unrecorded Lot)
Permit (Mobile Home Replace)
Improvements Permit (Addition)
.-. 7� ��-q�
Reinspection of Existing System (Loan Closing)
_ Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
1. Permit requested by: 7. Dimensions or Proposed Structure:
owner/prospective owner/agent: G �V'dth:
Address: �����w Depth:
ne Phone #:
iness Phone #:
. Name and address of current owner:
Cl�'o��� N�C �7 �7�
Description: Lot size: i A eYe
Tax Map#: /� �2 � -� a 3
Parcel#: � � �'aK"�°�
e
Tnwnchin� � �.� _/�'/� ���15
Directions to property: State Road #& Road
ames, etc� �
--,_�� i
Number of occupants or people to be served:
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?
9. Water supply type:
private � ublic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
10. Type of structure/facility: Proposed: �Existing: ❑
Type of dwelling:
House: B�Globile Home: ❑ Business: ❑
Type of business:
I�lumber of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No ❑
Basement? Yes ❑ No,C1 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 Person COunty Health Depat'tment for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that 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 property 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.
z Si ned Owner or Authorized
g
Permit Issued l�'
Permit Denied ❑
Plat Observed C�
. .
.
/
Signature Date 7__�� r� S
RECOMMENDATIONS/COMMENTS:
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:WMIPRO�DOCSIAPPSEC.SMFINANCE.PC
� PERSON COUNTY HEALTH DEPARTMENT� !
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # �� r% Parcel # %
Zoning Townshin (��i V e i� l�
(�wner/C�ntractor — i'7Gi. h P�ii �� i`i �+ '��o t,J Date �-- / 3'��
Location/
rh� Crvt�•,r�k �ri
Subdivision Name � S Lot# ,� ?
..• . -�l �i �
C531
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered
Well and Septic Layout by_�
Comments: `
Date Installed by Approved by
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
Individual_�Semi-Public Required Slab
Public Replacement Air Vent
Site Approved_�� Required Well Log
Well Head Approved Well Tag
Grouting Approved
Comments:
Date Installed by Approved by,
This repoR is based in part on information provided the homeowner o� 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 watrants 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 01/95 rev.1.0