A28 132�App?iaation Date: .�- 7 �C� Tax Map: /� �' ��
Amount Paid: � 0, C%C1 � Parcel #: _� ) 3�
Receipt#: � I �'3,� � G _ � ��
' '-� ���� ).� ������ �C��Lt / J ' �
;��43� ' �"' � ��TC���`� � �
�
t�J�i-t C ��, �. ��
1[=�.. �a-w�-�i u- xa nv ssan <c--, �ra 1L-:.�n 11 1C �.L a�,.�n, 71 �:7�a � i�
H«��� ��� �y
Application for Services (Septic Systems and Wells) �K � i; u��
Services Re uested
O Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d Fee is de endent on the e of s stem ermitted)
Mobile Home Replacement or Building Addition L Permit Revision
$150.00 (if site visit re uired) $75.00
C? Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Charee
1) Services Requested by:
Name: `�pQ�� �-{��,�
Address: �q � 0 �urirs� (�(.
�r�xhv�ro, NG a �15n �
Phone # (home):33(�-5`1 � - 5538
(work/cell):
2)Name and address of current owner (if different than applicant):
Name: Y
Address: ��S 7,r� Q S��-
�,l�Nd; ��,� !1 � rl �
3) Property Description: Lot Size: �`� G�ubdivision:
Address and/or directions to Property: _ j�3 �nn; e, Q���
4) Proposed Use and Type of Structure:
Residential ,/ Business/Type: Other
Number of bedrooms ,� / Number of people served (seats/employees):
Basement: Yes � No (wi� plumbing: Yes No )
Garbage disposal: Yes No
5) Water Supply:/
Private Well J (Proposed Existing �
Community Well: Public Water System: ,
Are there wells on the adjoining properties? No _
Lot #:
Yes -✓ (please show location on site plan)
Note: A completed avplication must also include:
➢ A pladsite p[an of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of tlze `Lot Preparation' form verifying that the property is ready to be evaluated.
I am submitting this application to request sen�ices from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
Permits and approvals shall become invalid.
P: ,
�gnature (Owner/Legal Representative): �� � � Date : 5 - '1- / O
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Ro�:boro, NC 27573 (336-597-1790)
; �� � �
��,���-;� ��
,� �., ,�: ,.
. �ti �: � � ����
I��.�.�{��.�.����.�.�1 �.��:.�.II�:�.
�
�u�����a�� I���g$Il�dfl�I PVg�l��flt� ��IIYfl� ��;D���E�Ilc2�Il�5
Tax Map #: A� Parcel#: 'L
Approval Requested for: 1Vlobile Home Replacement
Building Adcii.tion
Applicant Name: �,,� �n P�-�-���r�
Address: � Q
� ro 2�5
Phone #'s:
Permit Located: ✓ Yes No
Installation%�ate: -Z3- Designflow: ��D (gpd)
Current Contract with Cer#ified Operator on file (if required):
�/ �i5tia���
Water Supply: Wel Public or Community
Wastewater system shows no visual evidence of failure on: 5- j 2� I 0 (date)
(Applicant's signature if site visit is not required)
Comments:_,� a; n-i'�n 5� 'i"i o m +r, h KS __
A��Il�g��3������aa���� A���°�d��
� /3 -/o
En ronmental Health Specialist Date
11/15/OS
. ����,.� / .!!.. l.i..l1 �� ��
f
�� � � ���
1�,m��-�v��,��.��.11 ]H[��.]!�
��'�'� �7��1'��a
N�ne _ �►�v1 fv�Q ���,r�� _ Tag Ma. #�� �'a:��e1 � i � �-
Subdi.visi �
Sectian/Lot# _�
S- r 3 ra
u�h.orized Sta.te A�nt Date
S,ystesra cdmj�os�ents s�epresent upprsoximate�co9rtor�rs �rly; i�ie conimctor »aerst, j`%ag the sys�er�a1D�ior to
begzs�ra�r�tg $h� instudl�e'on to �nsaare tlaat j�no�ies�gsYtr�e as re�ru�tained
�--� �-�5�, �p1 i1r� �� aC � I r� ;, o r�, ��_ � f �� 1 �
`� ' ov+� -}-A h � S
lVl ��� r��u i n S� �
� � . �.
�. x� �� °'a= ' '+� �;�w � ���, � �s' � � � �, ��- -�,�h ,
� . �- *��r �i � � �" ' �k� ,. � ° ���' "� , � � ' z" k '�� � � �g a , .: "
-z,�c aiv-g � � e:. �a," '1. � � w� � � `� ,� j d � � �a�"'s� `�' "�i,f. ��.�
� r �'� � , � � � 'w � ;
,� 2 �.: - � " a �, � € k I
,rg , i, � �.:� �5���' 7 y _ s r.. � $ � .::3 °�. ,
1 x k �, r .�, , � E _�^ �, - 4 ,,a � a . � „� • °"� �' 0�, s � °x � � �r-. - � "` � j
� '�'Y��.. �`, . �,`' �°� � �� �� �y,. � :4, ,'�3����t# �.�. €� a
� �
'. y � � } . A'ro��,r ^N ,�� �y �'�;° 4r � -�, . � ,e �
'�I . � � ��� � y ,� ''� � ,.,� p,s � �; �` , � e ,�� �� r' $�; a rr ' �
�y � N �« `; ae�a' b � % . �' °� �',,�C` � `�`s'
', .,�! . x �. ,��`: . �., �r � F�„ey�, .. .,,�y � �'yfi
, �e. � ° `� � s� -� , °
, , .� � ,� ," � _
� . . , � t "++ . � g�qr� ,� . � .�.. � :;;� � � w �.� � ��
,,
� �� - � �a=� � � � , �
.. . � a ^'� s�i "� ' '� ' -'v 3 ��.. �-� ..- y �= '` w"a
� �� � , ,�
� . . � . " � � y � +ra�, s n� .� `s � '� _ v. � � . .
4 -
- �s�,` _<�. r � �' � x ,�� �. � � � " � " �, ��"� a€` � ,� ��
� ��"� � � � � ��
I ��i, : �-b � ;
.. 3 'Q -�""T�-� � 't- - • � ` S� 6��
�,; � � ' `� � � � � ,�
* �"� �� #,�. � „��'� # ,� �` ;� ����� ,�.. ',
i' ��_ � °as x° '4'.X-x re x ,�ri f �'' � � �
I . -2 �``i �'.c� �,�` _,� ..�m+�y��" � _ � � �,%���+r �� �� , '�,,��.� � �°�""�ri�. �� � - '°���` x�.��-<1
. � ��+ ��4 � yx�A �. "�.. � � d> '�` �' ��E_,� � '� ,� �,�� .,a h{, �z*:w � �... s .
. : "� `°„ `a . �� ' s, { r �� `� *� �, �� �?�r�-., �� �� � y
'�y, ��i.;; � .�.�� . t� � '#.� ;�`� �r�^ � "'''.�"s'�'T4� � � '°%'*: �-W . �.k� *
.� � � � ,er '1; 5 fi�. .
�. . A ,� "�� �'� P` � i- , � 3 ' a` z�— a�`,�,� �� y. 9 �' � 4 „�^ , ., '�`
�- , �<� ,h �, �t " ° n`pu� �+„'_ ' �;� .;> � ..;. �.4' b � v�.r;, � ��'�: . ,4 �' �
� � , ,,J�
. � � - $ h k 4a�� '� ti . . 4y�r"�k��� . '� `'k �5�.�� S N.,�"�� "��p � g r.�� � ,� �: .
� . .' x 3B� 'r` ' S �� �e `� "� � � �- ,, . �' 2 ;'�"�F '`� � � � a
" E � , j"4 � � S 4 �h
..
:, � �.i � -`z,�* � `�'� � ,� . " '�� s.a
�
�' � � �� �.. �. `� � �
� � ���� � � � � �� � . ��� � � � �� � � �� � ��
�g- "�a . i � •ri +. �
I � � � g" � � ¢�` '�';� � �' .e`4 fft-. � .t.� � o `�s s�' '�' �i�� ��'� �#+ � '4 � �• � s
' ���' �.., � . "� � "' �,�+'" . `� , � �.`� �' s� 4 � � �vry .�" i y � ,' � ,� �
, . �p 7�'.�,. 2'� �, t� n. .�� ^-�� :,^ �`y� ° �y" �� �" . ��� ;
�'Y '�- , , g a,.M '., x %,_,5;... � �m. �b , . �' � . ��� '. �`3 'j�� � � Y �� �., � ,}���` ,.
� �` ",� 5 � � �,.� „ �w 's �• �� � ...
���_ � � � �� � �^s.
>,
� � # o
'�. J � 'i:- '7l � -�" � r �$'�a �s. '%� ° `";�.. . . d � ,. � � '� � ;a�� . .
� qx
� � ' " ,+4° �i �,Gs� �, � . ,� Y' �4� , . � � .
3
�y�- �` � ��, � . ��ar� � �� i , � . � " . �� �,� �'i%G.. ,i�'.. , �,� � � °�'.-Z.
�- "� � t� " �,��� � �`� �� � � � m,,�"ei�`'� ��`��
�_ r�f
* �;
�> r +�'
? ° �,�� ;.�.. � �-' ��: � � - },2,� � �<-�,
` � .,° �^�v q T
� _ �.
� � � "� � ,� � � �,_ � + `3'2.�. � ��
, ,
� $ �,;� � � k �� d� ,s:,
'��, �...� �� ~ � � r' '�', .
� �"�'`��" s <� a' , . '� � �' s�' ' �
�.��;,. *� �,.' ��.. _ . _� �, �. ,
� —'"_
^, r
e�,.e�. �, , _ y � 'e& °�
�`�"� �'��°" `a F�?�" �� � ,. � '."" _ � � ,y. `'+t�-§. �� '��fr� ��
� �.�. � �, _ �-=-- �
x_�. � � �
��� ` -" _ ��� �.�'- ;. � � � �'�":;� `�!�y,, . _ `�` '. � s�' ��
}'k` �-^ _ .J I�: {�. � $'f �� �% .0 � ���
_r�-'_�';..� �3." � � � �' � '"�°, "y�
�� a� . �+' �" "�i "�. � � ,� ''�,sr"�� c� �
_�r � �"� '_�.— � "�� - f � � "'�`� ""'��,'A' i � .
'�-�r�' r , 3� .�. ^s, ' . w,� ,,�
_ ; � r �
A � ¢� �� � . ..T,.:,� -��� � �� - �.. *•'� 4' �`� `�`,� •i^ S_ A �i� ;at
>1*�a-'� . � ��� -�e^��� �� ..F` �.�`s�qa; ��'�'� .� .� � _ " ..... � , _ .... _
d � U� q���1
� C�- �; � _ .
�er�. � ,
. .� :
�
H
O
�
F��I�}—`��
_. ... _ _ __
Improvements Permit. (EstablishedJRecorded Lot) ._ Reinspection of Existing System an Closing)
Iml�ovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home R�
Permit for New Well
Improvements Permit (Addition) � Replace Existing Weil �
1. Permit requested by: .
owner/prospective ownei
Ar�lr�rPcc� . � v.�'_`C.\/
Phone #: `�`� q R—� 1 9
usiness Phone #:
7. Dimensions or Proposed Structure:
Width: � q X 7 � �^ �
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 addre&s of,current owner: 9. Water suppl type:
�` c i�,� private public ❑ community ❑ spring ❑
� ' --- Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
Description: Lot size: � � � � �- c-
Tax Map#: �1 �� �
Parcel#: � -� Z
•r...x,n�h;n• b�.i ye _ l� i 1� _
. Directions to property: State Road #& Road
ames;�tc.
t�8c�— �
�o:��c v � —
Number of occupants or
o� t3lo.\o c�l�
to be secved: �
10. Type of structure/facility: Proposed:'�Existing: Q
Type of dwelling: ��
House: ❑ Mobile Home: L�"Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �-
,Garbage Disposal? Yes ❑ I�o �
�Basement? Yes ❑ No�f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PeI'Son 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 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.
I
¢
Z Signc Owner or Authorized Agent
Pe-�it.Es�,ued l.�' Signature Date
Permit Denied ❑
Plat Observed
t:
���"�- . . ,
�
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope pattems, etc.) C:WM[PRCADOCS�APPSEC.ST1 FlNANCE.PC
..
�
� �� �I1 I � � 41 v �..7
�_
��
�... -
+V
M
�
a
w
U
�
a
B 1099
PERSON COUNTY HEALTH DEPARTMENT
WELL E1ND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT _
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 #_�1 � � Parcel #.
Zonine Townshi
Owner/Contractor
Location/Address
W� i i,� � P e�a S
Subdivision Name
�
3Z
�1�✓e /-IJ��I
Date � -
- � ��g � Y�►'v�� 1� A
� l�l��-f-v rf on ��n.�!��,.��' S.R.#
SEWAGE SYSTEM SPECIFICATIONS
Lot Area Size of Tank
Mobile Home ,/ Size of Pump Tank
# of Bedrooms�_ Nitrification Line
Max Depth Trenches
Permits may be voided if site is altered or
Well and Septic Layout by
Comments:
Date
Well Permit
Individual
� Public
Installed by,
ell H Approved
Gro mg Approved_
Comments:
Date Ir.
nd u e ch ged.
,�_Approved by
CATION5
Required Slab
Air Ve
uired Well Lo _
Well Tag
�
l�airv��^� �r.•.d
��
N l� ..�
, % /� h �i3�
aF;�s�
o�
�). .�� - �G
�
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 ia the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l