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provements Permit. (Fstablished/Recorded Lot) ._ Reinspection of Existing System (Loan Closing)
pFovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
imarovements Permit (Mobile Home Replace) I_ Permit for New Well
Permit (Addition)
Bacteria
1. Permit requested by: .
owner/prospective own�i
Arir�rPcc• _�D ��7�
W
¢
z
Chemical
ome Phone #: S`iGI --��5�
usiness Phone #: S�i� -�7�Z-
,_ Replace Existing Well
Petroleum _ Pesticide � _ Lead
7. Dimensions or Proposed Structure:
�' � Width: '
Depth:
Name and addre&s of,current owner: _
�! i,,,,, s A�,� �:.sz�� �za rt �� 25
� 38 Lt-�cL�_��_ Gt3�2 20�,�
x �� 2� , ,u � Z-�5�73
Pranertv Descrintion: Lot size: �� '
Tax Map#: � � �
Parcel#: � � � 1 `f" 3 � o �
Township: 0 I�: V e_�4 i I�
Directions to property: State Road #& Road
.,....,,�.....
. l� S l S� l,� �.S i' T�0 S�2 l l`S�j -
% ti;,1� o.� s� i�S� - o,�-� c.�-�
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 su ly type:
private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
10. Type of structurelfacility: Proposed:{�Existing: Q �
Type of dwelling:
House: C�"Mobile Home: C7 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: _
Garbage Disposal? Yes ❑ No 0
Basement? Yes❑ No�7 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 Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree [hat 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 [hat in the event I have not
delivered a survey plat of the property to the Health Dept. within GO DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signc� Owner or Authorized Agent
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
Signatur
�' Date �� 1 � �� ' J
� -_, ��
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:MMIPRO'�DOCSUIPPSEC.SM F►NANCE.PC
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ZSON COUNTY
'IFICATE OF ____________________,
"HE GOVERNMENTAL UNIT DESIGNATED
: CORRECT. THIS PLAT WAS PRESENTED
►ND RECORD IN THIS OFFICE AT
PAGE�� THIS ____ DAY OF
. AT ________ 0'CLOCK ____1�.
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NORTH CAROLINA PERSON COUNTY '"`''" '�
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NEAL C HAA�LETT � "'
I
_ � CERT I FY T `'`"���'
SURVEY CREATES A SUBDIViSION OF LAND WI �:
PERSON__ COUNTY. TVITNESS A�Y HAND AND `
_14_ DAY OF ---QSrS�---.�19_96_. -
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PERSON COUNTY HEALTH DEPARTMENT %5�p
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Not for waste water system constraction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # �,� �� Parcel # I�� w
Zorung Township � �
Owner/Contractor Date
Location/Address (s W eS -(�o �%L� f J�'�% v�� le� Voi �
Subdivision Name i e Lot#
er✓S
SEWAGE SYSTEM SPECIFICATIONS
Lot Area
Mobile Hom
# of Bedrooms��
Permits may be voided if site is
Well and Septic Layout by
Comments:
�
���
'Size of Tank � �
Size ofPump Tank ��
3�Titrification Line �c�0 -iv � 3
Max Depth Trenches G " _
use
Date Installed by Approved by
�
Well Permit Paid O WELL SYSTEM SPECIFICATIONS
' Semi-Public Required Slab
Replacement Air Vent
te Approved
ell Head Approved
-outing Approved_
Comments:
Required Well Log
Well Tag
Date Installed by Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permi� 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 condi�ions on the property or for statements in this �
report that may have resulted from false or misleading statemenis 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\permi�sam O1/95 rev.l.l