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Improvements Permit. (Fstablished/Recorded Lot)
ImpFovements Permit (Unrecorded Lot)
Reinspection of Existing System (Loan Closing)
_ Repair/Fteplace existing Septic System
improvements Permit (Mobile Home Replace) Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
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Bacteria _ Chemical Petroleum _ Pesticide
1. Permit requested by: .
owner/prospective own�f
Ar�rirPcc' .�D �a'�
ome Phone #: S`'i�i -a�s�
usiness Phone #: S�i�t -�7��-
Name and address of current owner: _
�! l� SAT.i�2F�=�Lt� t�FlleS
� 38 %1r�A2,11� GR2fL �O�Ps�
(�c�Y I�.r�(2c� . IV L Z���� ��.�
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Prnnertv DeSCriDt1011: LOt SiZe:
. Tax Map#:
Parcel#: _.
7. Dimensions or Proposed Structure:
_ Lead
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 t} pe:
private � public ❑ community ❑ spring ❑
ot"Z Are any wells on adjoining property?Yes ❑ No p
� If so, identify location:
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. Directions to property: State Road #& Road
iames;�tc.
�s �s� ��s�- r� sr� <<s� -
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10. Type of structurelfacility: Proposed:8'Existing: Q
Type of dwelling:
House: 0"Mobile Home: 0 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms:
Garbage Disposal? Yes ❑ No 0
Basement? Yes❑ No�71f so, # of basement fixtures:
[6 Number of occupants or people to be served: � �
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 that the contents of this application are tcue
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 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.
I
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z Signc� Owner or Authorized Agent
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
Signature Date
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RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:�AM[PRO�DOCN�PPSEC.5TIFWI�NCE.PC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Not for waste water system constrt�ction. No permit(s) for Construction Location or
Relocation Activity shalt be issued until Authorization for waste water system construction
has been issued.
T� Map # � �
Zoning
Owner/Contractor
Location/Address
Subdivision Name
Parcel #
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Permits may be voided if site is altered r nte ed use
Well and Septic Layout by �
Comments:
Date Installed by Approved by
,..,P� ���.c�, --
Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
dividual Semi-Public Required Slab
�blic Replacement Air Vent
te Approved Required Well Log
ell Head Approved Well Tag
-outing Approved
Comments:
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 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 eavironmental 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
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NCGS "BRADSHER"
N=957426.338
E=1979181.210
JAMES DONALD DAVIS
D8 217 P 420
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