A28 194�
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,�aolication Dat�: 3'02 %(S �
Amourrt Paid• I���
Recai �: .2.�_��, 6
� 8��
9�Ersan Cauntv Heaitfi Deuartment
�rrvironmentai Heaith Section
APPUCATION FOR SERVIC�S
i'ax �ao �: � � �
Parc�! #: � � K
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IF THE INFORMATION iN TNE APPI.lCAT10N FOR AN IMPROVEMENT PERMIT IS F,4LSIFlED. C9iAP►GE�. OR THE SiTE IS
AL'iER�D, THE1V THE IIIAPRO!/E�AF�IT PERMIT AND AUTHORIZATiON TO CONSTRUCT SFIALL BECOME INVALlD.
1j Permit r�equuested_ by: Ownedager�Uprospective owner): �i�w i vt 2cty Ifiar r i s
Home Phone: c. ��1� 3`1 O Address: 3°I �I C hc« 1 i e Ca�r r 12o ccc�
Busirtess Ph�e: _��17' (013� � 12o>cbo�ra N� 275� 3
2) Name and address of currerrt owner. � l� w I�l ��� H"a-r r i s
' �I Ci�a.r1�2 CTcvrr �d.
oxbow Nc a 57
3) Property Deacrlption: I_ot size: Township: ( I v e�-}i i I S �� 1�g�
DirecSons to the prope (Induding road names and numbers): ,�
��/2 V'Y�i12S.- f- �. L r i n l e�' 1" C�✓� - i he P_ N� S+ e- r o a �� �`�i� M� ��
�0 0 � al
lo�- is o�n -}he' ie�-►' " �
4) Proposed Use and Structure Deseription: answer each of the following questions:
a) Propased 1�; F�cisting ❑
b) Sbdc BuiR.�, ModuJar Q, Single Wide O, Double �de �
c) Number of Bedrooms: d) Number of occupants ar people to be served: �'
_el. . Basemen�� Yes �, No lf yes. # of basement factures: _ _ � _ _._ _ _ ._ _ . . ._ �. . ._
fl Garbage Disposal: Yes �, No � �„ ,„
g) Dimensians of Proposed Strudure: Width: �, depth: �S
5� Water Supply Type: Private fe((new�arexisting 0), Public �, Commu�ify �. Spring ❑
. Are any wells on adjoining property? Yes ❑ No� If yes, location
6) Pleasa 1ndlcaie Desired System . i ype: (systems can be ranked in order of yeur preferenc$)
��ornerrtior�al _Modifled Cornentlonal _ Aitemative (nnovative
Other (sP�Y)=
CL�ARLY STAKE ALL CORNERS AND L1NES OF THE PROPERTY.
STAKE THE CORNERS OF'ALL PROPOSED STRUCTURES.
PLE�►SE ATTACH SURVEY PLAT OR SiTE PLAN TO THIS APPLCATION
�i�Q 4
i hereby make appGcation to the Person Caunty Heatth Departrnent far a site evaiva�on for the an-site sewage disposal system for
the above-described property. i agree that the conterrts of this appiication are true and r�epresent the ma�dmum faa�ties ta be
piaced on the property. I understand if the site is altered or the irrtended use changes, the permit shall bemme invalid. I understand
that as applicant, I am responsibie for identifying and marking property lines, comers and making the site accassible for the
personnei of the Persan Courrty Health Departmerrt to condud their evaluations. I understand that I am responsible for notif}►ing the
Heaifh Department if property contains arry wetlands as designated by the Army Corps of Engineers. �
• � 3�7-�(
Owne or al Representative � Date
PCHD. rev.10J12199
Tan Map #:
, _... ppPlica�
. . .. ; _ Locatlore ,
PERSOid C�UNTY EiVVIRONMENTAL HEALTH
�;�:�=='1�
��I�
New • Addition _
# of OccupaMs D r�t 4X
Projected Daily Flow: �
Proposed Wastewater
Proposed Repair.�
er
PIN
Phasel5ectton LotS
Improvement Permit
, 7ype of Structure � /t��� - _ Water Supply �" `
___ ��
�# f Bedrooms � Other System Typ�
, g.�,d. ��ermit V�lid For. �-Five Years ❑ No Expiration
PeRnit Conditions: ��e S � � �T7 , � �
Owner or Legal Representa 've ignature: x� Date: � s�—� /
Authorized S#ate Agen� �� � Date: ��'� l
The issuance of this pertnit by the Health Dep�rtmerrt in no way guarantees the issuance of other peRnits. The permit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if
the siie plan, plat, or the intended use changes. . The Improvement Permit shall not be affected by a change in ownership
of the site. This permit is subject to compliance wiih the provisions of the Laws and Rules for Sewage Tr+eatment and
Disposal Systems of the North Carolina Admantstrative Code. �
Wastewater System Description:
Z UtGL
WastewaterFlow. � .p.d. Type: '�'�-`
Facility Description: "C $ �- New� Repair C� Expansion ❑
Basement? 4 Yes �.�lo Basement Fixtures? � Yes o --
Wastewater Svstem Requirements
Tankage: Septic Tank size �U gal. Pump Tank size � gai. Grease Trap size gal.
Trenches: Totai length 3� R. Trench Width � ft. Total Anea � sq. ft.
Max. Trench Depth: � in. Aggregate Depth:,� in. Soil Cover.� in. Trench Separation �ft. on center
Permit Expiration Date: lU ��� 0�
Authorized State Agent t Date: l5� ��� t .
'See attached site plan and addendum pages fo� additional permit conditions.
The type of system permiibed a does O� does differ from the type specified on the application. 1 accept the
specifications of this_permit ,
Owner/L.egal Represerttative Signature: Date:
6-�ra�
�ueration Permit
System Type (in accordance with Table Va)
This system has been installed in compliance with applicable North Cawlina t3eneral Stahrtes, Laws and Rufes for Sewage Treatment
and Disposat, and all conditions of the Improvement Permit and Constntction Authorizatlon. tssoance of this permit implies no
guaraMee that the sysbem installed wip iunctfon properly for any give� period of time.
Authorized State Agent Date
, PCHD, rev. 03/07/01
� ' ' . Applic�tlon �:
� � � . Tax Wl�p i: 2
. � P�rad �!:
� panon Countyl H•.Ifh Daparlmant , � � �
Environm�nhl H�alth Sec�lon
. � ' � � 81TE SK�TCH..
� �
� , plloant'� Name • �� SubdlvldoNBeotioNLot�
' Aut dzed tds nt Da s. • �
S'ysfpn oen�ponnqs r+�raeM �pPrarlma►i o°ewurr on(y. 7IIrt contrncfot mur! flal Ait syitain
' . prlor to b�we/wt fA�:IAdA'UAIIOM IO IAJWY (hR�DMD/l tM(�il � fIN1IlIGIIpt(L
�
r
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soa�e•
w..��� �.. Af�/Aq/00"
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Tax Map #: �a �
'����' )� �������d. � .. . ' � . .
.�= •ay .
� � �^ �. `\✓:���•��
]E�-�s��,�,n, ��¢.�.➢: IEiC,o.�.Il�
Parcei #• � � �1
Zoning: Townshlp: '
Subdivision: � Section: Lot:
Applicant: m�l'K �rrimcr''�
Location: e�cr� j L�Cc rr � d'
�peration Permit
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTH T N. -
11-9-��
A thorized State Agent Date
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'�1 - PTS ,00�
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PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SE�E A�'i'ACHE� PLAN FOR WEi.L SITE LAYOUT
Tax Map #: l� � � Parcet # � " �
ZoNng Townahip .. _
/U�ark �.-��n.er%
nPP��x . n
LocaUon• `�" "`" `���
Subdivislon•
SecUon• Lo�
Well Permit '
Tyae of Water Suaalv: Individual Community Pubiic
Reauirements•
Site Approved by -�d -o�
Grouting Appr ve b
Weil Log - � ,
Weli Tag
Air Vent �--s - �z-L�-
Hose Bib c�� �-�z-�-
Concrete Slab �/;�
Well Drilier:
Vlfell Approved By:
Date: 1- 22-� I
**See Attached Site Sketch**
Wells must be 10 feet from property lines. �,�
���ells must be 100 feet from septic systems. �
ells must be �at least 25 feet from any building foundation.
Other conditions:
PCHD, rev. 11/29/99
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