A28 201Auaiication Date-S��_� � Tax Maa #:/-1 O� �
Amount Paid: y�0� (%� parcEl #:
Receipt #: �
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APPLlCATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED THEN THE iMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. -
1) Permit requested by: (Owner/agent/prospective owner): Deborah M. Bowes, et al,
Home Phone: 336-599-0770 Address: 17 B a oc airy oa
Business Phone: 336-597-2251 Rogboro; NC 2757.
2) Name and address of current owner: Deborah M. Bowes, et al,
1714 Blalock Dairy Road
Rogboro, NC 27574
3) Property Description: Lot size: 1 ac. Township: Olive Hil�ubdivision: Lot# B
Directions to the prope►-ty (Including road names and numbers):
4) P'roposed Use and Structure Description: answer each of the following questions:
a) Proposed � Existing J Type of Structure: Width: Depth:
b) Number of Bedrooms: 3 Number of occupants or people to be served:
c) Basement: Yes , No R Will there be plumbing in the basement?
d) 6a�bage Disposal: Yes � No g
5) Water Supply Type: Private %(new % or existing�, Public� CommunityJ Spring _
Are any wells on adjoining propei-ty? Yes X No _ If yes, please indicate approximate location on the
� site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No g
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLlCAT10N.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED; �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAlCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department fo� 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 o� the intended use changes, the permit shall
become invalid.
` , �
Owner or Lega� Representative
OS/21/2004
Date
PCND, rev. 06/27/02
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Tax M��p � � ` Parcel # �
Suhtlivi,s•ion ; '� ��
Ph�a�se Sec�t�ion Lot # =
Applicant: ��e►�lc�,� �c�,tteS —
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Permit Valid for � Five Y
Type of Facility: —�
# of OccupantsM�i� # of
Proposed Wastewater System:
Proposed Repair: v(,V�
Permit Conditions:
Owner or Legal Represe
Authorized State Agent:
Improvement Permit
No Ezpiration
' New 4� Addition Water Supply ��''
�ooms Projected Daily Flow 3�� g.p.d.
�I,�J2�,�-i — TYpe' �
.► ra, TYPe: .� �
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Date:
Date: '�
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Caroltna `Laws and
Rules jor Sewage Treatment and Disposal Svstenis' (15A NCAC 18A .1900). 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.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan a�:d additional attachments 1_1.
Propose Wastewater System: 1.9��'I�ti�✓�-��� � Type `t'r'� Wastewater Flow ��.p.d.
New � Repair Expansion __ p Soil LTAR: �-�S g.p.d./ ft 2
Type of Facility: �1� ��z- Basement _ Yes 9CNo
Wastewater System Requirements
Tank Size: Septic Tank: �� gal Pump Tank: gal Grease Trap: gal
Drainfield: Total Area: ����sq.ft Total Length `� �� ft Maximum Trench Depth 1� in
Trench Width 7 ft Minimum Soil Cover: � in
Distribution: � Distribution Box K Serial Distribution
Specifications:
Authorized State Agent: __�/d-�C�l
Permit Expira ion Date:
Minimum Trench Separation: ( ft� �C-.
a ��.�
.;
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The type of system permitted is � Conventional
the permit.
Owner/Le�al Renresentative:
Pressure Manifold
Date: � `Z � �
Innovative Alternative. I accept the specifications of
Date:
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Tax Ma.p # Il � g .Pascel #1�
Section/Lot#
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Date
System components represent upproximate �contouxr only. The contr�ctor must, flag the syster�zprior to '
beginning the installation to insure that j�rojiergrade is masntazned
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map Pazcel #
Applicant: '�
Subdivision: 1 �n 5�
Location:
Township:
Lot #
Type of Water Supply: �'� Individual Community Public
Ytequirements:
Site Approved By:
Grouting Approved By:
Well Log:
Pump Tag:
Well Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Well Approved by:
****See Attached Site Sketch****
Liner:
Installed by:
Depth set: _
Grouted•
Date:
Water Sample:
Date:
;�l
Wells must be 10 feet from property lines. .
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD rev O1/27/04