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Bacteria ~ Chemical Petroleum Pesticide _ Lead
. Permit requested by: . 7. Dimensio,�ns; r Proposed Structure:
wner/prospective owner/agent: � ��'� �''' S N�4�.% Width:
�ddress: ,..� � 8 N-� � E 0 f�t�� � Depth: � 0
(��, X Q a v � d n G 1 � S 7 3 8. W h a t t y p e ( i f an y, additions, ex pansions, or
re placement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
ome Phone #: �5 S - b'a �y
usiness Phone #: .�59-�13)
Name and addre�s of current owner:
_S.i4-vy? C�� ✓gS r4 ad U �
Tax Map#:�
Parcel#: � �
T.......oi,Ir.• . - _ in
ion: Lot size: �
� �i .._ _
9. Water supply t} pe:
private �j . public ❑ community ❑ spring �
Are any wells on adjoining property?Yes ❑ No �.
�If so, identify location:
,��4 ��Re
: �- "�- l0: Type of structurelfacility Proposed: �Existmg: Q-�
-- ._ . ___�. �--. ._ _.
_ ___ __. __ _._._ ._._. __ __ _...
_ Type of dwelling:4 �
,
__House, � _Mobile Home: L� Business. ❑
_ __. _ ...—. .
__ .--- _ ._ . . _ __. . ._ ._ ..
— Type of tiusiness: u� � ' `
, Directions to ro ert : State Road #& Road � �
- P P y Number of Em lo ees: �"
�ames,�tc. _ --. _ P Y L'�----.. --
- ` Number.of bedrooms: � `' ` F' : : :
` . . ' S. � �e S /�z S Tone 1ti�A�c'e �T:: �
. ,__...._ � �_ Garbage�Disposal?Yes[� No� ._..__ _
(',, o� prza �. o? � �/PS To o/dNti � d o� �ement? Yes ❑ No �f so, # of basement fixtures.
Ke Rr f�fT- U hKd��J�w '��L �d�teo�/-�u:�T , :
__'
6.' Number of occupants or people'to be served: '� �� �'�'"`
_.
� CLEARLY STAKE ALL CORNERS OF;THE PROPERTY AND THE CORNERS OF ,ALL ,:
� : :�_
' � PROPOSED_�RUCTURES._ __
, ___ -- - ----- .._ _ ..----
- - - ___ - --- --- ----- - . _. _
I hereby make application to the PersOn COunty Health De�artment for a site evaluation for:the on site . i
��_.. g _� �P _ _ _ y , , .
sewa e dis osa l s stem foi t he a b o v e d e s c r i b e d p r o p e rt y= I a g r e e t hat the-contents of this a pplication are true .;
� I understand if the site is altered o'r the -°- `' �
and represent the maximum facilities to be placed on the property; '
: --- ,
intended use changes, the peimit shali become invalid: I understand thatbefore an Im rovements Permit.can. e
P
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 ihe Health De t. within 60 DAYS after the date of the evaluahon of �
.__. . _ _ _.P . __ . _.. P � - _ _ _.
the site by the Health Dept., this application shallbecome yoid.. nd all fees a�d forfeited _ _
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Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
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Signature
Date
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STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� ,.. , C:VIMIPR0IDOCS�APPSECSM FWANCEPC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT 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 # n ��
Owner/Contractor
Location/Address
Subdivision Name
Parcel # � � 2
Township 0�,�/ e l; i 1 �
_� ��_�� Date_ � - I �- �% �
� �'L�#- �./ � 2 -�,, S�� // 6 3
S.R.#
Lot#
SEWAGE SYSTEM SPECIFICATIONS
� Repair Lot Area �3, %�r.cvt s
SFD Mobile Home_�
Business # of Bedrooms�
�
�
v Permits may be voided if site is altered or
� Well and Septic Layout by /
a Comments:
Date 1 �l - 6
Well Permit
Individual
Public
Sit pprove
ell Head A
Grouting �
Comments:
Date / /
-� Installed by.
WELL
Semi- lic
Size of Tank�
Size of Pump Tank
Nitrification Line�
Max Depth Trenches.
ed
S� f !:► i�r..•• fi�,.- �
�'M SPEC
equired
Air Ve
R ired
ell Tag
�pproved by,
vrho,.,�,
c'TIONS
S1
Well Log _
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 in the future or that the water supply will remain potable.
c:\amipro�permit.sam O1/95 rev.l.l
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: � 9 IlVIPROVEMENT PERNIIT #:
TAX MAP #: PARCEL #: Z
OWNER/OWNER'S REPRESENTATIVE: �%r'��i'R r''1 S� �- W
LOCATION/ADDRESS:
�� 5� s� 1� �-s�f� �/�3 �'��,'���-����
.
SUBDIVISION NAME:
SECTION OR BLOCK:
LOT #:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit # U� . The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4
Y�
ti�
Person Requesting:
V'P VI� otJ
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S�I�`'� �� �t t r A 0� 1 O 1 4
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. PERSON CO HE TH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � � q Parcel # �
Zoning Township � f�,Ve �l
Owner/Contractor � r l �i w� � � c Date � - /� ��:
Location/Address �1 � -f� S I � � � � � � ��
s.R.# I C� � �/
Subdivision Name
�
r�Yout
1�o b'�C 3 �
-Gvl(a w °
v�l Lo��Y
S
I �� w�-�
,� ��-,, ,� c s r�� i r��
Lot#
SEWAGE SYSTEM SPECIFICATIONS
E�epair Lot Area�S?
SFD Mobile Home_
Business # of Bedrooms
� �z Size of Tank_�
/ Size of Pump Tank_
�— Nitrification Line
Max Depth Trenches
Y
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if s
Well and Septic Layout by
Comments:
Date
Installed by��
y� WELL
Indivi ual mi-Public
Public Replaceme _
Site Ap ed
We ead Approved
outing Approv
Comments: /
Date Installed by
,,..��-,. Approved by_
PECIFICATIONS
Requ' d Slab
� ent
Required Lo� _
Well
Approved by
vr;— ��p
�� /
Tivs repoR is based in part on infonnation p: ovided the homeowner or his/her representative in the application submitted for this pemvt The
environmental health specialist is not responsible for false or misleading infortnation contained in the application. The environmec�tal 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 in the future or that the water supply will remain potabler c:lamipro�petmitsam Ol/95 rev.1.0
Pers�n County Health Dept
Amount paid �S��.U� 325S.MorganSir��t
R e c e i p t. OI ' � OS y. � Roxbor0, N.C. 275?�
Cot�rier'�02•33-15
` �� ��� APPLICATIONFO�tSERVI
��i�.b; sir� '�'r � �-.R.: ♦i � x" S .i 3s�+ �1 !� e!S' � �;i�c a 7 ,. R w y+�ht .f'd.' � a.'1i� 1°t�x '"d`,�y' SLS�.9�Y � r �.::'�
.� * : � 3 0 - � x s . ,v,af �c � �:r
.
e.�t�s;�a�.s ) Y t t `�'�° z ,`3�.' .�.�x '" f��� +r� .Serv�ces.Reques�ed �' >.
. �; <>`�r�,�..,5 ,�..:�4. . , t..;:� .,",{a.... «itS.w'E... �.>..a. t..,... =:Y z�r..or,.:,,......:,_.-...c.5. >.»..—.a,.o�...�. ..,,:�.
_ Improvements Permit. (EstablishedlRecorded Lot) _ Reinspect
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of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot) �_ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) Pernnit for New Well
Improvements Permit (Addition) _ Replace Existing Well
l. Permit requested by: .
�wner/prospective owner
Address: .S`"S�' b�i��
Home Phone #: 3
Business Phone #:
S
-3t 3
7. Dimensions r Proposed Structure:
� ll iA� -S� �� Width: �£� ��
� Depth: ��i�
Lu, � , ecs
;� 1"0 �M �o �'
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage�isposal system is intended to serve?
2. Name and addre5s of current owner: 9. Water supply t�pe:
.S'�vW� A--$ /� �d vQ� _ private �public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes�No [�.
If so, identify location:
Property Description: Lot size: 0(�3•
. Tax Map#: �
Parcel#: �� �
Township: O�-� �� l-� i l.l,.
. Directions to property: State Road #& Road
mes,gtc.
S.
c o�
1
Number of oc
t`� S �h e. RdQ
� f i.+cpc„ C ao �
GNI,' .
nts or neople to be served:
10. Type of structurelfacility: Pro osed: DExisting: Q
Type of dwelling:
House: ❑ Mobile Home: Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No�f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF AL�L
PROPOSED STRUCTURES.
I hereby make application to the PeI'Son COunty Health Department for a site evaluation for the on-site
se�vage disposal sys[em 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 propercy to the Health Dept. I understand that in the event I have not
delivered a survey pla[ 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 an�ll fees paid forfeited.
�
Signcc� Owner or t�uthorized Agent
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IN�ROVEMENT 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 # Z.Q Parcel #
Zoning __ Township �; J� (-�'; ( �
Owner/Contractor
Location/Address LI �i' S TI �%Y�SI�e.� 5-�-� nP�UO �/�
� 55�
Subdivision Name Lot#
-tG—
SEWAGE SYSTEM SPECIFICATIONS
Lot Area alo. Od �QEi'
Mobile Home
# of Bedrooms ^1"
-'7-
Permits may be voided if
Well and Septic Layout by_
Comments: N � C' �
Date
is altered or
�
Size of Tank �a�',cQ �.•(.C�¢.( ��.LG(
Size of Pump Tank
Nitrification Line '35'�C3'
Max Depth Trenches �O"
��-f �00��(�. (�,�h'lSa�
nded use chansed. .
Installed by Approved by
ell Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
iividual � Semi-Public Required Slab _
blic Replacement Air Vent
Site Approved
Well Head Approved
Grouting Approved_
Comments: �Q� .�
Date
Installed by
Required Well Lob
Well Tag
Approved by_
�
��L
This report is based in part on i�formation 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 stateme�ts 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 in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l