A29 183Apaiicatlon Date: �'� �7"���
Amourrt Paid: T�
Rec�ipt#: �
Tax AAaa �- �� �
ParcEl �: � g -j
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APPI.ICA710N FaR SEiiVIC�S �
IF THE INFORMATiON IN THE APPLICATION FaR AN IMPROVEiNENT P�RMR IS INCORRECT FALSIFiED
CNANGE�. OR THE SITE' IS ALTERED. THEiN THE IMPROVEMENT PERMIT AND AUTHORlZAT10N TO
CONSTRUCT SHALL BECOME INVALID.. -
1) Permii requested b:(Ownedag�ntlprospective ownerj:
Home Phone: • � 7fl' Address:
Business Phone• �
2) Name and addr�ss of rairrent owner: �� �
5 S�
3) Property Description: l.ot s¢e: . � _ Township: ,��m�� Subdivisio�• Lat #
DirPctions ta the prope�/ (I�udin� road names and�u n,), ,Q rh�G���Zff /1/� f,
4j P'roposed Use_ a,p�Structure DescriQtion: answer eact� of the foilowj�q questions:
a) Proposed 1�, Existing , Type of Structure: S'�G%/,���/L� wiath: � �eptn:
b) Number �f $edrooms: �_ Number of oc�pants or people to be served: _ 7 ��
c) Basement Yes . No ��it th re be plumbing in the basement?
d) �arbage Dispasal: Yes . No �
5) Wa�er Suppiy Type: Private �,�(new _ ar existing„�, Public_, Cammuniiy , Spring _.
Are any wells on adjoining property? Yes �' No _ if yes, piease indicate approximate lacatiori on the
'siie pian. ,
6) Does your property carrtain previousiy identi6ed jwrisdictional wetlands? Yes_ No �
"- PLEASE NOTE THE FOLLOWING;
➢ A PLAT OF THE PROPEiiTY OR SiTE PLAN MUST BE SUBMITTE� WITH THIS APPLICATION.
➢ PROP�iZTY LINES AND CORNEiZS MIJST BE CLFARLY MARt�. •
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAi�� OR FLAGGED.
➢ THE SiTE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEi�ARTAAENT
STAF�.
I hereby make appiication to the Person CauMy Health Department iar a siie evaivation for tt�e o�-siie sewage disposai
system for the above-des�ribed property. I agree that the cantents of this application are true and represent the maximum
faciiities to be plac�d on the property. I understand if the s�ie is aitered or the ir�tended use ct�anges, tfie permii shail
became ipvalid. /1 n _ :,
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-17-0 �
Date
PC!-iD, rev. 061271U2
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Tax M�p �- Farcel # •
S��hclivi�s�ion
Fh��•se Sec�t�ion Lot #
Permit Valid for %� Five Years
Type of Facility: � P'
# of Occupants # o Bei
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Owner or Legal Representative i
Authorized State Agent:
Improvement Permit
_ No Expiration
; New � Addition Water 5upply �i%ef�
----- P' t d Dail Flow �Co� g p d
l�(,�, (?rLiu�
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ro�ec e y •
Type: � Q
Type: �---
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Date:—��--
Date: !a v� �
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 Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstents' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to functlon satisfactorily in the future or that the water supply will remain
potable.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_).
Proposed Wastewater System: �. ►�zt�P Type �q Wastewater Flow � 6� g.p.d.
New Repair Expansion Soil LTAR: , 3� g.p.d./ ft 2
T y pe�Facili t y: 3�l: ��S• Basement _ Yes� No
Wastewater System Requirements
Tank Size: Septic Tank: �DC� gal Pump Tank: gal Grease Trap: gal
Drainfield: Total Area: 26� sq ft Total Length Oe7 ft Maximum Trench Depth .� in
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: �_ ft�• C•
Distribution• � Distribution Box �Serial Distribution Pressure Manifold
Specifcations: �� S� � ��
Authorized State Agent: �/ �
Permit Expiration Date:
'The type of system permitted is � Conventional
the permit.
Owner/Le�al Renresentative:
Date: �� —6� 7
Innovative Alternative. I accept the specifications of
Date:
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Sub ' ' io
r
tluthorized State Agent
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Taa Map # �-� � .Parcel # 1�'3
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Section/Lot#
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Date �
sy� ��o� „�,��r �op�� ���u� �ry. 1'he contractor must. fTag the system prior to
beginning the i��on % insure that propergmde is srusintained �
/• ��COUNIKT tlKUUKC CJIHICJ" /
� � P.C. 4, P. 17
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map il ��1 Parcel #�'g� Township:
Applicant��Ar ry W �� Qi�
Subdivision: Lot #
�
Type of Water Supply: ' C Individual _ Community Public
Requirements:
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:
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:
Date:
PCHD rev O1/27/04