A29 202Arsalication Daie: �—t�� �
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�srson Cauntv Health Department
Environmentai Health Section
APPLICATION FOR SEtiViCES
T�x �ao �. �,� ;�;;
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IF THE INFaRMAT10N IN THE APPLlCATION FOR API IMPROVEMElVT PERMIT IS FALSIFIED. CNANGED. OR THE SITE IS
ALTERED. THEiU THE IRflPROVENIENT PERMIT AND AUTHORIZATiON TO CONSTRUCT SFIALL BECOME INVALlD.
1) Permit requesied by: Owneda�errt/prospective owner): � C<_ �� r l c 1;' <%f� •�
Home Phone: �' '�� � �` ;'��; � �,�'� �° Address: t_/ rP 7 `� � . - � ,� s � , � .- . y ,�` �s 1; �/
Business Phane: �� � .�' `I� � 4� � - ° ^ t �
2) Plame and address of currern owner. �� ti' �f Lc� F= �? � *
1.
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3) Property Description: �ot stze: � ct � Township: � i ��.1�� �� �.� `
Directions to the property (Induding d names and �umbers)• �� 1 e c! �, /� v v��� ,--1-� �_ r�'�� �; ��
�l ,' ; i � t� c � z� v%;!, �'� ..� �"r �- l� ,- r•' _ n f, '
4) Proposed Use� d Structure Description: answer each of the following questions:
a) Proposed E,Y E�Cisting ❑
b) Sticfc Built [3; Modular �, Single Wde ❑, Double Wide 0
c) Number of Bedrooms: � � d) Numher af occupants or people to be served: �
e) Basement Yes �, No ��f y�es, # o,�f asement fixtures: '
fl Garbage Disposal: Yes O, No [Y
g) Dimensions of Proposed Strudure: Width: 1-!< Depth: �7
� Water Supply Type: Private €�(new C3�or�existing ❑), Pubiic �, Community �, Spring ❑
. Are arry wells an adjoining property? Yes ❑ No � If yes, location
6) Ple�se Indlcate Desir�d System Type: (systems can be ranked in order of your preferenc$)
�or�verrtional _Modified Conventional _ Altemative _Innovative
Other (specifyj:
CL�IRLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
ST�4KE THE CORNERS OF�ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURNEY PLAT OR SiTE PLAN TO THIS APPLlCATION
I hereby make application to the Person Caunty Heatth Department for a site evaluation for the on-site sewage disposal system for
the above-described property. I agree that the contents of this appfication are true and represent the maximum faalities to be
placed on the property. I understand if the site is altered ar the irrtended use changes, the permit shall become invalid. I understand
that as applicartt, I am responsibfe for identifying and marking property lines, comers and making the site accessibie for the
personnel of the Persan Courrty Healt� Departrnerrt to condud their evaluations. I understand that I am responsibie for notiiying the
Heatth DJepartrnerrt if my property cor�tains any wetlands as designafed by the Army Corps of Engineers.
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C Owner or Lega RepresEntative Date
%� PCHD, rev.10M2/99
§
Tax Map �i: �?� Parcel #?�� Township Q� IJC rr i,� PIN
pppi[cartt Tn4 W���1 subdivision PhasQlSection lotiF
Lomtlon: �C'��'l 5 ivts� O�:.s'�- �iql�W�.0 la�ra� o,n�
� .
Imurovement P�rmit
New � Addition Type of Structure 3 �*'• �s �o1�`� Water Supply .
# of Occupants # of Bedrooms -3 Other
Projected Daily Flow: 3 6c g.p,d. Permit Vali
Proposed Wastewater System: � n���'�'i o�i
Proposed Repaic C-o nv e � w�!
P6rmlt
�y
f
Sa m�v�
� Five Years ❑ (da
�� -F-��w. �ui'�t�v��
System Type � a-
f�-�S o �. cz,�v,('
Owne� or Legal Representative Sig t Date: ��/` �/ '
i �/
Authorized State Agent: Date: 7'" �� �� �
The issuance of this permit by the Health Department i way guarantees the issuance of other permits. The permit hotder is
responsible for checking with appropriate govem�ng bodies in meeting their requirements. This site is subjeat to revocation if
the sibe plan, plat, or tlte intended use changes. The Improvement Permit shall not be affected by a change in ownership
of the site. This permi# is subject to compliance with the provisions of the Laws and Rules for Sewage �rea�nent and
Disposai Systems of the Nortfi Carolina Administrative Code.
, Authorization '% Construct Wastewater Svstem IReauired for Buildinq Permitl
WastewaterSystemDesCription: < hv��co`►�.� WastewaterFlow: �%� �,p.d. Type:�Q•
Facility Description: ��� o,n� S� �-►1 � New� Repair U Expansion ❑
Basement? 0 Yes�No Basement �ixtures? � Yes No
Wastewater Svstem Requirements
Tankage: Septic Tank size ( �Q(� gal. Pump Tank size �� gai. Grease Trap size � r1" gal.
Trenches: Total length 8 � ft. Trench wdth � ft. Total Area l ao a sq, ft.
Max. Trench Depth: g in. Aggregate Depth:.� in. Soil Cover. 6 in. Trench Separation / ft. on center
Permit Expiration Date: _�� '- 2? '" 0�
Authorized State Agent Date: r��"-� (
*See attached site plan and addendum pag � for additTional permit conditions. ,
The type of system permitted D does ❑ dces not differ from the type specified on the application. I accept the
specifications of this permit
Owner/Legal Represer�tative Signaturs: , Date: v'�` ��
; Operation Permit
System Type Cn acxordance with Tabfe Va) ' �
This system has been installed in compliance wiQh applicable North Carolu�a t3easral S�a, Laws attd Rules for Sewage Treatrnent
and Disposal, and aU conditions of the Improvemer�t Permit and Construction Autliorization. Issuance of this permit implies no
guaraMee that the system installed will functton propedy for airy given period of time.
Authocized State Agent
Date
PCHD, rev. 03/07/01
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P�rael #:
�� Person County Hsalth Dapertmerlt , �
Environmentai Health Sec�lon � �
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Site P+�Qroved bY �✓�"•J..N � . � .
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� Weils must b� 10 feet from pr+oQect�/ lin�. .
We�s musf be 100 feet from septic syst�• �� '• �
Welis musi be at l�st 25 feet fram ac�y. btt�ding fioundatio�►- .
Othe� cx�ad'ttions:
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/� �� Person Couniy Health Departme�t
� Environmental Health Section
Tax Map #: __,�a�' Parcel #• � °� � �
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Zoning: Township: t l��- �'� ��. �
Subdivision: Section: Lot:
Applicant: �a�l 1 W �-S � �P,t . �
Location• S 6 L ` 1� 1�U� ��j��
Operation Permit
System Type (In Accordance With Table Va): � r 1�
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
AUTHORIZATION. _
Authorized
Agent
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Date
Tax Map #: � ��
Parcel #: `� �
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Qu,e,lt
PCHD, rev. 10/12/99