A29 205A 'iication Date• `• l5���
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Ama�urit Paid: �'p � � 5'2� ic S �a ��
Recei t #:
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Person Countv Health Deaartment
Environmentai Health Section
APPLICATION FOR SERVICES
Tax Mao #•
Parcel #: '
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFlED CHANGED OR THB SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID
1) Pertnitrequeatedby: {Ownedagentlprospectiveownerj: FI^a�k(�,� .�_ 1�e�;uY i
Home Phone: ;5'� q—�3 � Address: � 0 v►�r �u '�CQ.;� ���t
Business Phone: o}c v ro t �-
2) Name and address of currer�t owne� `� Q'� �- ��`��� ��� C ��`' 7
�ed��_ t � ��
�-�. ��S
3� Property Descriptton: �t �: � T�: � g �+sl,y �� r�� c�" � � �
Direc�ions to the property Induding road names and um ers): � 9 S C�-O n� ��,� ���
_ ` eu, � S �,�. C�,i�. 'Rai-�
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4) Proposed Use and Structure Descriptlon: answer each of the following questions:
a) Proposed�Existlng �
b) Stldc Built �, Modular �, Single Wide �, Double wd�
c) Number of Bedrooms: ,� � � Number of occupants or people to be served:
e) Basemer� Yes �, No�f yes, # of basement fixtures: •
� Garbage Disposal: Yes 0, No ❑.
g) Dimensions of Proposed Stnuxure: Width: � Depth: ��
� Waier Suppiy Type: Private�(new 0 or e�ds�ng 0), Public ❑, Community 0. Spring �-
� Are any welis on adjoining property? Yes � No 0 If yes, bcadon
6) Please Indicate Desired Systom Type: (sysbema can be ranked in order of your preferencs)
�Carnecrtional �,Modified Conver�tional _ Aiternative Innovative
or�e� (specjiy):
CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTlJRE3.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLlCAT10N
I hereby make applica�on to the Person Caunty Heaith Depa�tment for a site evaluation for the on-site sewage disposal system for
the above-described property. I agres that the conterrts of this application are true and represent the maximum faa�ties to be
placed on the property. I understand if the site is attered or the irrtended use cl�anges. the permit shail become irnralid. I understand
that as appGcant, I am responsible for identifying and marldng property lines; comers and making the site aa�ssible for the
personnel of the Person Courrty Health Department to condud their evaluations. I understand that 1 am responsible for notifying the
Health Departrnerrt if my property contains any wetlands as designated by the Army Corps of Enginesrs.
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Owner Legal Representative . Date
PCHD. �. �a�uss
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Tax AOap Ik — — -- -�" � -/ P�rcal � Q .
- ZoNng TawnsWp �'�
" �P�� �• v� � p e�l �G. �'IUk.n.A..Ss
�n: ` C � . � �e � w�n � ��' �
subahru�on: r�,.tKli sxucn: �.�_
� Improvement Permit
A buildina aermit cannot be issued with onlv an Imarovement Pennit
New,�Repair � Adddion _ Type of Strudure� Water Suppiyr�Q �� �
# of Occupants �� # of Bedrooms 3 Other — • .
Basement? -~ Basement Fbdures? � �
Projeded Daily Flow: 36 a g.p.d. Permit Valid For. � Fve Years 0 No Expiration
Proposed Wastewater System T : l.�'�1'ev�'� ��
Pump Required? Yes � o
Permit Condi�ons: �-� �� � 5��2� C �,
Owner or Legal Represen tive Signature: Date: ��`�. � � G d
Authotized State Ager� rv� vv�� Date: � I` Z2'li'�
The issuence of this perimit by the Health Departmerrt in no wsy guarantees tha issuance of othac pemiits. The pertnit
holder ts responslble for checking with approp�iste goveming bodies In meating theG� requirements. This utbe is
subject to revoaatlon if tl�e site plan, plat, or the intended use changes. The improvement Perm(t shall not be
affecLed by a change in ownership of the site. This permtt la subject to compliance with the provislons of the
Laws and Rules for Sewage 7reatment and Disposal Systems cf tl�e No�th Carolina Admintstrative Code.
Type of Wastewater System �� �� I W�t�gr Flow: ��9.p.d.
Facility Type: • � � ''�' . New �- Repafr OExpansion ❑
Basemeni? 0 Yes No Basement Fi�dures? 0 Yes �-No
Wastewater 8ttstem Reauirements
Septic Tank Sfze: � L � 8ailons Pwnp Tank Size: �_ 9���$
Total Trench Length: �3 �P feet Maximum Trench Depth: � inches Aggregate Depth:� In.
Maximum Scii Cover. � inches Trench Sepazation: � Feet on Cerrter . �
�La-h�n .
` � d5 �
Permit Expiration Date: � �iZ` �
Authorized State Agent: � f Date: �`�ZZ �
The type of system parmitted ❑ does ❑ does not differ from the type specif[ed on the applicatlon: I accept
the speciftcationa of this pertnit �
OwneNLegal Representative Signature: � �a�= —1-1—=1���
PCHD, rev/ 10/12/99
� .. . ' �
- :; Application #:
, Tax Map #: 2
- � Parcel #: 20 5
- � • Person County Health Department :
Environmentai Hea[th Section
S1TE SKETCH
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� Applicant's Name Subdiv�sion/SectionlL t#
. � j � Zz�cr�
Autho ed State Agent Date
System components represent approximate contours only. The contractor must flag the system ': `.
�rior to beginnin� the instadlation io insure that proper grade is maintained
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�,�5 3 PCHD, cev. 90/1ZJ99
• . ' :. . . PERSON COUNTY ENVIRONMENTAL HEALTH
�° PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: /�f �� Parcei # ����-'
� Zoning — Townahip ��� �" f�
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AppUtanC � T �wl r--�� - � {�
�tio�: - �� �
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Subdivision• c
Tvpe of Water Suaplv:
Reauirements�
;� �l� Y�s
� v �� secnon: � �
Well Permit
�ndividual Community � Public
Site Approved by
Grouting Approved by
Weil Log � �� i 3�
Well Tag 5S � 1 t s� oZ. ..
Air Vent �—� � � -�� �� �
Hose Bib�� 1�-� S d Z-.
Concrete Slab C��S ��-►s oZ
WeU Driller: ,�>�{�'
Well �Approved By: - � �
� (�< 9= C�-���j
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Date: 1 I_ 1 S-- �Z_
**See Attached Site Sketch"`�`
Welis 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. 11/29/99
. . � Person County Heaith Departrnent
� Environmental Health Section
• Ta�t Map #: i�' oi 9/ Paresl #: �o �
Zoning: Townahip: !��'�"1 `��
Subdlvision: ��'� f�N .,/�-• �'ih n 7 Section: �_ Loti 2-
APPiican� �Ko'��� �h h �
Location: � u � � ✓p ��Iv► • �t1,e� �, r�
4pe�ration P�ermit-
System Type (In Accordance VYith Tabie Va): �- �� -
THIS SYSTEM HAS BEEiV INSTALLED tN COMPUANCE WITH APPUCABLE NORTH
CAROLlNA GENEftAL STATUTES, RULES FaR SEWAGE TREATMENT AND D13POSAL,
.AND ALL : CONDITIONS OF THE 1MPROVE�AAE�IT PERMIT � AND CONSTRUCTION
AUTHO Ti . �
-� — 2"� —o I
� Author¢ed Stat ent Date
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PC9�D, r�v. 10/12199 .
PEBSON COiJt3'�Y ENVIItONHENTAL H�ALTt�
WELL LOC
.�a«:�..�._�
Owner. -}�$ �.�E
I.ocation/Directi4ns:
Subdivision Name: _ 'U?��"�(
D�illing Con�actor: .—S
Sl�# '
Lot #,�_
�____
wEL�. carrsrRuc�rzoN v
�istance from I�Fearest Praperry Line ! U Distance from Saurce of
Follution t G o
Total,Depth: �. � Q Fc. Yie�d:� GPNi Stacic Wacer I.evel��t.
Wacer Beazing Zones: Depth �Ft. � Ft� � FL �t.
Casing: Depth: F7om 4 to��_Ft. Diameter:__�, Inches
T1''PE: Steel • Galvanized Steel -��j—
Xf Sceel, does owncr approve: Yes No
� � WeighL Thiclaness: t� Height�Above Gzovnd:�Inches
T�rive Shoe: Yes_� �___ No _ .
Were Problems Encouncered in Setting chc Casing? 'Yes Pio � �
ZF "ycs" givc r�ason:
G�rout: Type: I�Teat SandlCemenc / CorieTece
Annutar Space Widt�,,_.,, �nches � �
Water an Annular Space: Yes � No
. . M�thod: Purnpea Pressure � Paured �' . . . . .
Dcpth: Fxom 4 :o� Ft,
Materials Used: No. Bags Portland Cemenc Weight of .X ba�,_lbs.
�f mixture (sand, gravel; cuttings) - Rauo: t�
ID Plates: Xes � . No � � �
� 4 x 4 slab Xes i� No
T H�REBY CERTi�Y THAT THE A,BOVE ITIFORMA'iTON IS CORRECr' ANp THAT
T�$ W�LL WAS CONST�tUCTED �N ACC4RDAIVCE �VITH REGULATIONS SET
FORTH $Y� I HE PERSO� C�ui�I"I'X HTALTI-� DEPARTMENT.
f' I� ~ t C� �_ �_
gnacurc of Contraccor Da:c
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