A29 207� � .� �5��'�
� , A�oitcation Date. �,
Amaunt Paid: ' sd'��s� � S �a ��
: Recei t #: .
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Person Countv Health Department
Environmentai Health Seatton
APPl.ICATION FOR 3ERVICES
Tax Mao #•
Parcel #:
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 18 FALSIFlED. CHANGED. OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID
1) Permit requeafied by (Ownedagerttlprospective owner): F�'a� k 1�� /� . 1� e�! u�/' j
Home Phone: :5� � q— �3 ' f� Address: 3 0 v� �- u�-Cu�;,� ���`
Business Phone: �� d ro �
2) Name an d a d dress a f currertt ownec
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3) Properly Descrlptton: �ot s�ze: � Townshtp: � y
DirecNons to the propeRy Indudi�g road names and um ers): � 9 S GO A�
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4) Proposed Use and Structure Description: answer each of the following questians:
a} Proposed�Existing �
b) Stldc Built �� Modular �, Single Wide �, Double Wid�
c) Number of Bedrooms: ,� - � Number of occupants or people to be sen�ed:
e) 8asemerrt: Yes ❑, No�f yes, # of basement fixtures:
fl Garbage Disposai: Yes a, No ❑
� Dimensians of Proposed Strudure: Width: � Depth: ��f
� Water Supply Type: Privatei�(new ❑ or exis�ng ❑), Pubiic ❑, Communityr O, Spring ❑
�. Are any weAs on adjoining property? Yes � No O If yes, bcxtian
6) Please Indtcate Desired System Type: (systems can be ranked in order of your preference)
�Comrerrtfonal �,Modified Converrtionai _ Altemative _Innovative
Other (specifY):
CLEARLY STAKE ALL CORNERS AND L1NES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLlCATION
I hereby make applica�on to the Person County Health Department for a site evalua�on for the on-site sewage disposal system for
the above-descxibed property. I agree that the cotrterrts of this appllca�on are true and represent the maximum facilitles to be
placed on the property. 1 understand if the site is altered or the intended use changes� the pertnit shaU become invaUd. l understand
that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
personnel of the Person County Health Department to condud their evaluations. I understand that I am responsible for notifying the
Health Departrnent if my property contains any wetlands as deslgnated by the Army Corps of Engineers.
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Owner Legal Representa�ve . Date '
PCiiO. rev.10H2199
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Townshtp r
Zoning , .
�►PPIkaM:
t.ocatlon:.
.g6Gti011: ��
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` Improvement Permit
A buildin� uerrr�it cannot be issued with onlv an Improvement Permit
New �epair _ Adddion _ Type of SUudur+e�� Water Suppl�r,�,Q (� .
# of Occupants � # of Bedrooms � Other — • � ,
Basement? � asement F'ixtures? � .
Projeded Daily Flow:�� g.p.d• Pemut Vapd For. �Five Years ❑ No Expiration
Proposed Wastewate ysterri Type: vl,�ti�� i�
Pump Required? �Yes No .
permit Condi�ons: �"e- � � ��C�
� �� � ct�, �ate: 1( — � � _ o 0
Owner or Legal Representativ� Slgnature: �
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Authorized State Age� �
Date: I I- Z �~�
The issuance of this permit by the Heatth Depa�tment in no way guaranteas the issuance of other permits. The permit
holder ts responsible for checking with approp�ta goveming bodies in meeting thelr requfrements. This �dte ts
subjeat to revocation if the site plan� plat, or the Intended �se chan9es' The ImNrovement Permit shall not be
affected by a change in ownership of the site. This perm[t la subJect bo compliance with the provisions of the
Laws and RWes for 3ewage 7reatment and Disposa) Systems of the North Carolina Administrative Cude.
Type of Wastewate� 5ystern(�L1tre�
Fadtity Type: � �R � �'
Basement? C] Yes '�o
Wastewater Flow: ��.p.d.
New�l- RepairOExpansion❑
Basement Fi�dures? C] Yes �d No
Wastewat�r 8vstem Reauirements
Septic Tank Size: U � gallons Pump Tank Size: ►� � ! 9�lons
Total Trench Length: �� feet Maxlmum Trend� Depth: Z�- inches Aggregate Depth:� In.
Maximum Soil Cover. � inches Trench Separation: � Feet on CeMer .
Other. �" `��y � �
Pertnit Expiration Date: lI ZZ—ZciaS ��
Authorized Stete Agent: � �,� � � � Date: - ZZ`�
The type of systsm permitted Cl does (] does not dlffer from the type speciffed on the applicatfon: I accept
the speciftcatlons af this permit '
Owner/Legal Representative Signature: ��A � Dats: <�L -Do'
PCHD, rev/ 10/12/99
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SITE: S�K.�TCH
Name i�t �1 C�+
Su 'visio �� � b � �
Authorized State Agent
Ta.x Map # �� � Parcel # ��
Section/Lot#
�n` ��
Date
System components represent approximate �contours only. The contractor musi, flag the system prior to
beginning the installation to insure that propergrade is maintained
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PCHD, cev. �Q/12199
• ' • PERSON COUNTY ENVIRONMENTAL HEALTH
'.` PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
• �Z°� 2D''1
Tax Map �: Pareel #
ZoNng Township ' � �
Applica� I�
,.�tlon: S• fi � �( � � . �'l�. ` C� ./ ��
N � w `' /f /M,1 �nw i. /`Pi►n.O r�i ({in {�1 � 1
Tvpe of Water Supplv:
Reauirements•
Site Approved by
Grouting Approved by
Weil Log
Well Tag
Air Vent
Hase Bib
Concrete Slab
Well Drilter•
Well Permit
�ndividual Community � Public
Well �Approved By: Date•
**See Attached Site Sketch'"`*
Weils must be 1 Q feet from property lines.
Welis must be 100 feet from septic systems.
Welis must be at least 25 feet from any building foundation.
Other conditions:
PCHD, rev. 11129/99
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