A29 241��npii��r,�o�, Date: —rlv — � 56?c�
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ApPl.ICATIOM FOR SE�RVIC�S
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impravements Pemiit (Recotcled Lot) - 5200.00 ❑ Well Permit (New/ReplacamentJ- $225.00
lmprav�em�n� Permft- $150.00 0 ConstrucSon AuthorizaSfan tor SapOc Systems-
{1v3nb�ie Hame Repiaceme�fAddition} $150.001$200.QU
Exi.Sting
Pertnft Revision f
•�) F'e��nih recquestad L�y; (Owre�rlagenfl�rospeciive owner): �N `?��
Horr:�, �hon+e: � Address: 3�0 11
BL:;!t"lBSS Pl101i�: � ^ � S
:2) Narri�.� and a�d�tr�ss o� curren8 owner: .6'���1'1 � _
3) Pra�a��nty ilesr.a�i�taan: Lat size: �r'�- Township: ' e ��
OuEF�ciians #o th� pr+op�rty (lncluc3ing roatd njames and numbers):�''
-1"`�, ,'Y� i�P ti' .�S E/ n N f 1% I.SI fl it !7 //1 i� I
�i�rm
5�v � / e.- Lot #�
4) �'rupused Us� an� Siructure bescriptic�n: answer�ach of the foilowing questions:
a} !�>r�pposed ��! Existing ,�, Type af. Structure: �s i��-�i�i4- ) Width: Depth:Y
b) rlumber of Hedrooms: _� Number of occupants or people to be served:
c} B.as�ment: .Yes _. Nn � Will there be plumbing in the basement?
d� �ar�age Disp+osat: Yes ____, No �,
5} lAP�u9or Su�aply Ty�e; Private. �(new ,� or axisting,�}, Rubfic„�, Community_, Sp�ing „�
A�� any wells on adjoining property? Yes� No � 1f yes, please indicate approximate (ocation on fhe
'�site piari.
B) Dra�,rs yaur �ro�erty coontain preuBousiy identIIfied jurisdlctionat wettands? Yes� No r/�
PL�►�sE AIOiE THE F0l:LC)WING:
9 9�► PL�1T �!F T�IE �ROP�RTY OF� SITE PLAPI NiUST 8E SUB{fflITTE�D WIT�t THIS APPL9CAY1�Di�.
➢$��ROPERYY:.LINES �ND CCJRNERS MUST BE CLEAR�.Y MARKIED. �,
5�i'�i� PR�P(3SED LOCATIOM OF �1LL STRUCTURES �lIUST 8E STA1�D Oi2 FU�►GG��.
�.�'HE SITE� �IAfltlST BE 3iEADIL`f ACCES9IBL� FOR Afd EVALUATI�M BY THE �iEALTH DEPARTIiAEs'VT
:iTAFF.
I he�E:::r;� make applicafiorr fo th� Psrson Ca�nty Heaith Department for a site evaluation for the on-site sewage disposai
syste��n for ttte above=described praperty. 1 agree that the contents of this application are true and represent the maximum
fac9fitiE�:� to be piaced �an the property. ( understand if the site is aitered or the intended use ct�anges, the perm+t shaU
oecoPr��: ;nvalid: % �' .
ar
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Date
PCN�, re�. as�27rox
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S�ubd�ivi,s�i�an � � � �
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Improvement �ermit -
��rmit Valid for � 've i� _ No ��piration �e� %
Type of Facility: � New �Addition �Vater Suppiq �
# of Occupants o� # o edrooms Projected Daily Flow � g.p.d. ,
Proposed Wastewa er System: `?1�-ca � Type:
Proposed Repair: � Type: ��=4
Permit Conditions: �P�P S/� � ���f ^%C��1
Owner or Legal Represe
Authorized State Agent:
uaze:
Date: � f>
The issuance of this permit by the Health Department in does not guarantea the issuance of other permits. It is the responsibility of the
a�rplicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requiremenb are met This
Improvement Permit is subjetf to revocation if the siie plan, plat or the intended use changes. The Improvement Permit is not
affected by a change in ownerslup of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Itules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmental Health Specialist warrants that the septic tank system will continue to function satisfacton7y in the future or'that
the water supply will remain�potable. �
Authorization to Construc# Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_ j. �
Propo Wastewater System: \,o(��(b`�o1� � T�pe� Wastewater Flow 3��.p.d. .
New� Repair Expansion _ Soil LTAR: •�� g.p.dJ ft 2
Type of Facility: �� �� - Basement _ Yes No
�astewater System l�ecyuirements
'T�nk Size: Septic Tank: � gai Pnmp Tank: gal Grease Trap: gal
�rainfield: 'Total Area: �_F O sq ft Total Length �� ft � 1Vla�mnm Tr�nch Depth � in
Trench Width � ft Minimnm Soi� Cover: � in Minimnm Trench Separation: � ft �• C•
�istribation:
� �istribntion �og
�, Serial �Distribntion
Pressure Manifold
Authorized State AgQnt: �
Permit Expiration Date:
,The type of system permitted is �, Conventional Accepted Alternative. I accept the specifications of the
P��
Owneejrr/I,�gal �epresentative: Date:
• PC� rev. l l/10/OS
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N�am.e 11J' `N�S "� Tag .. # A�� Paxcel #��
Subdi '' n �S�t` • Section�%I.ot# 1�
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Authorized St�.fie .Agent • . Date .
°• Syst�ssr com�ionents �prgse�t a�pmarima�e �con�ours only. The contrutctor �rust, fTag the system prior to
beginning the imstallaiwn to insure #�at propergrade i.r maintaimed °:
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WELL PERNIIT -
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map � a� Parcel # � � Township:
Applicant• �2 '
Subdivision: ' r/�-i Lot # �O
Location:
Type of Water Supply: � Individual _ Community
Requirements:
Site Approved By:
Grouting Approved By:
We1T Log:
Pump Tag:
Well Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Well Approved by:
****See Attached Site Sketch****
Public
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