A29 247AppI�G'�� icsrt i72t�:�-l�v-os i ax il�an �:
�mou _F:aid:�# om" oi� �35��. e(.�-Qs) c�-�b�
Rec�' "�..-��Z7� Parc�9 �:
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Impmvertsents
im�3ryts perimi! - $150.00
Home R�placemantlAddEtion)
Zec�es E�cisiina Svstem Pem
dPP�IC�4T10N FOR SERVIC�S
- S2�U.00
��so.oa$zoo.00
Pemtit Revfsioa i
�) P�rrri:'rt r+equ�st��9 �y: (t3�wnerlagen4/prospec�ive owner): ��'��:._[L� � �---
Harc:�. �'hone: � Address: 3�� Ilr� [�
Busir���.,s Phone: ~ �-D �o S
2) N�r��� and address of caarreroft ownar. �$�i�Y�
3�) Prq�;IWr���i,y Descrd�stion: Lot size: cre.. TawnshiP: 'QL,ve l�7�
Dir��c:ti�ns to fi�ep�operty (Inciuding road names and numbers):�
�'r�rm
��, r�� �Qt # l �
4;) pr¢►��sec113�e �n Strcaciure Description: answer ach af the #ollowing ques#ians:
a) f'rc�posed �Exisiing , Type of Structure: ��� i P� i�'-1 Width: Depth:
b) 1�Jwnber. af 8edrooms: _=� Nurnber of occupants or peaple to be served:
c) E�asement Yes ,!�o �; Wili ther�e be plumbing in the basemertt?
d) ��cubage Dispasai: Yes , No. _,
:�) lNauc:r 5u�apfy. iype: Private �(new �, or existing�, Public_, Community_, Spring �
Ar� any wells on adjoining property? Yes� No _ If yes, please indicate approximate location on the
�site plan.
ai} Dacr�;s you� �rog�ePtE� �r��iain g�reviously lden�iiiecd jurisdlctional wetlands7 Yes� No ✓'
1'l.Ed1;iE'i f�1�7� �'i�9E FOLLOVUING:
9.A Pl..a►T OF T�#E l�R�PE�TI OR SC� PLAN MUST 8E SU�MIYTED WITN THiS AP�L9CA'��ORi.
9"I�OP�RTY LlAIES �4PID CORNERS iIAUST BE CLEARLY MARKED. ,
�'Ti�E PRO�'t3SE� LflC.4TlOM OF' �Li, STRUCTURES Ml1ST BE STi�iCED OR �LAGG�D.
9'l'S�iE SITE lUfUST BE 3�EADIL`t ACCESSIBL� �OR At�! EV�1l,UAT10M BY i-!E HEALTH i3E�'AiZTMIEN7
.� t'AF�.
t here����� ��nafie appiicatiorr ta the Persan County Heaith Department for a sEte evaluation for the on-site sewage disposal
:system �o+• the al�ave-de�crit�ed property. l agree that the cantents of this applicatian are true and represent the maximum
�aciliiiewa t�� be pEacet# on thc� property: l unrlerstand if the site is aitered ar the intended use changes, the germii shall
�ecomr•� ir�valid. � �'
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ar L�gak
Date
PCHI�, rev. O6l27102
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Applicant
��rmit Valid for � Five '�eaa�s
Type of Facility: �
# of Occupants f't�z� # of B
Proposed Wastewater System:
Proposed Repair:
T�x 11�a� ' � �rc-ei � • '
Subd;ivi�s�ion
►, � i �
'Fh�:s�e-Sectian'Lot � li
Improvement Permit -
No Ezpiration
��. New i<AAddition Water Suppiy ���
�ms `� � Projected Daily Flow 3� g.p.d.
tJG2� � . Type: CI
r2✓t �i v� _ _ Type:
Permit Conditions: �.� � 'V \ S�`���
Owner or Legal Representative
Authorized State Agent:
i� . -
..- ►'1N��,
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 aIl Person County Planning and Zoning and Bu�ding Inspections rei+»*�+P*+ts aze meL This
�mprovemeut Permit is subjecf to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affected by a change in ownerstup of the property. This permit was issued in compliance with the provisions of the North Caralina
`Laws and Rules for 5ewage Treatment and Disposal Svstems' _(15A NCAC 18A .1900). Neither Person County nor the
Environmeutal Health Specialist warrants that the septic tank system w�71 continue to function satisfacton7y in the future or'that
the water supply will remain�potable. � �
Authorization to Constract Wastewater System (Reqnirerl for Building Permit) .
* See site plan and additional attachments (_J.
Proposed Wastewater System: IUVIII�✓i �!�'(.a � Type�=�-�1 Wastewater Flow�� � g.p.d. .
New � Repair Expansion z Soil LTAR: '�o g.p.d./ ft 2
Type of Facility: , /g� '� S. Basement _ Yes No
�Vastewatea� System Rea�uirements
'T�nk Size: Septic Tank: � gai Pnmp Tank: gal Grease Trap: gal
�rainfield: Total Area: i2d d sq ft Total Length �v ft Ma�mnm Trench Depth � in
Trench Width 3 ft Minimnm Soil Cover. � in 1VI'in'imnm Trench Separation: � ft D'��
�istribation:
Specifications:
� Distribntion �oz Serial �istribntion Pressnre Manifold
� S..eJe S l� -�e 5,�� �c �^ _ -- -
Authorized State Agsnt:
Permit Frxp:
The type of system permitted is
permit.
Owne�/q,�gal �epresentative:
��
Conventional Accepted
Date: � D (o
_ GZ8- ��{
Alternative. I accept the specifications of the
Date:
pCFID rev. l l/10/05
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3ection/Lo�# �
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• Date .
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begirsning the installation to irtsur� that propergrrrde ir maia�ie�'.:
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I�r�rn:-�'a.�ro��ru.�a�a��m71 I�ZL��.IL�IEn; :
WELL PERMIT -
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map Parcel #
Applicant: 4 i.(�
Subdivision:
Location:
�
Township:
r, Lot #
Type of Water Supply: � 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