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�PP�1C�1TtON �OR SERVtC�S
� , _:. ;; ::.;.Senzices� �eq4�ested` ; .. ... . .. : . >
PeRnit iRecarded lot} - S2�O.U0 0 Well Pertnit (NewlRepiacemesrt)- $225.00
(Mabile Home FcephacemsrrtlAddltfonj
RQpairlReplace Exisiing System Pem
Construcqan Authorizauon for
�150.00!$200.00
Pemrit RevLsion Fee - $75.00
'�) ��rrn:'rt requ�s#��'�y: (Uv9merlagentlprosp�c�lve owner): !�/1!
Hom=. �'hone: � Address: 3�� � /lr�
Busiru.:s Phon�: r -- � �° `s
2) Maur��a anc� address of curre+rt owner: ���
3�) Prc�•iWt�t"�% D65C7'(�it1�P1: Lot size: cr� Tawnship: ' e !�
Dir�:c:t9�ns to the propetty (tnciuding road names and numbers): �
�' n„)� �` .� �, ���li Ui.S%n n_ �t�t �
�r3�''/n
��, r�� �or#�
d�) �re►��ased 13�e �� Struciura Descr3ption: answer ach af the foilowing questions:
a) I�rc�posed �' , Exisiing _, Type of Structure: ��1 %� i�1 Width: Depth:
b) P�wnber. af Bedrooms: _=� Number af occupents or people to be served:
c} Elasem�nG Yes,y,_,, No ,� Wil! there be plumbing in the basemertt?
d) C�rubage Di�posat: Yes . Na ,
;3} lMa�Fsr 5u�ply. iype: Private �(new ,� or existing„�, PublicJ Community� Spring �
Are any we{!s on adjoining property? Yes� No � If yes, please indicate approximate tocation on the
�site plan.
iij Da�::s �you� �ro@�ert�� �aniain �reviausiy idenlifiec3 jurlsdictional wetlands7 Yes_, �lo t/'
{a�FA►.�E: (�!�'i�'T'i�9E Fl7LLOWiNG:
9.� PL�►T t3� T�iE �RQPE�2TY OR Sl� PLAN MUST 8E SUBMITTE9INITl�i THIS AP�L9CA"T1E�Ol�.
9�'fi�PER'TY LlAtES �BVD CORhIEiZS MUS"�' BIE CLEARLY MARKED. .
�`iiiE PR�Pt3SED LS3CATIOM C!� �1i-!, STRUCTURES Ml1ST BE STA�CED OR �LAGG�D.
�'Tl�E SlTE 1WUST BE REaDILY ACCESSIBL'� FUR Ai14 EV�4LUATIOId BY TNE �iFr�►�T�H DE9��Ri�1llEN{T
�� tAF�.
I here��y rnake a�piicatiorr ta the Persan County Health Department for a site evaluation for the on-sife sewage dispcsai
aysierrr ioG• the ahove-d��cribecf property. I agree that the cantents of this application are true and repre:aent the m�imum
�acilitie�.:,� t�� be piaced on th� �roperty: E understand if the sife is aitered or the intended use ct�anges, the permit shal!
aecomr•� irivalid.
,�-,� ,,;� �� .� g. i� os-
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� ` Cwner or �egal R resentative Date
/r' PCND, rev.06127102
' ��} • �% �j T��x h�1a�� �� � ��rce�l � � �
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, Subd!ivi�si�o��i �
������� V"[��
has�e Sectia�m'Lot � �i
.�� - i i��. �r� i�r� r� �.�� i 3. � ( �.- � i ���
�ermit Valid fox� �Five i�
Type of Facility:
# of Occupants Q # o:
Proposed Wastewater System
Proposed Repair: �1' �
Improvement Permit �
No Eapiration � �
> , New �Addition Water Suppiy
�ooms , Projecterl Daily Flow �� g.p.d.
Permit Conditions: 'SP.�. Sr' � ��:�o�
Owner or Legal Represe
Authorized State Agent:
.-
_ �
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Date: O
The issuance of this permit by the Health Departmeirt in does not guarantee the issuance of other permits. It is the respons7bility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are meL This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Ymprovement Permit is not
affected by a change in ownerstup of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Rules for Sewage Treutment and Disposal Svstems' (15A NCAC 18A 1900). Neither Person County nor the
Environmental Heaith Specialist warrants that the septic tank system wi11 continue to function satisfactor�7y in the future or�tiaat
the water supply will remain�potable. � �
Authorization to Construct Wastewater System (Required for Bu�ding Permit)
* See site plan and additional anachments (_).
Proposed Wastewater System: �vt1�.✓��c�C.� � � _ Typec� W ewater Flow 3��.p.d.
New � Repair Expansion _ b Soil LTAR: •�� g.p.� ft 2
Type of Faciliiy: r ��1� �• Basement _ Yes No
�astewater System Requirements
Tank Size: Septic Tank: .�„� � gai Pnmp Tank: gal Grease Trap: gal
�rainfield: Total Area: �� sq ft Total Length � ft 1Vla�mnm Trench Depth � in
Trench Width � ft Minimnm Soil Cover: in Minimnm Trench Separation: ( ft O� ' C•
Distribntion: � Distribntion �og Serial Distribntion Pressnre Manifold
Specifications- 7� S� V� �NG � �''1
Authorized State A.gent: ,_/�ytl'�
Permit Expiration Date:
The type of system permitted is ,�, Canventional Accepted Alternative. I accspt the specifications of the
permit.
Ownef/LEgal �tepresentative: Date:
' PCHD rev. 11/10/05
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°. sy�,f, �„�an�,�„��t �npm���co�tnurs o�ly. The cuntrr#cbr must j�ag the system prior ib
. lregitaning thB iststaAat�vn to insu� that pmjiergrade is maintained :
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I�.�:w�x-��ira�n.a����.71 IE;-IL�,�,9L:�3L�i .
WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map a� Parcel #��� Township:
Applicant� 'Ut�IS �-
Subdivision• ' r,r►�1 Lot #
Location:
, "- z �,: Q 5 rS
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
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