A30 110{ ' •
Application�Date: 9'6 -(� L Tax Map #: ��O
Amount Paid: 00. O
Receipt #: t70 I i ParcEl #: i i �
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APPLICATION FOR SERVICES
IF THE INFORMATION IN TNE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIF!_ED
CHAiVGED OR THE SITE IS ALTERED THEN THE 1MPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. �
1) Permit requested by: (Owne a en rospective owner): - � Vl
Home Phone: - � Address: � � ,1LL.� •
Business Phone �"
. . . . . . �� ' � ��r /
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3) Property Description: Lot size: ��Township: Subdivjsion: A' ot #(o
Directions to the property (Including rqad name� and, n�}mbers): �i�, S� V �1 �., �1 L D�'
4) Proposed Use aqd Structure Description: answer each of the following questions:
a) Proposed ✓ Existing Type of Structure: j/lt�Id � Width: Depth:
b) Number of Bedrooms: � Number of occupants or people to be served: �
c) Basement: Yes , No � Will there be plumbing in the basement?
cj) Garbage Disposal: Yes , No �
5) Water Supply Type: Private �(new � or existing�, Public� Community� Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
�site plan.
6) Does your property contain previousty identified jurisdictional wetlands? Yes_ No_
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPE�2TY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid.
Owner or Legal Representative
PCND, rev. 06/27/02
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Su,bdivisiam � • � �
Fha:s�e,S�ct+ion.'Lot +"� �
Parmit Waiid for
Type of Facility: .
# of Occupants �
Proposed Wastew
Proposed Repair:
Permit Conditions:
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I�praveffient �ermit
I�To �gpiration
• New Addition
s „_ Projected Dai�y�low �f
�ater Snppiy �e/�
g.p.d. �,
Type:
'Ijrpe: �
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The issuance of this pem�it liy the Healti� DeparGment in does not guarantee the issuance of other pernrits. It is the resgonsib�lity of the .
applicant/property owner to in sure that all Person Couniy Planning and Zoning and Bu�ding Insgections requirements are met This .-
Impsovement Permit is snbject to revocation if the site plan;�pl'�ti'or'the intended use changes. The Improvement Permit is not
ai%cted liy a ci�ange in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina, .:
`Laws and Rules for Sewa�e Treabne�t and Disposal Svstems' (15A NCAC 18A .1900). Neither Person �ounty�: uor-:ttie-` �� =
Environmental Health Specialist warrants that the septic tank $yste�n w�71 continue to function satisfactorily in the futnre�or�tliaf.
thewater supply will remain potable. � •
� Authorization to Construct Wastewater 5ysiem (Required for Bnilding Permit) �
* See site plan and additional attachments (_�. � -. .
Proposed �iastewater
New l/ Rep�
Type of Faciliiy:
�Pe ��� Wastewater Flow �tQ g.p.d.
Soil L�F�1R: • ZZ� g.p.d1 ft 2
Basement _ Ye�
� ��Vastewaier System ]L�equirements
iank Size: Septic Tank:' DDv gai �'nmp Taak: -----ga1 Grease Trap: �-gal
larainfield: Total Area: Z!% 4 sq ft Total Length �Dv ft � 1Vta�mum Trench Depth /2 ia►
Tres►cii Width �,_, ft 1VYinimnm Soil C�opr. �Q in ll�iinimwn Trench Separation: � ft
Dist�ibution: �istribuiion �oz ' �erial �istribntion Pressare 1dl.wifold .
The type of system permitted i� Conventional vAcc�ted Alternative. I acc�pt the spe�ifications of the
Permi.t•
(3w�ei/.L�al �.ta�res�ntatflve: Date:
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Name ��� Ke �i �%n�y; Taz Ma.p #� 30 � Pa�rcel #�d
Sub ' ' ' n � Section/Lot#
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Authorized State Ag�ent . � Date . �
system camponen�t mpr�re�t appr�aaaim�tac
begiru�ing the tnstallation ta i�sut�s that pri
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