A30 150Application Date: /' � Zz= 8 q
Amount Paid: �qQ ,DO
Receipt#: 3 7 �
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TasNlap: ��30
Parcel #: J S —
Applica�ion �or Serv3c�� (Septic Systems and Wells)
Services Re uested
mprovement Permit (Site Evaluation) � Construction Authorization
$200.00/$300.00 (if> 600 g d) (Fee is de endent on the ty e of s s
❑ li�obile Home Replacement or Building Addition f� Permit Revision
$150.00 (if site visit re uired) $75.00
❑�i'ell Permit (New/Replac�ment/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Char�e
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�1) Services Re uested by: � ,
Name: � �, c� • ��tt � �' �d Phone # (home): S9 �'�gQ �
Address: 3 (work/cell): — 7
�
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2)1\Tame and address of cuprent owner (ii dif%re�t t9nan applicant):
Name: 5 �,��n F
Address:
3) Property �escription: Lot Size: � g� �e
� 2- •�ubdivision:
Address and/or direct�i�on� to Property: _��,� � q�' 7' ;
n � . e
Lot #:
as �- Hcn �
4) Proposerl Use and Type of Structure:
Residential Business/Type: Other
Number of bedrooms � / Number of people served (seats/employees):
Basement: Yes N� (with plumbing: Yes No �
Garbage disposal: Yes No _�
�j'��ater Supply: /
Private Well �(Proposed Existing _)
Community Weli: Public Water System: .
Are there wells on the adjoining properties? No Yes �please show location on site plan)
liiate: A conapteted at��lication must also include:
:� A�lat/site plan of 1/te property tliat sliows proper#y dimensions and the �ize and location of all
proposed struclures.
9 A signerl copy �.,�'tlze `.�ot �'reparation' form verifying that the property i� ready �o be evaluate�
� ami submitting ihis application to request services frona the Person Couni� �eai#h �epartmeut. I aanderstand that
�i the im%r�aiion pravnded is incarr��f or i�f the site is 5ubsequently alter�d, or f�' #�e int�nded use c�anges, all
per�nits �nd approvals shall become invalid.
. � � , _�� �
�ignaiu�-� (Owner/Legal Representative): � /C � �ate :
10/08 Person County Environmental Health, 325 S. Nlorgan St., Suite C, RoYboro, NC ?75 i 3(336-597-1790)
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J � � •7T']1'ti�71.77� cfD 7t7L7L7Y71 <C�=` Sta �..�1L ll Jl Jl � �:R. � ��
Applicanl
Location:
Tax Ma�p � � Parcel # •
Subdivision
Pha - Sect�ion Lot #
� Improvement Permit
Permit Valid for ^�Five Years No Expiration , /
Type of Facility: �r i Va�2 �QS;� �ce. New Addition _ Water Supply W e 11
# of Occupants �x � # of Bedrooms ,3 Projected Daily Flow ��_ g.p.d.
Proposed Wastewat r System: �,on� ` aq — Type:
Proposed Repair: —� Type: �
/'
Permit Conditions: �
Atn a�v► A SQ Q .S
Owner or Legal Represe
Authorized State Agent:
Date:
Date: Z � 3-- 0'3
The issuance of this pernut by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspecrions requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Rules for Serva�e Treatmei:t and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that
the water supply will remain potable.
Authorization to Construct �'asiewater System (Itequi�ed for Building Permit)
* See site plan and additional attachments (_).
Propose astewater System: COhVeh%1��n� Type �a( Wastewater Flow 3f�0 g.p.d.
New � Repair Expansion Soil LTAR: . 3 g.p.d./ ft 2
Type of Facility: �r iJ�i' PSi c�evlCe Basement _ Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: 000 gal Pump Tank: gal Grease Trap: ---gal
Drainfield: Total Area: 20o sq ft Total Length � ft Maximum Trench Depth ��in
o•G•
Trench Width �_ ft Minimum Soil Cover: �_ in Minimum Trench Separation: � ft
Distribution• Distribution Box 'V Serial Distribution Pressure Manifold
Specifications: a �,�q� Q[� SCl1�C�S
Authorized State A�
Permit
The type of system permitted is
pennit.
Owner/Legal Representative:
�
Date: �G � � T
`�Conventional Accepted
Date• — �e
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c.Zoo�-�o� � 2�L�1`3
Alternative. I accept the specifications of the
Date:
PCHD rev. 11/10/OS
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Sub ' ' ' n . � Section/Lo1:#
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A��Sfla��m��� t�a��: Clu�e {,�'��el�
l��ai�g Adc���s�:
��aon� i�1aa��e�§:
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�e��ndi �'onditaoras:
I� See attached site plan for proposed well location.
2) All czpplicable State and County reaulatians governing construction and setbacks capply.�
3� Permits expire � years from the date of isszre.
��3a�r Cmrada�Yon�/�'ommen�:
a� a� n a s Q� s
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�'���aa� ��sa�er� �g�: .;� ��ie: � -Z ' 09
���'�'�'��F�`�� ��' ��1��.�+ ���I�t
1��� �I�fl� �������n�ffi:
EHS/Date
Location:
Grouting:
Well Log:
iNell Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Hei .,,�iit:
Concrete Slab:
'b���1 �����er•
Pump Installer:
'Y'��� A��rm��s� �y�:
Date Sample Collected:
PP:son Counry Eavironmental Health
3�� S. Vtor�an ST., Suiie C
Ro::boro, �iC 275 � 3
�.,n�ne� ��5�e���an:
EHS/Date
Installer:
Depth:
Grout:
��� A���s���n����:
EHS/Date
�ompleted:
MethodMlaterial(s): _
3�a���a�� #:
License#:
��t�:
Date Results Mailed:
Phone: 336-�97-1?90 F�: 330-597-7808
8/lr'08