A30 29Application Date: � � "�� "a�
Amount Paid:
Receipt #:
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APPLICATION FOR SERVICES
Tax Map #:
Parcei #:
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT FALSIFIED
CHANGED, OR THE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Owner/ gent/prospective owner): �
Home Phone: �' ;L �-�u � Address: �
(v �.
Business Phone: 'yy� ' h �7,5't�/
2) Name and address of current owner: /�- ��7�r�� ��+�r.� ��U(,
3) Property Description: Lot size: Township: �� Subdivision: Lo #
Directions to the property (Incl ing road n es and numbers): 6 3�' � "� •
_9���� �%� Yl G' z 7 S
4) F�roposed Use and Structure Description: answer each of the following questions:
a) Proposed , Existing � Type of Structure: �h: Depth:
b) Number of Bedrooms: _ 2� Number of occupants or people to be served:
c) Basement: Yes_, No �Will ther be plumbing in the basement? n�
d) 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 previously identified jurisdictional wetlands? Yes_ No_
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LlNES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAICED 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 chanqes, the permit shall
Owner or Legal Representative
i l -� I -o.�
Date
PCHD, rev. 06/27102
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Applican�
Location:
T�x Map � � �rc�ei � �
Subdivi�sion
� ��se: Sect�ion' ot �
Improvement Permit
P2rmit Valid for ive Years No E�piration
Type of Facility: r"v`a� New Addition Water Suppiy �✓��
# of Occupants /1'la # of Be ooms Pro�ected Daily Flow Z. .p.d.
Proposed Wastewater System: °?o � ,r � Type:
Proposed Repair: Type:
Owner or Legal Representati i ture: �� ,t%,,,�.✓ Date:
Authorized State Agent: Date:
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 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 SewaQe Treatment and IDisposal 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 Wastewater System (Itequired for �uilding Permit)
* See site plan and additional attachments (�.
Proposed Wastewater Sy�s :/� CC.2D� l,�L o r C�►41�10P,f�Ype �� Wastewater Flow �g.p.d.
New Re ai ✓ E ansi n Soil LTA�i: •,� ..d./ ft 2
bP
Type of Facility: p�� {-�_ ��5 . Basement _ Yes L�o
VVastewater Systean Requirements
'I'ank Size: Septic Tank: / D�� gai Pump Tank: gal Grease Trap: ---��al
Drainfield: 'Total Area: j�, Q� sq ft Total Length z00 ft 1Vlaximum Trench I)epth �Q _�,in
�'rench Width � ft 1Vlinimum Soi1 Cover: �_ in Nlinimum Trench Separation: ��� ft �
Distribution:
Specif cations•
Authorized State A�
Permit
Distribution �ox Serial Distribution
Date:
Pressure Manifold
Date:
The type of system permitted is Conventional ✓ Accepted Alternative. I accept the specifications of the
pexmit. /�
Owne�/Legal �tepresentative: �iQ•c�%� U./��.vvv--i Date: �/ 2 d�
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`� System com�onents re�ir�esent a��mxissaate�contoasrs only. The cvntractor rrarastflag the systern�irior tr�
beginning taie iristaAatrmn to isasurs fhat�ro�iergrade is maan#uined
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Applicant: ��P 1Z2CC'� /.�"�fvr'� �
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Syst�m .Type (ln Accordance Wifih TaL�le Va): A
THtS SYSTEIVI i-��4S �E�iV INSTALL�i� IN COf�iPLIANCE VVi7i'H �►PPLlCABLE . NORTH
G�IROLINA GEi�ER�L STATUTES, RU�ES FaR SEUII�,GE TREATMENT A(�D DISPOSAL,
AND • ALfl.. COI1lDITiQNS �F � Tl-�E li1�PROV�1ViENT PERi�ItT AND C�NSTRUCTIO(�
AUTHOFZ ION. .
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� ax Map #��� Parce! # 2`� Sys%m Type (Tabie Va)
Ov►merlAppiicant � Subdivision
AddresslL�ca�ion Sec/Phas� Lat # '
State�iD/date �p,.e S�+
Capacity (�3 rSz� gal.
Tee and Fiifer �
Baffle
Sealant �
Riser (ifi appiicable}
Tanlc Outiei Seal
Permanerri Ii�arker
Pur�ap Tanls
c¢'+o .��+a .
. - �a auu
� Wate roof ISealant
Riser
Checfc ValvelGate Va1ve
Anti-s�� on o e
�(arm visable and audible
Electrica! Com o�nents
� Rate en ., :
A roved Pum iViode!
Blocl� Unde� Pump -
Pum Removal �Ro elChai
. � D"as�abu�ioaa: Sys�s�
� Serial Distribution
r/� �Trencfi �dih '
� Trench �Dec�fih ! f�—
. , �—
Low Pre�sure Pipe
�,�pr. Pipe l�ateriai and Grad�
\lalves �
�
i,rencn �engtn 5o a
Trencl� G�ade �
Tr�nch Spac9ng
Roc�C Depth and C�uai�
Daens/Stepdov+m� etc.
Pressure Laierals �
Hofe Spacinq �
Pipe. Siesve
Turn-irpslProtecio�s
�quired� Se�ac9zs
From� We!!s
From Prooertv iines
Surface �Waters
Public illlater Suppi
�feciicai Cuts {>2 ft.
Water Lines
Ve�iicle �Traffic
Ea�ements/Right of 1N
�es�
Easements RecorcJed
e perator on
`iri-Partate Aares�tent
Ca�amen�
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