A30 35A�olication Date: ��� �6 �
Amount Paid: I �• a
Receipt #: ��e21 �
1��1 "
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� sa�as�aa�-� ..�sa�mll 7F-�.amI1.�I�a
APPLICATIOId FOR SERVICES
Tax lflap #: �3 d
Parcel #: �3�
IF Ti-IE Ii1�FORMATION IN THE APPLICATlO(d FOI� Atd IMPROVEMEfVT PERMIT IS INCORRECT, F/�LSIFiED,
CHANGED OR THE SITE IS ALTERED THEN THE 111APROVEMEPIT PERMIT AND AUTHORIZ�►TIOiV TO
CONSTRUCT SHAL�. BECOME IMVALID.
1) Permit requested by: Owner/agent/prospective owner): �es�e g�alo ck
Home Phone: 33�- S94• bo48 Address �y�o g� ,� _�„ Q�
Business Phone: . I✓w.-a t� tn; I� r�c' �7�F�
2) Name and address of_current owner: (_ �� I g I (h�,�
�o �d
�� ��\c Vv� .' L c N '�`7 S� I
�FO �r k
3} Property Description: Lot size: ��� � 8 Township: � Subdivision: Lot #
Directions to the property (Including road names and numbers).
4) Proposed Use and Structure Description: answer each of the foilowing questions:
a) Proposed `�, Existing _, Type of Structure: M i� Width: ��� � Depth: `� S�--
b) Number of Bedrooms: 3 Number of occupants or people�to be senred:
c) Basement: Yes , No �C Will there be plumbing in the basement? �v�
d) Garbage Disposal: Yes _, No �
5) UUat�r Suppiy'Pype: Private �x(new _ or existing�, Public . Community_, Spring _
. Are any wells on adjoining properiy? Yes_ No _ If yes, please indicate a�proximate location on the
site plan.
6) Does your property contain previously identified Jurisdictional wetlands? Yes_ Ido `�
PL�ASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PR�PERTY OR SI'TE PLAN MUST BE SUBMITfED WtTH THIS APPLIC/�TION.
➢ PROPERTY L1NE5 AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AM 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, tiie permit shall
become invalid.
Owner or Legal Representative
S-/- 43
Date
PCHD, rev. 06127/02
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���a � � ��.--n-„ �.���.Il I�ZL � �Il �I�.
Tax Map #� Parcel # V�7
E�cisting Sewage System Report For: V Mobile Home Replacement
Addidon Twe:
Requester: l N�-�S ��Y �j I G I O�-K Home Phone �� 5 i�1"�% $
� �n � Business #
Nu �d (� rr� � I s� n�c. a � s� �
Location: �'-1� Dk�' �o?D ,�ri�< <b GICI'OSS Fron-+ �SSc l I
I-i�o r -�n `� oa d -
Original Permit Located: �
Water Supply:,0i\�u�- l.�C, ((
Septic System Designed For: V Residential Business
# Bedrooms � # Employees N ��t Other
Other
System Type: �c'�r1U�I1���n�c.I Tank Size: � Nitrification Line: ��� '
Date Installed: ��' ��i -� a Certified Operator Required: I�i(7
On-site wastewater disposal system shows no visual signs of malfuncrion on S' � r�.
Permission is granted to:
�'}'11-� t�S�d �Jr (Y1 i 9 ran t Lccbc�r
Comments: t;� t�� �U �edroom �Wm �(,tSCd a5 c� Orima�Y
R,cbi dcnc.c .
c�C..t �it� SKcf��.
Environmental Health Specialist
Date: —�
� � �D
f���� �� ' �^��'��\ �� `
• V � ��T�
�ID1Ya.a���TR4�TQ�� �B�.JL�w1�
' SI'I'� S�E.TC�
`R�la f �,� I�
State Agent
Tag 11�Iap # 3l7 Parcel #.�
• � Section/Lot# � 1 f�
� S'�-03
- . Date � . •
System cnsnponenis re�brrseHt a��ir»acimate�cnnt�urs only. The �dor must, flag the system�irior ta�
beg�g the �utallrsiion to inrure tJtat�iropergrade fs ��rrita�red
6
Scale:
n
E��S�n� .�
2 5�f
, �o�sc
Fa��
�1�0
�
I'G�3D, =ev. 09/12/U1
�1 S �y
P�rson--Count�; ,�Ith Department . �
Sewage. System Impr�rements� Perm�t
Date:�'� This PenniC Void After 5 Years Permit # G
�: i�t��S.��B1r� 1�6k �►► ���� ..
L,ocaation/Direceons; Sb
0
Subdivision Name: Lot # �
Lot Size• ype of Dwelling: �
Water Supply: Private: Public: niry:
Bedrooms: �_ Garbage Disposal
Basement Basement Fix
INFORMATIQ�i CF�RT�'iD BY
SanilBtian: �- owneror npresa,rauve
REPAIIt: _ REEVALUATION— — — — — — — — — --
Size of Sepaic Tank: V s Size of Pump Tank: � �`
Nitrificarion Line: � �
Depth of Stone: 12 inches • '
Max Depth of Trenches:
Altemative System: � Conv. Pump LPP Pump
LW��YYIYI� • .
Date Well Appioved: ��s Well shaild be 100 ft,. from any sewer syscem
BY__�,!S Sanitarian
Date S e Appr�v : �� 1 �/ - i Z
BY Sanitarian
�ERT�iCATE OF COMPLETION
Conttactor.
— — — — — — — — — — — — `=�— — — — — — — — — — — —
Sewage System location. installation; and .protection must meet state and local
reguladons. Sep6c tank should be ptunped out every 3 to 5 years-and ahall be maintained
by : owner in such. msnner ss not to caeate a public health tisiard.: :' �Septic tank aid
nitiificadon line must be inspected and approved. by a membei:.of. t}�e Person County
Healtti Departrnent before any portion of"the instalTadon is covered'�and put into use. If
the site plans ar auet�ded use change'this pem►iC is subject to revocation. .
(G:S. 130 A-335�
I.00ation of sewage disposal sewage system sketched on back.
(OVER)
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--- Per�on County ���alth. :Department �
x '° � We(I Permit
� :��Dafe• 2, (.7. q2 Ttiis Pernut YnYd After�3"Years �
Owner:� l�e .��`o�� ' ,i��Q � `�#
Location/Directions:l ' � T ` - �\^�
CA`_
� ` � � _..
SubdivisiomName:. ;�, �---. __ , Lot#
Drilling Contractor: _�: L�r s��c ltl�,
. � _wEt,t;-eoxsrRucr�ox �„-� , b�:
Distance from-Nearest � Iane��� Dis "tance from Source of '' �
Pollution . t3 O w3 _�-�
Totel Depth g t Yie�, �GP1� tic� Level FG ,
Water Bearin Zones.: D FG 'Ft ' F� �
Casing: Depth: Fr�ti � to 6 y-�-Ft;,-' Diameter. �� y 7� Inches
7'YPE: Steel ' Galvenized Ste,cl 'r—T-
If Steel, dces owner approve: Yes No
WeighC J :3 Thi �S: ; - � �Height Above Grotmd: � Inches '
Drive Shce: Yes No
Were Problems E�otaitered,"in Seuing �he.Casing? Yes No ,�:
If "yes" give reason: � ' ' = 'd
Annu]nr spnee vu;�th " Sand/Cemcnt' z— .. ;Concretc �-!
4rov� Typo: Neat - - -- - - --
• ,r _s� ;Inrhea --
W�t fii Attitul� S��e! : Y� � No �
Mettwd: Pumpe� � . Pressure ; _.-- - .. Po�aed `
DePth: .From � to:_�'.� �
Mateiials; Used: No. Bags Partland Cement.� Weight of 1 bag
•g �f Ibs.
If.inixturc (sand, grave cuttings) = Raitio: � w�_
m rne..r: ..v.e �r .�
.
I HEREBY CERTII=Y THAT THE ABOVE INFORMATION IS CORREGT AND THAT
TI•IIS. WELL WAS';CONSTRUCTED IN ACCC�RDANCE W1TH REGULATIONS SET
FORTH' BY THE� PERSON COUNTY HEALTH DEPART1VlENT.
�'+ �
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i o� Con�a�or _ � • Dete
Datc Ltsued
�
Sanitarian's Signature Date Completed �
Sketch well location on reverse side.
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