A31 161,�aniication �ate: �'J -� �
Amount Paid• � )
�ec�iot #: �
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P�rson Cauntv Health Deoartment_ ,
Environmentai �f�a9tli S��ti�n . : �. � � -
APPLlCATION FOR SERVECES ` ' �
T�x Ma #: `�
Parca! #: / � /
IF THE INFORMATiON_IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANG�D. OR THE SITE 1S
ALTERED, THE9V Z'HE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by:(Owner/agenUprospective owner): -yaG' %� a�p����� ��
Home Phone: _���G- S-`I �(- lcs.�8 Address: a'� �.s- S�-�,,,,�,�- ?c�.
Business Phone: g�� � 60- ?�/c� i?c,•� ��� �.t/C a'7 f7 7
2) Name and address of current owner.
j/, �3�2 /k��f 7J✓.r.� � /�
3) Property Description: Lot size: Township: _�, d�
Directions to the property (Including road names and numbers): -•
� �.i'� ����le �il:L Ls �.-e � ,�1� .+.co
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Proposed Use and Strvcture Description: answer each of the following questions:
a) Proposed 5i�� �sting ❑
b) Stick Built'�,'Modular 0, Single Wde �, Doubie Wide ❑ �
c) Number of Bedrooms: .3 d) iVumber of occupants or people to be served: �
.. . ... ... _. ..
e): Basement: Yes �, No f yes, # of basement fixtures: - �_, -
� : G�ra� n r.;d�4s: �;: Ye� �, "�'� � . _. . .. _ .
g) Dimensions of Pro posed Structure: Width�� De pth: �t%
5) Water Supply Type: Private �(new � r existing �), Public ❑, Community �, Spring � /
Are any welis on adjoining property? Yes'�No D If yes, location z1 �ho/'
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
Conventional _ilAodi�ed Converrtional _ Altemative. _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LIMES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPUCATiON
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 represenY the ma�dmum facilities to be
piaced on the property. I undersiand if the site is altered or the intended use changes, the permit shall become invalid. I understand
that as appliqrrt, 1 am responsible for identifying and marfcing property lines, comers and making the site accassible for the
personnef of the Person Cour�ty Health Department to condud their evaluations. I understand that I am responsible for notififiying the
Health Department ifi my property contains any wetiands as designated by the Army Corps of Engineers.
-.� ��� ` �-- ��- � � �
Owner or Legal Representative Date
PCHD, rev. 1a/12/99
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A D.B. 180-1 8 �
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A (API7ROL CORNER 290:�61'
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P�3�SaM COl9N� E�IVlROIVME�ITAL HEALTH
Tax Map #:..,�_ Parr.el � ��_ Towttship 17 � i'�1�. �� i� PIN
ApPpcant rn �• �� (� n�-.� Subdipision PhaselSecBon Lot�
Locatlon: r `. ,�5 � ; l...r� 1 � �y)
Improvemeni Permit w) ���'�'Or1D �
New ��Addition Type of Strudure �� Q'�J , Water Supply ��
# of OccupaMs i1�1A # of Bedrooms � Other System Type�
Projected Daily Fiow: �L%�_ g.p.d. Permit Valid For. ve Years 4 No Expiration
ProposedWastewaterSystem: rl ���-; �
Proposed Repair.
PeRnit Conditions: �Q iP . � . /`�'� ��,5`� � � Um
���' � -
Owner or Legal Rep 've Signature: Date:
Authorized S#ate Agen� Dffie: lU �� ��_
The issuance of this pertn y the Health Department in no way guararrtees the issuance of other permits. The permit holder is
responsibie for checking with appropriate goveming bodies in meeting their requirements. This site is subyect to revocation if
the site plan, piat, or the intended use changes. The Improvemerrt Pertnit shail not be affected by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Tneatment and
Disposal Systems of the Nortfi Carolina Adminfistrative Code.
Authorizatio� To Construct Wastewater Svstem 1Required for Buildin4 Pertnit)
Wastewater System Descripti n: �1'l['\� C'(1�-r`O�L1� �����Zi.�/astewater Flow: �� Q.p.d. Type: �,
Facility Description: � � New'6� Repair 4 Expansion ❑
Basemerrt? O Yes �- Basement Fixtures? � Yes o
Wastewaber Svstem Reauir+�ments
Tankage: Septic Tank size_l� gal. Pump Tank size ! v /4— gaL Grease Trap size �� gaL
Trenches: Total fength � ft. Trench Width c� it Total Area sq. ft.
Max. Trench Depth: �_ in. Aggregate Depth: ��- in. Soil Cover. �� in. Trench Separa6on � ft. on center
Permit Expiration Date: � " �--� � -
Authorized State Agent Qate: 1� �
*See attached site plan and addendum pages for additlonal permit conditions.
The type of system pertnitted ❑ does 0 does not differ from the type specified on the application. 1 accept the
specifications of this pertnit
OwneNLegal Represer�tative Signature: Date:
O�eration Permit
System Type �n accardance with Table Va)
This sysbem has been installed in compliance with appllcable North Carolina General Stahttes, Laws and Rules for Sewage TreatrneM
and Disposal, and all comlitions of the Improvemerrt Permit and Construction Autho 'm.ation. Issuance of this permit implies no
guara�rtee that the system installed will tunction properly for arry given pe�od of time.
Authorized State Agent Date
PCHD, rev. 03/07/01
AppUcation #:
Tax Map #:
Parcel #: 1 k��_.
• Person County Health Department
. Environmental Hea(th Section
SITE SKETCH
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SubdivisioNSectioNLot#
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Date
System components represent approzimate contours only. The contractor must flag the system
nriar to beginnin� the insiallation to insure thai proper �rade is maintained
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�or �:�k�.re add-��'� �
PCHD, rev.14/12199
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8��rse�n C��n�j �leaith Depaa#ment
� ��avironanental i�ealth Seciion '; I� �' _
Tax Map �: � Parcei #: 6
Zaning: Township: '
Subdivision: • Section: Lot:
�C �uyVt
APPlicant• J�� �/i 1
Location• �l i'�U'�—
Operation Permit
System Type (In Accordance With Tabie Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AiVD CONSTRUCTION
AUTHORIZA 1 .
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Authorized State A nt Date
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3az Map �: Parcel #:
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PCHD, rev. 10/12189
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PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL StTE LAYOUT
Tax AAaP �: r t l�' Parcal # / U! /
Townshfp ��—�•t•�'" �/ / O �IL
Zoning .
�►PPlican�
�o� �� ��rrQii� �—
�.owtion: l�n 1��1 �� �U U C, �1 U I'G� � 0� d
y (J � � Saction• �
Subdlvlslon•
Well Permit '
T e of Water Su I: V Individual Community Pubiic
Reauirements:
Site Approved by '� T� q�a0 ���
Grouting Approved by �µ i ��"��
Well Log ��+ a �-o �
Well Tag
Air Vent
Hose Bib ____— -
Concrete Slab
Weli Driller: �' ��
Weil Approved By: �r�
Date• ���� Z���
**See Attached Site Sketch**
Welis must be 10 feet from property lines.
1Nells must be 100 feet from septic systems.
Welis must be �at least 25 feet from any building foundation.
Other conditions:
PCHD, rev. 11/29l99