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Pe�son Cauntv Health Deaartme�t
Enyiro�mental Health„Sectfon
. APPLICj�TI�N FOR S6RVICES
.... .......:::.... .. � �... ., . •
.. . .:Setvices equestsd �.;.
� prowmants Pertnit (Recorded Lot) - 5150.00 • O Wa9 fyertnt (Ne�
Imprnverr►bnW Permit-(Unracncded Loq-i1S0.00 q Edstlng 3yatarr►
❑ ImprovementsPertnd-s100.00 ❑ RepetirlF2Ep1�Ce
(Mobilo Homs RaplscemenVAdditlon)
Con3L'uCUoo A�ori:atlon - 5700.00 � ReGravr Slte PW
P.03
T � -3�
Parcel #• 31.
IF�TF(� INFORMATION IN THE APPLICAI"1�N FOR AN IMPRO1lEMEN1' PE�MIT IS FALSIFIEO CHANG�D OFt TH� S17� f5
ALTERED, THEN TNE IMPRGVEM�lJT PEEtMIT AND AUTHORIZAiION YO CQNSiRUCT �NALL 9�COM� INVALID.
1) Permit requestsd by:
Home Phane:
2)
3)
�
Bus�ness Phone: - - (P � ,ZO - ------- -- � V �� � . C
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Name mnd addreas of curt�ent owner. �C. (� (���
lU 1� -�LIr�L� (�i�a�
�.
�Y P 4 (� C�AC2� p � �
Prope DesCri tlon: Lot s;za• � rownant : � � 1/� r R,�
Oirecsions to the prape�ty Ilttduding road names and num 1� _ _`�.'7 5��L , c*�r�-"^'"
�
a �s� 1
4) P�opoaed Uss and Stru�turo Description: answer each ai the fotlowing questicns:
a) Proposed , Exiating CJ
b) SGck euilt , Modular �, ngte Wfda �, Douhl� Wide ❑ 3
c) Numb�r of edraoms: � d) Number of accupants or peopla !o be senred:
e) Baseme�t: Yes a, No � It yss. # o! basament fi�ures: �
� Gacbage Oiaposal; Yesa, No�( �
g) Dimensio�s of Aroposed Structure: Width:�, Depth:
S) Water Supply Type: Pcivate� �(new � or ebsting p), PubPrc fl, Community ❑, Spring ❑
Are any wells on adjoining property7 Yes Q No � If yes, location
6) pleaee Indlcate ovsirod 5ystem Type: (aystam� can be rinfcod in anier of your preferenca)
2Convanttonat �N9od�fled Co�yoritlona( ,� Altemsttivs Innovattve
� Other (apectty): �Ll�.�.°� 1. \Z� �V ��',� lU'`�-) .
CL�ARLY SYAfCH ALI. CORNERS ANO LlNES 0� THE PfippERTY,
STAK� TNE COFtNER8 dF ALL pROPOSEQ STRUGTUItES.
i'1.�A8� ATTACH SURV�Y PI.qT OR SITE pLAN TO TN13 APPLICAT1oN
I hereby make applicatlan to the Peraon County Health Department tor a site evaluadon tor thQ ocrsite sewaga diapoaal system iar
the abpve-dBgCtjbed prope�t�,, � agree that the contents ot thia applkation are t�ue and represeht the msximum taaGties to be
placed on the property. I understand ff the slte ls altered or the intertded use changes, the peanit ahall hecome Invalld. I understand
that as appucant, I am responei6le for ldentifying and marlcing propetfy lines� c�mera and maicJng the aite axessihl� fo� lhe
Petsonne! of the Person County Neatth Oepartmerrt to condud their evaluatlons.l undersi�nd thst I am r�sponsib4e b� nodfying the
Health Depanhrient li my property contains any weeanda as designated by the Army Corps of �ngineers,
�Y f r � .
Owner or Legal Reproseptative Date
.
�� � �
� A 100 YEAR STORM FLOOD \
• HAZARD AREA EXISTS, ALONG ��� �
. �-• � ' FLAT RIVER.
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OPEN '• / �RucE E. MO�RE �
ANNETTE A. MOORE
D.B. 244, P. 625
D.B. 249, P. 273 �
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, �-
PERSON COUNTY ENVIRONMENTAL HEAL-TH
ATTACHED PLAN FOR SOIL AREA AND SYSTEM l
i ax Nfap #: �'3 � Parcel # �� i � �
Zoning Township � %�15�� � n(Z.�
Appiicant: —L� EITt� qr.e-■ ����-
�ocauon:__ e.-t�'�1.1E L�N`� 1ZQ•.
Subdivision: r� Section: ��` LoL �—�
Improvement Permit
A buildinq permit cannot be issued with only an Improvement Permit
New l Repair Addition Type of Structure�� Water Supply WE�-l-
# of Occupants�AX � # of Bedrooms Other
Basement? � 0 Basement Fixtures? �
Projected Daily Flow: �� g.p.d. Permit Valid For. �ive Years ❑ No Expiration
ProposedWastewaterSystemType: OSSI(3LE P�mP � oNd�NT►OnlA�
Pump Required? Yes No P�1�.�S��j�
Proposed Repair:_R�SSi$L� PUt�1P'fU �}1,1,�(� Conil�F�n1T�o�JAC. w►Tr� is'`� SOiI CAA
Permit Conditions:_ �NS'TAIt, �N ('oNTOIn
Owner or Legal
Authorized State Agent:
Date: l �G- �?Od'�`1
Date: 3 `�3.`'1 � OC1
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit
holder is responsible for checking with appropriate governing bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater System (Required for Buildinq Permit)
Type of Wastewater System Qc�s�B1� Ptr*.p (�,�wyfi,lTiG�astewater Flow: �$� g.p.d.
Facility Type:_ }�OUSE
Basement? O Yes C�I'IQo
Wastewater Svstem Requirements
Septic Tank Size: locso gallons
NeW ]'C�Repair OExpansion ❑
Basement Fixtures? O Yes�lo
Pump Tank Size: � gallons
Total Tre�ch Length: �3f� feet Maximum Trench Depth: � inches Aggregate Depth: � a in.
Maximum Soil Cover: �o inches Trench Separation: � Feet on Center
other:_ 1►�STAI� 0� o�3T0UR
Permit Expiration Date: 3-�. --Q�
Authorized State Agent: �S Date: � -Ob
The type of system permi �oes 0 does not differ from the type specified on the application. I accept
the specifications of this permit
Owner/Legal Representative Signature: �/�� ��rrr.��� � Date: G�t� ao�-r
PCHD, rev. 11/18/99
Application #:
Tax Map #: ' 31 ,_
Parcel #• ��
Person County Health Departrnent
Environmentat Health Section
SITE SKETCH
�
—.�E1�CN �P.�DS�4ti" _
Applicant's Name Subdivision/Section/Lot#
JoN K. 'Fou?�� 3•2s'c�
Authorized State Agent Date
System components represent approximaie cvntours only. The contractor must flag the system
.._,,,_ ,,, %il/�jNN%MO �l�n incfnl7n}inn �., ;�.cure that nrnner Qrade is maintained
Scale: � ��_ (�U�
PCHD, rev.10/12199
PERSON COUNTY ENVIRONMENTAL HEALTH
' PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: ,�„_� 1 Paroel # c��
ZoNng _ Towaship �f� lV iM �
ApplicaM:
Locatlon:
Su6division• � SecUon• "� LO�
Well Permit
Tvpe of Water Supplv: �ndividual Community
Rectuirements�
Site Approved by 0 �19`�
Grouting A roved y - `�
Well Log
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller: ���i ✓.� �
Well �Approved By:
Date:
'"`�`See Attached Site Sketch*'"`
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Public
PCHD, rev. 11/29/99
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