A31 2811/03/1999 11:58 5971799
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PLANNING AND ZONING
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Tax Map #:
Parcel p:
PAGE 02
9 ) Parmi! requ�sbed
Home Phone: �
8usiness Phone: �
2) N�ms and �ddres� of cqn+sllt own�r. i�1- s�'�t'•
3) Proprrty Wac�ipdort: l.ot tite�,:,,,��c.Towttsh�p: � F�r k[ ovrr c G� ��
Directlons t0 ths pr+oper�t r[Indu�tnp road rtames u�d�): i.a-lc.. �, .,�
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4) Propos�d Use a�d Structuro p�scripqon; answer each of the lollowing questiona:
a) Propoaed a�Exia�n� p
b) Stick SuNi Cd; l�Aodular Q, Singfe YVids D, Oouble Wide G
c) Number of Bedrooms: � c� Number of ocwpants or people to be served:
e) Basemant: Yea 0, No [rT( yes, # of basemant 16dures:
t} Garbape Dispos�i; Yea 0, No �' �,
8) �imensia�i o! Pnbpossd Structu�e: Wfdth: S�4 Depth; ��
5) W�ter 8uPP�Y TYpd: �'rfvste $.'(new �or exiaNnp t1�, Publlc 0, Community o. Spting [7
Are eny w�s11s vtt �dJoining ptq�etty? Yss 0 No�.'If yes, Iocation
6) Plesse Indicatb De�i�d 8ysqm Type: (vysNtrt� can be ranked In orde� of yaur pratenence)
�ConvenUon�l „`Modiflsd CvnV�ntlo�uti ,,,_ Alternsdv� Jnnovativa
Othsr {speclfy);
CLFARLY STAKE ALL�CQltNER�{ AND UNE$ OF i'NE PIiOPERiY.
SiAKE THE CORMl�R8 dF ALL pROP08ED STRUCTUFtES,
PlEA8� ATTACH 3URYEY P�.AT OR 51TE PI.AN TO THI3 APPLICATION
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I hereby make epplfcatio� to the Pet�on Caunty Her�kh pepartment for a site evaluatfon for the on-site sewage disposal system for
the above-described property, I sgrae th�t the oontente af thia �pplicetian are true and represent t11e maximum facilities to be
placed on the property. I underatar�d it the sits ia elierod or the intended t�se changes, th@ parmit ehail become irnraiid. I understand
that aa �pplicant, I am rosponSiplB tor idetltifyirtg arld markin� property lines, comers and making tha sit� acoessible for the
peraonnel of th@ Person County He�Rh departt718nt to ConduCt thei� evptu�tiona. 1 unde�stand thet I am respo�sibfe for noGfying th@
Heelih Depa ent ii my property Canteine ally wetlant,H es designated by the Army Corps of Ertig' eers.
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ner or Legal Representative Date
PCHO, rev, 10/12/99
' PERSON COUNTY ENVIRONMENTAL HEALTH
�•" 'PLEASE �EE ATTACHED PLAy FOR SOIL AREA AND SYSTEM t
v Tax Niap #: �� I Parcel # � u
Zoning Township _ O ��.J���i �/�.�
,Q�jy� /�., �
Applicant: ✓/'�`/� � (�/�N �
r
Location: %/✓/O/1/ .�j�I�VE C/�iLl2G�J /e0/.1-J
Subdivision:
SecUon:
Lot:
��provement Permit
A buil�inc� we�mit canno� be issuer� with only an improvement Permit
New ✓ Repair Addition Type of Structure �� Water Supply P��l'� wF�
# of Occupants �/y'IGC. # of Bedrooms .3 Other
Basement? _ .1 lo Basement Fixtures? �
Projected Daily Flow: 3� g.p.d. Permit Valid For: �Y ars ❑ No Expiration
Proposed WastewaterSystemType:_GOr1!✓8,�fjorl�i/ �Z1'-ti)
Pump Required? Yes ✓ No
Proposed Repair: �O�'!lieyl oh�/ �--4J
Permit Conditions:_J,�l�j� �pTy �N�TiI}L S�11T£�'h f�/D oPc�of}-ii2
T 7� D� ��F'
Authorized State Ag
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 Svstem (Required for Buildinq Permit)
Type of Wastewater System
Wastewater Flow: _g.p.d.
Facility Type: New ❑ Repair DExpansion ❑
Basement? O Yes ❑ No Basement Fixtures? ❑ Yes O No
Wastewater Svstem Requirements
Septic Tank Size: gallons Pump Tank Size: gallons
Total Trench Length: feet Maximum Trench Depth:
Maximum Soil Cover:
Other:
Permit Expiration Date:
Authorized State Agent:
inches Trench Separation
inches Aggregate Depth:_ in.
Feet on Center
Date:
The type of system permitted ❑ does ❑ does not differ from the type specified on the application. I accept
the specifications of this permit.
Owner/Legal Representative Signature:
Date:
PCHD, rev. 11/18/99
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Appiication #:
Tax Map #:
Parcel #:
Person County Health Department
Environmental Health Section
SITE SKETCH
6A�2i2y G�ON �
Appiicant's ame Subdivision/Section/Lot#
' �� �._---- �f /L�L/ ��'�7
Authorized St Agent Date
System components represent approxi»tate contours on[y. Tlie contractor must flag tlie system
to
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the installalion to insure tliat
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PCHD, rev. 10/12/99