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� Rerson Cou ty Heal�t� D�partment �
Sewage System Improvements Permit
Date:�3 This Permit Void After 5 Years Permit #
Owner: (� i/ v_.__r_�-�o Ql[(; 1 ���i'�✓� SR# ll�
Location/Directions:
Subdivi�ion Name: � � Lot # '
Lot Size: Type of Dwelling: �
Water Supply: Private: Public: Community:
Bedrooms: Gazbage Disposal
Basement Basement Fia tures _ �
INFORMATION CERTIFTED BY � �
Environmental Health Specialist: owner repr�s�raci�e ��
�'��e s.�e �f `
REPAIR: _GL_t. i ' � � ; , .
, ,�=�3,1 l...' �o_��s _...�' ��
Size of Septic T-anf: /�OO gallons � Size of Pump Tank: � S y��M
Nitrification Line: .7 O 0 � X 3 r
Depth of Stone: 12 inches
Maac Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks: n� /) ! c.,,-�' E��r, .� c-
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Date Well Approved: Well should be 100 R from any sewer system
BY Environmental Health Specialist
Date Sewage_ ,S/�'s_tem Approved: 3" j�'�-s
BY ��-�-�° •'�y�'� Environmental Heal[h Specialist
CERTIFICATE OF COMPLETION
Contractor. ` �`-.2-���
Sewage System location, installation, and protection must meet state and local
regulations. Septic tanlc should be pumped out every 3 to 5 years and shall be maintained
by owner in such mannet as not to create a public health hazard. Septic tank a�
nitrification line must be inspected and approved by a member of the Person County
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pennit is subject to revocation fi
(G.S. 130 A-335F) �
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L.ocation of sewage disposal sewage system sketched on back. Gy
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(OVER) .
I'�OTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, grivies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations m1y be located
at later date. Note location of water supplies on adjacent lots.
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�4palicatton Date: � �� � —1 • Tax Map #:
Amouht Paid•
Receiat #: Parcal #:
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APPLICATION FOR SERVICES
CONSTRUCT SHALL BECOME INVALID. �u..ol/� /i!; /lS �/ l= l�
1) Permit requested by: (Owner/agent/prospective owner): `K/�- � S_,�A�r,'-s �
Home Phone: °3.�G — 3� y-f�lvG Addrsss: �G : o-. G-��_ •
Business Phone: � ;�� -- 3G �/- � S'C � � l � /�?rl, / c .,T � - �� 3 y /
2) Name and address of current owner. �7`Gf �'��c �i`llS ///"�.v
Y� i��,�3'YdV � r
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. �� o� 7s ���
3) Properly Descriptian: Lot size: !•��.�ownship: �� Subdivision: Lot #
Directions to the properftyyllncluding road narr�es and numbers)�����; ������
4) proposed Use and Stwcture Descrt tion: answere�ch Fie foll in �1u stions: / /
a) Proposed �,/Existing _, Type of Structure: �Su �Q ►^ /�cc S/� N� Width: ti � Depth: ��{
b) Number �f Bedrooms: � Number of occupants or people to be served:
c) Basement: Yes___, No �ill the� be plumbing in the basement?
d) 6arbage Disposal: Yes J No'�
5) Water Suppiy Type: Private ci (new ,_ or existing �Public_, Cammunity� Spring _
Are any virells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
'site plan.
6) Does your property conta�� p!'+Bviously identifled jurisdictional wetlands? Yes_ No �
PLEASE NOTE THE FOLL��NG: ,. ,.':
➢ A PLAT OF THE PrR�P�RTY OR SIT� PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARL,Y MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUSi BE REI1�ILl( ACC�SSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make applicatfon to the person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-desc�ibed.property, I agree that the contents of this appiication are true and represent the maximum
facilities ta be placed on tt�e property. l undetstand if the site is altered or the intended use changes, the permit shall
become invalid.
� D 0 . .P ��L�.r� � C�r�� `l - a � � d �{
or Legal ,Rep�esentative
Date .
PCHD, rev. 06/27/02
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Tax Map # � Parcel # �
Existing Sewage System Report For. Mob�e Home Replacement
- _� Addition Type: �t,c,�.t,- ��I�c
Requester: �-iW� �•\�s � \/'F � Home Phone# �% � � � �
�� ( �.r; �„ Cj�e �',l�,,�. � s��esg # �c��r� a�a�
�.�,,-�,� 11�� I� � ����ri �
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Locadon:157 S 7 !�o� � -�i..t (� _ ri►� _ _ (�n v�. �e �,/vvYs, /�'
Original Permit Located S fL,� s_ Water Supply: ' i�'1l.'+C��rte.
Septic Sqstem Designed For. R.eside�tial +�Businesa Other
# Bedroams # Employees Other
System Type: ��Nw.�.►.�� Tatik Size: t caa� Nitrification Line: a�n 3
Date Installed: �-����5 Certifled Oper�tor Required: i�c �
On-site wasteWater disposal system ahows no vieual signa of malfunction on 7� 2 a--� < � .
Perinission ie gra�ted to:
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Environmental Health Spec,ialist Date• 7�a�-��/
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Section/Lot#
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Date . . �
sy� ��o�� ���r �p%������u� �ty. The contracto.r must, flag the system�iior to .
beginnr'ng the i�utallation to insure thut propergmde is ma.intained
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