A31 83° p►QqI1C'i�Ofl DatB• VJ�`-�' � O
�,our�t Paid• � �
_�� • �
Tax Maa �k
�areei #:
Persoo Comrtv Heaith Departme�
Errviro�mertt�i Heaith Saction
. APPUCATION FOR 8EitVICE3 .
1) Petmi# roqueatnd by: (OwnerFa9��P�P�e ��� cR.� i
Home Phone: ,33 G� v c� - a 57 s • qddras� ,� o SD
Bt�ness Phone: � f/�
Z) Name and address of currertt owner:
3) Praperty Despiption: Lct sizx ! a.c Townat�ip-,���°"�-
D'a�c3ians ia the praperty (I�g coad names and n k—
4) Pcoposed Usa and Structure Descrtption: anawer each of the foibwin9 qnes�ons:
a) Propoaed 4 Ex�tlng �
b) Stidc 8 Stngte Wide 4��� Wide � �
� Number oi - 3 c� Number af o�� oc peaple to be secve�
e) Basemer� Yes�No O lf yes. # of baae�tunt �uex
� t} Garbage Disposak Yes q No �
9? Q�ensia� of Proposed Strcu�ue: VVidth: Dqrt�
� Water SwPPhf TYPa: Private �(ttew � ac �9 �I. P� 4�Y 0. Spc3�9 �� .
� � anSl ����9 ProP�Y� Yes � No � if yes, ior.atIcn
6j Pleaae lndlcata Deaired SYs� �YP�= �� can be raaloed 1n c�de�r oiY�' P��
_Canvecrtlonal Modified Cotn�entionai _ Aim�irs �nncva�ive
Othu (sp�d[y�:
-j' CLEARLY STAKE ALL CORl�IERS AN� UNES OF THE PROPERT1f.
. � 3TAKE THE CORNERS OF ALL PfiOPOSED STRUCTURES.
PIEASE ATTACH SURVEY PU1T OR SRE PUW TO TH13 APPl1CAT[ON
I hereby make app6c�la� to the Pecaan CouMy Health Departme�rt ioc a a�e evaluatlon tor ttroe ar�it�e sewage disp�al s�lst� fa
the ab�ove�lescr�ed p�opeiiy. t ag[ea fhat the contents af this a�Q�1on are tn� and rapres�t tha maximum �ea t�o h�
ptaced on the propetty. i tmde�and ifi the s�e is a� ar the ir�Eanded use r�angea. the peim� sh� became irnteitd. l tu�detstan
that as ap�iCarrt, I am cespons�ble foc idec�ing and rtmddn9 P�Y �, � and matdng tt�e s�e � foc th
perso�nel of the Person Ccuniy Hearih �epartment to condud the� aval�llona.l t�nd tttat 1 am t� ��9 �
Hea�h De�autrnent !t perty c�s wetlands as desi� bY the Arm�l Co�s of �s-
G� c�� '
O�emer or Rep�eseNative . �,e
�� �
� �Pf�
�
A 1541
�-, - ' ~ ` �PERSON C4UNTY HEAL'1,H DEPARTMENT
ERMIT
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WELL AND SEWAGE SITE, LOCATION IMPROVEMENT P
Tax Map # � 3/ Parcel #� 3
Zoningv_ __ ._____ Township
Owner/Contractor �/ � C e p� �er i e/ d Date $- S- C�C7
Location/Address /$�� Po�ndcx-tcr Road ��'�.st ��� o� �
S.R.#
Subdivision Name N//� Lot#.
SFD
Business
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�1CC�flCi ��lle<
ma�«<a
�,� 4�� �af �
Are.a�o Wor4c In
tharKed W/ 6L��TAP6
OI Gl,tt.K d-rcQiaCe �nitarX Tcc i F(1 t S��i
Q=�ta1� 43u11 Run1 V AWE o 2 Ft.oca D� u�d�r
�=n&EaLt a5 rnu-�-� Li nc a5 �SSi Ic
_�� (a"dex.(�r (o`W�de. Trcnc,�,� (�' OFSo� I
(Ot-�W cen -�rc1tC..[�CS ,
� C�v cr N- L� nts w�th �oo d tvPs � I
o r R� L�"^ Y��-�"i a f
�te y�M �' Frar�+ Wc.�(� S' FrarY►bui Id.in���s'
SEWAGE SYSTEM SPECIFICATIONS F�n► � cat,
Lot Area Size of Tank E X ti 5 t i ��
Mobile Home Size of Pump Tank _
# of Bedrooms 3� Nitrification Line �. 7C (.o
Permit Void after 60 months.
Permits may be voided if si
Well and Septic Layout by�
Comments:
Max Depth Trenches �o�'�
Permit Void if not in compliance with zoning regulations.
� alt,�re� or iry�ended use changed.
Date s 10-0(7 Installed by �..f e�r�CCQ.Q Approved by /� �D,t i�riH
WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public _� Replacement Air Vent
Site Approved R Required Well LQ�
Well Head Approved -°� Well Tag
Grouting Approved
Comments:
Date
Installed by_
Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this petmit The
environmental health specialist is not responsible for false or misleading information contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:lamipro\pemut.sam Ol/95 rev.1.0
ORIGINAL
Person County Health D.epartment
• Environmental Health Section
Tax Map #: ' Parcel #:
Zoning: Township: Gt,�Shy For (c
Subdivision• Section: Lot:
Applicant• � �I Ct {�or-E.,-��Fie I d
Location• �� TO i ild eX`� r 1�p0. �
�� O eration Perm it
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
' . S-IO'Ov
Authorized State Agent Date
o.t 5
a����r
Tax Map #:
ts'
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5
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Parcel #:
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=^�Ikd �c�a
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b- DcS �`�nQEcs �f a� U e
�� 13ut( i2.un
L�nca. 33�X3�
L;�c 2 �9`
3�
ia� ,'-t- (�OXb�
Lint 3
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l.incq (��'X �" IS x3
� u��al[nt � 3a �!X 3 �
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PCHD, rev. 10/12/99