A32 169` �. � �
�Dpljcatton oate. � - a 1-Od
Amount Paid• � � �
Recei #:
C�'� ✓
Person Countv Health Deaartment
Environmental Heaith Section
APPLICATfON FOR SERVICES
Tax Mao #: .f�'�-' �
Parcel #: � �' �
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IF THE INFaRMAT10N IN THE APPLlCATION FOR AN IMPROVEMENT PERMIT IS FALSIFlED. CHANGED. OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVAUD.
1) Permit requesbe by :(Owneda er�lpros e� ii � w� c� ` �L C�
Home Phone: 6 � 6 9� Address: B O N� )� i�
Business Phone: z' //L , C. �.. 7��3
2) Name and address of carrerrt owner. �� ����� I z� •/' R'� i��
3) Property Descriptton: �ot s�ze: , 6�i �7ownship: US �' �d �%L �
DirecNons to the property (Induding road names and numbers): f �� (i � � � � � �V � �S �'�
/�9 v� iv G r%�L55 ��� nr�/,� sG�'�i ! ir��, rl��'/xG��lif�/�
HE,f �� a� r�� �z ..N,� tii�t Ra. - i�v�.c,,���t� ihr �3 vow.s �� t 3 6��� �
4) Proposed Use a d Structure Descrlption: answer each of the following questions:
a) Proposed ��ting ❑
b) Stldc Built , Modular ❑, S' gle Wide �, Double wde ❑
c) Number of Bedrooms: � � d) Number of oxuparrts or people to be served: �
e) Basement Yes �, No � If yes, # of basement fuctures:
f� Garbage Disposal: Yes 0, No � �
g) Dimensions of Proposed Structure:lMdth�� Depth:
� Water Suppiy Type: Private I�(new [9'or existing �, Public ❑, Cammunity 0, Spring ❑
� Are any wells on adjoining property? Yes � No 0 If yes, locatlon
6j PI ase Indicate Desired System Type: (systems can be ranked in order of your preference)
v Conver�tlonal lModifled Conventtonai _ Altemative _Innovative
Other (sPecifY):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES,
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPUCATION
1 hereby make application to the Person County Health Department for a site evalua�on for the on-site sewage disposat system for
the above-described property. I agree that the corrtenb of this application are Vue and represent the maximum faalities to be
placed on the property. I understand if the site is aitered or the irrtended use changes, the peRnit shall become irnalid. l understand
that as appiic�nt, i am responsible for identifying and ma�lcing property tines, comers and making the site accessible for the
persannel of the Person CouMy Health Department to condud their evaluations. I understand that I am responsible for notdying the
Health Depar�ne 'f my property contains any wetiands as designated by the Army Corps of Engineers.
1
�. �1.�/ —1 % ��d
Owner or Legal Representative . Date
Pct�, r�. �a�z�ss
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60' R� �I
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i.93 ac. �
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PERS�N COUNTY ENVIRONMENTAL MEALTH
Ta�c Nap i: rl J �C Parcd �
Zoning Township _ U$ F D{r �
�PU�c � • W , Srv��.�f � ..
Locauon• t�1 5' � QkeSS �. L0� or Ap fiYbX. ' Y�►1 .
s�,,►�,o�: �' h 2ada� s.�,,. � 3
improvement Permit
A buildinct aermit cannot be issued witt� onlv an Imarovement Permit
New �epair Addition Type of Strudure � Water Supply W¢.� �
# of Oxupants #•of Bedrooms � Other
Basemerri? �Basemertt Fudures? . �
Projeded Daily. Flow: ��Og.p.d. Pertnit Vai For. 0 Froe Yea ❑ No Expiratlon
rs, ira
Proposed Wastewater SystemType: ur� Co veJn io►�1
Pump Required? ✓Yes No Purhp @,ouj �oSsi61� �jQ 0.Vot�� by rnov►n �1okSQ, S��. •
Propased Repair : v.�eh � K �
PermitCond'dions: lQPn -sen-�-j'c� S�s .n.. �ra�� r►��n;w,.,�,w. -�,�,r,. ,..�II c;�,o �n� �,..., nw,mr
� J:.A,.._ !]IA1��I
Owne� o� Legal
Authorized Stat�
Date:
Date: fl a
The issuance of this permit by the HeaRh De�ent in no way guarantees the isauanca Qf other p�rmits. The pemut
holder is respansble for dledcing with . appropriate goveming bodles in mesUng 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 pertnit is subject to compliance with the provisions of the
Laws and Rules fo� Sewage Treatment and Disposal Systems of the North Caroilna Administrative Ccde.
Type of Wastewater System
Faaliiy Typ
Basement?
Wastewater Flow: �.p.d.
��� New� Repair DExpansion
No Basement Fucriues? 0 Yes j�No
Wastewater Svstem Reauiremenb
:Septic Tank Size: �O gaqorts Pump Tank Size: D m fl gaUons
Total Trench Length: ,�� feet Maximum Trendt Depth: f� inct�es Aggregate Depth: �� i�.
%'y1 �h�vnU/� ' q
�m.Sal Cover. � inches Trench Separation: l Feet on Center
o��:�.`� w��K � �.w�, sA� l eo ve� w %l� ,,e�� � 1 �e ���'�� �o ✓�r ��, h � �r� �� �r �o��
Pertnit Expiration Date•
Autharized Stats Agen� �a�: � � � •
The type of system pemnitted Cl doe� es not differ from the type specified on the applicatio�. I accept
the speci8cations of thts permit
Ovmer/Legal Representative Signabure; Date:
�
PCHD, rev.11/18/99
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• , ' Appltcation #: ____
� . Tax Map #: �
� Parcel #: /� _9'
� Pereon County Health Dapartment .
Envfronmental Health Sectlon
SITE 3KETCH ..
� c, w .� �� �� o �� o� ��
.Appllcant' Name � 3 diviaion/Se ion/Lot#
( � `c�� o0
Authorize tate Agent Date , � �
Syalem components i+epresent apprauctmate contorrrs only. The conlractor must Jlag ltis aystem
nrlor to be�t�tning the InstAllcitlon to lnsure lhat proper grade is malntained
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soa�e:
vr_un r4v. 4A/42/99 �
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