A32 209Tax :Nap �
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lacation: _
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�2-T Su6dhrisioa � PhaseJSec�on LotEt �
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�13'iit�iOVG�Yd@t3t ���'i�71$:. L�,%w(,
Newt�Addition Type of Structure"I /�i� 1 i�i Water Suppty
# of Occupartit�4��i,� of Bedrooms � Other System 7ype�
Projeded �aily Flow: `'�f� g}�.d� Permit Vaiid For_ Five Years ❑ No Expiration
Proposed Wastew�,ter System: �a
Proposed Repair (�tit.t/
Permit Condi
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Owner or Legal Representative 'gnature: Date: 5`' ����
Autharized State Agent Dafe: t��- �'�`� r
The issuance of this pertnit by the Hea{th Department in no way guarantees #he issuanca of other pe�rnits. The permit hotder is
responsibie for checicing with appropriate govemirtg bodies in meeting their requirements. This site is subjeCt to r�evocation if
4he site ptan, plat, or the i�ttended use changes. Ttre lmprovement Permit shali nat be affected by a change in awnership
of fhe sifie. This permii is subject #o compliance vvith the provisions of the [aws and Rules for Sewage Treatmerrt and
Disposal Systems of the iVorth Carclina Administrative Code.
Wastewra#er System Oescription:
✓
Wastewater Flaw: � a.p.d. Type:�' '
Facility Descriptio�: -•C� ��%t,_,/�'-�� ' idew`�--
Basement? Ci Y�'s'�JVo Basement Fi�ures? ❑ Yes o
Wastewater Svstem Requiremerits
Repair � Expansion ❑
Tankage: Septic Tank size 1, �� ga1. Pump Tank size gai. Grease Tcap size gaL
Trenches: Tata! tength S 3 S ft. Tr�nch Width �_ft. Total Area � 6vS sq. ft.
Max. Trench Depth: t� in. Aggregate Depth:�Z in. Soii Cover: �% _ in. Trench Separatiort ( ft. an center
� Permit Expiration Date: � �`�`T-+ o�v �
Authorized State Agent +/J�'— �e- �� � C 2"� �
*See attached site plan and addendum pages €or addfional permit canditions.
The iype af system p�ermiited � does � does not d'riFer'f�m ihe type spec�ed on ihe application. f acc�pt the
specifications of this permit
OwnerlLegal Representative Signature: Date:
O�eration Permit
System Type (in acxordance with Tabls Va)
This system has been installed in comptiartce with applicabte North Carol"ma Generd! Statutes, Laws and Rules for Sewage 7reatrneat
and Disposal, and all conditions oithe Imp�ovemeRt Pcrmit and Conslrucbon �lufhoraation. issuance oi this pemii� implies no
guarantee that the system 9etsia[led wiil iunction lx�PeriY fOr arry giv� period af time.
Authorized State Agent Date
_ PCHD, tev. 031D7/O�t
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,� lication Date: '� "16"� �
�mount Paid: ._�C �.� j
�ecaipt #: _,;�35
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Psrson Caunt�l �leaith �eoartment
�nvironmentai Health Section
APPLlCAT10N FOR SERVICES
Tax �flan #. -
Pares! #: -
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IF THE INFORMATION IN TNE APPLlCAT(ON FOR AN IMPROVE�IIENT PERMIT 1S FALSIFIED, CNANGED. OR TIiE SiTE IS
ALTERED. THE3V THE INiPROVE�1flE�IT PERMIT AND AUTHORIZATION TO CONSTRUCT SFiALL BECOME INVALID.
1) Permit requesbed b�y: Own�a entlprospe�tive owner): 5+� �• oJ�
Hame Phone: �' C��I -� -�S3 � Address: Q��
Business Phone: �1 i y-�.3 �= �c=--;`c c. 3 �:Z
2) Name and address of cumerrt owner. ��� Si'��
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e o�r • ov k.tl
3) Property Description: lot size: �'"2T ownship: a�s-1-. �t,t-�. �
Directions to the property (Including road names and nNmbers�:
4) Proposed Use and Strueture Description: answer each of the following questions:
a) Proposed Ef Existing ❑
b) S6cic Builty�Modular �, Single Wide �, Double Wde ❑ �
c) Number o# Bedroams: 3�- d) Numher of occupants or people to be served:
e) Basemer�t: Yes O, No �'If yes, # of basement fixtures: -° --- -
fl Garbage Dispasai: Yes O, No ❑ c� ,
g) Dimensio�s of Proposed Strudure: Wdth: Depth: ��� d s�- "'�`� �' ��"t'lw�'`
5) Water Supply Type: Private �(new 0 ar existing �), Public �, Community �, Spring ❑
. Are any wells on adjoining property? Yes ❑ No � If yes, location
6) Please Indicate Desired System i ype: (systems can be ranked in order of your preferenca)
✓Converrtional _Modified Conventional _ Altemative tnnovative
Other (specify):
CLIEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY.
STr'�KE THE CORNEitS OF �4LL PROPOSED STRUCTURES.
PLEt1SE �►TTACH SURVEY PLAT OR SITE PLAPI TO THIS APPLlCATION
1 hereby make appiication to the Person County Heafth Department for a site evaluation for the on-site sewage disposat system for
the above-described. property. I agree that the contents of this application are true and represent the maximum faalities to be
placed on the property. I understand if the site is alteced or the irrtended use changes, the permit shail become invalid. I understand
that as applic�nt, I am responsible for identifying and maridng property lines, comers and making the site accessibie for the
personnel of the Person Courrty Health Oepartmerrt to conduct their evaluations. I understand that i am responsibie for notifying the
Heaith Departmer�t if property contains any wetlands as designated by the Army Corps of Engi es
' � A/�/ � �
" v+mer or Legal Representative D e
PCND, rev. 10112/99
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Zoning To+er�mhiP _ .
AppliCant
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Yv�e of Water Suat�iv:
Reauiremenis-
Well Pertnit
�- ' Commun' Public
Ind�v�dual �Y
Si�e Approved by
Grouting Approved by .
Well Log
Weli Tag �
Air Ver�t
Hose Bib
Concxete Slab _
Weli Driller:
W�11 Approved By: � Daie:
. ;
i'"'S�e Athached Site Sket,ch'�°'
V1lelis must be 10 feet from property lines. �
�1j.�elts must be 100 feet from septic systems.
Wells must be �at least 25 feet from any building foundation.
Other conditions:
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PCHD, rev.11/29l99
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