A32 210� iicaiton Date: '4' "1� "C �
�enount Paid: ��0 , D 0 �. � �
�e��� �: .� 2 �35
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��rson CauntY Heaith �ec�artment
Environmentai i�ea(th Section
APP�lCATION FOR SERVICES
Tax �llao �•
Parc�l�#:
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8 y�.ds C �-ce k�
IF THE INFORMATION IN THE APPLlCATION FOR AN I➢IAPROVE3VIENT PERMIT IS FALSIFIED, CNANGED. OR THE SITE IS
AL'TERED THEAI THE INIPRO!/ENIE�IT PERMiT AND AUTHORIZATiON TO CONSTRUCT SiiALL BECOME INVALID.
1) Permit requested by: Owne a�ent/pcospective owner): � +� S�al�(
Home Phone: `� C�7 - � �59� Address: 'Z
Business Phone: �I i �=r - �3:�- ��-� �. 30:2
2) iVame and address ofcumerrt owner. ��� '�-1'��
0
e �r . a k�1
3) Property Description: l.ot size: a''7 � Township: !3 uL��/ FaNC- r
Diredions to the property (Induding road names and n�ambers�: ` d
���
+�.%C._ �20.
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed [f Existing ❑
b) Sticic Built�Modular �, Single Wde �, Doubie �de ❑ �
cj Number o Bedrooms: 3+ d) Number of occvpants or people to be served:
e) Basement Yes �, No �If yes, # of basement fixtu�es: ' _
fl Garbage Disposal: Y�a E7. �!� ❑ - �
g) Dimensians of Proposed Strudure: Width: �epth: )� d 0 s�. �� �� 1� ��uwL�-
� Water Supply Type: Private �(new Q ar existing ❑), Public Q, Cammunity �, Spring ❑
. Are any wells on adjoining property? Yes ❑ No � If yes, location
6) Please Indlcate Desir�d System Type: (systems can be ranked in order of your preferenca)
✓Converrtionai _Modifled Ccnventionai _, Altemative Innovative
Other (specify):
CLEARLY STAKE ALL CORIdERS AND LINES OF THE PROPERTY.
ST�KE THE C�RNERS OF ALL PROPOSED STRUCTURES.
PLE�SE ATTACH SURVEY PLAT OR S1TE PLAN TO THIS APPLIC�►TION
1 hereby make application to the Person County Heatth Depar4nent for a site evaluation for the on-site sewage disposai system for
the above-described. property. I agree that the conterits of this appiication are trus and represent the maximum facilities to be
placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand
that as applic�nt, I am responsible for identifying and marking property lines, comers and making the site acc$ssible for the
personnel of the Person Caunfy Health Departmerrt to conduct their evaluations. I understand that I am responsibie for notiiying the
Heaith Departmerrt ifi property corrtains any wetlands as designated by the Army Corps of Engi ee
. A/`Ce/ � �
' wner or Legai Representative D e
PCND, rev.10/12/99
r�s��t�9� ����9�''� ����I�i�6�i�1E���L. N���3
Tax Map � � 3� P-�c'�J � �.
:appftcan�
AlN
Ptiasd5ec�ot�
Lot� �
LacaUore %�S � 'F' L�f��( � lrllfVb(� 1'L�i'
Im�r�vernent �errnit:
New ,�Addition Type of Struc�ur+� K�? I�. � 7��5' Water Suppty "� '" '
# of Occupartt�� # of Bedrooms � Other System Type ��
Projeded Daily Flow: �� g.p,d. Permit Valid For. i�t.Five Years ❑ No Expiration
Froposed Wastewater System: ���'3W� • '
Proposed Repair. �^-� ��
�-aP a,�( A�.�d-s �- �e P�� c�- G�x-� �' �., �,�J�l,(S �p �
Pertnit Conditions� , --__ _ — /
L`S, �D `
Owner or Legal
Authorized State
Dafe:
Date: l �' � � '� L
The issuance of this permii by the Health Departmerrt in no way guarantees the issuanca of other permits. The pertnit holder is
responsible for c�eclting with appropriate goveming bodies in meeting their requirements. This site is subject ta revocation if
the site ptan, plat, or the i�rtended use changes. Tt�e Improvemer�t Permit shatl not be afFected by a change in ownership
af the site. This permit is subject to comptiance with the provisions of ifie laws. and Rules for Sewage �reatmerrt and
Disposa! Sysbems of �e IVorth Carolina Administrative Code.
Wastewa#er System Description:
Wastewater Flow: -` v v a.p.d. Type: �
Facility Descriptior�: ��� � � ' Alew �
Basement? � Ye's "f'9,1Vo Basement Fcctures? � Yes o
lNasbewaber Svstem Requireme�rts
Repair C� Expansion ❑
Tankage: Septic Tanic size �Q�� gal. Pump Tank size gal. Grease Trap size gaL
Trenches: Total tength � 3 s ft. Tr�nch Width 3 ft. Total Area `��� sq. ft.
Max. Trench Depth: ` 1 in. Aggregate Depth: ��" in. Soil Cover: � in. Trench SeparatioR �ft. on cerrter
Permit Expiratio� Date: � � `� �-' �� �
Aathorized State Agent �����— �te; 4� v` � �
�'See attached site plan and addendum pages for addfional per►nit caaditions.
The type of systern permitted ❑ does �3 does not diifer from the type spec�ed o� the appiication. 1 accept the
spec9fications of this permit.
OwnerlLegal Represerrtative Signature: Date:
�+�eration Pennit
System Type {in accordance with Table Va)
This syst+em has been installed in compliartce with applicabfe �lorth Carolita General Sta�bes, laws and Rules for 3ewage Treatrnerrt
and Disposal, and a!1 conditions of !he Improvem�rt Permit and Conslructia� Autlxirization. issuance oi this pern�i� impltes �to
guara�rtee that the system u�sta[leat wii! function ¢raperly for arry giv� pe�sad of time.
Authorized State Agerrt Date
_ PCHD, rev. Q3/07/01
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Lontion:
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T e of dllater Su 1: Individuat Community
'U1�9 pt� V
Reauiremenis:
S+te Approved by
Grouting Approved by . _
Weil Log
We!! Tag �
Air Vent
Hose Bb
Concxete Slab __
Weif Driller:
W�11 Approved By: _ � Daie:
. j
'�""'See A'tffiClied $ite S{CetC!'1'�'k
�Welis must be 10 feet fram property lines. �
1�yelts must be 100 feet from septic systems.
Wells must be �at least 25 feet from any buiiding foundation.
Other canditions:
' �' � �r
S
Public
,-.: , ►
PCHD, rev.11/29l99
PERSON COUNTY HEALTH DEPARTNIENT
3��A SOUTH NIADISON BLVD.
ROYBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAlYIPLEANALYSIS
Name of Owner or Tenant �QhQld /"l /
Address 2�� fi���u r l�e �6 _ County j�e rso h
Collected By �5
Date Collected 3' 2`O Co Time Collected �'- y�/
Source: L�Vell ❑ Spring O Other
Location: t.t�nouse Tap
pNo Charge harge
pWell Tap ❑ Other
�����********�**�*�*��***�*���**��*�********�****��*��**�*��*�*********��*�**�
********�*���****�*******�****�t�***�***�*��***�**�******�**��****�*�*x�*****��
Total Coliform
FecaVE. Coli
Resulls
Present Abse,nt
� ��
❑ CK
Reported By ��-� ;'Y1�
bactreport