A32 211,�pQlication Date: �'16"� (
,�enount Paid• �0 �.[ �
�tec2ipt #: . �
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�i��
S�� )��a�l
�'srson Cauntv Health �eoartment
�nvironmentai Health Section
APPl..lCAT10N FOR SERVICES
Tax �lao �:
Pares! #:
Ld— �
t3 y►�d .� C re�e �
IF THE INFORMATiON IN THE APPLlCATtON FOR AN lMPROVE3UIENT PERMIT IS FA�LSIFiED, CHANGED. OR THE SITE !S
dLTERED THEIV THE iNiPROVE�AEAIT PEi2MIT AND AUTHORIZATiON TO CONSTRUCT SFiALL BECOME tNVALID.
1) Permit requested b�,y: Own errtJprospective owner): 5 +� S oJ�t(
Hame Phone: `� C��l - � - �{59� Address:
Business Phone: =� i y-�.3 �= �c =� e- 3 �:2
2) iVame and address of currertt owner: ��� S T� �
3 6 � e o�r
3) Property Descriptlon: lot siza. � Township: �
Direaiions to the property (Induding road names and n�
4) Proposed Use and Structure Desc�iption: answer each of the following questions:
a) Proposed Cf, Emsting ❑
b) Sdck Built Modular �, Single Wide �, Double Wde ❑
cj Number o Bedrooms: 3-E- d) Number of occupants or people to be served:
e) Basemer�t: Yes 0, No �1f yes, # of basement fixtures: - --- -'-
fl Garbage Disposal: Yes �, No ❑ - : - �
g) Dimensions of Proposed Strudure: Wdth: Depth: �'j � d s� �� �'y' � N"�c�'t'`
5) Water Supply Type: Private �(new Q or existing �), Public �, Community 0, Spring �
. Are any welis on adjoining property? Yes ❑ No � If yes, location
6) Piease Indlcate Desired System i ype: (systems can be ranked in order o# your preferenc$)
✓Converrtior�al _Modifled Conventionai _ Altemative lnnovative
Other (speciiy):
CLEARLY STAKE :4LL CORIdERS �1ND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLF�SE ATTACH SURVEY PLAT OR SiTE PLAN TO THIS APPLlCJ�TION
I hereby make application to the Person County Health Departrnent far a siie evaivation for the on-site sewage disposai 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 altered ar the irrtended use changes, the permit shall become invalid. I understand
that as appiicant, I am responsibfe for identifying and marking property lines, comers and making the site accessible for the
personnel of the Person Courtty Health Department to conduct their evaluations. i understand that I am responsibie for notifying the
Heaith Department if property coniains any weUands as designated by the Army Corps of Es�gi ee
. A/`Ce� � �
' wner or Legal Representative D e
PCND, rev. 101�2/99
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�`. = 1 4 `1 � � � 11 �
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IE�������.����.]L IHL�:�.11�7�.
T�x M�� � P�rcel # -
►
Suhelivi�s�ion ��' '
Ph•a•se Sec�t�ion Lot #
Applicant: > :,•-?U,� � �'� �'P�
_ . r. ., . .
Permit Valid for iL
Type of Facility: �
# of Occupants �_
Proposed Wastewater
Proposed Repair: �
Permit Conditions:
�
�
Improvement Permit
ears _No Expiration , ��p�/
IN "1—
� # of
System:
G
Owner or Legal Represe
Authorized State Agent:
��R
�
New � Addition _ Water Supply
Projected D�uly Flow �,rv g•p•d•
Type: q
Type: oc
Urst,S� �d �
Date:
Date: "( 0
'The issuance of this permit by the Health Departtnent in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is su6ject to revocation if the site plan, plat or the Intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewa�e Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to functlon satisfactorily in the future or that the water supply will remain
potable.
Authorization to Construct Wastewater System �Required for Building Permit)
* See stte plan and additional attachments (�.
Propo d Wastewater System: c1'E✓1� cv1�� Type �R Wastewater Flow ��.p.d.
New � Repair Expansion _� Soil LTAR: r�7r g.p.d./ $ 2
Type of Facility: Z�/` 1��- Basement _ Yes D� No
Wastewater System Requirements
Tank Size: Septic Tank: � gal Pump Tank: gal Grease Trap: gal
Drainfield: Total Area: (��� sq ft Total Length ��� ft Maximum Trench Depth �� in
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: ( ft�• C�
. Distribution Box
Specifications:
Authorized State Agent: �
Permit Expiration Date:
DL Serial Distribution Pressure Manifold
»,�.. �;� 1P�,,��- I��t�%.
�
The type of system permitted is �Conventional
the permit.
Owner/Le�al Rearesentative:
Date:� �^ � 3�
_�
Innovative Alternative. I accept the specifications of
Date:
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SITE. SKETCH
Tax Ma.p # �30� .Parcel # �. I �
Section/Lot# �
�S�l3--� `f
Date
System components represent apprnximate�contours only. The contractor must, flacg the system prior to
beginning the installation to insure that�iro�iergrade is maintained
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