A32 212�pplica8on Date: � '%6-� �
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P�rson Cac�ntv Health �ec�artment
Environmental Health Section
APPl..1CATION FOR SEiZVICES
Tax �lJao �•
Pares! #:
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IF THE INFaRMAT10N IN THE APPLlCATiON FOR AN IMPROVE9VIENT PERMIT IS FALSIFIED, CHANGEfl. OR THE SITE !S
AL'TERED THEA1 THE iMPRO!/Es1AEA1T PERMIT AND AUTHORIZATiON TO CONSTRUCT SFIALL BECOME INVALID
1) Permit requesbed b�y: Owne �jent/pcospective owner): 5 ��•i ��al�l
Home Phane; `� /`7 - � �FS�� Address: '2
Business Phone: =1 i y-�� �- �c.=.yc c. 3 ��
2) Name and address ofcarrerrt owner. ��� J-T��
3) Property Description: Lot size: �� �� Townsh�
Direcctions to the property (Includin�g road names and
���
n1c._ �2�.
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed E!, F.�dsting ❑
b) Sticic Buiit J�'Modular �, Single Wide �, Double �de 0 �
c� Number o� Bedrooms: 3+ d) Number of occupants or people to be served:
w) B�ser:�enL• Ye� 0, No �'If yes, # of basement fixtures: ' -- �
f1 �=arb��� ����nsal: Yes 0, No a (� -� ,
g) Dimensions of Proposed Strudure: Width: Depth: ��� d s �`� �' ��' '�'��'i'`
�.
� Water Supply Type: Private �(new � arexisting �), Public Q, 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)
✓Ccnverttior�ai _AAodifled Conventional _ Altemative Innovative
Other (specify):
CL�ARLY STAKE ALL CORNERS AND LIIdES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PL�ASE ATTACH SURVEY PLAT OR SiTE PLAN TO THIS APPLlCATION
I hereby make application to the Person County Heatth Departrnent for a siie evaluation for the on-site sewage disposai system for
the above-described. property. I agree that the corrtents of this application are true and represent the maximum facilities to be
placed on the property. I understand if the site is altered or the iritended use changes, the permit shall become invalid. ! understand
that as applicant, I am responsible for identifying and maridng property lines, camers and maki�g the site acc�ssible far the
personnel of the Pe�son CaurYty Health Departmerrt to conduct their evaluations. I understand that I am responsibie for notiiying the
Heaith Department ifi property corrtains any wetlands as designated by the Army Corps of Engi ee
,� � �� � V �
' wner or Legal Representative D e
PCND, rev. 10/12/99 .
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�aa�n�^��n�na��n�.rn.� �'�a��en.Il��a.
T�x M�ap - F�rcel � -
Sllh(��IV1�5•1011 � ��
Ph�se Sect�ion Lot # �
Applicant: �k2� �OLY�/ _ .
Improvement Permit
Permit Valid for �F've Ye s No Expiration
Type of Facility: ,� New � Additi _ Water Supply �'��
# of Occupants Q # of drooms Projected Daily Flow �O g.p.d•
Proposed Wastewater System: vUl�n, C Type: R
Proposed Repair: �1J`Q- Type: �
Permit Conditions: h� ,�D CX�� �G�1� � ��`h� s y�✓� � �S* � C
Owner or Legal Representat �atu Date:
Authorized State Agent: i�""" �'h � ✓1�-e� Date. � I3 `�
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure khat all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject 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 Zaws and
Rules for Sewaee Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to funct3on satisfactorily in the future or that the water supply will remain
potable.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_).
Proposed Wastewater System: � k� t-� 0�'1 Type � Wastewater Flow `Z �Og.p.d.
New � Repair Expansion _ �1 Soil LTAR: ��� g.p.d./ ft 2
Tyre �f Facility: —l.� L� - Basement _ Yes � No
Wastewater System Requirements
Tank Size: Septic Tank: CD�gal Pump Tank: gal
Drainfield: Total Area: �RZ � sq ft Total Length �� ft
Trench Width � ft Minimum Soil Cover: � in
Distribution: Distribution Box
�c'�-
Authorized State Agent: _ '�/�
Permit Expira ion Date:
Grease Trap: gal
Maximum Trench Depth ��S in
Minimum Trench Separation: � ft ��•
D� Serial Distribution
S�',�d-eJ�-,
�ir'��
The type of system permitted is �Conventional
the permit.
Owner/Leeal Renresentative:
Pressure Manifold
Date: ��� 3=�'t'�
Innovative Alternative. I accept the specifications of
Date:
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SITE SI�TCH
Tax Map # �"3°2.Parcel # � � �
Section/Lot# CO
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Date
System com,ponents represent approximate �contours only. The contractor must, flag the system prior to
beginning the installation to insure that propergrade is maintained
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