A32 217� lica4ion Date: -�{'16-0 f
Amount Paid: ��0 �.� �
��caiat #:
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5���� vals'
Psrson Countv Health De�partment
Environmenial Health Section
APPLICAT10Pl FOR SERVICES
Tax 'slHan �:
Pares! #:
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IF THE INFORMATION IN THE APPUCATION FOR AN IMPROVE9UIENT PERMIT IS FALSIFIED, CNANGED. OR THE SITE IS
ALT�RED. THEAI THE IMIPR01/ENIENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by. Owne a�jentlprospective owner): 5 ��. oJ�
Home Phone: gC�1- - �{S9� Address:
Business Phone: y Iq- '�3:�- `��3o t 30�
2) Name and address of current owner: ��� 3���
0
Z � . a 1t.�1
3) Property Description: Lotsize: 3� S3To�,sh�P: �USi1y FG� r
Directions to the property (incJuding road names and nrmbers�: d
���
+�.k_ �2�.
4) Proposed Use and Structure Description: answer each of the foliowing questions:
a) Proposed [�l Existing ❑
b) Sticfc Built�Modular �, Single Wide ❑, Double Wide ❑
c) Number o Bedroams: 3+ d) Number of occupants or people to be served:
e) Basement Yes O, No �'lf yes, # of basement fixtures: �
fl Garbage Disposal: Yes �, No ❑ r ��
g) Dimensions of Proposed Structure: Wdth: Depth: I� 6 4 S�- +� M� N� M�'"-
5� Water Supply Type: Private �(new 0 orexisting ❑), Public �, Community �, Spring ❑
Are any welis on adjoining property? Yes ❑ No ❑ If yes, location
6) Please Indicate Desired System i ype: (systems can be ranked in order oi your preferenc�)
✓Conventional _Modified Conventional _ Altemative _Innovative
Other (specify):
CL�4RLY STAQCE ALL CORPIERS APID LIIdES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEf1SE ATTACH SURVEY PLAT OR SiTE PLAfV TO THIS APPLlC�►TION
I hereby make application to the Person County Health Department for a site evaivation for the on-site sewage disposal system for
the above-described property. I agree that the contents of this appiication are true and represent the maximum facilities to be
placed on the property. I understand if the site is altered or the irrtended use changes, the permit shall become invalid. I understand
that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible far the
personnel of the Person Courrty Health Department to conduct their evaluations. I understand that I am responsibie for notifying the
Health Department if property coniains any wetlands as designated by the Army Corps of Engi ee
� l � Q✓K�/ �_ �
wner or Legal Representative D e
PCHD, rev. 10M2/99
Tax Map il:
AppllCan� ,
Locatlon:
PERSON COUNTY E6VVIRONMENiAL HEALTH
ri'ACHED PLAN FOR SOIL AREA AND SYSTEM LAYO
Parcel #� Township /�ltS`, v ��/'� P1N
��G!/".C'1>>'' Subdivision�„c.h�L'f (�/���L Phase/Section f3", 2 Lot� ��
Improvement Permit
New ✓ Addition Type of Structure i� ��+ �� ' H�- Water Supply /-!�'✓cc �� ����
# of Occuparrts �' S # of Bedrooms �_
Projected Daily Flow: � C� g.p.d. PE
Proposed Wastewater System: �� �
Proposed Repair. nn.t ✓P.t.. ; �,.tc�.
Other — System Type�
iit Valid For. ive Years � No Expiration
Permit Conditions: �� -�- .s�'.�p �S',�.� �� � �
—t`
Owner or Legal Representative Signature: `^' Date: 5- 3-��-Y
Authorized State Agent: G �. : s. Date: l� /3 Q/
The issuance of this pertnit by the Health Department in no way guarantees the issuance of other pertnits. The permit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if
the site ptan, plat, or the intended use changes. The Improvemerrt Permit shall not be afFected by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and
Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem tReQuired for Buildinct Permitl
Wastewater System Description: ��it v-���F,'C��ct- � Wastewater Flow: ��c� q.p.d. Type: �
Facility Description: �i�lZ :S,:z� �aryi, l, %zlsic�rl� New �� Repair ❑ Expansion �
Basement? O Y�s'" o Basement ixtures? 4 Yes 0'No
Wastewater Svstem Requirements
Tankage: Septic Tank size ODO gal. Pump Tank size gal. Grease Trap size — gal.
Trenches: Tatal length �,�� ft. Trench Width 3 ft. Total Area _1l0 � sq. ft.
Max. Trench Depth: �� in. Aggregate Depth: �� in. Soil Cover. � in. Trench Separation � ft. on center
Perrnit Expiration Date: "/.3 -� G
Authorized State Agent �S Date: /�3�Q l
*See attached site plan and addendum pages for additional permit conditions.
The type of system permitted ❑ does ❑ does not differ from the type specified on the applicatian. 1 accept the
specifications of this permit
Owner/Legal Representative Signature: Date:
Operation Permit
System Type (in accordance with Table Va)
This system has been installed in compliance with applicable North Carolina General Stakibes, Laws and Rules for Sewage Treatrnent
and Disposal, and all conditions of the Improvement Permit and Construction Authorization, Issuance of this permit implies no
guararrtee that ffie system installed wifl function properly for any given period of time.
Authorized State Agent Date
. PCHD, rev. 03/07I01
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Authorized State Agent
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