A32 221�plication Date: � �0� % � Tax Map #: N3o�,
Amount Pald: O� 0
Recsipt #: l 73 4 7 Parcel #: o'��- �
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APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHAiVGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTNORIZATION TO
CONSTRUCT SHALL BECOME INVALID. �
^ ��S'�`��' �1c�3
1) Permit requested by: Ownedagent/prospective owner): � P�1 i=SD✓�
Home Phone: '(n -� Address: 5 n
Business Phone: 3 ( • �"b� -D1�� � oru !UC. r?r15'1 �f
2j iVame and address of current owner �� iCi'ln� �.Y�-�X
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3) Property Description: Lot size: �.� Township: � C� LS�u�,,b-divi�sii
Directions to the properiy (Including road names and numbers): ��
Lot #�
4) P'roposed Use and Structure Description: answer each of the following questions:
a) Proposed ,�, Existing Type of Structure: �( 1« �+-I-2 {�c..z�' Width: � Depth: 5�
b) Number of Bedrooms: �3��a��%lumber of occupants or people to be served: �_
c) Basement: Yes , No �C ,�Vil! there be plumbing in the basement?
d) 6arbage Disposal: Yes , No �
5) Water Supply Type: Private �, (new �, or existing�, Public_, Community_, Spring _
Are any wells on adjoining property? Yes_ No � If yes, please indicate approximate location on the
� site plan. �
6) Does your property contain previousiy identified jurisdictional wetlands? Yes_ No�
�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMiTTED WITH THIS APPLICATION. .
➢ PROPERTY LlNES AND CORNERS MUST BE CLEARLY MARKED. �,
➢ THE PROP.OSED LOCATION OF ALL STRUCTURES MUST BE STAICED OR FLAGGED.
�➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF:
I hereby make a plication to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the ab ve-described property. I agree that the contents of this appiication are true and represent the maximum
facilities�o�e pl ced on the property. I understand if the site is altered or the intended use changes, the permit shall
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Owner or Legai Representative Dat
PCHD, rev: 06I27/02
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J0� PRIVATE ORIYEWAY
s�u
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23
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iiE JEthETTE PARKER ESf.
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4.18 AC.
- 30' PRIYATE ORIVEWAY EASEl1ENi
ANO O.O.i. STORUWATER EASEMENT
N83'53'31�E
560.11'
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RtYERPLICE
PS 4:0T0
L47
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4.65 AC.
579.�a 59-w
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4.77 AC.
N88'54'00'E
762.02'
13
4.63 AC.
���'31'W
97?.54•
12
s��r�f i =?6.41 AC.
QEPARli�ENT OF THANSPOR�ix i!(
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.T CA.B �, HA.NGER ��� ��< :� 7.3o Ac.
in Person Count}• Register of Deeds on the w� y
a • of ll � � z002 @ J.�'�'J o'CIoCl; �.M. �-'- '°� FLOODZONE 'AE" -!
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xda W. Garrett, Register of Deeds • m
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Applican�
Location:
P�rmit Valid for ✓ �`ive'iteaa�s
Type of Facility:
# of Occupants �C # of BeL
Improvement �'ermit
� No �apiration
T��x h�1ra�p �� � r c�e l y�—
Su.bdiiv�i:s�i�a�ia � . - •
Ph�:s�e Sect+io�n'Lo# = .
New ✓ Addition �ater Snppiy ejp�_
Projected Daily Flow �/�> g.p.d.
Proposed Wastewater System: � Type: �Q--
Proposed Repair: � �_' _ Type: :� t�.
�� �
,- _ �. ,
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Pennit Conditions: -�1�� ��P �� )
Owner or Legal Represen tive Signatvre:
Authorized State �Agent ` � '
�. - r. S��
The issuance of this pe�it by the Health Department in does not guarantes the i�c�,�e of other permits. It is the responsib�ity of the
aPPli�PToP�3' owner to in sure that all Person Coimty Plannmg and Zoning and Building Inspections requirements are met This
Improvement Permit is snbject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affected by a ci�ange in ownership o# the property. This permit was issned in compliance with tlte provisions of the North Carolina
`Zaws and Itules for Sewage Treadnent aad Disnosal 3vs�teras' (15A NCAC 18A .1900). Neither Person �onnty nor t3ie
Enviranment�l Health Specialist'warrants that. the septic tank system w�71 cnntinue tn function satisfacton7y ia the futnre or'that
the water supply will remain�potabie. - =- . � �
Authorization to Constru Wastewater System (Required for Bu�ding Permit)
* See site plan and additional attachments (�• �.
Proposed Wastewater System: C�1�/� i�� oC'Y�Q � Z`ype��'o� Wastewatez Flow �J g:p.d.
New � Repair Expansion Soil LTAR: . 3Cl g.p.d./ ft 2 �
Type of Facility: �, j�,���P -�- rcvl � A��. se Q 4 4 nn Basement ✓`Yes _ No - �
Wastewater System Requirements
Tank 5ize: Se�tic'�ank: l�1 gai Pnmp Tank: — gal �rease Trap: — gal
�rain�eld: Total Area: � sq ft -Total I.ength �� it � 1Vla�mum Trench Depth I� in
Ts�enc� �Vidth 3 ft 1Vg'inimum Soil Cover. � in 11Tinimnm Trencli Separation: � ft
Distribntion: �istribution Bo$ � Serial Distribntion
Spe�iffications:
Anthorizesi State Agsnt �S�
Permit Expiration Date:
The type of system permitted is
P��
�wsae`�l�,Egal �.t�presentalive:
Pressnre Manifold
Date:
Conventional Acce�te3 Alternative. I acc�t the spe�ifications of the
Date:
PCHD rev. l l/10/OS
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SITE PLAN
Name � �n � YISS�f`cl Tax Map # Parcel #�
' 'sion K section L r# _
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Authorized State Ageat Date
Syarem compoaenrs represent appm�mare conmurs oalp. T3e contraaormusrtlag t6e system pdor m begian-ne� thelnstal/atiaa to
iasure that piapergrade is maintained
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�ELL PERM[I�
]PL�S� SEE ATTA�]D PLAN F�R V�ELL S� LAitOYJT
Tax Map ��_ Pazcel # �_ Tou�nship:
Applicanf: L� IPnn Fir'� c.�m
Subdivisian: �, ,�� � ('rP, k Lot # l2 �
Location: N�,Y,�� R�;\1� C�,� ..a. �, __.,,., �„ .�.� r�_i , n - - � _ . „ ,.
Type of'Water 5upply: ,/ Individual
Ytequirements:
Site Approved By:
Grauting Approved By:
Well Log. �
Pump Tag:
Weil Tag•
Air Vent:. `
Hose Bib:
Gaeing Height•
Concrete Slab: , � `
Well Driller:
Well Approved by;
****See Attached Site Sketch****
Community Public
Liner:
Installed by: _
Depth set: _
Grouted•
Date;
Water Sample:
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems,
Wells must be at least 25 feet from any building foundation.
Other canditions:
Date:
PCHD rev Ol!27/04