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A32 225A licatio� Date: 2'—� Amount Paid: � � Receipt #: Tax Ma #: 2 Parcel #: 7�i� ����.5� �l I�I�..� ��T _ _ - � � ���� ��a-nrn�a-�i�r-o�r�.�i-�..m�rn.Q�.cn-n ��mmnQ=�E-n. APPLICATION FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT,_FALSIFIED, CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit reque ted by: (Owner/agent/prospective owner): ��� V• i' �I�T�IU�' ���1 Home Phone�9l�1� �{p3'/SD �' Address: S I/ Business Phone(��g) �l�'i —/�96 I'v'�! iLt— Ak- -.���/ 2) Name and address of current owner: . m�� J�! L�1�64 L�/�LSON �l�'��'C'/ ������� D S�-: .�'�mU�� PA�K�k-, �� LL�' C �� f � 3) Property Description: Lot size: ���"Yownship: Subdivision: f./z'1c Lot #� Directions to the property (Including road names and numbers): ��u�t,S �� -E f��f�� ) orr.r% -frv_i � n r �k.�X..h c.�' Ynlc,c.s 4) Proposed Use a Structure Description: answer ea h of the following questions: A i� a) Proposed _, Existing , Type of Structure: �,�/hfic� CFL Width:� Depth: .3� b) Number of Bedroom�� Number of occupants or people to be served: ,� c) Basement: Yes V, No Will there be plumbing in the basement?� d) Garbage Disposal: Yes �No _ 5) Water Supply Type: Private �(new ✓ or existing�, Pub ��_, 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 previously identified jurisdictional wetlands? Yes_ No V PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be� laced on the property. I understand if the site is altered or the intended use changes, the permit shall become invaFfdl /% � Owner or Z' zo -o� Date PCHD, rev. 06/27/02 ���� ��; ���� � -� �� >. � _ -�- _ � � �I�.�`' � ��.���m�� ��.�:�.�. 1�.��.11 Tax Er9r p � arcel ' S«� � diivi�s�iom . . Ph�s�e:Sect+ion.Lot � �'�rmat 'Valid for Type of Facility: . # of Occupants LY1 Proposerl Wastew Proposed Re�air: Owner or Lega1 ] Authorized State 've � � # of System: Iffiproveanent ��rmit " ATo� ��iration � '�� New '� Addition qVatei Su�piy I�V � 1% s Proje�ted Daily Flow 1$ _ g.p.d. .. 8 � � Type: _ Type: Date: _� !�—Db The issuance of this pemzit by the Health Department m does not guarantee the issuance of other permits. It is the responsibility of the applicant/property owner to in stue that all Person Coimty Plannin.g and Zomng and Btu�ding Inspe�tions requirements are met This Improvement Psrmit is subject to revncation if the site. pl�n, plat or tr`►e intended use changes. The improvemeut Permit is. not :.�,,:;.. aifected liy a cha.nge in uwnership_,oi.tit�property. Z7ais pex-mit�vss issuesl in�eompliance with the pt'a�}sio�s of.the.No�thEL3ar.alina • .'�'..�f,Lmvs�-vnd .Ru1�s far Sesuas� Tre�t�n�eritruxr�.Disuosal Svstems' (ISA NC��.�18A _1900. 1Veither Persun�;�a �o�:g#he.�;.: ) !!�..Z._____ . .. •���n�t�uneutal �ealtiisS�.e�i��-�ra�fs:�xat�;aEhe.septic tank.systsm mll:.��nap,�ia:f�uc#ien'satisfacto�7y� ' .�_#-y,: ,._::_�::the.�¢ater.supgly will remain.potabie �� • - - - - _ . . ._ _ *,.:.. �- �� � ,.:,�._._ _..__ _ . .... ... .._ _ .._ ,. .. ._,. . ... _ . �-:^�.. �: .�.�, .,F..:s ;` Aut�io�izaiion to �oristruc# Wastewater Sysiem (Iteqn�es%fa��Biutding Permit)� • • ,- .* See site plan and additional attachments (_). . ." - /1 � Proposed tewater System: (�ahvE��ona � Type ..��+ Wastewater Flow �(��.p.d. ._ New i�IteP ' F,�p .'on Soil I,.TAR: • 27 g.p.dJ ft 2 Type of Facility: ri ✓df�� [_si �nC� Basement _ es _ No '�astewate� Syst�m Res��nire�e�$s '�ank Size: Se�tic Tanic:�� g�l Pnmp iank: �gal Grease Ta�ag�: -�—��1 Drainfield: 'Total Area: �%yssq ft Total Length 58/ ft � Ma�mum Trench Deptli �._ a�n Trench Widt� � ft lYg'in'imum Soil Cover. �2 in Minimnm Trench Separation: � ft �istribntqon: `� �'istribntion �oa �rial �isi�'b�ion Pressnae Manifold � Specifications: 'i'he type of system pertrritted is �/ Conventianal Acc�ted !�lternative. I accept the spe�ifications of the permi,t• 4�w�e�/���1 �e�res�ntative: Date: ' PCED rev. 11/10/05 .�-���� �� 1�. 1i.%l��.J �� �- . � �O��T�T�� ��.��-�„�T,.,.,effi¢.m.n. ���n,�. - . ��'�'�. ��.'1C��: . - Name 4� _ ra�rr' . i R 1' .�r Tag Ma #�`� A 3 Z Pa�cel # . �--- P .�'_�� Subd�v�sion C � � Section/Lot# . --�— . , �-L-�j(v Authorized State Agent . � Date `� System conr�onents re�r�esent u�b�r+vxisnate�contosers only. The conircec#or snustt fTag tlae syste�rtpri�r to _. eg�nning the installation io arasur�e that pr+upergrad'e is maantazned - _ �r�ia1 Sus�m • �J�O . •� � �l ��. �9 P ' S81 ' Con ven-�'ona% — 27s ��R ,. . /8.'' �rehc� dof�a�►s . �Zsp � �„K s��• � ��� ���, .'�+r►�„�',�+'' A /'M�,.� .k . i'+�,�7�"�'�'"R��►� �� � � i T ) ,• �.�!M '_s �:::j: � � � � y � 1 � � � � � E;� ` /a ° � / ���� � � "�' � �'J ���;�` � e , � A � � �� . . 'i , . �� � � ,� � � �' � �� � �i'`�; ► « � � t L/ 1 a,� - Qb �� ` �\ 1 �tt � � i , C�¢. � � �� � ,.�,' �! �"''���_ , ,� �l :�, ... . . � :.�,.~ K' Q/+ax .•.:. ' . .f • : .x =. ' . { ; � . _ { :• 7 } .M . . { : ••��"Y ��• •:�� t � 'y�� r '1�-. • �� + "a� ��•��i.•Y� . M,;� y'_� E . •a ��':. YA • .,�• •�,,G;• ;,7•• '°~'•"" Aa �_•.,�� Mr ' < ' '; .�. �. : 'v:k.i:i'•:.'n•......:.v,'... .,; S..' : .; •• � . . . ��'• ny�'�' . • �� • . ���• pw:fiw�t{L'•ri'n'.ti.eaM r�wRj+:(�'�1!Y�t1�;!t��- ��;'1:�� ����'^ �/I�.wT+,�� ,�i.Y. .K+Tj�+14w:M:.i �;��� : � �Jl�i�r�� . � ��� � ��� ���1 �� •'+� � �3�� � � T� �� Z p� # 22,� r�: ApPlioan� - � � Subdivieion: R � � �� s _ (:rv.P I � Lot # _1 tQ_--- - ' 0 •`�'�D8 O��'�%S�',►��1�: ��' lII�1V1� L'OI��f.�j P11b11C ��IDICHl�B: �. Sito Approved By: .�io�ing Agproved By: ' Wail Lo� ' � T� . � --= . We11 Tag: . Air V� ' ' . � H+oae B�: - . � �� . Cow�eta Slab: � � � LIIIQI: . �histailed by: " De�th set � DGrouted: V�iater Sample: ' ' �Veil Drs71e�: � Well .App�ruved by: ' Date:, - � � ��**9e� �ttac� S�t+a 3Bcetclt**'�* Welle must be 10 fect from praperty lineg. . 'Q{�ells mnst be lU0 feet fmm seQtic sj�st�ms. � �Tells must 1ie at least 2S feet �from any baild'ung foundatian. � , . Other conditions• PG"� rev 01l'L?J04