A32 225A licatio� Date: 2'—�
Amount Paid: � �
Receipt #:
Tax Ma #: 2
Parcel #: 7�i�
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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
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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 �� • - - - - _ . . ._ _ *,.:.. �-
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,.:,�._._ _..__ _ . .... ... .._ _ .._ ,. .. ._,. . ... _ .
�-:^�.. �: .�.�, .,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
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Subd�v�sion C � � Section/Lot#
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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 - _
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ApPlioan� - � �
Subdivieion: R � � �� s _ (:rv.P I � Lot # _1 tQ_--- - '
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•`�'�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�: - .
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Cow�eta Slab: � � �
LIIIQI: .
�histailed by: "
De�th set �
DGrouted:
V�iater Sample: '
' �Veil Drs71e�: �
Well .App�ruved by: ' Date:, -
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��**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