A32 89Appiication Date: �1J�
Amount Paid: zSD �
Receipt #: ��Z-7 Gl
�
Person Countv Health Department
Environmental Health Section
APPLICATION FOR SERVICES
Tax Map #:
Parcel #:
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CHANGED OR THE SITE IS
ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Owner/agent/prospective owner): S��C�� e S1J t �e, S�
Home Phone: 3�q- �36`7 � Address: 8 t,`b� uk{ C�-4�GVe ���
Business Phone: g� •�G �f � _ W uhdl l e AA � 11 �� �4 �
2) Name and address of current owner:
C
3) Property Description: �ot size: 1�� Township:
Directions to the aroaertv (Includina road names and numbers): GO d OWI� �u�
t; � 1 �. �d
� r�
� -� �4S c�dcf �s �
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed�xisting ❑
b) Stick Buiit �, Modular �, Single Wide�Double Wide ❑
c) Number of Bedrooms: � d) Number of occupants or people to be served: 3
e) Basement: Yes �, No � If yes, # of basement fixtures:
fl Garbage Disposal: Yes �, No ❑ •,
g) Dimensions of Proposed Structure: Width: �� Depth: ~%d
5) Water Supply Type: Private (new � or existing j�Public 0, Community ❑, Spring �
Are any Ils on adjoining property? Yes ❑ No ❑ If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
onventional _Modified Conventional _ Alternative _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
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
placed on the property. I understand if the site is altered or the intended 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 for the
personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the
Health Department if my property contains any wetlands as designated by the Army Corps of Engineers.
�.,,..,�;•�i, � 4�1/
Owner or Legal Representative
�-lq-Q
Date
PCHD, rev. 10/12/99
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Apalieation� Date: 3 "I -6L , T�r �aa�
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kmourr� Waid: ,�_ , o � ., :�Tro..Vt- � �e�r� . � �� �. � � ; � . •
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�� p.,� �,�a �: �o�e�����e ��: �- a � � e_q. s� � � e��l -��
Home Phone: �� � 0 6 Address: • f 1�i �`
Business Phone: � �. `�� s
2j Name and ad�ness �f carr�n# ov+mec �,,Q� ��'�'Q'O"'�
e,.,, � � N �-; � � �' �.,� -
3) Property �'es�iption: Lot size: �� Toumsi�ip:�_�-?�Sui�division: Lot#: I
Dit�ions to th� I�P�hI (]ndudi raad. nu��e�s): /' ,- r ee �v 1-�a A,� -e
. � C7 B t t.�l c�� �-r ��� ,. �. G U�. 61.��� ��--�
4) Proposed Uee and �nachare �ca�ptlon: an.swer each o# the following ques�o Widttc. Deptfi:
a) �F� _ , ��9 —, TYPe of Strudure: �
b) Number af Bedroom� ;�_ Number of oxupar�fs or peapie to be seroed: � , ._
c) Ba�nen� Yes _, No � Wiil there t�e ptumbing in the basemeni?
d) Ga�e Dispasar Yes � Nc _ �
5� WaEe� �P�Y �lP� P�� —(�+ Car � 9�. Pt�b�c� Carrununity ,�, SP�9 _. -
Are�any wells cn adl�n9 P�P�Y���No _ If yes� p[ea�e indk�e aPPro�dmate Ioc�tlon an the s�e �.
6j Does the pr+op�rty cmntain previousiy tdetrt�ted jurtsd&�nai w�fands? Yes� No _
PLEASE NOTE TNE FOLLOWING•
' 9 A PL�T OF'it�� PROP�liTY OR Sif.E PL#N 11/UST BE SUB�IiTTE� 1M'fH THlS ds1PP1-ICACttON:
��ROPERN WdES AND C�RNHZS �IItIST BE q.�RLY YAR�. .
➢. THE BROPOS� L�CATlON OF ALL STRUCTURE3 NUST HfE STAI� OR FiA►[�8�. • �
� 7HE S1TE �IUST BE R�ADILY A�SiBL.E FOR �►At EVALU�►T�N BY THE HEA►LTH DE'P!►RT�lT STi�.
1• heseb�r make �n tn the Person Caw�iy H� Deparhnent fcc a s�e evaivation for the nc»-siie seurage dis�osal
sy�em iur tfie above-de�bed property. 1 ac,g�ee that the carrtents af this appGcxtion are true and repr� the ma�num
fac�ittes ta be plac�i on the properiy. 1 understand ifi ihe s� is aite�ed or the intended use changes, the permit shall
��8��-��t ��.( � � : �� �. � �2�� � .
Owner or Legal Rep�ve �� Date
p�}p. lev.10f17/01
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II���a�-��.���¢�.IL IE 1L��.Il�1�..
Applicant:
T��x M��� ' - P�rc�el # %
St�if�clivi�s�ion
Ph��s:ecSe.c7t�i,o,i,illo,t �
Improvement Permit
Permit Valid for �ve Years _ No Ezpiration � ``
Type of Facility: �� � New �Addition Water Supply � S�
# of Occu ants • e r m �
p ✓�� # o B d oo s Pro�ected Daily Flow �� g.p.d.
Proposed Wastewater System: CAlr1,�. ' Type:
Proposed Repair: C �vUV, � Type: _�
Owner or Legal Represe�
Authorized State Agent:
Date: � �� E� � �
Date: '-�' 1���
The issuance of this permit by the Health Deparhnent in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permlt ts subject to revocation�ff 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 wtth the provisions of the North Carolina `Larvs and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900).
-' Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_).
Propose astewater System:,�,�,�/Q��`�,tq � � Type�Q Wastewater Flow�_�.p.d.
New �,� Repair Expansion Soil LTAR: ► 3 0 .p.d./ ft 2
Type of Facility: � Basement _ Yes �No
Wastewater System Requirements
Tank Size: Septic Tank: OOC� gal Pump Tank: gal Grease Trap: gal
Drainfield: Total Area: l a p O sq ft Total Length � ft Mazimum Trench Depth � in
Trench Width 3 ft Minimum Soil Cover: �P in Minimum Trench Separation: � ft
Distribution: Distribution Box �erial Distribution Pressure Manifold
l �r�
SpeciRcations: ��iS�r� ��✓t� Q�S I�,�� as_ �ds� �p�Q- lA/ �-�t
Authorized State Agent: �
Permit Expira ion Date:
�tr
Date: ��- � �� Z
The type of system permitted is �/ C nventional Innovative Alternative. I accept the specifications of
the permit. �
Owner/Legal Repre�entative: � � o Date: �'�`�-�` � �-
'��,;;�� ������. �`�
� � ���
7� ��a-�mm -�-�„ �m�.11 IE�T��.Il�
SI'I'1E SSI�TCI�
Name Tag Ma # �� �.Parcel # ° �
. P
Subdivisio Section/Lot#
-v
tluthorized Staxe Agent � Date
sys�m �o�o,�,z� ��s�t �pro��� ���tou� onzy. The contractor must flag the system prior to
heginning the installation io insure that jimpsergrade is muzntained
Sca1e:
0
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pGHD, re�. 09/12/01
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IE�.�.s��� � ��.�.I1 IL-3I��.Il�.
Appiicant:
Location:
T��x fvl�.p i P�rc�el � J• '�
S�ubcl'ivi�s�ioia
Ph�se Sec�tioil `Lot r
Operatioii PE�rii��t
System Type (In Accordance With Table Va): �
THlS SYSTEM HAS BEEAI INSTALLED IN COMPLIANCE MIITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RUI�ES FOR SEWAGE TREATMENT AND DISPOSAL,
�►IVD � ALL CONDITIOPlS OF : THE; :.IMPFZOVEMENT PEi2MiT Ai�ID CONS'FRUCTIO(d
AUTH TIO : � . . . � � � �
. . . � �. � � Y ; . : . j�l�z � - . � � �
. . Authorized e Agent . . � . Date
� � �/ �,
Installed By: J 1 ���� � , ... Date .. �' W � .. .. .. �
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_ . .. - . . : :-: _..�.: ... �.. _,. . �-- � " _ - . ��_ _ -- . -=- ..
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PCHD, rev. 07/29/02
32 s��-�c �-���c iNs���c�o�u c�E��s-� �z��� i� - n� �
Tax MaQ # arc�! # System Type (Tabie Va)
Owner/A�piicant Subdivision
Address/l�ocatior�, � �,� SeclPhase Lot #
State ID/date
Tee and Flter
8affle
Sealarrt {
Riser if applicable
Tank Ou�et�:Seal
� Permanent Marker
� Pump Tank
tate ate �
. Capaciiy � �
. . � VI/aterproof /Sealant
Riser .
Tfench Wi�h
Trench. De�th
Trench Grade
Trencli Spacing
Rocic Depth and
ft.
:i -
Dams/Stepdowns etc.
Pressure.Laterais
Hole Spacinq
Sleeve � - � .
Setbacks
Water Tight � From Wells� �.
� . Purnp _._. From Pnoperty lines
_ , G#�eck Valve/Gate Valve. �.. .. ..._ .� _ _.� _ .� Structu�slBasements
_, :; Anti-s� an o e . � �tc . es raina�e a�
-. - . - . , _ Fioats/Switches .'. .. _ . . ...__ . .- .- . . :. � . .. . __: ... _ ., .. _ Surface Waters
Alarm visable and audible � Pubiic Water Sup lies
Electrical Components Verticai Cuts >2 ft.
Rate pm � Water Lines
Ap roved Pump Mode! Vehicle Traffic
Blocic Under Pum � -
Pump Removal RopelChain
Distribution System
Seriai Distribution '
ressure an
Low Pressure Pipe •
Appr. Pipe Material and Grade �
Easements/Right of W<
Other
Easements Recorded .
Comments
pci�d rev. 3113/01