A34 250 � , a°
;ount paid 1��� . ��' 9� O-
, ' �d �-� .� � - / ��
.eceipt f� Date
� r � APPLICATInN FOR SERVTCES
F
-., �� ,�' ° �.E-� �� �� .�+"� eques�ed '���-y.,� -� �� : r�-�.�-�
`..I�ii.+� .+,a, s,+..�_ .i w�YtIIQ..s�.i•�%%��-�:Sec�Ytces�� � `�'_ t r ..�!!,,`-�.MY-�":�� r.LlX `4.�.�ti.��
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Improvements Perr.iic. (Established/Recocded Lot) _ Reinsoection or Existing System (Loan Closir
Improvements Permit (,Unrecorded Lot) I_ ReoaidReplace existing Septic System
Imorovemeats Permic (Mobile Home Replace) I_ Pe.;nit for New Well
Impcovements Pernit (Addition) _ Replace Existing Well
,.w� -fr ;.� - 1.M �. u Y i � � F./ :.1-. . �Zv �.. � -, ,,... .. . � � ,..*r" 4�q.� .,�h,Ca '�.' .Y � , �..: \;�i'F'i�
:�,. », ° ° '"° _ ��� Ls-� ��'Wafer�ample:to be.Collected_ �` �` ''�'� ; `` `
v.� � �s,r, .a s��� 7�_t,_.n.rwf•xVSR.-.:1. _ _ 't"' .:..:_Y3��.:�`����..�; 4: �.J..�:,...o��
�r...M.��...��, .... ...�2u.wi.s... - • . .���. r .. ...r `
B acceria � Chemical PetroIeum� �I �_ Pesticide _ Lead
. Perr;.it requesced by: . 7. Dimensions or Pro�osed Structure:
wner/prospective owne:/�;ent: �'� r-i: S Co�e'�►o-N Width: .� � iC %�
,ddress: � �'' Deoth:
u � �- 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
�� ` � that this se�va;e dis�asal system is in[ended [o serve?
[ome Phone �: r--q� c�, z� �V�rtc, .
✓ 7 — �`7
usiness Phone z:
ame and a�dress oc:c� � enc owner:
�
�,
.
9. Water suooty cype:
� private `t?j . public ❑ community ❑ spring ❑
Are any wells on aejoining pro eRy?Yes � No �
If so, identify Iocaeion: �� �o�'t� Se'�'e�
3. Propercy Desctiption: Lotsize: 3.09 /�t�ts• _
. Tax Map�: � 3 1Q�pe of structurelfacility: Proposed: �Existing: C
Parcel�: � 1 Type of dwelling: �
Township: �� �. House: ❑ Mobile Home: L1 Business: ❑
5. � Direccions to proper�y: State Road #& Road TYPe of business:
ames,ytc. 7ake /,3G c� o+�� o� r� i C�i1�� ���ld Number of Em ployees:
� 1, — Number of bedrooms: —�—�
,�4��� .� P� p���:,.; �E.:.� ..��. u,-
l���� ��� o ����,�;�.. :',XM1 nv ,�;r��- GarbageDisposal? Yes❑ No
��,,���;, rc� ��� �' , Basement? Yes ❑ No so, � of basement fixtures
6. Number of occupants or people to be served: �_
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUCTURES•
I hereby make apptication to the PerSOn COun�y Health Depat'�ment for a site evaluation for the on-sit�
sewage disposal system for the above described property. I agree that the contents of this application are crue
and represent the maximum facilities to be placed on the propecty. I understand if the site is� altered or the
intended use cbanges, the pecmit shall become invalid. I understand that before an Improvements Permi[ can b
issued, I must present a survey plat oP the propeRy to the Health Dept. I undecstand that in the event I have not
delivered a sucvey pla[ oF the propeccy to the Health Dept. wi[hin 60 DAYS aftec the date oF the evaluation oE
the site by the Health Deo�, this application shall become void and all fees paid forfeited.
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pwner or Authorized Agene
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� Johnnie Terrell
I D.B. 117-72
1
� N-83-12-27-E
291.56' � �
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iots 66, 25D 8� por} of 25
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Johnnie Terrell
o. B ii�-�2
� Johnme 8 Mottie Terrell
� D 8. 127-217
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N-85•12-27-E
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542.91'
S-B5-�2-27-'N
199.66'
-85-12-2�-W
Roberfa Woods
D. 8. 119 - 25
I hcrchy certif.y that the subdivision plat �s
�li'f�icCc�l licrcon IiaS 1�crri };r�ntecl fianl t�pJ�r-��v,tl
pursuant to the Person C��unry Subdivision
F;c�;ulati<�t�s. „
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t� t�. Wood, Land Surveying, P. C,, Roxb
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STATE OF NORTH CAROLINA, COUNTY p
I� ER
certify that this
vision from an actualtsurveyrma�e
supervision; that the raio of pre
calculated by latitudes and depar
adustment is one,part in /�o�
area is calculated by electronic
llPU method; that this plat was pr
cordance uith G.S. 47-30 as amende
Witness my hand and offical seal t
of /hqRt�4 , A.D. 19 ,9�,
� �---� u, - �
� :
REGISTERED L SURVE
STATE OF NORTli CAROLINA� COUNTY�OF
I, ` IENCX— � M. _MOGVAti1 �y
do hereby certify that E�NE�' �
Surveyor, personall a a' M
and acknowledged the dueeexecutionr
going plat.
Witness my l�and and Notarial Seal t
of 1u�,n,�_, i sq, .
-------_�m�o�cGt rn �,�
�1y commission explres �OM� _ N
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued. „",�
Tax Map # �3� Parcel #_
Zonin� Township
Owner/Contractor (�� r.� ;
Location/Address, �1C�'�
Subdivision Name
� ��
. �
Dat ��
1 � C� �,�..! _ .4c�es
S.R.#
Lot#
SEWAGE SYSTEM SPECIFICATIONS
� Lot Area � ,1 �%�� Size of Tank� `^J • }er' �-�� Sef<
Mobile Home � Size of Pump Tank
;ss # ofBedrooms '� Nitrification Line r-r;,�5'�3 '
Max Depth Trenches p2 �''
Permits may be voided if site ' tered or intended
Well and Septic ayout by �
Co ents:
Date S-18- 9 9 Insta ed by
V[�ell Permit Paid l� WELL SYSTEM S EC
V Semi-Public
Replacement
Site Approved ✓
Well Head Approved
Grouting Approved �
Comments:
Date � � 7 �I �1 Installed by
�19'
changed.
Approved by!
aa�.pO � �
IFICATIONS
m
Required Slab
Air Vent
Required W� Log c�
Well Tag
�as� (o � (� ✓
-� . _ _ . ��
Approved by,
This report is based in part on information provided the liomeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditio�s on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
APR-21-1999 09�38
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OAKWOOD HOMES 910 597 8305 P.62i02
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D. B. 127-217
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D. B� 117- T2
RFFERENCE
D. B. 206 - T66
D.B. II7-72
T� Mop A34 Lots 66,2:iD8 po�1 ot 2'S
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I hereby certify that the subdivision plat os
dcj>ictca hereon has been granted €iar�l npproval
pursuant to the Person County Subdivision
Regulations.
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