A34 94z
�- P�rson County Health Department �
Sewage System Improvements Permit
Date:�� This ermit Void After 5 Y s Permit # �'`' - i6,gR
Owner: SR# �}.
Location/Directions: �-''� �Kc C
Subdivision Name• � Lot #_� ,�.�
Lot Siz�:" 5�� � c- v� S_ Type of Dwelling: c.�
Water Supply: Private: —� Public: Community:
Bedrooms: �.� Garbage Disposal
Basement Basement Fixtures �
INFORMATION CERTIFIED BY �"— ��
Environmental Heal[h Specialist: ner oy�epresenrat P
REPAIIZ: REEV UATION: •I�
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Size of Septic Tank: gallons ize � Pump Tank: .
Nitrification Line: f ��
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks��� � i i� �� n✓.� ,J., „,._�
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Date Well Approved: Well should be 100 ft� from any sewer system
By Environmental Health Specialist
Date w ge roved: — J
By Environmental Health p ialist
TIFI ATE OF COMPLETION ,,.�
Contractor. � M .���5 �
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Sewage System location, installation, and protection must meet state and local �
reguladons. Septic tank should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person County
Health Depaztment before any portion of the installation is covered and put into use. If
the site plans or intended use change this pernrit is subject to revocation.
(G.S.130 A-335F) �
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I.ocation of sewage disposal sewage system sketched on back. �
�
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(OVER) °°
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
'supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
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S � '33C�
�pplication Date: `� -d—I-�
Arnount Paid: 150. c� _
Receipt�#: �-(�i�� � _
TaY vlap: 1-1 -3 7
Farcel #: �_
���'45 ��`"�� � � ►�_- �� ��.��
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Z.�...uh-a...:i•*r�i�s.�,,.,.-...cr•ssa�i:,cai1 �E���c�..w..�tii�.z.
���➢ic���on �oa- Se�-vie�s (Septic Systems and Wells)
Sea-vic�s �e uested
� �mprovement �ermit (Site �.valuation) ❑ Construction Authorization
$200.00/$;00.00 (if> 600 g d) (Fee is dependent on the ty e of system ermitted)
❑ i4lobile �3ome �2epiacement or Buiiding Addition �J Permit Revision
�1�0.00(ifsitevisitre uired) $75.00
C�'eil �ermit (I`dew/12eplacementl�2epair) IJ Repair of ��isiing Sep[ic System
$300.00/$200.00/$75.00 No Charae
�) �ervic�s �teque teri �y:
Name: � fif �
Address: Q
Phone # (home): � ,� � / 7 ��
(work/cell): g l � � �/ a S�Qb
Z}l�atn� and adcflr�ss off z�aa-r�m# awnea� (a� diifer�nt tb�n appl�cant):
Name:
Address:
3) �r�g�erQ� �escrn�tIlon: Lot Size: Su,bdi ision• �ot #:
Address and/or �r tions to Property: 1
V'12u,� �� S �G�N�-� � �
4) �roQosed Use and T3�pe of Structure:
R�sidential � Business/Type: Other
Number of bedrooms 3 / Number of people served (seats/employees): ,�
Basement: Yes No (with plumbing: Yes � No __�
Garbage disposal: Yes No �
5) Water Supply:
Private Well Proposed Existing _)
Community Well: Public Water System:
Are there wells on the adjoining properties? T10 �- Yes
(please show focation on site plan)
1�Tate: A co�san[eterd �rvnlication mus� n��o incluc�e:
� f4 �ladsite plun o, f 1hQ �roperty �laat s�iow� p: o,pe�� �li�raensions rand the �ize ��a�l �ocr�tioaa n.J`'tedl
proposed structures. .
5� �1 sagr�ed capy af �dae `�at �r��aratio3�'�OF'}B8 7��Y�831a tha� P�ae�roperiy �� rPady �o ve evalura�esl.
� a�a �ubmiitan� thas ��p�l'ncation io re�aaesi 3ervic�s �'rona t�e �erson �ou�nty '�e�1th �epa�#dne�at. � uaac�ersta�ec� t�a��
i�' #h�e infoa-�nation �rovide�i is �ne�rr��# or i� ��e ���e is su�s��ue�ntly a��e�-e�, or i�'thQ �n6ended use chang�es, ��d
per�a�ts and appruva�s shal� �ecame invaiid. -
�ag�a�hu�-� (Owner/? egal Representative): _ "I/ ` � �ar� : 7 '� S—� F
l0ii�8 Person County Environinenial. �?eai_th, �?5 S. �iior?an �t., Suite C; RoYboro, NG 2757� (336-�97-1790)
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Tax Yiap #:��
Approval ReqLested for:
Parcel#: l
- = Nlobile Home Repl�.cement
Building Adziition
Applicant Name: e
Address:
a s'a � G _
Phone #'s:��{) 33�- Sqq -1�1q I �Wi q �R- 7Z�f - Z5R(e
Permit Located: V jles i�io
Instaliation I.7ate: - - Design flow: Z�D (gpd)
Current Contract with Cerrifie Operator on file (if required):
Water �upply: Well �- Fublic or Community
Wastewater system shows na visual evidence of failure on: S� s' Q�' (date)
(Applicant's signature if sit� visit is not required)
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Aa� ' '��/h3��fi������� ����°��r��
. S-S- �'I
Envir nmental Health Specialist . Datz
11/15l05
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.1J.�./lm'V31]C�(D�'e"'* �833.�.1L ��0�1GLLA
. � SITE S%�TCH � �" .
NaYne M� /� �P Taz Map #�r.Par�el #�.�
Sub _ � Section/Lot#
. . �_ �_ 09 .
� . uthorized State Agent . � Date .
Systesre cam,�ionen�ts re�resent u��tiroaeimate �contours only: The contmctor naust flag the system prior to ;
beginni�ag th� in,rtallrrtion io i�sure thatpropergr�ade is m.acintained
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