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� � APPUCAcTiON FOR SERIRICES -
SHALL BECOME iN1/AL1D. �
1) Permit requested by: (O er/agent/prospective awne � U "��
Home Phone: -qC4� Address: s � �ti -
Business Phone: A1- o � a�'��
-;
2) Name and address �f carr�nt ownec j'1�
l
3) Praperty �esc�iption: Lat size: Tawnship: Subd'nrisian: Lot�:
Directions to the property (Induding r+oad. names and num6ers):
4) Proposed Use and �ructure Description: answer eacti of the following questions:
a) �p� _,��9 —, TYPe of Struc�ure: � Width:. Deptfi:
b) Number of 8edrooms: �_ Number of occupants or people to be served: ,
c) Basemen� Yes _, No _ WiII there be plumbing in the basemeni?
d) Gattiage Disposa� Yes _, No _
�) �1later Supply iype: Privafie _(new ,_ or existin9 �, Pubiic_, Cammuni'ry _, Spring _
Are arry weUs on adjoining property? Yes _ No _!f yes, ptease indicate approximate locatton on the site plan.
6j Does the prope�ty contaln previcusiy identifled jurisdidional w�iands? Yes _ No ,_
PLEASE NOTE TNE F�LLOWING:
' 9 A PLAT OF THE PROP�i2TY OR SITE PL.�►Pf 9WST BE SUBBAfR'E� WITE1 THIS �►PPUCATiOM:
9 PROPERTY LlNES AND CORNERS MUST BE CLEARLY NARI�U.
➢ THE PR�POS� LOCA770N OF �1LL STRUCTURES NUST BE STAK� OR �1A►GtiED. •
9 THE SiTE RIUST BE READILY ACC�SSIBLE �OR AN E1/ALilAT10N BY THE HE�►LTH DEP�T�AE�IT STAF�.
1- hereb�r make application to the Person County Health Department for a si�e evaivation far the on-siie s�urage disposal
system fo the above-descnbed properiy. 1 agree tha# the cante�rts of this application are true and repre�nt the ma�dmum
faa7 a be the prope . I understand if the site is aitered or the intended use anges, the perrnit shall
b. . �oa
Owner o Legai Represenfative � ��
pC�{p. tgv 10M7/01
'��' ' �palication oate• 3 -15 _b�
Amount Paid•
Receiqt #: (�
�-.
Tax Maa #• .�Y 3 �
Parcel #: � �T
Person CountY Health Department
Environtnental Health Section
. APPLICATION FOR SERVICES .
1) Permit requeste :(O e�/a ent/prospective owner):
Home Phone: Address• 0�
Business Phone: – q � �
2) Name and addcess of cuirent owner: ��a�r��S GJ 0.'i'SA.�—
�
3) Property Description: lot size: � Township: �V �oo( '(a�.P�
Directions to the property
4) Proposed Use and Structure Descciptlon: answer each of the following questions:
a) Proposed �. Existing � ICf�-
b) Stick Buiit 0, Modular �, ' gie Wide �, Double Wide ��
c) Number of Bedrooms:� d) Number of occupants or people to
e) Basement: Yes �, No f yes, # o basement fixtures:
� Garbage Dispasai: Yes �, No
g) Oimensions of Proposed SUudure: Width: Depth:
;��1 ��
�� Di1�
�r��
be served: �
5) Water Supply Type: Private 0(new Q ac existing O), Public 0, Co�n'ity �, Spring � f^„ „���
Are any wells on adjoining propert�t Yes No 0 If yes. loca6on �����
6) P,lease Indicate Desired System Type: (systems can be ranked in order of your preference)
/
�� Conventional Modified Conventional _ Altemative innovative
Other (specify):
-% CIEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPLICA710N
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. 1 agree that the co�te�ts of this applica�on are true and repcesent the maximum faaGties to be
placed on the property. I understand if the site is altered or the intended use changes, the peRnit shali become invalid. l understand
that as applicant, I am responsible fo� identifying and maricing property lines, camers and making the site accessible foc the
personnel of the Person ounty Heatth Oepartment to condud their evaluatio�s. I understand that I am responsible fo� notifying the
Healt D partment if y p ntai� et nds a� ted by the Artny Corps of En in rs
/ QV
Owner or Lega epresentative . Oat
�r .
..,�,� '��1 C,t,;�i�e-� �m ;-4- �j�' A 1716
, , �
PERSON COUNTY HEAL`TH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � �� Parcel # %�
Zoning Township V� n c�5(.�Q� -
Owner/Contractor�C2.('�,� �]n(�,�l��-t� Date 3-/S-�
Location/Address�Q__O /V�c-(�-�►��; ll�
S.R.#
�
�
U
�
a
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair �/ Lot Area � A-G Size of Tank �'`�
SFD V Mobile Home Size of Pump Tank N�,,r�-
Business # of Bedrooms_�_ Nitrification Line oi ��' �C �'
� Max Depth Trenches c9�/'�
Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if sit altered or inten�d ne hanged. �
Well and S�ptic Layout by �`�� � 0 �� � l=„ , � .
�J v.�-�-
Date - �0� Installed by,
Approved by
WELL SYSTEM SPECIFICATIONS
j/ Semi-Public_
Replacement
Site Approved
Well Head Approved
Grouting Approved_
Comments:
/
Required Slab _
Air Vent
Required Well Lo�
Well Tag
Date Installed by v Approved by.
This report is based in part on information provided the homeowner or his/her representative in t}►e application submitted for this percnit. The
environmental health specialist is not responsible for false or misleading infoRnation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in tivs report that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist wartants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�unipro�peanitsam O1/95 rev.1.0
ORIGINAL