A35 47Apalication Date: ��
Amount Paid: 3�+�/b
Receipt #: �.81�f(.
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APPLICATiON FOR SE32VIC�S
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��rcEl #: . `TCo�ff'
IF THE INFORMATION IN THE APPLlCATION FOR AN IMPROVEMEiVT PERMIT fS INCORRECT. FALSiF1Efl.
CHAiVGED OR THE SITE IS ALTERED. THEiV THE 1MPROVENIENT PERMIT �1ND AUiHORIZATI.OM TO
CONSTRUCT SHALL BECOME INVALID. � „ < <
1) Permit requested by: Owner/a ent/prospective owi
Home Phone: °I 19 � S�O� - a`6 a�] Address:
Business Phone: SG3 -�7K�
2) Name and address of current owner. EM�a f� � k'�L�.11^ -
3) Property Description: Lot size: Township: Su
Directions to the property,(Inc!},Zding road,na►Y}es and �umbers): �
K�� ��`����
-�ti�r �' w�l
4) F�roposed Use and Structure Description: answer ach f t e f Ilowing questions:
a) Proposed _, Existing �Type af Structure: s� v-: �• Width: � Depth:
b) Number of Bedrooms: ;� Number of occupa ts or people to be served: %F-1ci. �L�oot,n .
c) Basement: Yes . No _'�/Will there be plumbing in the basement?
d) �arbage Disposal: Yes , No ✓ ,
5) llNater Supply Type: Private _(new _ or existing�, PublicJ Community� , Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
'. �site pian.
6) Does your property cantain previously identified jurisdictional wetlands? Yes_ Wo ✓
PLEASE NOTE THE FOLLOWING:
9 A PLAT OF THE PROPE3�TY OR SITE P.LAN MUST BIE SUBMITTED WITH THIS APPLICAiION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. �,
9 THE PROPOSED LOCATION OF Al.l. STRUCTURES MUST SE STA�CED OR �'LAGGED.
9 TD-IE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTME�YT
STAFF.
I hereby make application to the Person County Health Department for a site evalua6on 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 permii shall
become invalicl. .
or Legal Representative
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Date
PCHD, rev. 06/27/02
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Application Date: )'`3� r� 7
Arnount Pald: �
Receipt #:
Tax Map #:
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APPLICATION FOR SEitVICES
ParcEl #:
IF THE IMFORMATION 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 requested by: (Owner/agent/prospective owner): �f}�5�.� �/ '� �o � ,
Home Phone: .3�1 �� y� . 9� $�6 Address: YZa-� -�
8usiness Phone: 3�/_. .s-�r� i ��� co X u o� >1� a� 5'� Ca
2) Name and address of current owner. �i�kti E�! - S v v�
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o ��4���..d %� �o . g-�, � `i.�
3) Properly Description: Lot size: %,�� ��Township: Subdivision:
Directions to the property_(Including road na�ne,s and numbers):
Lot # `
4) P�roposed Use and Structure Description: answer ach of the following questions:
a) Proposed �, F�cisting � Type of Structure: U,O,��,-Il W'dth: ��tS Depth: 02 �
b) Number of Bedrooms: `, Number of occupants o people to be served: �
c) Basement: Yes , N��there be lumbing in the basement? �
d) �arbage Disposal: Yes � , No �
5) Water Supply Type: Private _ new _ or existing�blic� Community , Spring _
Are any welis on adjoining property? Yes o_ If yes, please indicate approximate locatiori on the
'site plan. �
6) Does your property contain previously identified jurisdictional wetlands? Yes_
�
PLEASE PIOTE THE FOLLOWING:
No_
➢ 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 STAICED 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
faci j�es to, be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
Owner or
�� 1 ~ � � a �
Date
PCHD, rev. 06l27/02
l�ic�hees Mil� Rc�, .
S,R, 1337 C60' Pub�ic f�
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Jar�es A,Long IV,Trustee
W.B, 71-E-8
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00 in EXISTING Z�NII
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Gladys DUncan et c
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Applican� �,
P�x�t 'Yalid �or ✓ �ive �ear�
ear
Type ofFacility: ��� e �
T�x Ma�� � � �rcel r
Su!bdivisiar�i
Fha:S�e,S�ct,ion:'Let +�
l[�npraveiaen� ��rmit
iYo �iira�ion � % ���rS��i� )
. Ne�v �/ Addition �� �ater snppdy - e C!
Projected Daily Flow � g.p,d.
# of Oc�upants �_ # of Bedrooms
Proposed Wastewater System: CC
Proposed Re�air: �
Permit
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Type: T
Type: � �
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Owner or Legal Representa ' ignature: ' � �� `-' � /
Authorized State A � ate• 2-,�3-�7
The issuance of this pe�it b the Health Department in does not guat�tes the 1ss�,�r of other permits. It is the responsib�ity of the
aPPli�Pr�P�Y owner to in sure that all Person Cauuty Pianning and Zoning and Bu�dmg Inspections requaemeats are met. This
�provement Permit is snbject to revocation if the site plan;�pTa#''or'the intended use changes. The Improvement Permit is not
a�'ected by a change in owner"si�ip of the property. This permit was issued in compliance wit6 the prnvisions of the North Carolina, .
`Laws and Rules far Sewage Treat�nent and Drsposal Svstems'. (15A NCAC 18A .1900). Neither Person �ouniy.: nor`�tlie.`` �� �
Environmental �eaIth 5pecialist warrants that the septic tank systetn w�7t continue to fnnction satisfactarily in the fntnre�or:tliat.
the-water supply will remain potable. • •
� A�thoriz�tion to Constrnct �Vastew�ter 5ystem (Required fur Bnilding Permit)
* Ses site plare and additional attachments (_J. . � . -.
.. �
Proposed W ter System: �iCC�p�e� �. � � Z`y'Pe _�� Wastewater Flow �.p.d.
New ='�Repair Ex�apsian � .� Soil LTA�: � 2.�g.p.d1 ft 2
TypeofFac�ity:��a� �eSrdPh�;;� � Basement_Yes_No r
� �'�astewate� System Req�rements � . . .
Tank Size: Septic'Tank:'�0�6 gai aamp Tauk: —gai Grease Trap: --gni- -
Iarainfield: Total Area: %�� sq ft Total Length ��- `'�� ft ' Nta�mu� Trench Depi� 1 8� � in� .
Trenc� Width 3 ft lY�ini�nm Soi� Cover. _� in Minimniri �remc.i� Sepazatimt: � ft �.
IDistYibution: ✓�I)istribu�ion �oz ✓ Serial �istribntion Pressnre Manifold . � .
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Spe�cations: .Sc�►w�' o� �-6oX a�i. j t� ���ae>c ,n.�a�.��r��M c'�t{�� ���'iz�lf� F'ee�;.: `;..
state A.�
Permit
The type of system permitte� is
P��- �
i�e�/�,�ai �t��a-�s��tatave:
Date:
Date• 2 /3-0 7
Alternative. I
,�.�e spe�ifications of the
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pC� rev. l I/10/05...
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Name �e �- 5 n Ta.z Ma.p #%� 3� � P�rcel #� i
Subdivisio . � Section/Lot#
. . L-�3-o7 .
� . thorized State Agent . � Date . �. � .
System cvm�ronents mjimrent a�i�s,oarimate�contours o�ly.' Tha coniracrMr must, flag ihe system prior to .
beginsurig ihe i��Aation to i�sure thatpm�barg�ade r:s mari�tained
—�+,,,�-i1�a � SyS�2yv�
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S,R, � "1337 C60' Public (; �
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V���, IL`,
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Jar�es A,Long IV,Trustee
W;B, � 71-E-8
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S 87°11'Ol"E
IV �t3 CU U�S W
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L�cation: . �
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_ : . . � , System Type (In Acx�rdaa�c� Wn�h Table Va�: �E�
i'HiS SYSTEi�I ,.H�S F3E�i II►iSTP�1.LEi3 � Il� Ca�IIPl�1VG� 1MiN �►I?4�LlCA�i..E NOR?3-t �
�P � C�►ROU�► ��EiZAL ST�'i'UTE�, RULES Ft]R S�fA�� TREAT�d1FiVT AAID DlSP�S�1L; •
AI�D "AL•,L � C�l�lDlTi��IS • C�F '�'t�E 1�A�l�OV�Bd%3�iT PE�611� �4AdL1 CL)PdSTRllCTIC�N
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lnsta�4�i y: . /"[,�l ,��wt5 _ � ' Date: 7--�9'07 ' ' .
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