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� � APPLI�A'�I(�+"N FOR SERViCES '
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> F E z t _ Y r.�� � Ser��c�saReq `uested: " _ �, . �: ���a= ,�s
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x Improvements Permit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
_ Impxovements Permit (Unrecorded Lot) ,_ Repair/Replace existing Septic System
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Improvements Permit (Mobile Home Replace) _ Permit for New Well
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Improvements Permit (Addition) I Replace Existing Well �
1. Permit requested by:
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rospective owner�agent: r���`�� �� ����
: l�l0 4� ��a� �'.ve� C�hvsc,�. R �—� � �
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ome Phone #: 3��� - ��� —
usiness Phone #: -
Name and address of,current owner:
Property Description: Lot size:
�. Tax Map#: J �1 �t�
Parcel#: 3a� �
Township:�1_� :� - _
5. Directions to property: State Road #& Road
Names,�tc.
rroN. �k�oarb or� s�� QoC�� o.5S
7. Dimensions or Proposed Structure:
Width: � 5" A��� ��� a gt-
T�enth: �s " �. e�c��h
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility .
that this sewage disposal system is intended to serve?
Number of occupan[s or people to be served: `�""�` '
9. Water supply t}•pe:
private �j . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
10. Type of structure/facility: Proposed: DExisting: Q I
Type of dwelling:
House: ❑ Mobile Home: L7 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: _
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ No�7 If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
� PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COunty Health Depal'tment 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 before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
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Owner or Authorized Agent
rmit Issued ❑ .�
:rmit Denied ❑
at Observed ❑
Signature . . Date.
RECOMMENDATIONS/COMMENTS:
SITE CLASSLFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �11
areas, wells, water bodies, slope patterns, etc.� C:�AMIPRO�DOCS�APPSEC.ST1 FINANCE.PC
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PERSON COUI�TTY I;�EALTH DEPARTMENT
WELL AND SEWAGE SITE, LQ�ATION IlVIPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location c�r
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
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Tax Map # A 5/D Parcel # � Z�
Zoning Township y��q ��j v�iZ
Owner/Contractor�i�Fv_� j,,3� A ck L'�/t; t L Date ��- z�- ��
Location/Address ,��� � �'« j ��iv;=T� �i� . ;�.D
S.R.# ���
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area � 2 Size of Tank rx i s ri,,.� �/o�o �-� L
SFD � Mobile Home Size of Pump Ta ��
Business # of Bedrooms� Nitrification Line�� �' ,r ,3 ��'"X/s T.
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Max Depth Trenches
Permits may be voided if site is
Well and Septic Layout by
Comments: � �, � � v, ..
r intended use changed.
Date �= z�_�'�I�nstalled by �;� i S f�,,/ �� Approved by
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Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS L� � S-- s�
Individual Semi Public Required ab
Public e cement Air V
Site Approved Requi Well Lo
Well Head prove Wel ag
Grouting A roved
Comments:
Date
Installed by
Approved by.
This report is based in part on information provided the homeowner or his/her
representative in the applicatio� 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 conditions 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.sain O1/95 rev.l.l
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rence E. Blackwall
Cla _ 60
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R,erson County Health D�partment
3�`wage System Improvements Permit
Date: `'l'��-� � T�'� Permit Void� ��eer 5
Owner. �'��t-�� "� K/�.S
L,ocation/Direcaons: �.,, e fIr ��
c�t�► i�Yl�/!r� � :.n-r���rr -�-.
Subdivision Name: �
� S�: Type of Dwelling.
Water Supply: Private• Public:
Bedrooms: �_ Garbage Disposal
Basement Basement Fixtures_
INFORMA�-�T�F�jI BY
Canitarian• i ,OU(� �Lis n�.D owna
REPAIR:
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Communiry:
Size of Septic Tank• gallons Size of Pump Tank:
Nitrification Line: r '
Depth of Stone: 12 inches
Max Depth of Trenches:
Alternative System: Conv. Pump LPP A�mp
Remarks: ��.�1� .�� S�: ��L � 1 a'��,',,,/lh.t, o,�, �„ �! s
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Date Well Approved: �Z-�3'9 � Well should be 100 ft from any sewer system
BY Sanitarian
Date S�wage S ste �Approved: /2- / -91
BY � •
�-�-�— Sanitarian
CERTII�iCATE OF COMPLETION (sf;�s� „�
Contiactor.2'''.�l,c�/ o,.:s rerJ �'.. ,��.� .,�D �%./„�.R �
�l;�l �Ja� e�,��.�'�•1�.1?m��l� �'�s�z�.�d d� �if."�
hoLts� ltc�c� a ppco�ia�.� �./i/l �4ssv�c RN�jpr,n�s�?�f1�'J�r �r /Dyfea�s�
'Sewage System locafion. ins[atladon. and protection must meet state and local �
regulations. SepHc 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. Sepdc tank and
nitrification line must be inspected and approved by a member of thc Person County �.
Health Department before any portion of the installation is coveied �d put into use. If =
the site plans or intended use change this permit is subject w revocacion.
(G.S. 130 A-335F7 �
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Location of sewage disposal sewage system sketched an back. �i
(OVER) �