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A40 351��� � J(! � l`` J � •Y��,�� / �1. .�., .�-�--- � � �J��'��.� -� � � ^ J:��.�ud���.��.�����;��.�1 1C �.C��.11,�1h�. Request �or Septic Sysfiem or WeII Information When reqaesting information from the Person County Healtl� Department re� rding thc septic systen� or weli on a property, please complete and submit this form. The informatzon provicled wi�l better help the HeaIth Department attempt to locate the requested permits. Your rc�uest wiIl Ue processed within 1 to 2 working days. Property Infot�nation: , . ' .. • �.i . � � r�I �iri ���� i�� ' r . % 'I "`' ' ,, . ��/ . . , �: , , . .. • �I��: �� : . � �„�, _ � i - - � r � ,; � . � • ./��. / , ,, /• , . , �_ Address: -��lJn � Requested By: Name: Address: , ► Eddie & Laura 8urton — Keller Williams Preferred Realt �3 Hillsborough Road Timberlake NC 27583 Phone Numbers: 919-451-6251 Fax Nunaber: Please email all weli & se mau.com :a�e�x a,�x:��:�:m:r.:txsmx:e:e::xm=�. xs:ws:t��r:�.�:u�,.x�::uW�m��:m:w�wxa::r•��:w:r.x+u�xm:a=nz�uxmp:+k PCHD Section 1'ermits Lacated: � �,'es Na —' � � �-_ Copy of form: �4�i}cc} I ,�e�f Signa ture: Comments: Date: 8 Persv�a County Environmental Health Plzo�ze: 3�6-5�7-179U 325 S_ M�raan St., Stcite C ' Faz: 336-597-7b'0� Rozboro, NC 27573 e ���sa� cauPmr ��n�NnnE�rraL e��i�a-i Tax 3tap_� fTTv _ �� • � � -�A W►mLt t�'►ks �-� n ,..�,�.,�. «� s � �.� . .� ...., _ � _ �, � ► � � Pttedi� J�-+ � . To�hip �� a�' I }�1 vC.�' �f'e gu�rhio� C� �Iri e�..N.,... Lat P! � improvernent Permi# . A buildino �ermit cannot be issued with aniy an lmorovement Psnnit New,� Re�air � Ad�on Type af Struc�a ��� � VVate�' Su�/ �% 1 . # af 0� �cf Bedroaras _��� Otlter . 8a�sers�rd? �/`O Ba� �o�tt+�? Prcjeded t�y Fbw-q���� Pam� Val� For:fd��e Years 0 No � pnoposed V�Lewa� S�ts�em Gert ✓�z �.?�rtq / PumP R�d?' Yes No . � ��= � PermitCart�onx Q f � u,7cir:� a�e�a��. ac.y.� (o� .n,a... rL� er �hS��� aI- aYho�r �i1mdP_ 1.,��nweKa /ii�Oh/dur. . Ov+rner or Legat Represet�hre s. 0 �a �� � � -V � Author¢ed Sta�e Ages� Date: l � 60 The issuartce �cf this pertn� by the Healf� Departrr�t In tto way gtmtartEees tlu issusnca of otha p�. The � holder is responsi6le �or che�t9 � aPPro� 9� � In meeitng the� r�.riranenfs. This site is subject to ravoc�tion if the siba plan, plat, or the irrtetfded tise cttangoa. The hnQrovetnent Pemiit shall �t be affect8d 6y a cfiange in ownocst�ip of the aita. This perm� ts subject bo compiianca vdth the provisioes of the Laws and Rules for Sewage Treatrnenf and Dispo�l Syatems cf fhe North CaroIIna Administeativa Code. Type oflA�ew� System (La�1 UQ/l�! �l't� ( ���, � T���/�r, �, � �. • �� � Q Ba�nt? 0 Yea 8�a�rt Fb�a�? 0 Yas�'f� Wastewaier Svabem Reaulnements ' ' - . . . SeptEc Tardc S'¢e: ID� � Pump T� S1ze: "'— c,�a�ans Tctal Tc'ertd�t y� Ma�dcnum Tte� DeQtfr r g irx��es Ag�be peptt�%2in. Naxi�wm Sa7 Caver. � ind�es Trencl� � �% Fa� an Cat� Pamii Exp�ation Date: `a P� 5� Aumorized state Ag� d�0'�'`����Jv� The iype of sys�ecn geRnitted ❑ does 0 the sp�a�s cf this parmdt Ownerlt.egal Rep�er�tive Sigtmtcu�e: pate: • f 2 2 J a c� . . dtfier from the type sper.iSed ort tt►e appiic�tian. I acs�pt � Daie: � '°�-� �- Pc�1D, rev. tln8rss 0 Person Gounty �ealth Departrr�e�i �nvirvnmental Health Sec�on % Tax Map #: �� Parc�i #• 3� l Zoning: Township: � 1�ClT � � "� � � (�J Subdivision: Section: Lot: / Applicant• !iV]o � Location• ��_1���t',G���V � Operation Perm it System Type (In Accordance With Table Va): ��� THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPLICABLE NORTH CAROUNA GENERAL STATUTES, RULES FOR SEINAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTIOH 3' 5 � , �I / . �� L►�IV / i _ - •.- � �_ - Tax Map #: Parc�l #: PCHD, rev. 10/12l99 �-•-�---- [� � � ? � R �/ • �.� y % �� . _... •227Q ��c�..�i.�,�• .._..,,`-.� .,r ���.� �11� �,,,. , � ,��� .,�� � ---� -�'' C t� �r��"'Y �" . . � - .�.o� �.sa.+^��o�►.s�e�o.ts� 7�oslf.� � �� �� � , _ /� , ,,:,. , , � • ,,. ., :, � � WcIl I� Taa Msp i%Q Pntcel #�� _ , Lot # We� Ca� Di�e �rao� u�t+eet PropertY �° i� 10 fieet) Di�aaca fi� Septia ����M 3C�tic iiV� Le�veL• ,�....__, � Tdal A�th: ,�/ ��. n g � w.a: s�ias z,o�s: � � �-,-�-$.�.�.- -- - � � �� � ��, ft. Diamobr�t: � ia �; • ,.-- Wait���� .''�'doa�: �.�s� � °b°ve (3�d. ""L�� Ye.4 / No Dd�rre Sbo� _�,,�Yos �No AnY Psoblocns aa°°uat�d w� ��.— Z{�* g�ve raaaom: � C°�r�eb� _"'"'` �� Yos Na�st: �/ Sa�d/t'.eauusut ____..l. W�er iu A�mw�i� space f. '� p�° Anatula�c 3psca �'� � � Po�ac+od � � �' �-°--- p�' Mothod of C�+ow� .,.,_._ ���' We� of 1 Hag ��!'� Poma�a No. Ha�s P� �t �--. If mi�ure (�d, g�, �8�) - �O — �D — m p1�as; ✓Yos No 4:4 elab�,Y�..,,No ,,. .�. _ _ . � � Leestlott 11�'i�vba� Y�by cextify that ti� above ���� t� this wdl aet foztb► by tbe Pessan Cou�Y ���g' z' ♦ ..� MI / Il /S / N .�� . � � �d ia a�cordauca a�n n8�0°da Tn � 2�9�- ae. 1..�. b0 3J�d 9NI'1�I�lQ��3M 113Nh13ff £ti8LV5hti�8 Cj'• /a? • �, a.� 9���� 566i/6i/t0 T . � � (� _�. 7 � ` '� !►ooliatlon Dat�: � , Amo�nt P�id: � t� Q. 0 d �—�.� �-#� 43 6 . s 1-.L� _ I � • • 11 •, L � � Ctt _it .r� . r a`�l! t � i �• �. ;� • `� . . �►iL �i� IF THE INFORMATION IN THE APPUCATION FOR �AN IMPROVEi11ENT PERM�T �g FAL9IRED. CtiANGED OR THE SiTE IS ALTERED 'THEN THE IMPROVE3IAAENT PE32MIT AND AUTHORiZATfON TO CONSTRUCT SHALL BECOME INVALID i� �tlR{� � "7• ��MfROf�'1g�[1�1f'O��Y�W OWflO[': ._">/r m vn � a �`in , l+, � I+S HOfi10 pt1011Q' _. _`�G- L1 _:Z-4 �, �.1 • �' ,��'I,S-S k�1u �rl f w vna- f l f BuiiiO� �IOi�: �� IR �1, P�5 F-�r 6. n r n Zj Naa� and addcess of ciunsrtt owrter: .�� m� 3) Prap�rty D�iptiocn Lot s� ,!, r�r�, Taw�t� �'.t�. OYections t�a the property pr�}dtr�q to�d twntes and numbe�ak 4) Pcvposad Us� and Structu» Description: anawa esd� aithe tosawinq qu�ioc�a: � ��� � � b) Stldc Bu� 4 Modutar 4 Sinple Wlde 4 Doub►e Wide � d Number at Bedtooma: �_ � Number ot ocxvpatlb� ot peopla to be senre� y e) Basem� Yea Q No C�tt yes. � of basert�ent fix�tuex •� Gacbape Di� Yes q No � � Qi�nsiottsot Propoaed Stitudtua: lAlidth: � Q Daplt� /�v a1 ��PP�Y �IP� PrivaLe 0(r�w � ar aodatlnq �). PubYcq Co�mxa�jl o. Spri�+p �. Ars any weda on �djoining pcopetty'? Yes 0 No (8-ltj�s, location 6) P{as� Indipb Daii+�d SYamm Typ�: (systema can be ranio�d !n otd� oi Y� P�l �Cotive�ttlonal Modifled Cot�v�ntlasai _ A�iv� �tovatlw OttMt �: CLEARL.Y 9TAKE ALL CGRNERS ANG �1NE3 OF THE PROP�RTY. STAKE THE CORNERS OF ALI. P4�OPOSED STRUCTURES. P�EASE ATTACN SURVEY PUIT OR SRE PUW TO THlS App�.lCAT10N ��Y �� to the Pexson Cam1y Fkalth Oapa�tmm�t 1br a a�e ev�kn�tion ior the a�-sibe saw�p� dbPoaal sysi�n ttw sbove�esaibed propecty. t apcee ttmt the �b af this aQpW�tion acs trus and ro�ani tt�e m�rtuan � bo Ptecai on the propecly. 1 und�ac�d if ths s�e is alteced arthe ��ieaded � d�anpes. the peRnR shaY becort�s inw�d. l� ttt�t as apQ�utt, I am rospor�te tor idauifying and marian9 ProP�tY I�S. �mec� and ttwldng tl�a siGe a�i� fac patsa�uial of Person County H�h Oepartrnart to co�uct tt�ir avakmtloru. l ta�ecatand ihat 1 am t� ��9 Heaah fi rtry �s a�ry wotianda aa desi�na�ed b�f the Am�Y Co�s of 6�Oers- _��_oo o� LeQal Repceaac�tfire . oaLe . . __�_._ _.. � .__...__..._._...___..... .. _._ . P�rs�n Caunty �9ealth. Departrnen! . � iEs�vironmeniai hHeslth Section � STi� Sl4ETC� � rn . __ � �✓�rti S ��/a�r�l � � ApP s Na e � bdt �n,�,, i� �%� OG Tax� �IAAap #: � � ' Psresi #: 3 ' ( �� / � � . " AuthoriZed $ta,� Ager�t va#e/ V ,Sy�tan ca�po� �r.e�re�rt rrppra�e cantnrr� only. Tbs coRtrador m�rt, fYag the � pr�or to b� tlie i�allation to 6vune that pmPer grad� i� � ,� (�,�[ - a�e Sa-� '- �r,s-�I I c�:i �ro Per �ro.� e.,�ro l lv w� n� � l�v hT� t+l,c • '� �/lct.�Ci m u m `�InCh �PP� � g �( ` Si� y �� Yh i v► � n-► u�. -� r+� �,e . g e� �o�,d � . f —�e� a.�l ��r l5 0-� Sy s�� �; ��� � , h�in�muw► .-�row�. �Yo�f�� �� � +� ���, 0.�'l� �J, 1'Hin�rnum � ..�h� Jt,�,l �� � ri -�-e1�1►'�JCRI � Oh• � SC�e: � `` � c f� t , �,,, . , � • PERSON COUNTY E�IVIRONMEAITAL HEALTH � P�EASE SEE ATTACHED PLAN F�R WELL SITE tAYOUT �-� �3S' ( 7mc llaa �k � � — �� � To�tdp � �� � 1 V Q,� ��r_r- �..�...r L.Oeatlon �if. f.ti , � - / Well Penr�i# � ' . Tvae of Wa�er Suaatv: r/ Ind'nridua{ Community . Public Reauir+ements: Site Approved by � Grouting Ap�roved by _ (�-� Well Log . Weli Ta � � � Air Vent • Hose Bib Conc7ete Stab �' - Well Driller: Well Approved By: o�: � 1- a'7�� *'See kttached Site Skefich'°` � Weits must be 10 feet from property lines. Wells must be 100 feet from septic systems. WeUs must be at feast 25 feet from any building foundation. Other condi�ons: r � 5 Y � � PCHD. rev. 11/29/99