A41 3A�piication Date: � �°?�-o � Tax Map #:
Amount Pa1d: a6��
Recelpt #: I 7.3� � Parce! #:
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APPLICATION FOR SEi2VICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT F�►LSIFIED
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AiVD AUTHORIZ�►TION TO
CONSTRUCT SHALL BECOME INVALID. �
1) Permit requested by: (Owner/agent/prospective owner): �% ilV����/ (T� �����u�
Home Phone: 5 9�t� S���S Address: f-1-�s ���`� �o�..� X�'
Business Phone: 336� 5�17- u�21+� bc7�'t� � NL �?S��
2) Name and address of current owner: 1�'"`��� �/ `� ��M�e^ly G�'/��`ai�'l.
3) Property Description: Lot size:
Directions to the property (Includ
�3�•��c,Township: �M��� Subdivision:.
�g road names and numbers):
Lot #
4) �roposed Use�d $tructure Description: answer each of the following questions:
a) Proposed _, Existing , Type of Structure: Width: Depth:
b) Number of Bedrooms: 1 Number of occupants or people to be served:
c) Basement: Yes ✓ No _ Will there be plumbing in the basement?_�
d) 6arbage Disposal: Yes � , No ✓
r� y�.
5) Water Supply. Type: Private ✓(new ✓or existing�, Public , Community , Spring _
Are any wells on adjoining property? Yes_ No _ If yes, piease indicate approximate location on the
�site plan. �
6) Does your property contain previousl� identified jurisdictionai wetiands? Yes_ No_
�
PLEASE AIOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. .
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. �;
➢ THE PROP.OSED LOCATION OF ALL STRUCTURES MUST BE STAKED 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-siie 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,�nders and if the site is altered or the intended use changes, the permit shall
becom ' valid.
,�,� _ / ' �, �
Ow er or Legal Representative ate
PCND, rev. 06127/02
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Applican� �I �i tc� � � 1\ �
��� .� 1. _ �.. �
T�x Map , �rc�ei .;
Su,bd!ivi,s,ian
Fh�s�e S�ct+ian:Lat �
Iuaprovement ��rmit -
�ea mit Va�id for �D�ive �e� 1+To �apiration
Type ofFacility: '�',',-�� �;i � Cr el Li New,,,�Addition �ate� S�pply liv�!/
# of Occupants $�� # of�earo � Projected Dai�y Flow 44�� g.p.d.
Proposed Wastewater S tem: �v�ni,'�1nc�S1 � Type: � Q
Proposed Repair: �vP n�ii � � Type' � �
Permit �Conditions• � I � �� � Sl �te ,D�(�h ,
Uwner or Legal Representative Signa,itue:
Authorized State �Agent � i�i�2n�1� �
Date:
The issuance of this pe�it by the Health Department in does not guaiantes the s�s�sa of other permits. It is the responsibi7ity of the'
applicant/property owner to in sure tha# all Person Cotmty Plannmg and Zc��g and Bu�iding Iuspections requiiemeats are me� This
�nprovement �ermit is snbject to revocation if the site plan, plat or the intenderl use c�anges. The Ymprovement Permit is aot
affec#ed by a change in ownership of the property. This permit was issned in compliaace.with tlte provisions of the North Carolina
`Laws and Rules for Sewage Tretttment and �isnosal Svstems' (15A NCAC 18A .1900). Neither Person �Connty nor t3xe
Envirannaeutal �eatth Specialist'warranis Wat.thg septic tank system w�71 continue ta function satisiactorily in the futim-e or'that
the water supply wi71 remaiu�potabie. - -- .. . " .
Authorization to Constrac� Wastewater SysEem (Reqnired for �wlding Pex�muit)
* Ses site plan and additional uttachments (�/ ). _
Proposed Wastewater Syste�m: C��EP f'T�'I �I�G'� � Type �� Wastewater Flow �i�D g:p.d.
New �,/ Repair Exgansion _,,, - Soil LTAR: , c37S g.p.d1$ Z�
Type of Fac�ity. �-1%�' i n� I� � i_� �(`��,�,�P� �/t9 Basement ✓Yes _ No � � .
�aste�vater Systean A�eq�irements �
Tank Size: Septic Tank: 1�� , gal Pnmp'Tank: — gal Grease Trap: L gai
�rainf�eicl: Total Area: � sq it -Total Y.,ength � ft � 1Vla�mum Trenc�► Depth �� in
Tremch RVidth � ft l�iaauma Soil Cover: �D in lOTwimtam Trench Separation: � �t
�istribntgon: �istribution �og �O , Seriai �istribntion
Spe�ifications:
Anthorizesl State Ag$nt .
Permit Fxpiration Date:
The type of system permitted is� Conventionai
P��
�w�erli��ga1 �apres�utative:
Pressure Manifold
Date:
Acce�te3 Alternative. I accspt the spe�ifications of the
Date:
pC'�ID rev.11110/OS
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SITE PLAN
Name� M�� �, � a1V� Tax Map #� Pascel # 3
�.bdivision Section/Lot# �
m �� !� - 1 o I�W �i1
Authorized State Agent Date
Sysrem camponents repiesent app�aadmatt conmurs only. The contraaormust 17�g rfie system pdor to begianing rhe instnllnion m
insure that propergrade is malntained
_ _ _ _ _ _.
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wek c�,c��-�+�s
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'�- ►�y 4��,.es�i�s G�r�ack
�r�v. �_`�� � �7- ��90
�n���
�1 bed
�-1 �o �p�
5�3a ��- �C c�-w. � �'ne
l� ic�`EC'e►1Ch c1e(��
�le-1,,.�,
-b ao' AccPss Ea�'�'�
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P�,EASE SEE A�A�D PI,�' I'aDlt �LL S� LAxOiT'�'
Tax Map ��l 1 Parcel # 3 ..
Applicaut: -t;n.� �`i i I li0.m
Subdivision; '
Location: uo l 5--� �R cx� . R—�1bo�r�1
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Tavynship:
Lot #
'�ype of �Vater 5upply: �Jndividual _ Community Public
�.tequireffients:
Site Approved By:
Grouting Approved By: •
Well Log:
Pump Tag: � .
Well Tag• �
Air Vent: � �
Hose Bib: �
Casing Height: �
Concrete Slab: �
Well Driller:
Well Approved by:
****See Attached Site Sketc�i****
Liner:
Tnatalled by: _
Depth set: _
Grouted:
Date:
Wate� Sample:
Wells must be 10 feet from property tines. �
Wells must be 100 feet from s�ptic systems.
Wells must be at least 25 feet from any building foundation.
,
Other conditions:
Date:
PCHI� rev OI127/04
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ADDR.�SS: .. DATE �TALUr1TE�_ i
PROP09ID F4CiLITY FRflPOSED DESIGi�F�OW (.1949): Pi�OPER2Y S1ZEE: .
L�C.�TION OF STTE:. � FRflPERTY RE�flRDID: --
WATEItSUPPLY• � Pablic Wdl 0 Sgriag Q Other
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