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�Appiicati�n Oate� �'1 �%� 0
Amo�nt Paid•��� ��
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Tax Maa #: ��'
ParcBl i!� �
Perso� Countv Heaith Department
Environmental Heaith Section
. APPUCATiON FOR SERVICES .
fF THE INFORMATION IN THE APPLlCATION FOR AN IMPROVEMENT PERMIT IS FALSIFiED. CtiANGED. OR THE STTE IS
ALTERED. THEN'THE IMPROVEMENT PERMR AND AUTHORIZATION TO CONS'TRUCT SHALL BECOME INVALID.
1) Permit requesfied by� Ownedage�t/prospective owne�: �/� � u LD -� ��1C J� � 1��
Home Phane: C 3 tr ����-�t 22� Address: D
Business Phone: C� t a S- 3� 4'� A- �F A �l _ ��
Z) Name and address of currer�t owne� ��G�a�-f' -t-� � i�av� S
3) Property DescriptSon: Lot s�ze: I�aw�shtp: ,
Direciions to the property (indu g road names
�L '7 '7 5Y n. r_ . �c _ V,
�-�.��c ,f�'�!s
��3_ �-�,��a I Q��111 t2d C 15� �s�
4) Proposed Use and Structure Descriptloo: answer eact� af the foaowing questions:
a) Proposed�. Existlng 0
b) S�cic Bwlt�, Modular �Sin le Wide �, Dauble Wide ❑ 2
c) Number of Bedrooms• � � Number of occupanis ar people to be senred:
e) Basemen� Yes �. No�9,if yes, # of baseme� fixtures:
t� Garrtiage Disposal: Yes q No�
� Oimensions of Proposed Strudure: Width: G Depth: ��
j�Ef2C-2
3� Water SuPP�Y TYPe: Private'�(new � or existin9 �. Pttbt�c 4 Communit�l �. SP�9 0.
Are arrywells on adJoining properiy? Yes�No � Ityes, bcation 4,o�e o� � r�cir
�'cJl
6) Please indicata Desi*ed System Type: (systems can be raaked in order of your preference)
J� Ccnve�tional Mcdified Cornantional _ Altemattve Innovative
Other (spedfyj:
cLEARLY_ STAKE ALL. caRNERs ANo uNEs oE THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SiTE PLAN TO THIS APPLlCATiaN
I hereby rtiake appQcation to the Person County Health Departmertt for a site evaluation for the on-site sewage disposat sYstem fc�
the above-desaibed property. t agree that the contents of this appNcaHo� are true and rep�esent the maximum faa�tes to be
placed on the propeity. 1 understand if the site is altered cr the irrtended use changes. the pertnit shaU become invaqd. I undersiand
that as appQcant, I am responsble fac identifying and madcinq property I'u�es, comers and making the site actess�ble toc the
personnei e Person Ccw�ty Heatth Depadment to condud thefc evaluatIons. I understand that 1 am cespons��e fo� nofiiying the
Health p ent ff my P Peity con ar}�etlands as desigtmted by the Acmy Co�ps of Esigineers.
� ` ��� � -! �- d d
er or Legal R tive _ Oate
. � ' ` PERSON COUNTY ENVIRONMENTAL HEALTH
-. PLEASE SEE ATTACHED PLAN FOR SO1L AREA AND SYSTEM LAYOUT
Tax Map #: _ [1�� Parcet # �
Zoning Township �-il��l-� m�•1,�,5
Applicant• _�AC 1 +/�]�, pr- 2��
LocaUon: _ ���5"Ll�i�klT'�1�,� '��
Subdivision: `—� SecUon: Lot �� S i J e /
Improvement Permit `'�
A buildinq permit cannot be issued with oniv an Improvement Permit
New ✓ Repair Addition Type of Structu�e �l( E
# of Occupants �X4�� # of Bedrooms 3 Other
Basement? •.s iu Basement F'ixtures? Wv
Water Suppiy i.t?�1.�
Projeded Daily Fiow: 3� g,p,d, permit Vatid For.L9 Five Years ❑ No Expiration
Proposed Wastewater System Type: C,c3aJ�r�lc�On!/tl,
Pump Required? Yes �No
ProposedRepair: �n1�O�A'i1�e S�v %-,(�37�JS Sr(3�
Permit Conditions: en1S�Ai � c,.�� r�,.srn, i� . r�, � lr- n, ,-�l �.�rr. ��
T�oN
Owner or Legal
Authorized State Agent:
Date: ' j r ��
Date: � ZS-p0
The issuance of this permit by � tieafth Department in no way guarantees the issuance of other permits. The permit
holder is responsible for chedting with appropriate goveming bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This pertnit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Building Permitl
Type of Wastewater System �Nd�.t'ftOnf�(, Wastewater Flow: 3�� a.p.d.
Facility Type:_ �� New �epair DExpansion 0
Basement? O Yes 81Qo Basement F'ixtures? 0 Yes (�T10
Wastewater Svstem Requirements
Septic Tank Size: _ 1 e�oC� ga(lons Pump Tank Size: �%} gallons
Total Trench Length: v d� feet Maximum Trench Depth: � inches Aggregate Depth: I� in.
Maximum Soil Cover. � inches Trench Separation: ci Feet on Center
,
� Other. I�SC�I,�- o� �p�'�p�
Permit Expiration Date: ; "� 'OS
Authorized State Agent: S Date: S`Z�'0 b
The type of system permi d 0 does �C] does not differ from the type specified on the application. I accept
the specifications of this permit
Owner/Legal Representative Signature: Date:
PCHD, rev. 11/18/99
Appfication #: _ '
Tax Map #: _ ��—
Parcel #: _ 6
• Person County Heaith Department
Environmental Health Section
SITE SKETCH
S'a��►�..�►�� P�e.��,
Applicant's Name Subdivision/Section/Lot#
�J '�. o �tx�; . 5-25 0�
Authorized State A ent Date
System components represent approzimate contours only. T7te contractor must flag the system
prior to beginnin� the installation fo insure that proper grade is maintained
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Scate: 1�h1t
95�
PCHD, rev. 90112/99