A41 22AA�plication Date: 1�" �d �� iax 1Aap #:
Amount Paid: 60 . UO �
Receipt #: ParcEl #:
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APPLICATION FOR SERVICES
IF THE INFaRMATION IN THE APPLICATION FOR AIV IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED, ,
CHANGED OR THE SITE IS ALTERED. Ti-IEN THE IMPROVEiVIE1NT PERMIT AND AUTHORIZ�4TIOR1 TO �
�' 1
COtVSTRUCT SHALL BECOME INVALID. � � �\Z���
1) Permit reques ed by: (Owner/agent/prospective owner): �j � r.vo W���� � ���
Home Phone: �i - Addres • `d
Business Phone: `\ - 5 L �
2) Name and address of current owner: S��
3) Property Description:
Directions to the pFoQe�
bdivision:
��
4) Proposed Us nd Structure Description: answ�ach of the foilowing questions: I
a) Proposed.�.� Existing � Type of Structure: ��� idth: l� � Depth: ��
b Number of Bedrooms: Number of occupants or people to be served: �
c) Basement: Yes_, N�o '� Will ere be plumbing in the basement?
d) Garbage Disposal: Yes , No �
5) Water Supply Type: Private _(new _ or existing�, Public� Community_, Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
"- � site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ iVo_
PLEASE MOTE THE FaLLOWING:
➢ 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 STAI(ED OR FLAGGED.
➢ i'1-iE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTME�IT
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
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid. (��\
� C�,..l _,...� � 1• 11U,�.._�J� \/�. e 4,� � �- l 0- p5
or Legal
Date
PCHD, rev. 06/27/02
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]�.�.��-�„�,�„ ���.71 IF-3L��.Il� . �
�nparo�eanent Permit �
Permit Valid for �]E'ive Years. Nq Ezgirat�on �� � �
Type of Facilityf: r ' ' New �Addition 'PiTater Snpply �!'nl,t�,,�e.
# of Occupants c, •�.x # of Iiedroo �_ Pmjected Dai1y'Flow �� g.r.d. �
Propoaed Wastewater 3y$tem: .L°��nv¢n�,v�•� � . Type: �1 �
Proposed Repaii: ' �a�►- �n n�v�.i,,�,�. C as'/, re�.+.e.�.,� ' ' 'I`ype: -- .
Pernnit Conditions� - �o� �+
Owner or Legal Representative S' �� -��� � liate:
Authorized State Agent: • ._ � Date• /- a y- Us
'Tho issnanco nf t�ia permit by t� Heaith Depariment in does not guarantee the issnanca of other pem�its. It is the responsi'bility of the
BPP��P�P�Y oo�iaer to in suro that all Pcaeon Couniy F'lanning and• Zoning and Building Inspectiona requirements are met 7['his
Improvement P.ermit is subject to revocation !f the pite plsn, plat or the inteuded use changes. The Improvement Permit is nut affected
by a'chunge in ownet�hip of the propertg. This permit wae issued h► compliance wit6 the provisions of tlie North Carolina `Laws and
��1's, � r��e 7S�er�trit�nt and Disnosal ����' (15A NCAC.IBA .1900). Neiti►er Person Connty nor the Enviro�emental Health
Specialist warrants that the aepttc ta�nk syatem will continue to fnnction satisiaetority in the futara or that the vva#ar 8upply will remann
potable. � '
�Autho�ization to Cons�ract Wa�tewate�'� S�ste�ri (Reqnired %a� Bnilding �ermit) ,
* See site plan and additfonal attacl�ments (�.
Proposed Wastewater System:�,w�,,,a ��,�,,,e� � Type �e�, Wastewat.�r Flaw 3Cfl�.p.d.
New ✓ Repair Eapansion _ So� �TA�.t: , a-�S g.p.d.! $ 2
Typa of Eadlity:. SS' ,h� r�•.� � a-�-w�?�,�;.., -' - - � ' �Basement �Yes �c No
V�astewa#er System Reqairements
Size: Septic T�xik: /L� gal .. PnmP �ank: �� gal' Grease Trap: �— ga1
:fie1d: 'Total Area: � aq $ Totxl Lengtht��_ ft Mazimum Trench Deptla a� in
ch W�dth � ft M�ooiiunm Soil Coeer: �' i � _ in Minimum Treuch �eparation: � ft
on: � Distributioa Boa � Seri�l Dishdbution
inns: � ��.. ��hs�,..Q\ Sus�¢N►. �� '^'e�. �
1
AutLorizea state A.gea�t:
Pem�it Expiration Date:
.Pressure Manifold
n�: /-��/-c�
The type of system pennitted is ✓ Conventional Innovaiive Alternative. I accept the specifications of
the permit. ' � y ' � .
O�nes/g.egal �B.epresentaiive: � . � .. . Date:
� � � PGHD7/30/2002
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SiTE. S��E']CC�I:
Name ��,o + 5��.. Wr,��Q �z Tax lYla.p # � � � Paxcel # a� �
t��:a � Section/Lot#
- • � - ) 7=05
Authorized S e Agent • Date .
�� System componen�s r�r�esent appmarimate�co��ours only. The contrrtctor mrestflag the system prior to
lregiraning the i»staAa ' n to irisure that pmper�rrrde is-�ntained ::
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WELL PERMIT � � �
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
�
Tax Map �� Parcel #�� A Tovvnship: -1-b,,} 1�v�
Applicant: iMorah�n �- � Y, W�i� �; eaZ
Subdivision: Lot # ( � �
-� IS� � �
�
Type of Water Supply:
�lteqnirements:
✓ Individual
Sita Approved By:
�Grouting Approved By: �
Well Log. �
Ptmap Tag: � �
Well Tag �
Air Vent: � �
Hose Hib: � �
Casing Heigh� � .
Concrete Slab• �
Well Driller:
Community Public
Liner.
. Installed by:
Depth set: � �
Grouted:
Date: �
Water Sample:
Well Approved by: � Date•,
****See Attached Site Sketch****
Wells must be 10 feet from property lines. �_
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
, �
Other conditions: �,
PCHD rev O1/27/04