A41 72�° Person County I-�ealth Department u�
, Sewage System Improvements Permit �
Date: $ �?" � This Permit
o,�vner: C= ���,v.. �
Lacation/Directions:
Years Permit #
�e�' se�, _ SR# /13/
r�
Subdivision N e: : Lot #
Lot Size: � U� �t Type of Dwelling. o� Mc
Water Supply: Private: Public: Communiry:
Bedrooms: 3 Gazbage Disposal _
Basement Basement Fixtures �
INFORMA'��tV ���'IF'�D BY �__ /�,
REPAIR: REEVAI.UATION:
--------_------------
Size of Sepdc Tank: _���f._(�l,e
Nitrification Line: .
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump
/ Size of/Pump Tank: �-`�� '.��i
�i 3 �-�.,► f�
LPP
�:r:w��X ' � �/ e "� rc: Z "
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Date Well Approved: Well should be 1
BY Sani 'an
Date S e � s ved•
BY Sanitarian
TE O C MP
ft from any sewer system
O ,..�. ,�
Con tor. �
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Sewage'_ System location, installation, and protection must meet state and local �
regulations. Septic 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. Septic tank and
nitrification line must be inspected and approved by a member of the Person Counry
Health Department before any portion of the installation is covered and put into use. If
the site pl� or intended use change this permit is subject to revocation.
(G.S. 1_ : A-335F)
Locaaan of sewage disposal sewage system sketched on back.
(OVER)
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # Ay_/ Parcel # 7_
Zoning Township F�A r.Q�v -
Owner/Contractor �O y .T����t'�� S Date �- ,z � - q �
Location/Address �..�- .�w Y/s7 S T/L a•J c.�+�'Es �"i � ��-
/`'�" �lZ,Q[ v�/ivF Cr-�l Gr F T S.R.# //-�f
Subdivision Name _ Lot# �—
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank tX /s TiN�r /oo d�.4 L
SFD Mobile Home Size of Pump Tank �•D/A
Business # of Bedrooms 3 Nitrification Line Cx i s Ti�� ,�v o� x.3
Max Depth Trenches — -
Permits may be voided if site ' alt ed or intended use ch nged.
Well and Septic Layout by
Comments: �i�M/T W2irT� ^! Fo,� /a'' `X /Z � �DD�TIOl�
cr.l �.�n�.n� �.lo LNAn1Crt To Sc�T�c S`(STct�'1_ �
Date ,�.1P- 9 6 Installed by � x is Tir/� Approved by �� C C�� �/
ell Permit $aid ❑ WELL SYSTEM SPE�IFICATIONS
Site A r ve
Well He A
Grouti p�
Co nts:
Date
V
W�
l�:l
Installed by Approved by.
This report is based in part on information provided the homeowner or his/her
representative in the application 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.sam O1/95 rev.l.l
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: � ZS-p6 IMPROVEMENT PERMIT #: ,,�oDZ'7
TAX MAP #: �¢ y/ PARCEL #: 72
OWNER/OWNER'S REPRESENTATIVE: _�oY ,7'EFF�Q1 � S
LOCATION/ADDRESS:
�Y /S`7 .� ,�.�/L Drct CA TE S M/Lc. � D
/s� ��vf3L_c v.li�c p�l L��r'
SUBDIVISION NAME:
LOT #:
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit # ddZ The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
�RM/T v�/�2�rT��/ i� rn� /8'�'�2 � ,¢DDiT/��
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Person Requesting:
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