A41 147� . Y � Z �J,
A lication Date: �'9'�-1
Amount Paid•
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APPLICATION FOR SERVICES
Tax Ma �:
Parcei #: ��.
1) Permit requested by: (Owner/agent/prospective owner):,,� �d� � ,�� �v'�
Home Phone: � b�'� Address:
Business Phone: 6 / '�" �
2) Name and address of current owner: �ha- �i�� 3'�s —T-�c • CC� d�G(, re v ur7�► �
S
� _� �� ? � ��
3) Property Descriptfon: Lot size: 1iy'z�Oc-Township: ���"�u�/ ubdivisiorr. !"✓on(2S2�j Lot#�
Directions to the property (IncludiAg road names and numbers): ��e i s n��—%� 57
4) Proposed Use and Structure Descript(on: answer each of the foilowing questions:
a) Proposed �, Existing _Q_, Type of Structure: �'� Width:�_ Depth:�_
b) Number of Bedrooms: 3 Number of occupants or peopie to be served: o?—S?
c) Basement Yes_, No �Wiil the e be plumbing in the basement?
d) Garbage Disposai: Yes . No �
5) Water Supply Type: Private v(new �r existing�, Publi _,_, Community_, Spring ,_
Are any weils on adjoining property? Yes No � f yes, .piease indicate approximate location on the
site pian.
6) Does your property contain previousty identified jurisdictional wetlands? Yes No �
PLEASE NOTE THE FOLLOWING:
➢�► PLAT U� THE PROPERTY OR SITE PLAN MUS7 BE 5UBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CQRNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATlON OF ALL STRUCTURES MUST BE STAKED OR �lAGGED.
➢ THE SITE MUSt BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEAL.TH DEPARTMENT
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
� � �
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PCHD, rev. U6/27l02
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Applicant
Location:
��
. . .� �Wi�
T���x (`�1��_��� � � �a�rc-�,I `
5�u ia �l�i v i-��i.c� r�
f'�ia��.� ;.c� �-5 c��� l,i;o ��i � L.o�t �= '�
�- '/a �. � le .
. ][�np�rovea�ent Permit
Permi# �alid for �ive Years. Ncr Ezgirat�on �� +
Type of Facilit�: ` ' ' New `��ddition '��ter Supply � i�n Uc�e
# of Occupa�s .�� # of B oms 3... Pmj Dai1y'Flow ��c� g.p.d. �
Proposed Wastewater S�st�m: i� ��,b .��m9 � Type: �'a
Proposed Repair: ��c�.�Q � La� I. �-��-1 ' � 'I`ype: i .
Peunit Conditions: ��� S �s�,m. �,�,- -�-o ���.A.e..s�w., � N �- �;,_ �„�,,Q �; �-c
�m; .� yae.c.�,rnc v�; Z, — -- - ---
v1n.._, n�._r.1��� �ionn.E..4„�n i-.�,o� A7or (�i�►%�� S?�4iZ 4'iQG •!u .�ro.lG��?raS�(0�1. .
Owner or Legal Re�presen#ative Signature• X C��. CJ"`e '�U�����" � ��` Date: �� ��
Authorized State Agent: iZ�S • � � Date' i i-�-oy
'Tho iseuanca nf tfiis permit by tbe Health Da}�arhmeut in does not guarantee the issua4nca of other pmnits. It is the respons�biliiy of ihe
applicant/property o�iner t� in aura that aIl P�son Couniy planning and• Zoning and Hw7ding Inapections requirements are me� 7�his
Improvement P.errmit ie subjeet to revacation if ti►e �ite plsn, plat or the intended use changes. The Improvement Permft is not affected
by a'ch�tnge �n ownenship oi tha propertg. Tbis permit was issu�d in compliance with the provisionis of the North Carol�a `Laws and
,�P �„� .r.�oe Tre�ent med �isnasal S`e�stems' (15A NCAC.I8A .1900). Neitf►er Person Go�unty nor the Euviropmental Healtei
SpecialYst wsrranta that tLe septie tank eyatem will continne tn faadtoa sati�factorit� in the future or that the wa#ar �uPP1Y will remain
Putable. � .
�Anthorization to Construct Wa�tewatea� S�ste�n (Required for Bnilaing Permit) .
* Ses site plan and addiKona� attachmentr (�.
Proposed WasteWater System: l i�o �-w� Type �_ Wastewater Flow �. g.p.d.
New ✓ Repair Ezpansion _ � So�1 �TAR: .'�-75 g-P.d.� $ 2
Typa of Eacility:. �s�,c�;l,_ �,\ �� �� � ' �Bas�ment �Yes �No
l�—
�Tas#�water System Reqairements . �
Siae: Septic T�k: l�ro gal ,. Pamp Tank: �' � gal' Grease Trap: -' gal
fie1d: Total Area: l''�, x, sq ft Toial Length y Uc� ft Maa�mum Trench Depth �_ in
r.h W�dth .��' f� Minimnm Soil cover: �'� in Minimum Trench �eparation: �i ft
��#�on; � Distn�bution Box Serial Distribution �Pressure Manifold
' . , . . . . ..
Speci6cations:
Authorizec� State Ageut:
Pertt�it Exp' on Date:
Date• I 1- 3o-v`/
The type of systein per�nitted is � C ventional Innovative Altemative. I accept the specifications of
the permit. ' f /' � ,� �
Ow�neslY.egal Represe�aiive: � ' ��� 1�� � Date: �-- ' �>
� � � � P /30 002
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Name _( m�+�. t�,. E��.. . Tag lYla.p # �l l Pa�cel # I �17
Subdivision � Section/Lot# A
� � � � � -�e-�
Author�.zed tate Agent . � Date .
` System components represent appr+oxi9nate �contours on1y. The conlractor s�srast, flag t`he .rystern prior to
beginning the installatzon to iresur8 fhatproper,�rrde is »�aintainP�
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WELL PERMIT �
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map (� 1 � Pazcel # 1 u� Township:
Applicant• [��1�,_ (a►;�c En�cr,snscs
Subdivision: Lot # A �
Location: � 5�7 S a((� a+ �'a�c� n'trll i�c -'� 10+- w• _� •�. '/�. •,..,4.
Type of Water Supply: ✓Individual
ltequirements:
Site Approved By:
�Grouting Approved By: �
Well Log: �
Pump Tag: �
Well Tag: �
Air Vent: �
Hose Bib: �
Casing Height: �
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.
c�C 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