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APPUCATION FOR SERVICES
Senrtces Requested
1 tmprovemer�ts Permtt (Recaded Lot) - 5200.� 0 We8 Permit (New/RePla�r"eny
� �mprovaner�a P�r� - a� 50.0o ca�tr� a,t�ation for se
��aobi� t{ome Rea��emenvnda�on) stso.00r$2oo.00
� �___�_�n_.,�.,.... �,a..e.... e...Fs.., ne...,tr O P�rmit RevisiOfl Fe9-575.00
1) Pennit requested by: (OwneHagentlpro�pective owne�): i�.� u`� �� ,�'`��.,.,�'�
Home Phone: �G� � 3e�'3—' Address: � �
Business Phone: 6 �! ""� � � -�
2y tdame artd address of current owner: " t�,v-� �J�¢- ���� �.-�C • CL o�� r� .�ur�► �
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3) Pwperly Descrlpiion: Lot size: ����c-Township: �<�" ��!' Subdivision:
Directions to the propertv (Inc�udi�g road names and numbers): f�il-^-��'- � s,� L'���� S7�-
4) Proposed Use and Structure Description: answer each of the following questions:
a) Prop4sed „�, Existing �„ Type of Structure: S�e� w��=� ���=�
b) Number of Bedrooms: .3 Number of occupants or peopte to be served: �?
c) Basemen� Yes_, No „j�Wiil the e be piumbing in the basement?
d) Garbage Disposai: Yes . No,y/�
6) Water Suppiy Type: Private �new �r e�cisting�, Public_, Cammunity_, Spring _
Are any welis on adjoining properiy? Yes No ✓(f yes. -please ind'�cate approximate location on the
site pian.
6) Daes your prepe�ty co�ain previousiy tder�tified jurisdictiona! wedands? Y�s No t!
PLEASE NOTE THE FOLLOWtNG:
➢ A PLAT O� THE PROPERTY OR StTE PU�W tlAUST BE SUBMfRED WITH THIS Ai�PLICA7�ON.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED L�CATION O� ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MtiST BE REAUtLY ACCESSIBLE FOR AN EVALUATiON BY THE H�ALTH DEPART!l�EWT
STAFF.
I heneby make application to the Person CouMy Health Department for a s�fie evaivation for #he on sibe sewage disposal
system for the above-described property. 1 agree that the contents of this appiication are true and represent the maximum
facilities to be placed on the property. i understand if the sde is aiter�ed or the intended use changes, the permit shall
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Applican�
Location:
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S�uei� ei�rv�i ��i.���i��i
P'6r,:�.;c� �ec-tioi���L��[ �
]Lanparoveanent Permit �
Permit Valid for ✓Tive Years. Nq Ezgirat�on �� �
Type of Faciliiy: �'r 4��� � New ✓ Addition �V�tea� Supply 1� 1,�.
# of Occupatrts �.x # of B 3 �� Prnjected Dai1y Flow 3coc� g.p.d �
Propoeed WasteWater S3i$tem: �'o�n��n�-,b�– • ._ 'I'ype: �G
Praposed Repair: —S��c�.�.� ' CaS % �u�.,�-.w.� - . . Type' ,,��
; .
Pe�tit Conditl�ons:1��,� 1��-i�so �h ��o��eZ. _ cf� .� r�J�- �bcst 1C�l��wc�.�� �►-�
Date•
�n�: �a -a-v y
Tho isausnce nf ifiia permit by the Health Depar� in does not guar5ntea the issn�nca of other peunits. It is the msponsibility of ihe
$pp��P�P�Y o�ner to in s�re tl�a# all Pesson Couniy p7auning and• Zoning and Bw7ding Inapectione requirements are me� 7fbIs
Improvement P.ermtt is sub ject to revocation !i khe �ite plan, plat or the intended use changes. The Improvesnent Permit is not affected
py a'change in ownership of the propertg. Thts permit was issu�d in compliance wlth the prov9siona of the North Carol�ua 2aws and
,��t for c'gwaee ?ireatntent anid Disnosrrl S`vatems' (15A NCAC.IBA .1900). Neiti►er Person County nor the Enviro�mental Health
gpeciallst warrante that tlle aeptic tank eystem will contLtue to fiandion satisfactority in tite future or that the �►wa#er aupplY will remain
potable. � .
�Anthorization to Cons#:rraci �a�tewater Sj�ste�n (Required for Building Permit) .
* See site plan and addittonal attncJtments ( v 1. �
Proposed Wast.�water System: �nY-1`�ontiv�aX Type __ ( 4. Wastewater Flow 3c�c� g.p.d.
��y ,% sir P.gpaneion S o� ][; T A R: , 3� g.p. d.! $ 2
T y p a of Facility:. ` 1< T�wu��: ���Basement �Yes X No
_ �astewater System Reqnirements . .
'anlc Si2e: Septic T�k: 1,c� gal ,. Pamp �ank: `— gal' Grease Trap: ^ ga1
)rainfield: 'Total Area: 1�� aq $ Totnl Lengt� �.� ft M�mum'Y`reueh Depth � fn
�rench W�dth � f� Mfi�um Soil Cover: �� in Minimum Trench �eparation: � ft
�
`K Distri'bution Bog
Specifcationa:
Aut�orized 3tate Ageait: _�_`.
Pea�it Fxpiration Date:
X Seri$1 Distribution .Pressure Manifold
�
Date: �a-a--c��/
The type of system pex�iitted is � Conventional Innovative Alte�ative. I accept the specifications of
the permit ' f
Ow�nes/I.ega� �Representative: . . . .. . Date:
PCHD7/30/2002
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Na.me � 1.,��,� C��s�� Taz lYlap # �'I 1 Patcel #� �/FS
Subdivision � Section/Lot#
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Authorized Sta Agent � Date .
rnt approximate�con�ours onl,y. The contratctor must, flag the system prior to
to� at pmjierg�rrde xs masntained ::
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WELL PERMIT �
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �1 y 1 Parcel # 1�-i8 Tovvnslup:
Typ� of Water,Supply: �Individual _ Community
�ltequirements:
Site Approved By:
Grouting Appmved By: �
Well Log: �
Pump Tag: �
Well Tag: �
Air Vent: �
Hose Bib: �
Casing Height: � .
Concrete Slab: �
Well Driller• -
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:
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PCHD rev 01/27/04