A23 1440
Sit�' Evaluation Application
Fee Collected YES �/ ��
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� 5 Io5-°� APPLICATION FOR IHPROVEttENT5 �'F..�!!IT
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7,. Permi.t requested by:
Address: 6'
Home Phone �P :
owner/pruspective own�r:
. _ agent:
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2. Name and �ddress of cur.rent owner:
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3. Property Aescription: Lo� sxze:
Business Phone ��:
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4. Tax map �l: Township: �,�t Nivi.�q_
Sub�ivision Name: �'%e (r/�� s� .�Nd�� Lot #:
5. Airectzons to propez�ty:• State Road �E � Road Names, etc.
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6. Permit request�d for: New Tnstallation: .{_/ Repai.�:
Addi:ional Renovation re-using present system: �,_
7. Number o£ occupants or peopl� ta be served: Z
8. Dimensions of proposed SCructure: Widths ,�� � Uepth: Z�
9. 61hat type (if any) addi�Cions, expansions, or �eplacQment is anticipated to the scruc-
ture or faci.7.ity that this sewage disposal system is itatended to serve?
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10. Water supply private? 1�
Oth�r sou�ce? (Specify):
Are the�e any wells an adjoini
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publio?
property
camniunity? __
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spr3ng? -�_
ation:
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17., Type of structu�� o� facility: Proposed: � �xisting: j
Type of dwelling: House: � Mobile Hom�� B�iSYIZ�JJi T�
Type of Uusiness: Number of Employeesr �_
Number of bedrooms: �_ Garbage Disposal? Yes Nc �
Basement? Yes �C No If so, z�umber of basement fixtures: �„� �
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12. Cleaz�ly stake all co�ners of the prope�ty and th� corners of all proposed structures• ,._
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1 t�ereby mal�e appl.icati.on to the Pesson Caunty Health De�a�rtment for a site �
evaluatian or exist�ng sys�em evaluati.�n for the on-sitie sewuge di�sposal system for �
the above desoribed property. x a$ree that the contents of this application ar� tru�
and �epresent the maximum facilities to be placed on the prQperty. I anderstand if �
the site Ys altered ar the intended us� changes, the p�rmit shall.beaome invalid.
Permi�s ar� vaX�d fo� 60 months �rom date of issue. T?ermission is hereby granted to
enter the properfiy for the evalua�iQn. G.S. 130A-335(F) ;
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�"e�s�c� County ��Ith Department
�ewa'ge System Improvements Permit
Date: "ri i-y 3 This Permit Voidj� ter 5 Years Permit # { 7
Owner: �/i�1 �- �''�1'�/--.�"��I�J-�1 SR# -�/��
Location/Directions: �
Subdivision Name: �' � � � Lot #� I
Lot Size: �� Type of Dwe11i .
Water Supply: Private: Public:--�— Community:
Bedrooms:�_ Garbage Disposal ��J
Basement Basement Fixture� �
INFORMATION CERTIFIED BY ----�-
Environmental Health Specialist: ' `. "'1e` `e.`e"►�u°e
REPAIIZ: REEVALUATION:
Size of Sepdc Tank: � gallons Size of Pum Tank• /L1�Q c�
Nitrification Line• � '�, �
Depth of Stone: 12 inches �' �
Max Depth of Trenches: �
Altemative System: Conv. Pump LPP Pump
Remarks:
Date Well Approved: 1���-�Well should be 100 f� fmm any sewer system
gy XUY� Environmental Health Specialist
Date S age, Sy Approve�.d '� ------
By Environmental Health Specialist
� 1,�. CER TE OF COMPLETION y
Contractor. � � �� � } �e
— — — — — — — — — — — — — — — — — — — — — - — — — ��
Sewage System location, installation, and protection must meet state and local �
reguladons. 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
niuification line must be inspected and approved by a member of the Person County
Health Deputment before any portion of the installation is covered and put into use. If
the site plens or intended use change this permit is subject to revocation.
, (a.S. 130 A-335F)
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