A23 173,Aqplication Date: � �-�� � �
Amount Paid: l 0 O
Receiat #• .j
02 ��
Person Countv Health Department
Environmental Health Section
APPLICATION FOR SERVICES
Tax Map #: �� 3
Parcel #: � � /d-'
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED, OR THE SITE IS
ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Owner/agenUprospective owner): � �U
Home Phone: 33�-�34-��fX ( Address: 5�. t1 � �
Business Phone: an� � � o� C.�
2) Name and address of current owner. a� �� �1't ��C �
5a'1 nh�t C A �
5�� � ' _
3) Property Description: Lot size: Township: W
Directions to the propertK(InGuding road nam�s and numbers): � ���
4) Proposed Use a d Structure Description: answer each of the following questions:
a) Proposed �Existing ❑
b) Stick Built ❑, Modular ,�ingle Wide 0, Double Wide ❑
c) Number of Bed ooms: � d) Number of occupants or people to be served
e) Basement: Yes�, No o If yes, # of basement fixtures:
� Garbage Disposal: Yes 0, No �1
g) Dimensions of Proposed Structure: Width: �F6 Depth: �Q
5) Water Supply Type: Private �(new 0 or existing 0), Public �, �ommunity �, Spring ❑ 04'
Are any wells on adjoining property? Yes �9 No 0 If yes, location 3
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
✓ Conventional _Modified Conventional _ Altemative _Innovative
Other (specify):
�
� , 4� �0'Q� �i y
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
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. I understand
that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
personnel of the Person County Health Department to conduct�their evaluations. I understand that I am responsible for notifying the
H Department if my property contains any wetlands as designated by the Army Corps of Engineers.
_�
,15 ,�i
wner or Legal presentative Date
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section
SITE PLAN WORKSHEET
Piace a mark (X) beside each item as you indicate them on your site plan. incomplete site plans
will be returned to you for completion. Remember: Your property will not be scheduled for an
evaluation until we have received a completed appiication, site plan, and all proposed
items are marked on the property. Your property must be made accessible for an
evaluation.
N/A
/A
N/A
N/A
.�,...�.�..�...�..---.-�_��.�....�.�...w _.�_.
C��n �nGi�Am
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The dimensions of the property.
The proposed location of the house. Show the setbacks from the road and the
side property line. When showing the location of the house, be sure and give its
dimensions. If you are unsure as to the house size, please show the dimensions
of the MAXIMUM area of the lot that you anticipate the house will cover.
The area you would prefer your septic system to go in.
The preferred driveway location.
Any future structures or improvements to the property such as garages,
workshops, pools, etc. If there are none, circle "N/A"
The location of any existing septic tank systems and wells on your property and
on your neighbor's property within 100' of your property lines. If there are
none, circle "N/A".
The location of any easements or rights of way on the property. If there are
none, circle "N/A".
The location of any designated wetlands on the property. If there are none,
circle "N/A"
USE
F NEEDED
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PCHD, rev. 10/12/99
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Tax Map #: _
Zoning _
Applicant
Locat(on:
Subdivision:
PERSON COUNTY ENVIRONMENTAL HEALTH
'ACHED PLAN FOR SOIL AREA AND SYSTEM l
Parcel #
Township
S2�tion:
Lot:
�mprov�me�t Permit
A�U�Iding perrv9it cannot be issued with oniv an Improvement Permit
New � Repair Addiiion Type of Structure S�� Water Supply i� (�(�,
�
# of Occupants o� # of Bedrooms Other
Basement?.1c�� Basement Fixtures?�
U
Projected Daily Flow: � g.p.d. Permit Valid For: Five Years O No Expiration
Proposed Wastewater System Type: ShC.( (al.� ��n��rn D--'('� �Z
Pump Required? Yes �No
Proposed Repair � (A.,►-rtn ��i ti // r . 'F
Permit Conditions-r� � KPAn �� � Un-� �/�?�vvY��tr ��E-
Owner or Legal Representative
Authorized State
Date: ' �'� '"��'i
Date: �
The issuance of this permit �the Health Department in no way guarantees the issuance�of other permits. The permit
holder is responsible for checking with appropriate governing bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Building Permit)
Type of Wastewater System e �e(1'�ik�Nastewater Flow: �Qg.p.d.
Facility Type: ��� �� New L�YRepair OExpansion ❑
Basement?� -9-h�e-�r- Basement Fixtures? �L9'I�r��
�-``..
Wastewater System Requirements
Septic Tank Size: -,�� gallons
Pump Tank Size: N C� gallons
Total Trench Length: � feet Maximum Trench Depth: `� inches Aggregate Depth:l2 in.
Maximum Soil Cover: � inches Trench Separation: � Feet on Center
Other:
Permit Expiration Date: -- � �
Authorized State Agent: 1 Date: l a$ '�
The type of system permitted 0 does �cfoes not iffer from the type specified on the application. I accept
the specifications of this permit �
Owner/Legal Representative Signature. Date: ��`W
PCHD, rev. 11/18/99
Appiication #:
Tax Map #: l4- �3
Parcel #:
Person County Health Department
Environmental Health Section
SITE SKETCH
� �� .
ApplicanYs Name Subdivision/Section/Lot#
� t....S p�- �
Authorized State A ent Date
System components represent approzimate contours only. The contractor must flag the system
_._..._ �.. t....d......�.. �l.,. :..�i.,.lJ..�:nas 1n is.cvrn flsnt nrnnar orn/IP tC iltQlltiQLKelL
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PCHD, rev. 10/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map 1k. �`� Parcel # I/-✓
Zoning Township �
APPlicant �lJl�(/1, .Y �� :Y � l4 �lA —
Locatlon:
Subdivfaton• Sectlon- �
TVpe of Water SupplV:
Reauirements•
Site Approved by
Grouting Ap rovE
Well Log
Well Tag .
Air Vent ✓
Hose Bib
Concrete Slab
�
Well Permit
�ndividual
), ,�i
- � �i: �' / 1 ..�
• . . . - . .�...� - L.�/ �i�.l
Community � Public
Date: �I - � ���
**See Attached Site Sketch"""`
Welis must be 10 feet ftom property lines.
Wells must be 100 feet from septic systems.
Welis must be at least 25 feet from any building foundation.
Other conditions:
PCHD, �ev. 11/29/99
r' `
Person County Health Department
�a� Environmental Health Section/
Tax Map #: Parcel #: l �3
Zoning: Township: �ai�n;�. �c .�►
Subdivision• Section: Lot•
Applicant• . 0 �^�- `
Location: ��l � �� 'L ` h4� %2rQ o� � °�-�, �Sa%S
Operation Permit
System Type (In Accordance With Table Va): /��--
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
/< � %i%d o
thorized State Agent Date
Tax Map #: Parcel #:
PCHD, rev. 10/12/99
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