A23 187Apalic�tion Date.� . Tax Mao #: ��3
Amount Paid: ''? o� C9�� �"G
Rec�IQt #: . . Parcal �: 3 G }� C+x�
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APPLICATION FOR SEiZVIC�S
�ot, - �oo.00
Home Replacama�Add�fan)
�Placa Existin9 Sjlstem Pstmit
co�on am
$150.00IS200.00
Pem+it f2evision F
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IF THE INFaRMAT10N IN THE APPI.ICATION Ft)R AN IMPROVEiNENT PEi2MR IS INCORRE�T FALSiFiED
CliANGE�. OR THE SITE' IS ALTERED, THEiV THE IMPROVE�VIENT PERMIT AND AUTH�RfZAl10N TO
CONSTRUCT 3HALL BECOME INVALID. -
1) Permii requested by: (Ownedagerrt/prospe�tive ownerj: C%� S� e f 1�1 � r� b I�
Home Phone: �Iv' S"'qct' Ll !33 Address: Gl ,�i� f'.�Dl-«�u5 l'_-1, 1�
Business Phone: � � M � ( ('� N1 �, �1 � � 3
2) Name and .addr�ss of curre� ovmer. ^ 1,�
`�..�_m c� f � � Y1C_- �'�/j�"�3
3) Property Descripticn: Lot size: �� Tovmsfilp•�n����� Subdivision: Lat#
Directions to the property (lnduding road names and numbers):
`Ta� (Yl �� h P cs m � 1 I � �I +f /! �I.� � . �a.,. .�-, � a � : r�n_ T� ;
4) P'roposed Use and Structure Descriptlon: answer eaci� of the fai owing questions;
a) Proposed �,, Existing , Type of Structure: 5: ; Width:� Depth:�
b) Number of �edrooms: � Numi�er of acc�pan or people to be served: � �'
c) Basemen� Yes . No � Will there be piumbing in the basement? �
d) �arbage Dtsposai: Yes . No ✓
5) Water Su�ply Type: Private ✓(new _ or existing ✓, Puhlic� Communiiy� . Spring _.
Are any welis on adjoining property? Yes No _ tF yes, please indicate appro�cimate locatiori on the
'siie pl3n. ,
6) Daes your property cantain previousiy identified jurisdictlonai wetlands? Y�_ No � �
� PIEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPEitTY OR SiTE Pt_AN MUST BE SllBMI'TTE� WITH THIS APPl.lCATION.
➢ PROPEi�TY L1NES AND CORNEi�S MUST BE CLEARLY MARKED, -,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAI�D OR FLAGGEi�.
➢ THE SiTE MUST BE READILY ACCESSIBLE FflR AN EVALUATION HY THE HEALTH DEPARTRAENT
STAF�.
1 hereby make application to the Person Caurrty Health De�artmerrt for a siie evafuation for the on-siie sewage disp.asai
system for the above-described property. I agree that the contents of this appiication are true and represent the maximum
faciiities te he piaced on the property. I understand if the siie is aitered or the irrtended use ct�anges, the permii shail
became invalid.
or Legal Representative
c�1 �a \ � � �-
Date
PCND. tev. 0612T1�2
�
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�~� � � ��� �l. �
I���s-���.�.-� ���.IL IE-1L�,�.1I�Il�.
�
T��x NT��E� � � ' `►rr_ :_� ' �
S+u!f� cf i v i��i �aa
Fia��_�e.'Se�cti;o�tn��Lot #
Applicant: �L� �`�� �� �
Location: „ , , y � , ,� �, � ,, ,
Permit Valid for � �'+ive'Years.
Type of Facilityf: c� ��
# of Occupants ��, # o ec
Proposed Wastewater S�stem: C
Propos�ed Repair: �
�prc�vea��n$ h'ea-�t
I�tq �piraiaon
: . SG�-a�
�.i
New i� t�ddition �aier �upply Cifi�°C�
Projected Da.ily Flow a�{c� g.p.d. . �
T�e: �—G7'
. . �- � ..�
Permit Conditions• ��e �l��c ��srP�ie l--1 .
Owner or Legal
Autharized. Statc
Date:
Date: �� �
The issuance pf thia permit by the Health Department in does not guarantee the issuanca of other pemuts. It is the responsibiliiy of the
applicantlproperty owner to in sure that all Person County Planning and� Zoning and Building Inspectiona requirements are me� T�is
Improvement Pernilt is subject to revacaHon if the site plan, plat or the intended use changes. The Lnprovememt Peranit is not affected
b� a•change iai ownerahip af the property. TLis permit was is�ueai In compliance with the provisions of the North Carulina `Laws and
Eule� for Se aPe Treatment and Di�posal stems' (15A NCAC. 18A 1900). Neither Person County nor the Environmental �eaitl�
Specialist warrants that tLe septic tamlc system will continue to funct[on satiefactorilx in the future or that the water supply will remain
potable. �
�,�ntiaorixation io Con��uct �ast�water Systeni �lteqnired %a� �ttalding i'ermit)
* See site plan and additional attachments (_�.
Propos d Wastewater System: �9������,( C%��II�� 'I`�rpe��t Wastewater Flow� �og.p.d.
New i� Repair Ezpansion _ � uoil I�TAlt: � 3 � g.p.dJ ft 2
Type of Eaciliiy: 02 j ��. lasement Yes N�
� i�ast�water Syste� R.eqnirements �
Tank Size: Septic Tam�k: L�c�vg�1 ,. Peiffip Tank: � gal� Grease Trap: ga1
Drainfield: 'Total Area: �s-�o sq ft Tobl Length � ft R�Iazimu� Treaaeh IDeptla l$=aZd an
'Trench �fidth 3�it 1V�iniip�rm 3ofl1 Co�er: ��O iia Minimum Tr�nch Sepazation: � ft �-�.
; � I3istribution Box
aa: 9--CQ� Gt.�' � C� .Sd
Aaa#�or�ed State Agent: �
Permit �xpiration Date:
Serial Distribution Pressure Manifold
! c�
The type of system permitted is �Conventional Innovative
the permit. ' � .
Oevner/�.e�al �t��r�ses�ta�ave: .
Date: 3_' �"�S
Alternative. I accept the specifications af
Date:
PCHD7/30/2002
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1�.,�cn�vn�-amir.ns.na���.�.rn,�� �FZ�a,m.1��J�1
Name ����r �a� �'�tx�
Subdivis�
Authorized State Agent
SITE SKETCH
Tax Map #�� 3 Parcel # c g�
Section/Lot#
'�.,�� S_
Date
System components represent approximate contours only. The contractor must, flag the system prior to
beginning the installation to insure that�iro�iergrade is maintained
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