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F��ceip�#: � �8 $ 3�}-�
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���Ua�� .�pp�ic�t�oa� %�- �er�ic��
(Septic Systems and Wellsl
L Improvement Permit (Site Evaluation)
$200.00/$�00.00 (if> 600 apd)
V Mobile Home Repiacement or Building Addition
$150.00 (if site visit required)
I.� VI/e!1 Permit (New/Replacement)
$225.00/$12�.00
1 ax N1ap:
Parcel �:
S��ice� Re ueste�l . -
C Construction Autliorizatioz�
(Fee is de endent on the ty e of s s
❑ Permit Revision
$75.00
❑ ➢-tepair of Existing 5eptic System
" No Charee
Important: If tlze information in the applicatiofr for an Improvepnerit I'er�nit x� ir:correct, falsified, or ihe site is �zltered, tl:en rl:e
Lnprovernent Permit anrt ihe.9utl:orizatio� to Construci sliall become invaliri.
1) Services �equested by:
Name: /,� Phone # (home}: �,��� S /�(���� �'
Address: D �l % (work/cell): b�i�'J�y1.Lp�"� ,�
_t���i�, G c��+��,.� . �---
�)1�lareae and add��s�of cur��n� o��er (if difge�r�aat t�aan ap�laea�at): '"" �/ ��' 9��
Name:
tlddress: � �� � �� � ��
_ - �ir,� �Lr �o� � sr;�
3) Property D�escrip�ion: Lot Size: � Subdivision: Lot #:
Address and/or directions to Properly: ��p,�i�,����� a=���J�,�l, �� �� f�. �,� j�
,�-�
4) Propo�ed i�s� ar�d Type of Str�cture:
Residential � Business/Type: S � � Other
Number of bedrooms �/ Number of people seiv seats/employees):
Basement: Yes _ No _(with plumbing: Yes _ No Garbage disposal: Yes _ No _
Ap�raxi��te sixe oi buildin� %tax�da�ion: ]Len�th �ec$�i�
. � .�,
5) 'Wates� Suppfly
Private Well� (Proposed Existing _) �
Community ell: Public Water System:
Are there wells on the adjoining properties? No /�Ces (please show location on si�te plan)
1�Tote: A com�le�ed anndicaiaon n�aa�sst also include°
➢.4 plat/site plan of the property t'hat sl�ows pr�ape�•�-y dirraensioras unrt thQ saze and locra4ion of ald
proposed structures.
� A signeri copy o,�"'tlPe `Lot.�reparrzPio�a' forrr: ver�irsg eha� ¢�ie prope�iy is �eady to be evaluated
d a�n subm�itiing ihi� appIica$Aon to request services from tbe Perso� Coum�ty �ealtln Deparf�ee�ai. �'he in%rrraation
provided is accurate. I unde�•stand Yhat if �my site ns altered op t�e intemd�d use cbanges, �Il permiis shal! become
invalic�.
SHgn��ur� (Owner/Legal Representative); �i,�e,,�.,/ �7j � �� � �
� ���e• � !�!� �
11!07 Person Coun�� Environmental Health, 32� S. Morean Sl., Suite C, R.oxboro; NC ?7573 (336-597-1790)
� ��� � �� � � ��� �� T��x M�p �.� Pa�rcel #
� � ��� � � � - � - � - Su���bd�ivision
I- ,. �� .,����.. �,� , I I 1, .�I� I.�
Ph�se, Sect�ion Lot � �.
Permit Valid for
Type of Facility: _
# of Occupants �
Proposed Wastew
Proposed Repair:
Pernut Conditions:
�� Im�roveane�t �ermit
V�i e Ye s No �gpiration
� j �y,� New ✓dd.
� # of B�drooms,_ __ Projected Daily Flow
Owner or Legal Representative
Authorized State A�ent: _�
. Water Supply,�!��_
g.p.d.
Type: �
Type:
Date:
Date: j = Co -�g
The issuance of this permit by tlie Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Rules %r Sewa�e Treatment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmental �ealth Specialist warrants that the septic tank system will continue to function sausfactorily in the future or that
the water supply will remain potable. •
Aut�or�zation to Co�struct Wastewater Systean (�2equired %r �uilding Permit)
* See site plan and additional attachments (_�.
Propose astewater System:���' _ I lC L�1lu ) TYPe � Wastewater Flow �g.p.d.
New � Repair fExpa sion Soil LT ,� g.p.d./ ft 2
Type of Facility: �,� � vpt-.e �.� sj�Ge Basement _ Yes No
�Yastewater System Itequirements
�ank Size: Septic Tank: �� gal Pump Tank: gal Grease Trap: gal
Drainfield: Total Area: � sq ft Total Length �{Qn ft Maximnm Trench Depth �_ in
p,C�
Trench Width ft Ndinimum Soil Cover: �_ in Minimum Trench Separation: �_ ft
Distribution: Distribution Box Serial Distribution Pressure Pvlanifold
Spec�cations:
Authorized State Agent:
Permit Exp;
The type of system pernutted is
permit.
�wner/I.eg�l 12eprasentative:
�._..�L1 1 '. ,.� .
Date: S (Q -"�
Date: 5' -/�
�/ Conventional Accepted Alternative. I accept the specifications of the
Date:
PCHD rev. 11/10/OS
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, S�TE S�TCl� � .
Name 1,o�v� %� ,✓ Tag Map # a3 � Par�el #%� �3
Sub ' . � Section/Lot# �
� -S /1-08' �
uthorized State Agent . � Date
System cnmponents s1e�bs�efent a�iproxirnate �contours os�ly.' The contractor muss flag the system prior to .
beginning the installation to i�sure thatpropergmde is mai�tai�ed �
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Tax Map
Applicanf:�
Subdivision
Location: S
Parc�l #
�`,�� O��%��bi'►�U�&�D��: ��Ild.l'V1d13�
�e�vir�naea�:
Site Approved By:
Grouting Approved By:
Well Log: �
Pump Tag:
Well Tag-
Air Vent:. `
Hose Bib:
Caeing Heigh�
Concrete Slab: : �
Well Driller:
Well Approved by:
��**See.Attac�aed �ate Slce#ch**��
Tbvvnship:
Lot # _ j�
0
Communiiy Public
Liner:
'Installed by:
Depth set: _
Grouted:
Date;
Wate� Sample;
Wells must be 10 feet from property lines.
Wells must be 100 feet fram septic systems,
Wells must be at least 25 feet from any buiiding foundation.
Other canditions:
Date:
PCHD rev 01!?7/04