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�Va.i � .�pplic�t�o� f�a- �e�-vic��
(Septic Systems and Wellsl
L improvement Permit (Site Evaluation)
�200.00/$300.00 (if> 600 gpd)
� Nlobile Home Replacement or• Building Addition
_ $150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$12�.00
1 ax lvlap:
Parcel �:
-
�eg-9✓ices Re �aesterl
G Construction Authorization
(Fee is de endent on the ty e of sy,
❑ Permi# Revision
$75.00
f� �iepair of Existing 5eptic 5ystem
" No Charee
Important: If tl:e informativn in tl:e applicatior: for an ImJ�rove�neo:i Permit i,s incorrect, falsifr.ed, or the site is aftered, tl:en tfie
Lnprovernent Permit and the.9utltorization to Construct slsall become invalici,
1) Services �equested by:
Name: /,� Phone # (home): �,�,�� ,� ���f1�%
Address: Q �/ `'
� (work/cell): , � ,3'I)��,,1 J,��----
�S��y�2A-, G �),,� Q � �
'?)Naraae and address of curr�n� oot�yaer (if differ�nt tl�aan appl6eant): ��l ���g'��
Natne:
Address: � �� � �� � ��
- �ifl� �t� Yarl o�� sri�
3) Propert3� D�escrip�aon: Lot Size: � Subdivision: Lot #:
Address and/or directions to Property:
4) Proposed IJs�e amd Type of Str�ctur�:
Residential � Business/Type: s � � Other
Number of bedrooms �/ Number of people se�v seats/employees):
Basement: Yes _ No _(with plutnbing: Yes _ No Garbage disposal: Yes No
Appro�ix��te size of building %uttda4ion: ]Len��th �l�g� — — ``,,,;
S) 'Water Suppiy ��
Private Well �� (Proposed � Existing _) �
Community Wel1: Public Water S stem:
Y
Are diere wells on the adjoining properties7 No /�es (please show location on si�te plan)
1l�ote: ,4 com�leied an�licaPion �uaa�st �Iso incicede°
��4 plat/site plun o_ f'the propeYty thal shows pra,�e�•ty dir�aensaoras ancf thQ size and loc�ction of all
p�oposeci structures.
� A sagned copy o�''t/Ye `Z,ot �reparrztion' forrrz v�er�issg PhaP P�ie property is rer�dy i� be evaluated.
� QYY� ��xomirring xn�s apptYcatzon to request serviees from the Person Cou�e�ty �eaa�h Depart�ae�ai. 'The in%�maiion
provided is accurate. I undex�stand ihat if �ny site as altered o� t�e in�tended us� �laanges, �lfl per�nits s➢�all �ecome
invalid.
Seg��¢a�r� (Owner/Legal Representative): �� �j� � �T'��--'' ��Te. ��� j d�
11!d7 Person Counr� Environmental H�alYh; 325 S. Morean Sl., Suite C, R.oxboro; NC 27573 (336-597-1790)
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I -��.�a� <m ��<e� �n�.,�n..11 �I a�.zn.I1iL-I�n.
T�x M�p . Pa,rcel � �
Su�bdiivis�ion
Phase Sect�ion Lot
Permit Valid for
Type of Facility: .
# of Occupants �
Proposed Wastevc
Proposed Repair:
Y
` # of
System:
Improveme�t �ermit
PTo Egpiration
New Addirion R'ater Supply �_
s Projected Daily Flow 4�'0 g.p.d.
, _ � - Type: �
Type:
'- • . .
► � r. a ��1'�:�.
Owner or Legal Represe
Authorized State Agent:
Date:
Date: �`% �O�i''
The issuance of this pernrit by the Health Department in does not guarantee the issuance of other pemuts. 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. Tlus
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Impravement 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 Sewage ?'reatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
�nvironmental �ealth Specialist warrants that the septic tank system will continue to function sausfactorily in the future or that
the water supply will remain potable. � �
Au��or�z�tion to Construc� �Vasteyvater Systean (Recguired %r Building Permit)
* See site plan and additional attachments (__).
Proposedj7dastewater System: ���F7 -�f d[.� a� ���IvQI% Type� Wastewater Flow �g.p.d.
New �►/ Repair Expansio 5oi1 LT •�-7,� g.p.d./ ft 2
Type of Facility: p,-; ��� �s�cl��c�.. Basement _ Yes ✓No
'FYastewater System Requirements
Tank Size: Septic Tank: ��D.._gal Pump Tank: '__ _ gal Grease Trap:- — gal
I)rainfield: Total Area: � �3� ' sq ft Total Length ���� ft Maximum Trench Depth _�_ in
� �,f ,
Trench Width � ft 1Vlinimum Soil Cover: � in Minimum Trench Separation:
Distribution: �✓ Distribution Box Serial Distribution Pressure Manifold
Spec�ca�ions• �Atn�"Ri�n F� �� r ��tc� —
Authorized State A€
Pernut
Date: � (� D��%
The type of system �ermitted is Conventional ✓Accepted Altemative. I accept the specifications of the
permit.
�wner/I.egal Reprasentative: Date:
PCHD rev. 11/10/OS
0
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SITE Si�TCH
1Vame �, n►,►,n �ihendl�r
Subdivis'
A thorized State Agent
�
Tag Map #�.Pa:i:�el ��` 1„�
SectipII�I�Ot#�
— �- g-p8 •
' Date
Syste»p cvmpo�enicr s��s�esent upproa�imate�contours only: The contsnctor mustfiag the system�irior so
beginning the instalXa�ion to i�sure that projbergnxde is murntained �
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T� � a3 Parc�l #
AppliCallf: _ p e n►� � 1� r�
5ubdivision:
To�n�P:
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'�yp� of ���err 5�gap�g�; �dividual _ Community Public
�8er��r�ffienis:
Site Approved By:
Grouting Approved By:
Well Log: �
Pump Tag:
Well Tag•
Air Vent:. `
Hose Bib: �
Gaeing Height:
Concrete Slab: � � '
Well Driller:
'Well Approved by;
�'��*Se� ��t��3aed Sit� ��e#c����*
Liner:
�Installed by: _
Depth set: _
Grouted:
Date:
Water Sample:
Wells must be 10 feet from property lines.
Wells must be 100 f�et from septic systems,
Wells must be at least 25 feet from any building foundation.
Other canditions:
Date:,
PCHD rev 01!27/0�