A23 215- -rr--- --- --....., �' � 7� �
Amour Paid: (�OO,d O
Fy�ceip��#: .58 d 3 �-�
. c��-�.� I ��`�_�. J�'J�IP�� �l`�
p —�--�.=.�-- – <� � rC�=��`7C'�`-Y
��?� �� �'` � 7F'w:ca...�n�r-.r:n.ica_�rrY�..e.-�rn.'2..u�.)1 7E"'��aa.nn..�l.ii]�a.
J �Ya.� �pplicat�o� f�� �ei•vic��
__ (Septic Systems and Wellsl
L Improvement Permit (Site Evaluation)
�200.00/�300.00 (if> 600 Qpd)
❑ Mobile Home Replacement or Bvilding Addition
_ $I50.00 (if site visit required)
❑ Wel1 Permit (1Vew/Replacement)
$225.00/$12�.00
S��ices �teaueste�l
1ax Niap:
Parcel #:
C Construction Autliorization
(Pee is dependent on the type of sy:
❑ Permit Revision
$75.00
❑ 1Repair of Existing 5epiic ,5ystem
" No Charee
Important: If tf:e information in tl:e applicativn for an Improverrzeazi t'erfnit i,s incorreci, fa[sified, or the site is attered, t1�en t{:e
linprovement Perrnit anrl the.9utl:orizaiion to Cnnstruci slsall become invalict.
1) Services �equested by: p
Name: �J,� Phone # (home): �,�� S �(�%��
Address: � �'/ j ' (wot•k/cell): �Z�[ .;'J)�.��'�
lS�l�'�P�, G c��;� � 7
2)Naa$ee and address of curr�nt o��er (if diffe�-�nt tbaa� applgcant): '"` �` ��' 9��
Address: � — . �� � �� � ��
` 4/l� r�iLy Ya� r�� sr i�
3) Property D�escription: Lot Size: � Subdivision: Lot �:
Address and/or directions to Property: �'�{/� (���� �►cQ=���P�� �a h�/ /�, �f 9 ��
`� � v ' �
4) Proposed Zjs�e ar►d T'ype of 5trvcture: r-�
Residential `-� Business/Type: S 9� (� Other
Nurnber of bedrooms �/ Number of people serv seats/employees):
Basement: Yes _ No _(with plumbing: Yes _ No Garbage disposal: Yes _ No _
Appro�imiate size o f bui l ding %undafion: Y,en�th �idfh
S) �ater Supply
Private Well� (Proposed Existing ) �
Community ell: Public Water System:
Are there wells on the adjoining properties7 No ,/`Yes (please show location on site plan)
l�lote: A comple�ed applicr�Piota �vaa�st c��so irzcZcade•
➢ A p[adsite plttn of the property thai sliows property dirraensions and thQ sfze and locr�tion of ald
proposed siructures.
a A sagneri copy of the `�ot �repcar�ati��z' forrrz ver�ir�g Plaat Phe property is �eady io be evaluated.
� am submitiing thi� applicatian to reques# serv�ees from the Perso�a Coure�y �$eaatk� 1)eparfu�ae�at. 'I'he iniaa�maiion
provided is accurate. I underrst�nd t1�at if �ny site is altered or the im�tender] us� changes, all permiis sfl�all becom�
invalid.
✓
Sign�taar� (Owner/Legal Representative}e • +�a� /)1 • �� ��ge: ���'% ��
I 1!07 Person Counri Environmental Htalth, 32� S. Morean Sl., Suite C, RoxUoro, NC 27573 (336-597-1790}
i f � , �
� � ��� I . �� � ( � T�x M��p � Pa�rcel � .
1 L
� - �•� � • \ - I � � - Subdivision
1 � , . , , .. , , , ,., , � , I I I . . � f � I., Ph�se Sect�ion Lot #
Permit �alid for ✓�ive Ye
Type of Facility: �- i va�
# of Occupants Max g # of
Proposed Wastewat Syste�}:
Proposed Repair: C c�
Permit Conditions:
Owner or Legal
Authorized Statf
Improvement �ermit
1�To Egpiration
�P New _ ddition _
Water Supply �<z
g.p.d.
Type:
Type:
Date:
Date: S� �8"
The issuance of this pernrit by t�he Health Deparhnent in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicantlproperry 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 for Sewa�e Treatment 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 sacisfactorily in the future or that
the water supply will remain potable. •
Authorizat�on io Construct Wastewater Systean (R�quired %r Building Permit)
* See site plan and additional attachments (__�.
Proposed W tewater System: " I(�z.-NcW o� ��r��r�f�e'�'�. Type� Wastewater Flow �g.p.d.
New �Repair Exp si _ Soil LT�R: .�S g.p.d./ ft 2
Type of Facility: �� Basement _ Yes��l O
�astewaier S�siem Itequirements
Tank Size: Septic Tank: D v gai Pump Tank. gal Grease Trap: gal
I)rainfield: Total �rea:1� sq ft Total Length �So ft Ma�mnm Trench Depth _� in
p,C.
Trench Width ,� ft 1Vlinimum Soil Cover: �_ in Minimum Trench Sepazation: � ft
Distribution: '�Distribution Box Serial Distribution Pressure Manifold
, +
Spec�cations• �
�iuthorized State A�
Permit
The type of system permitted is
permit.
�wner/I.egal i2epresentative:
�
Date: S—� Ub'
s-�=�3
Conventional `��ccepted Alternative. I accept the specifications of the
Date:
PCHD rev. 11/10/OS
:����.)� ����'L.J'�. �y • ,
� ' �` � � �pJ 1V` .!L t11T
�]Cl'VIlY`fDwn �rw�w �8��'.�.JL ��B��G[y
..�- ,..r .r,.
�• � � ��
_ .
� �
. �_ ��
� - —
� • r - � ' � � �
SITE S�TCH
T� �p # Aa3 � P�:�� � � �s
Section/Lot#- 1� .
S–/� –�8" '
Date
System cvmpor�ents s�e�is�ese�rt approximate �contours os�ly: The confmctor must fYag fhe system prior to
begimung the installrti'ion io i�sure that pro�isrgmde r's nraintained
�,n�"ia l � S�CryI
�
- � bed. � 4 so 9.P.�.
�'$d� 1��� �
J �
..7'l�oX
_ � g ►` .�en��, ��m5
0
Scl�%� • �`;_ so � .
���.—__`-: �Il 'Pi. . ;.J 1. _�. .1. . ..'..1�. 't". .0,. t.L'1...._ 1 . ...:� :
� �.rt'��'�t , f � _ ~ �j% ��! �
•,�~��''�c:-....� .� f� 'k
`� I t lo' � j
,
0 0 �,o
� �, �
1. o.c. r
—� -
1a ��'�' �ar �-- -� , �
t ���`''' ;
E �
C� . �u��din
t
; ' ���� p��
1
Iro
�1���
q �
� ��
:.ic.:::f%: .... . _„ .:iLl?:....:_ .. . , .. .. ... . ., ...- ;��V�Ot � j, �
.'�� :; .. . .-r:� - . . ... .. .. ���,
�� '' J ,
.., . ,.
y'� �'�
. . . . � rtii ( IA� �
�d
IRt�:.•.�7� .. , . . . ........
�
.i. . _'.
:�.��`.'� � .
..:�1 ..�;:..
'� .;�;\:>,.�-•1 �J:: .� • .`::���•� . �
�� ��
. ��•`S:='S.{::� .. .:
:�':�:�:�.���:.•::•• ;•' . • �y �
. " ' � ..:'- :.:..:.. p�-�
•........' ::yTi.::.::+:•::. :'.....::;'•'••:. � �p
... ........:.v :::._ ;•: +.: •.v �: � :::• _.ry:: � •: -: �:::'1 .
♦ .v. ..,F...,..;.:�.�.....:.,.� :.�....i�.. : �
.�.,
... . . . . ' .:.: � .
. . {
. •. ;7� 7�� �r .
�i•7i31;��7:71ti1i�q�' •�r'1�'nv '' :�: �.LL �
.. •. :..� . . .
, ' .�—�+:-...9C13KAI�.`:�i�'''1Il�•l�.cP•v�p-1L'�'�:ll� �.
'ii.LL'Jg.J� Jt:PJYuaz�LC$ .
����+ �u�+ E ��`�AtC1�� �� �+'Q�1� �+ �.,L ���i + .��'��J"�
Tax Map Aa3 Parc�l #� 15 Township:
Applicant: Ilohha �,�„�] ( r
Subdivision: T ,,,. � ,;�
'�yp� o��a�ea-�5�a � : 1/Individual
�P �' — .
I�ea���aaaen�:
Site Approved By:
Grouting Approved By:
Well Lag; �
Pump Tag:
Well Tag:
Air Vent `
Hose Bib: �
Caeing I�eight:
Concrete Slab: � � '
Well Driller:
Well Approved by:
��*��e�.A�tt�c�aed �i� �ke#c�����
Commwuty Pubhc
Liner:
'Installed by:
Depth set: _
Gr�uted:
Date:
9iia#er Sample:
Wells mt�st be 10 feet from property lines.
Wells must be 100 feet from septic systems,
�1Uells must be at least 25 feet from any buiiding foundation.
ather c�nditi�ns:
Date:
PCHD rev 07/�7I0�