A23 47Application Date: � �'��
Amount Paid: . O�
Rec�tpt #: � ,� �j .� 3
C�-'�`�
Tax Man #: l��3
Parc�! #: �T /
����__ � ���..� ��
- - -t � � �C.J1�T�C�Y'
^ �.va�aosaa-�—�--� .Ds:a�m71 ��Lr_s�.71�7�a
APPLICATION FOR SERVIC�S �
IF THE INFORMATIOPI IN TME APPLfCATiO1V FOR AN IMPROVEME�lT PERMIT 1S INCDRRECT, FALSIFiEa,
CHANG�D OR THE SITE IS ALTERED. Tt-iEN TiiE InAPROVEMEl�T PERIIAIT AND AUTHORIZ�►'t101V TO
CO(VSTftUCT SHALL �ECOME INVALID. • �
1)
2)
Pennit reques4ed by: Ownedagent/pros�aective owner): ���✓g �H L
Home Phone: 3.�6 �;�d6 Address: 3 TII1�V �f..
Bus�a�s� P e• � O • G a�3
{JU cL ,� G�2 � 91 � 69 � � �t� (� �s�
idame and address of current owner �!0 w.B �
. A.� �4- f� � r
7r3� - --
%� .�� ����/G
3) PropertyDescription: Lotsize:,��� G Township: c�U�,�/.(J Subdivision: � Lot#
Directions to the property (lncluding road names and numbers):
4) F�roposed Use and S,tructure Description: answer eact� of the follow g questions:
a) Proposed . Existing Type of Structure: �rA� ��� �dth: Depth:
b) Number of Bedraoms: � �. Number of occupants or people to be served: � _
c) Basement Ye� . No�,L Will there be plumbing in the basement? C�D �
d) 6arbage Disposal: Yes ��. No � �
5) Water Supply Type: Private �� _ or existing ; Public . Community , Spring _
Are any wells on d�oining property? Yes No _ If yes, please indicate approxima#e lacation on the
• �
'site pian. � . �
fi) Does your properly cantain previously identified jurisdiciional wetiands? Yes_ No�
PLEASE NOTIE THE FOLLOWING:
➢ A PLAT OF THE PROPERN OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
9 PROPEiZTf L1NES AND CORNERS MUST BE CLEARLY MARI�D. �,.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAi�D OR FLAGGED.
➢'Y'HE SITE MUST BE READILY ACCESSIBL� FOR AN EVALUATION BY THE HEALTH DEPARTMEiVT
STAF�: �
I hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposai
system for the above-described property. I agree that the cantents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the siie is altered or the intended use changes, the permit shall
her_c�me invalid_
��
Owner or Legal Representative
oZ,�'�—
Date
PC}�1D, rev. 06127/02
a
� s�� ��� ���.� ��
`►.v > 1 d
•�� � � ����
�zrn.-s-n.a-�-n-n „-�-� �a�..�.�e.11 �-��.�.�i-�E11�.
•` � .
. ��,��� �7
ao 0
P�h �:s e;�S �ct i�a�n� Lo�t �
P�rmit �aiad for c/�`ive 3�e
Type of Facility: �
# of Ocxupants �qp�� # of
Proposed Wastewater System:
ProposedRepair: Arc�
Permit Condifiions:
�prave�ent �ermii
I�To �+ ��irra�on
a' �
� New ��Addition . . �ater 5upply (,v� /,r
s Froje�ted Daily Flow �$0 g.p.d
�
Type: .Ll.. 4
Type:
Owner of� Legal �
Authorized State
Tbe issuanc� of t�is permit by t�e Health Department in does nnt gvaza�ez the issuan�ca of otiier permits. It is the msponsibili�ty of the .
�Pli�P�Y owner to in sure tha# all Peisan County Planning and Zo�ing and Bu�7ding Inspections req�rement� are met This
Ymprovement Permit is snb ject to revacation if the site plan; �pla�''or� the intended use changes. Tlie Improvement Permit is not
a�ected Iip a c�ange in ownersiup oi the property. This permit was is�ued in complianca with the provisions of the North Carolina, .:
'Laws axd Rules for Sewa�e Treutinent and Di.rnosal Svstenis' (X5A NCAC 18A .1900). Neither Person �Cown#y: mo�*�;tlie-�` "� :
Environmental Health Specialist '�'arranta that the septic tank spstem m71 continue to fnncl3on safisf�ctorily in the futnre'or�tli�f .
th�water supply wiII remaia potable. � � __ __
• Anthorization to Construct YVastewater Sysiem (Required for Bnilding Permit) �
* See site plan and additional attachments (_�. � � .�
Proposed astewa#er SYste�m: �:�..�..�,��¢NQ. � • . . ,I,y,pe .LT-a Wastewater Flow g0 .p.d.
New �Repair Expa�sion � � .� Soil L'TAR ..Z'7S g.p.dJ ft Z .
Type of Fac�ity: �r iJa-�e ��P.��. � � Basemeut _ Y—�No .
� �'qVasiewater Systeug �iurements � .
Tank Size: Septic Tank:' DOo gal Pnmp Tank: `�' gal Gre�se Tragr —'gai � .
I�rainfie�d: Totai Area: 1. 7yo sq fiE Total iength 80 ft ' Ma�mnffi Trenc3i Dep� �� .
o.c.
Trsnc�t Width 3 1VYinim�m Soil Cover. �2 in M'wimwn'I�enci� Separation: �_ #t
Dist�ibntion: ✓ I3istri`lbntion �oa Serial �istTTbntioa Pressnre lA�ianifold
Specifications:
0
State Agent-
Permit F�pirati Date:
�
D"ate: F� � � A'7
The type of system pezmitted is �onventional Ac��ted Alternative. I acc�t the s}�e�ifications of the
P�• �
i�v�e�/L�3i �a�a-�s��tatflve: Date:
�
pC� rev. 11110/45..- °
,.. .. .
�
�
Pv��'2! �.
J
�
.`t
m �' yl� i.� �
m il S. ra � ' �
Y �
:j L W O .
. ''A ��.�, � � � - .
. . . � ���0 �.
:���,�� 1�I�I�.��� � � .
� � c�v���
������ � ��� ����
: � SiTE S�TC�I � .: . .
Name �o,nnn �a�� �o_r Tag Ma.p # A� ..P�xce1 #�.�
Subdivi , � Section/Lo�#
, . g�. q-o7
. uthorized State Ag�ent . � Date .
System cnmponen�ts r�prese� ap�ireximate�contours only: 1'he contractor must, flag the system�irior to ;
beginning the installution to i�sure that propergrr�de rs �naintained
���-; a( � �m
_ �{�o . . � � `� b� �
�r
— 5go' c on��-� o�a f,
�� �.� � i�5
� I� ..�,��C� 'ba�m �a� S����r d s r5s%t
p(ac� Z
�t a� �'' "' �; Y
f� 1 �r �o Cotit�h rM,
on MCZ�t'1� ivlarldG�D�'�
� Qr�—� ns�a��a�i` .� �nS�al��
house-
areQ `�" 5°i�5 ar�1 `'`'�
�
, .�';;<...;'. ''�..;'�..'�.:�?: �: . .. �.
��,..,�:; �;� :::�.� � . . .
• :}... aci„
' . ��'��
•.�;'.—,+r:•'y ::• ... ....... . ..:. �.�. .
va... .: : f, .� ..
',2;�,�•��.���..• .
•...,..:':';:••,n::.�_.�.•...,.....�v.,,,..•—.:•.:• . '� . �
. ...
'. .. .. . .. ;.i.:., .;.. :. .' . ,,. . : , . ... :: .; :.. • . . ,
. � � . ,. ...:.
. . , . . . . .... . . ��
..
��7am'a'.�9:73i'1L^V�`_�,T'^�'.--��„''A�71:�i:�:.i#71:' •,':�..
. ,..
..: �:cl�'s�D.1lm.�
� ..., _
'1`78J�../Y� �a�.��l'1LL1 -
�YJJ:�L�l.J� L7�dJ iAS S�58..�J�i./ � o'r �� �O� �I JL/BJ I�a J. Ji:J . n' � JI O�LJ I�
Tax Map �23 Parc�i # .. To�vnship:
Applicant: .
Subdivision: � r �+ � �
T3�pe of �a#ea-'�upp�y: t/ Individual _ Community Public
�equireaneaa#s:
Site Approved By:
Grouting Approved By: �
Well Lag. �
Pump Tag: �
Well Tag: . � '
Air Vent: � �
Aose Bib: �
Casing Heigh� �
Concrete Slab: � � � ' � �
Well Driller:
Well Approved by;
**�*S�e Attac�ned Site Sl�e#ch****
Liner:
�Installed by: _
Depth set: _
Grouted:
Date;
Water Sample:
Wells must be 10 feet from pmperty lines.
Wells must be 100 feet from septic systems,
Weils must be at least 25 feet from any building foundation.
Other canditions:
Date:.
PC�C rev O1!27/0�