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Application Date: "� b '�
Amount Paid: V
RecEipt#: �
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APPLICATION FOR SERVICES
Tax Map #:
ParCEI #:
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALS1FiED
CHAFVGED, OR THE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZl�TION TO
CORISTRI�CT SH�4LL BFCOl11lE IN�lA�Ll�.
1) Permit requested by: (Ownedagent/prospective owner): G�4191Z�b�ti G- -%.�.n C= t..c�� cY�TE - K� t N C
Home Phone: 3'� - 3`i�i -`I �S � � Address: �I o Q� � p�,•� �,.,- f 5� .�4 t�T, 3
BusinessPhone:'��C,-3Hg-11$S 2E�o5v1�.t,E �.�'�-3��%
2) Name and address of current owner. �1qrv� ��
C�l NN I N(Y N'Y}YV�. �5�1�1 N C�. �T� (ZE.E�-L
3) Property Description: Lot size: 1�, ��3Township: Subdivision: F�,Z,v� .L-ot#���-r�_
Directions to the prvperty (Including road names and numbers): q'u 1�. -Fw� 'S� v�no R-v� -
•A;�r,� �. Cc,�.n�;...�.�.,,.r,. _'��tiv..�- o.�- Tew-�i1 ���„� 1��.. Qe.�,- �.e{�-
c�.�- \y �v/1� �r.��o �Pr�"vc�-� Dr. - Wtnw�v. �C-a- o�r- v���- �v�a-ev�9cc:liu-� . ►--�-F�- �-
r,�e..aYa�r.u� C�*� �4wei \a�e� �-r.,�- c�. ��rc,per �,-i� bv-�- c�e,-. �wi�l �e.e, SC�v�S,
4) Proposed Use and $tructure Description: answer each of the following questions:
a) Proposed �,, Existing , Type of Structure: QR�vY�Tc l-�v�n �� Width: Depth:
b) Number bf Bedrooms: �_ Number of occupants or people to be served: �
c) Basement: Yes , No � Will there be plumbing in the basement?
d) �arbage Disposal: Yes , No �
5) Water Supply Type: Private �(new � or existing�, Public , Community , Spring _
Are any wells on adjoining property? Yes_ No ZC If yes, please indicate approximate location on the
'site plan.
fi) Does your property contain previously identified jurisdictional wetlands? Yes_ No,�C
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LlNES AND CORNERS MUST BE CLEARLY MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR �LAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEiVT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid. -
or Legai Representative
l U l
Dat
PCND, 2v. 06/27/02
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T�x Ma�� � �rc�ei �
Su�bd�ivis�iar��
P�ha;s�e�Sect�iam:'Lo�t +�
P�r�nit Valid for �/ �'ive 3�f
Type of Facility: �.�,;, V c�-�-e.
# of Oc�upants m� # of
Proposed Wastewater System:
Proposed Re�air: �.�{�
Permit
][�praveinent.�'ermit
l�To ��piraiion / �����
��^�- � New VAddition _ � �Vater SnPP�Y '� � L_
rooms 3 Projected Dail Flow �( _ g.p.d. -�-
Z � m � Type: �L!_�
`2.. - C.'l,� : 'I�pe: �—.
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Owner or Legal Represen 'gnature: � Date•
Autiiorized State A � '� � ' Date: 2- '1-0 �,
The issuance of tlris permit by the Hea1t3� Department in does not guax�tes the ;s�,a*+��-"of other permrts. It is the responsib�ity of the
aPPlica�t/praPert}' owner to in sure tha# all Person Couniy P3anning and Zomng and Bu�7ding insPections requaements are met This
Improvement Permit is snbject to revocation if ttie site plan;�pla#`'ur'the intended use changes. The Impravement Permit is not
a$ected by a ciiange in owner"ship of the propertp. This permit was issued in complianca with the provisions of the North Carolina, .
'Laws and Rules for 5ewage Treat�nent and Disoosal Svstems' {�5A NCAC 18A .1900). Neither Person �onnty:nor�°rt�ie-`'� �
Environmental Healih Specialist warrants that the septic tank �ystem w�71 cantinue to fnaction satisfactorily in the fntnre`or:t�t.
the-water saPP1Y wi71 remain potable. • •
• Authorization to Construct Wastewater System (�2equired for Building Permit) �
* See site plan and additional attachments (_,. . . . -•
l ^_ .
Proposed astewater System:� ��`L -�cw �cr %�w;nt,��� T��pe._J1�.L Wastewater Flow ��.p.d.
New � Repair Ex�a�sion! .• Soil L�A�: •� g.p.d1 ft 2 �
Type of Fac�ity: �ri ✓�� �e5 rc���� � � � Basement _ Yes�N�o�
�'Vastewater �yst�m Req�rements
Tank Size: 5eptic '�ank:'� gal PumP Tank: gai Grease Trap: -------gal d�c� 5��� e.
Drainfield: Total Area: � OD sq ft Total Length �Ot� ft '�mam Trench Depth �_ in S� d e
p, C,
Trench �Vidth 3 MCinimnm Soi� Cover. �_ in 11d'inimuxn �'remci� Separation: �_ #t
IDist� ibntion: Y i)istri`bution �oz Serial Distribntion
spe�ificatiuns:
state A�
Permit
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The type of system permitte� is Conventional '✓ Acc�ted Alternative. I acc�t the specifications of the
P��- �
i�e�/�agal �ta���s�nt�tive: Date:
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. �ELi, PERN9IT .
PLTAS]E SEE� ATTA�ID Pg..e�N �pga yyEI.L S� I�AAY'OYJ�'
Tax Map � Parcel # �� .. Touinship:
Applicanf• _ G�,c� �a� t l„�� I(�, �.ca��-z— �fe�.,�o
Subdivision: r „+ �
'Pype of Vi�ater,5upply: ✓Individual _ Communi Public
tY
Itequirements:
Sita Approved By:
Grouting ApProved By: �
Well Log: �
Pump Tag: .
Well Tag• ' •
Air Vent:. ` �
� Hose Bib: �
� Casing Height: '
Concrete Slab: • � � � ' � �
Well Driller:
Well Approved by:
****See.tlttached Site Sketch****
I,iner:
7nsta1led by: �
Depth set:
Grouted•
Date: .
Water Satnple:
Wells must be 10 feet from property lines.
Wella muat be 100 feet from s�ptic systems,
Wells must be at least 25 feet from any building foundation.
,
Other conditions:
Date:,
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PCT3D rev 01!27/0�
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Ta.z Ma.p # %�" 23 � P�tcel # �
Sectian/Lot#
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Date
System cvmponent.r s�epr,erent ajiproximate �contours only: The contractor must fCag the system prior to .
beginning the installcdion to i�sure thatpropsrgrnde is marnt�ned '
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