A23 63O.� '. . Q
�rsalication Date: �_� � urG � �� �6 1 Tax iUlao #: ���
Amount Paid: �'O� . OQ �� - (�� � 1 N S � 3 "�� �
€tec�ipt #: � � � O-�` Parc�! #:
Psrson C�untv Health De�artment
Environmentai Health Section
APPLICATION FOR SERVICES _
IF THE INFORMATION IN THE APPLlCAT10N FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED OR THE SiTE IS
ALTERED. THEId THE IMPROVEiVIEPIT PERMIT AND AUTHORIZATION TO CONSTRUCT SFIALL BECOME INVALID
1) Permit requested by: (Owner/a ent/prospective owner): ���� ll�e�' o�
Home Phone: � . . ��D Address: S �o►
Business Phone: � d
2) fVame and address of current owner: At' � I,Yfii'
� �
6
3) Property Description: �ot size:� T�ownship: � u,nni �9 h��I
Directions to the property �jac�lu id�ng,road names and nutrabers): � �
vT���:�LL����'SG�SV�'� � �� , • V%D
�
�c�
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed 0, Existing�
b) Stick Built �, Modular �, Single Wide,�<Double Wide ❑
c) Number of Bedrooms: _,�� d) Number of occupants or people to be served: �
e) Basement: Yes,O, No,�(If yes, # ofbasement fixtures: �
fl Garbage Disposal: Yes 0, No� Z� �
g) Dimensions of Proposed Structure: Width: Depth: � r
5) Water Supply Type: Privat� (new � orexisting ❑), Public �, Community �, Spring ❑
Are any wells on adjoining property? Yes � No ❑ If yes, location
6) Please Indicate Desired System Type: (systems can be renked in order of your preferenc$)
_Conventional _Modified Conventional _ Altemative _Innovative
Other (specify):
CLEA►RLY STAKE ALL CORNERS AP1D LINES OF THE PROPERTY.
STAKE THE CORNERS OF A�L PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAfV TO THIS APPLICATION
pQra-1�Y � ��
ie -$ p a�
�� Y rs.
I hereby make appiication to the Person County Heaith 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. I understand
that as appiicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the
Health Department 'rf m property contains any wetlands as designated by the Army Corps of Engineers.
�
�"� 1 ,
Owner or Legal Representative Date -
PC!-1D, rev. 10/12/99
Person County Heaith Department
Existing Sewage System Report For: �ile Home Replacement
Addition
Requestee: ��I(0 �I�VG� Home Phone# srg�'��%6
1���p �$ttiS �r��rC� �• Business�
�W�OY�c�. � C.. ���J'C3 �'Pax Hapx ��13 �'� 3
Location/Directions: (�L�b 1.��� `� �-�' M�Gk.2l�, ✓l{r���d
! /�/ �h hO S LcS l�L. K�/ � � Q � _ �
A
-� . •
Original Permit Located /Ud
Septic System Uesigned �or: _
Kesidential �/ Business Other (specifyj
# E3edrooms � # Employees Other
Uate rnstalled uh�hOw^ Water supply btJ� `�
Type or System C��✓'e�fian�f
� � �
Nitrification Line Gih�kD�h —�% 3oa u
Tank 5ize /00 4
�
Certified Operator Required �✓d �
. On site wastewater disposal system showes no visually apparent
malfunction on �'1 � �� 0 �
, �ermission is qranted to: KafJl��2 Z✓ %�f�• ���Ka�� �r��e w�7� —
� �{ /��. l�n�,Gle G�', �IP
According to the�at�ached site plan.
Comments:
Environmental Health $'�..
♦."l ' a
_ . :._yi,.,�'� �::
.. . . .. ;S',�;'i�.:t,.:.
�
�