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Applican�
Location:
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�ha:se Sect�ion'Lot � '
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� . Improvement Permit S ���� P��
Permit Valid for �ve i� s No �zpiration
Type of Facility: �I3 i� S � New � Addition �Yater 5uppiy W�� �
# of Occupants � # o B�drooms 2- � Projected Daily Flow �� g.p.d.
Proposed Wastewater System: t�v �u►�c--a � � Type: �.�a
Proposed Repair: � CGP s' . Type:
Permit Conditions: �'� S� ,'�c S �'e � �"
Owner or Legal Representa.tive
Authorized State Agent: _S
Date: l �� �f � �
The issuance of this permit by the Health Department in does not guarantes the issuance of other pezmits. 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 This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement �ermit is not
affected by a change in ownerstup of the property. This permit was issued in compliance with the provisions of the North Carolina
`Luws and Rules for 5ewage Treutment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmental Health Specialist warrants that the septic tank system will continue to function satisfacton7y in the futnre or�that
the water supply will remain�potable. �
Authorization to Constraet Wastewater System (Required for Building Pernut)
* See site plan and additional attachments (_J.
Proposed Wastewater System: �Q�1�1�.✓I�'t��vi-q- l � 'I�pe � Wastewater Flow� �� g.p.d.
New � Repair Expansion _ Soil I.TAR: ��l' O g.p.dJ ft 2
Type of Facility: g� � S• - Basement x Yes _ No
. �Vastewat�a System ]l�ec�uire�aents �
wv� —
T�nk Size: Septic 'Tank: ��ai Pnmp Tank: gai Grease Trap: gal ���
�rainfield: 'Total Area: �lfl sq ft Total I.ength ��� ft � Ma�mnm Trenci► Depth _� in '
�'rench Width � ft Minimnm Soi1 Cover: b in M'in'imnm Trench Separation: � ft Q• C.
Distribntion: Iiistribntion og � Serial Distribntion
/ . j
Spe ' catio / �l "� ��d�K'i( SQl �
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Authorized State Agent:
Permit Expiration Date: • �
The type of system pennitted is � Conventional
P��
�wner/.L,�g�l �epresentative:
Pressure Manifold
i�r
Date: /O ` `{'�
�-I��l'� -�V►rr�
Accepted Alterna.tive. I accept the specifications of the
Date:
PCHD rev. l l/10/OS
A
'A n Date: � ���� . Tax Maa #:
Amount Paid•
Rec�ipt �: Parcal #:
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APPIJCATION FOR SERVIC�S
IF TNE INFORMATION IN THE APPt1CAT1�N FOR AN IMPROVF�IAENT PERMIT 1S INCORRECT, FALSIFiED,
CHANGED OR THE SITE� IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZd�TiON TO
CONSTRUCT SHALL BECOME INVALID. -
✓ �
1) Permit requested by: (Ownedage prospective ovme : /� � _/� �
Home Phone:3�L�.�BT�j,[� ress: ��D �s_S /Zcv�. ��
Business Phone• �� -� a �-1 � 70 �Z�-► rU c_� .� ��
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2) Narne and .address of current o er. / � dL-�'C. C'`'y✓1����
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3) Property Desraiption; Lot size: �� Townshi�v�l.li . Subdivision: Lot #,_(,[%'�
Directions to the property�nduding rqad n�es and nymbers): � A / �r } � � ,�� ,
4)
5)
�� ' —� /'/ 4�" ' �G , �'✓\'/ / v •a. ��-il
/ �fy�
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�RfO�as se and tfu�ture �] np� a�Lv�r �f o� lowi� ue�.s��is C� �% � U��
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a) Proposed �,, Existin9 - YPe of Structure: - Width:� Depth: a' /
b) Number of Bedrooms: Number of occx�pants or people to be served: _,? _ �
c) Basement: Yes�C , o i the be qiuf�bing in the basement?�
d) �arbage Disposal: Yes �, No I��GJaf� �
l
Water Suppiy Type: Private �(new iC or existing,�, Public_, CommunityJ Spring _.
Are any wells on adjoining property? Yes� No _ tF yes, please indicate appraucimate locatiori on the
'site plan.
6) Does your property contain previously identified jurisdictional wetfands? Yes_ No�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPEiZTY OR SiTE PLAN MUST BE SUBMI7TED WITH THIS APPlICATION.
➢ PROPEi�T`( L1NES AND CORNERS MUST BE CLEARLY NIARl�D. •,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAf�D OR FLAGGED.
➢ THE S1TE MUST BE READILY ACCESSiBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAF�.
1 hereby make appiication to the Person CauMy Health Department far a site evaluation for the on-site sewage disposai
system for the above-described property. I agree that the cantents of this application are true and represent the maximum
faciiities to be piaced an the property. 1 understand if the site is aitered or the intended use changes, the peRnit shail
Owner or Legal
?� �i
Dat
PCHD. rev. 06l27102
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SITE PLA.1�T
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WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map ��I P cel #� 7 Township:
Applicant:
Subdivision: Lot #
Type of Water Supply: � Individual
Requirements:
Site 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 Attached Site Sketch****
Community Public
Liner:
Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:
�
PCHD rev O1/27/04