A24 23Person County �-lealth Department
Sewage System Improvements Permit .
Permit # �� �g��
Subdivisio�['Name: � Lot�E �' 3
Lot Size: Type of Dwelling: \��''�s
Water Supply: Private: � Public: :__ Community: �
Bedrooms: _�..� Gazb e I
Basement Basement
INFORMATION CERTIFTED BY
Environmental Health Specialist:�
REPAIR: REEVAL
--- � �------------
Size�6f Septic Tank: -�� �ons _ Size of Pum Tank: 4
Nitrification Line: � � 0 �' Sc� �{�
Depth of Stone: 12 inches ��'".-� /�/ ��•
Maac Depth of Trenches:
Altemadve System: Conv. P�mp ---LPR Pump
Remazks:
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Date Well Approved. Well should be 100 ft from any sewer system
By Environmental Health Specialist
Date Sewage System Approved: � � �" ��
gy LJ -r�t-2 8-�-�-�,�., Environmental Health Specialist
CERTIFTCATE OF COMPLETION ,.�
Contractor. %f'� � ' ��—�-�y � �
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Sewage System location, installarion, and protection must meet state and local �
regularions. Septic tank should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
ni�ificadon line must be inspecteci and approved by a member of the Person County �
Health Departrnent before any portion of the installation is covered and put into use. If
Ihe site plans ar intended use change this permit is subject to revocation �
(G.S. 130 A-335� �''
I.ocation of sewage disposal sewage system sketched on back.
(OVER) ..
Aooilcation Date: � 3 -� � . - Tax 11A� #: �� -f
Amourit Pald: )�. O
Rec$iot �: � �I . Parcai �: o? 3
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3) ProQerty D�criptton: Lci size: �f iQ_�C�tZlus - -ubdivision_��� Lat#
Dtrections to the ProPeKj/ (lnduding r�oad names and n ): �
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4) t�raposed Use Structure Description: answer foilawing qu '�n.s.- i /
a� Proposed �Ex�sting � Typ Nu ber �/ or served: Wicfth: ,�� t�;��
- b) Numbec of Bedrooms: �' P�P�
c). . Basemet� Yes . No �#he�-be plumbing in the baseme�tt?�
d) 6arbage D�osai; Yes . Na � �
� 1Nat�er SuQPhI TYP� p�e �ew _ or existin� �+/ , Public . Communii�l'._, SP�9
Are arry wells on adjoining property'? Yes�/ No _ if yes, plea�s indic�e approximabe I�iori ort the
.sifie ptan. � �
6j Does your property �ain previousfy iderrti�ed Jurisdictionai w�tds? Yes_ No ��'���G6-G,���
PtEASE NO'tE THE FOLLDWING•
➢ A PLAT OF THE PROPEiZTY OR STTE PLAN MUST BE SUBAILTTE� 1NITH THIS APQ�ICATION.
➢ PROPE�ZTY LlNES 11ND CaRNE3Z3 �UST BE CLEARLY MARl�r �,
9 THE PROPOS� LOCAT70N OF ALL STRUCTURES MUST BE STAi�� OR F�.AG�E�.
➢ THE SITE dIUST BE READiLY ACL'�SSIBLE FaR AN EVALUATION BY THE HEALTH DE�ARTMEi�IIT
STAE�. " �
I hereby maice aQpiicatian to the Person-Couraty Health Depar#ment far a site evatuation far the on-siie sewage disposa!
sysiem for the above-described proQerty. I agree that the caritents af this appilcation are�true and re�resenf the ma�dmiun
facaiiiies to be plac�d on th roperty. 1 understand ifi the siie is alt�red or the irrtended use c3�ange.s, the permii st�ail
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