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Property of
Ralph �c Hilda Stockard
Cunningham Township
Person County, N.C.
Lot 21 , PB 1 1, P 15-1 6
Scale: 1" =50'
NOT FOR RECORDATION
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
� � (Void sixty (60) months from date of issuance)
DATE: �j��,2- � �% IlViPROVEMENT PERMIT #: � ��f �I
TAX MAP #: PARCEL #: � I
OWNER/OWNER'S REPRESENTATIVE: �a �%�Li S��a�'c�
LOCATION/ADDRESS:
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SUBDIVISION NAME:
SECTION OR BLOCK:
. AUTHORIZATION FOR
ISSUED BY:
AUTHORIZATION CONDITIONS
LOT #:
l. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #�9 y�l %. The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
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(7 r l!� ri[l' i' ��'C L9 � l.�r �^ � Q
Person Requesting:
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B 1447 '
PERSON COUNTY HEALTH DEPARTMEN'T
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � � � � _ Parcel # �'
Zoning Township G ✓h > !� •�
Owner/Contractor a r� ti o r� D e 3- l� - GrJ
Location/Address��j n1 � 5��13l� �-tu %nPs�o�-� �� /4� �/o!� Ntalla��t✓�
��F S.R.#,
Subdivision Name _ Lot#
SEWAGE SYSTEM SPECIFICATIONS
� Repair Lot Area � �'1 � �- � . Size of Tank �� , ;f��-i
� SFD Mobile Home Size of Pump Tank NL �
Business # of Bedrooms Nitrification Line C r T�-�j
�����`.� �� ��2 ��try,� �,,� � �;,,� MaxDepth Trenches
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Permits may be voided if site is altered
Well and Septic Layout by
Comments:
Date _ Installed by
Permit Paid ❑
Site Approved
Well Head Approved
Comments:
Date
use
WELL SYSTEM SPECIFICATIONS
Semi-Public
Installed by,
by
Air Ven
Re red Well Log _
ell Tag
1
Approved by
�;.
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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Improvements Permi4(FstablishedlRecorded Lot) ,._ Reinspection of Existing System (Loan Closing)
Imarovements Permil (Unrecorded Lot)=- _. RepaidReplace cxisting Septic System
_ Iln„provements Pecmit (Mobile Home Replace)
rovements Permit (Addition)
Permit for New Well
_ ReplaceExisting Well
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�Permit requested by: .
wner/prospective owner/agent: �N�- �
.ddress: CU IJN I I�} �-l�A-►'Li ����� �%�
Home Phone #: �4 z��' g�
Business Phone #: =r��'�.-�-G
I�Iame and address of current owner:
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3. Property Description: L,ot size:U�
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Tax Map##:
Parcel#: _
Township:
�
. Directions to property: State Road #& Road
ames,�tc.
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7. Dimensions�or Proposed Stn�cture:
Width: �=8 �
Tl.,.,►h• �-�i
8. What type (if any, additions, expans�ons, or I
replacement is anticipated to the s[ructure or facility
tha� this sewage disposal system is intended to serve?
I _ ��J�N �=
9. Water supply t}'pe:
private�.'�.public❑ community❑ spring❑
Are any wells on adjoining property?Yes`L'�'�o [�
IIf so, identify location: �J �r � �� � �� � � '��'���' `'
,� t�� �it{//- � //�= �
Number of occupants or people to be served: Z
of structurelfacility: Proposed: �Existing: Q
Type of dw,�elli g:
House:Li Mobile Home: C� Business: ❑
Type of business: f ���
Number of Employees:� �
Number of bedcooms: 3 ,...,,/
Garbage Disposal? Yes ❑ No l�
� Basement? Yes C�No�31f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTX
AND THE CORNERS OF ALL
PROPOSED STRUCTURES•
I hereby make application to the PeI'SOn COunty Health Department for a site evaluatication ahe �rue t�e
sewage disposal system for the above described property. I agcee that the contents of this appl
and represent the maximum facilities to be placed on the propercy. I understand if the site is altered or the
intended use changes, the permit shall become iavalid. I understand that before an Improvements Pecmit can b�
issued, I must present a survey plat of the propercy to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date oE the evaluation of
the site by the Health Dept.� this application shall become void and all fees paid forfeited.
-- � - ,� �%
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�� Signc� Owner or AuthoriT,ed Agenl
Permi� lssued ❑
percnit Denied ❑
plat Observed ❑
0
Signature
1. SIAPE (4.1
2. SOtI.TFJC7URE(�2•361Na
(SwNDY. LOJ�MY. CIJ�YEY. NOTE 2:1 CI�Y)
7. SOTf.S7RUCTURE(12-361N.)
(MYEY SOII.SI
�. SOILDEY171(W.)
S. RES'[RICTIVE HORRANS (M.)
(Q.IPEAVIWS SfR/1TA. ROC1U
6. SOILDRJIINAGFJ'CROl1NOWA7ER
fEJCTFRNAI. � II:IE1W /LLI
7. SOQ,PERIdFABRSLY
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(PF�tCO[AATION RJ17wi
�. AVI1ItJ18LESPACE
9. STfEMSSiFlG1TtON(SEEBELO�
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SSUITADLE KtA0Y1S10ttAIJ-YSUTfADLE LLUNSUiTAeLL
RECOMMENDATIONS/COMMENTS: _
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, coads, slreams, gull►es, wet areas, t>i
\ C:V�FtIPRO'�DOCS�PPSEC.S�� ��HCE
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