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A24B 2- �� f� � �� '��;�, v�-�, �� sfi� �� ,.,'�G�,e f � ��- �'l �� , �� f�� ,,�,.� � � c� r�u� �_��_o� a� . . - ��L � .;��ii a,"oa Daie: .1 � T��. Mae� � i� T ;�enourat �ai�: � / � 0.� . � ��e�imt �: ,�2.� R Q �— . � �re2! �T � �-� . ��s�ra �aur�iv �?ea�th �3e+partmer�t `7� �:..-:: : .:. ,,:..<. : .: :. �;��i�orrr��ntai Fteallfi Section � . . ' ";:. ;4P�L'tCATI0P1 FflR S�1/IC�3 � . � . :.�.. IF THE 1NFaRi{AATiON IN THE APPt1CATiON FOR AIV IMPRO�IIIEi�Ii' PEi�MIT 1$ FALSiF9ED, C9-IANG£�. OR'FHE S1TE 1S �,L�c �;. T'�ic�i TiiE IliliFRt1VE3�E�IT RE�tMi f' AR�D �i3TF;t)S2€Z�Tl�o�f T� Ct�N3T�UC'i' S�IALi ��0�� iiJi�Ai.iD. 1) Permii requestied by: uC �aJa9�P�Pe� owner�: R tJ E" `Pt L LE Q� i,� �HomePhone: Rt4- q4a-�-b��o � adc�ess: t�o P2iNGH1�� FoR6ST RD, BusurteSsPhone: Ri9-q6Z-o63� � cNRPe� NILL , Nc a�-si6 � Name and addness of cvnerrt owner. t+ 2nre I`. Gt� ( � e� e!z (r . _ � . llo Prt�u[r[�tc�. .r�„c,E-�t K4 � _��A P�L ,.�aC'.•�clC 'L�--S`�6 - 3) Pro�erty Descr3ptiom tot sus:` �'��i To�+anshla � ' ,� �+a �►�. , . Vi'NN�{n Diredions to the Property pndudirtg road�r�ames and numbers)• Z Zo �^'I �Nc�a -d �� e ��d MfG e cs M:!/---/�`( �_ C�ore 2�! J'i S srQ /.�c�es -'� 4) Pr�oposed Use and Structt.are DescriQtion: answer each af the following questions: a) ProPcsed� Existin9 ❑ ' . b) Stldc Bwlt a. Maduiar� Single Wide 0, Double Wide ❑ c) Number of Bedrooms: 3 � c� Number af cccuparrts ar peogle to be served e). ..Easetner� : Yes� Q Na�lf yes, # of basement fi�res: . . . : . . . . � . . - � � � '� ' G8[�2QE, DIS�G i�' �iE8 � ; i� ;._ _ . _ .�...� .. � - . ....: � . . . , f. . • . . � , •�, . . � Dimensions of Proposed Strucxure: WidN�.Zg Qepth: �� , �j Watef S�AlY Tyne; Private�.(new Q o� e�ds�ting�ji), Pui��c Q, Cammuniiy �, Sp�ing ❑ . • Are acry wre�ls aa adjoiniag pc�opert}rT Yes ❑ Nq,� If yes, lo�atia� �) Piea� Indicate Desired System Type: (sys�ems can �e raniced in order of yoisr prefeience) �,Canvernionat � 09odifled Conver�tionai � Alternative. �Innovative other (sgec�iy): CL�►Rl.Y STAKE ALL CORNE3iS ��1iVO L1NE� OF Ti�iE PROPERTY. STAKE THE CaRNEFiS OF ALL PROPOSED STRiJCTURES. PLF.�ASE ATTACH SURVEY PIAT OR S1TE P�AN TO THlS APPt1CATiON �- -�- �� sfJ � 1 ttereby make apQiicatian to the Persen Caur�ty Heaith Department fnr a si�e evaluation far the an-site sewage dispasai system for the above-described property. 1 agcee that the catrter�ts of this appiicatian are true and represent� the m�amum fac��ties to be piac�d on the property. I unders#and if the site is aitered or the intended use ct�anges, t�e permit shail became invaiid. ! understand that as appiicant, 1 am responsibie for ider�ifying ar�d mar�ng propes#y lines. cameis ancf maidng fhe siie ac�ssibie fo� the persannei of the Pesson Caur�ty Heaith Departrnerrt to canduct the�r eval�ations. I wderstand that 1 am respansible far n�iying the Heaith Dep errt ii my roperty caritains ar�y wetlands as designated hy the Army Corps af �ginesrs. l� - f o 9 �.ao� Owner or Lega1 Re entative . Qate � PcxQ, rev �a1�2tss � '1' Person County He aith Oepartment ''s ' Sewa e S stem Report For: V Hobile Hocce RepI.acemen� E�xi zinq g Y � Addition ' Requestee: Home Phone�� Z �� Busiaess��l �l�Z�%(¢��o � Tax Hap� � Location/Directions:. ►Mcf�Gi,�s /�'l��l —� i)�'� p��Q .--�' �-�i�, vr,� -� 0 _ T Oriqinal.� Permit Lccated _„�� . . Septic System D igned Ecr:. . _ _ Kesidential Business Other (specify} � f3edroams ( # Employees _ Other llate Installed (� Water supply �� Type of Syste� Nitrificatian Line Tarik 5ize Certified Operatar Required �C� , �n site FrasteKaLer disposal system sl�cwes nc visually apparent � maifuncticn on �% �� .� Yermissien is ranted to: �k1�1S`�'u�%�• �$c �- ` o ( � ..� . q According to the attiached site plan. mme ts: Q11 I' l'1 �C �'F.�ACi� ��'TIYWI Prl� � �J � . fi�is G� �` �;��et�- a� � . � Environmental Health g�l�• � Application Date: — �"OZ Amount Paid: Receipt #: ��_s� I�I�I�.��T - --�- � � �� --�� aavaa-�aa�• �aa��.Il ?L��mIl�I1a APPLICATION FOR SERVICES TaxMap#:/"��'� `� Parcel #: Cv�— IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED, CHANGED OR THE SITE IS ALTERED. TFiEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. �-�(�5�� 1) Permit requested by: (Owner/agent/prospective owner): l�ie � Home Phone: Address: �1 ��y�, Business Phone: S((� Y/v� 2) Name and address of current owner: ` ' . � p CN�i�. . �_ r`�.', �, ' Y • . 3) Property Description: Lot size: •��tGTownship: Directions to the propertv (Includinq roa� n�mes and Lot # 4) Proposed Use and Structure Description: answe,r ea h o the following questions: a) Proposed _, Existing _, Type of Structure:�j ��/ Width: �� Depth: � SI b) Number of Bedrooms: � Number of occupants or people to be served: _� c) Basement: Yes , No _ Will there be plumbing in the basement? d) Garbage Disposal: Yes . No � 5) Water Supply Type: Private ✓(new _ or existing�, Public� Community_, Spring _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the site plan. 6) Does your properly contain previously identified jurisdictional wetlands? Yes_ No_ PLEASE NOTE THE FOLLOWING: � A PLAT OF THE PROPE6�TY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. , ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAlCED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT 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 becom�, invalid. ,. or Legal Representative � �g-v � Date PCHD, rev. 06/27/02 ��,ss ��.�� . - c� � �.T�T�� I��.�a��:��.lL R III��,Il�]�. Applicant: Location: � Permit Valid for � Five Years Type of Facility: T��x Ma�� i r Parcel u V- s��f��.S��o�, Ph��se Section Lot � Improvement Permit _ No Ezpiration # of Occupants # of Bedrooms Proposed Wastewater System: Proposed Repair: �— New Addition _ Water Supply Projected Daily Flow g.p.d. Type: _ Type• Owner or Legal Representative Signature: Date: .. Authorized State Agent: ' Date: The issuance of this pertnit by the Health Deparhnent in does not guarantee the issuance of other permits. It is the responsibility of the applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permtt is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit ia not affected by a change in ownershtp of the property. This permit was issued in compliance with the provisions of the North Garoltna `Laws and Rules for Seivage Treatment and Disposal S stv ems' (15A NCAC 18A .1900). Authorization to Construct Wastewater System (Required for Building Permit) * See site plan and additional attachments (�. Proposed Wastewater System: ,7 [� 1 Type — Wastewater Flow =g.p.d. New Repair 1� Expansion _ Soil LTAR:. — g.p.d./ ft 2 Type of Facility: Basement _ Yes _ No Wastewater System Requirements Tank Size: Septic Tank: �U gal Pump Tank:— gal Grease Trap: � gal Drainfield: Total Area: �. sq ft Total Length '— ft Magimum Trench Depth _� in ITrench Width IDistribution: � Specifications: � ft Minimum Soil Cover: '' in � Distribution Box — Serial Distribution Pu►M � ot,��-� �v�us�,� a�cd �► ( j�eX�� Authorized State Agent: _ Permit Exni Date: � Minimum Trench Separation: ft � Pressure Manifold S��C �� • ��" �� -�K ,h ot � o ✓1 • The type of system permitted is Conventional Innovative the permit. Owner/Legal Representative: � Date: � � vz Alternative. I accept the specifications of Date: