A25 104- -rr-------..__ ...,...., _��a�v��
Amount Paid: �^(�
Receipt#:
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lE �.� :ca-�+n n: ,cn n-n_iriT..c.-�rn. �.z.n..11 i�t �c�.zn.I�. �t�tla.
Applic�tiorn for Services
(Septic Systems and Wells)
L Improvement Permit (Site Evaluation)
�200.00/�300.00 (if> 600 apd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Repiacement)
$225.00/$12�.00
1 ax Map: ��_
Parcel �: �-�_
Sere�ices �ie uested
� Construction Authorization
(Fee is de endent on the ty e of
❑ Permi# Revision
$75.00
pair of Existing Septic System
No Charee
Important: If tlze information in t/:e applrcation for an Improvemelit Permit is incorreci, falsified, or the site is rrltered, tl:en the
Improvement Permit and the,9utlrorization to Cor:struct shall become invalid
1) Services Requested by:
Name: (n)Gw n[' �3 �d,e I 1 (,,��'1ST�/�
Address:,3 p�,
_Serr,o ,rr� ,.�, �
Phone #(liome). 3 3� S�j �j- S 6 G S
(work/cell): �33 G Sq q— 6 �;�,��
2)Name and address of cn�rrent o6vner (if differ�nt t�an applicant):
Name:
Address: - �
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
Lot #:
4) Proposed Use and 'I'ype of Structure:
Residential �� Business/Type: Other
Number of bedrooms ,3 / Number of people served (seats/employees):
Basement: Yes No �with plumbing: Yes _ No � Garbage disposal: Yes No r
Approgimate size of building foundatian: Length Width
5) Water Supply:
Private Well � (Proposed Existing _) �
Community Well: Public Water System:
Are there wells on the adjoining properties7 No v Yes
(please show location on site plan)
Note: A cmm�leted annlication rnust al.�o include•
➢ A plat/site plan of the property that slzows prope�ty dimetzsions and the saze and locaiion of all
p�oposed structures.
➢ A signed copy of tl:e `�ot �repaa�aiion' form ver�ing that the property is ready to be evaluater�
I am submitting this agpiication to request services from the Person County Health Departanent. The information
provided is accuraie. I understand that if aaay site is altered or the intended use claanges, all permits shaIl beeome
invalid.
Signature (Owner/Legal Representative): �,���(,t�(� (� ' �� �ate: 3 as'o8�
I I!07 Person County Environmental Health; �25 S. Mor�an St., Suite C, RoxUoro, iVC 27573 (336-597-1790)
' � -7 h�.�-U�stri�r rfecti,rn vepa rmenr
,' ; � . ; � .
' �'� CASWELI: -:CHATHAM LEE - PERSON C �UNTIES' '.
w �
I�� 4'� Wa#er Su' p�:y and.: Sewc� `�`�� �;�;os.al
P. �
�,�, ,�,,,, IMPROV�MENTS�•:PERMIT 'No: ` .
� � �� '` .. 4'� r �• Date r:' 7<"= ,�'.�'-r,.
�- � � Owner' ' .
1�'�' _ ,� ` "
' � ;pq� Locationc � �� ._
��=� �� -- -�� ���-- - - - �-
1, � �._...�
;� ,
� (��J��� k'w'�- � Contractor � : � . ; _
G 1.�/ C, i a . . . ;._ .. ,, .., �
; � L�j� W32es' Suppiy.; .Pr;vate Public
I: �fl� T�f' It '.''n _ �
�, � . — . . r
, , ,
... . . . . . . . . � �f . �
S� age �Disposal Facilities:. :, drooms Dishwasher, D:isposal,
_ �..
�:�shing � machine, otiier automatic appliances `
Size , of tank: 1-� �+ " NYfrification-� line: � -
- ��: �: , ... � �., _
- t ":� - E)1
Other disposal facility � � j
��.r.^�. ..e.,.—_�-.�..-'<':.... . .4 . _.. .. ... ..;_ ,.po-� �.:..,�. .....-::- .-:, .:�:r�.,,_ ...
^ W.ater supply. and sewage disposa faci ities location, installation . and ''�
a, protection must meet state".and :' local regulations; . ;':
�: Septiic tank �"stiouTd be pumped out� every. 3•.to 5; years. and �shall be main-
.... tained.by owner: in such a manner.as not to.create:a�public health hazard.
= Septic tank" and nitiification line MUST BE �INSF'EC�ED �YND AP-"
w PROVEI3 BY A-MEMBER��OF THE DISTRICT iiE ART11(IF�T'1
5 STAFF 'BEFORE ANY :PORTIUN OF THE �IN�A �. TI� N IS COV
ERED AND PUT - INTO �USE. . . . .
/�% p�� � '.:
� . . . _ ... . .. / .rl 1`� ':� ... . ..l�f-1L�ir.,•-�... .
. . � . . , :. f , _ 1i .. �
'. Date approved.'. $igne � �
. �,
� Well• . ' " .,. . ..� , .. .
_.. _ . _ , ...
:<•Sewage Disposal Counter= � � •
;. By , " 9igned. �
(Owner or his representative) �
.. ;
: Certii'icate of..Compleli n /
'•,
Date Approved: Y:
anitarian /
(OVER) � •
� Location of well and sewage .disposal facilit'ies sketched. on back. • ;
.. _. , ;:.
-- - -----� --- --------- -- .. _ .... .._. _ . .�
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Q,., ����.; A 13 0 6
PERSON CO TY HEALTH DEPARTMENT
WELL SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Tax Map # ��5 Parcel # /��
Zoning Township � � �'] � /�+n ��,r,r�.
Owner/Contractor � ` I}�te 3 —31— R �
Location/Address ; `r L c..t,
�t.�p _ S.R.#
Subdivision Name Lot#
As Installed
Layout '
�
�b ��5 e
— — — — +
� �e
siness
SEWAGE SYSTEM SPECIFICATIONS
Lot Area �� Size of Tank _ r ^
L/ Mobile Home Size of Pump Tank n',¢
# of Bedrooms � Nitrification Line
Max Depth Trenches —�G�,-�-E'�{`. �ri A
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended e changed.
Well and Se tic Layout b
Comments� `
` � rt , 2 � �r c$—.- �
Date Installed by Approved by
WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved Required Well Lo�
Well Head Approved Well Tag
Grouting Approved
Comments:
Date
Installed by.
Approved by
2"�C�t,1.e.�
This repoR is based in part on infom�ation 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 infonnation contained in the application. The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resu(ted from false or misleading
statements provided to him in the application. Neither Pe�on Counly nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\peimitsam O1/95 rev.1.0
ORIGINAL
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� SITE S�'I'��i � .
Name W a �� d Taa Map # Z� Parcel #!o
Sub ' ' n -� . � Section/Lot#
� 3 -2 7- 08' .
utho�ized State A.gent . � Date .
System cvmporients stepresent appr�ximate�contours only: The contractor »aust, flag the system�irior to
beginning the installat�ion io inszcre thatpropergraa�e is �naintaaned
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