A25 70Aopiir.atlon Date:�/��6
Amowrt Pald•
Rec�iot �•
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APPIJCATIOM FOR SEi�VIC�S
Tax Ma #: `� .
Parc$! #: �d
IF THE INFORMI�TION IN THE APPLICATION FOR AN IMPROVEiWENT PE3�MIT IS INCORRECT. FAi.S1FiE�.
' CNANGED OR THE SiTE IS ALTERED THEN THE IMPROVEMENT PEiZM1T AMD AUTHORIZATiON TO
� - CONS7RUCT SHALL BECOME 1NVALID. -
.1 j� Permit requested b:(Owner/ entlprospective owner}:� � i
Home Phone: - D 3'�- Address: 3 5 � ' �) �
Business Pha�e: 33b - 50 3-f�b��1 �,�..gll•3 7� 3
2) f1lame and address of rairrent ovmer. ��.( �,�C� V�� S _
� 3R� 3 rn h�e,s rr�►�
g�e rno rc., r'� C �'13�r 3
3) Property Description: Lot size: 1ar!�E.Tovmship: i� it�ubdivision: Lot#
D'�rections to the property (Induding road names and numb : Y
� s' ' '' �,� d
> >, ►
4) proposed Use and Structure Description: answer e�cfi th ilowing uestions:
a) Proposed , Existing ✓ Type of Struc�ure: , � th: � Depth:
b) Number of Bedrooms: � Number af occu or peopie to served: �
c) . Basement Yes . No ��11 there be plumbing in the basement?��}
d) �arbage Disposai: Yes . No �C
5) Water Suppiy Type: Private ,_,�„ (new _ ar existinca �). Public . Community� Spcing
Are any welis on adjoining prope�fy? Yes No � if yes, piease indicate approximate la�tiori on the
'siie ptan. .
6) Does your properly co�rtain previously identifled jurisdictional wetlands? Yes_ No�
PI.EASE NOTE THE FaLLOWiNG:
➢ A PLAT OF THE PROPEiZTY OR SiTE PLAN MUST BE SUBMITI'E� WITH THIS APPLICATI�N.
9 PROP�itTY L1NES AND CORNEi2S MUST BE CLEARLY MARl�D� •,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE ST�►1�� OR P�AGG�.
➢ THE SITE MUST BE READILY ACCESSIBLE FaR AN EVALUAl70N BY THE HEALTH DEPARTMEiVT
STAFF. '
I hereby make applicatio� to the Person Caunty Health Department for a site evaluatio� fnr the on-site sewage dispasal
system for the above-described properiy. I agree that the cantents of this application are true and represenf the maximum
faciiifi ,�s to be piac� on the proper„�. I undesstand if the siie is altefed or the ir�tended use ciianges, the permii shall
Legal
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Date
PCi-l�, rev. �6127102
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Applicant
Location:
��rmit Valid for _ �ive '�
Type of Facility:
# of Occupants # of Bedrooms
Proposed Wastewater System:
Proposed Repair: _
N
Ymprovement �ermit
No �zpiration
Permit Conditions:
Owner or Legal Representa.tive
Authorized State Agent:
New
Projected D ' y Flow
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T�x Mra�p � � �rc.el � �
S u.b dii v i�s�i�a n
Ph�s�e-Sect�ian`Lot �
i
_ i�ater Supp�p � l(
g.p.d.
Type:
Type:
Date:
The issuance of this pe ' y the Health Department in does not guarantee the issuance of other pe 'ts. It is the responsibility of the
applicant/property o to in sure that all Person County Plaaning and Zoning and Building Inspections ' ements are meL This
Improvement Pe 't i� subject to revocation if the site plan, plat or the intended use changes. The Improv t Permit is not
affected by a ange in ownership of the properiy. This permit was issued in compliance with the provisions of the Nor rolina
`Laws an ules or Sewa e Trentment and Dis osal S stems' (15A NCAC 18A .1900). Neither Persan Coanty nor e
Enviro eutal Health Specialist warrants that the septic tank system wi71 continue to function satisfactor�ly in the future or�that
the wa er supply will remain�potable. �
Authorization to Construct Wastewatea� System (Reqnired for Building Permit)
* See site plan and additional attachments (_�.
Proposed Wastewater System:
�q4t(/�Q�, �i U'10( l Type � Wastewater Flow ,�,g.p.d.
New Repair� Expansion Soil LTAR: '"- g.p.dJ ft 2
Type of Facility: � Basement _ Yes �CNo
�astewater Syst�an A�equirements
Tank Size: Septic 'Tank: ��� gai Pnmp Tank:
�rain�eld: Total Area �O sq ft Total Leng#h �� 2A'� ft
Trench Width � ft 1VIin'imnm Soi� Cover: _� in
IDistribation: �,,, �istribniion Boa Serial �Distribntion
gal Grease Trap: gal
Ma�mnffi Trench Aepth � in .
Minimnm Trenc� Separation: � ft d• C. •
Pressnre Manifold ` �a( �
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Authorized State Agent:
Permit Exui
The type of system permitted is � Conventional A te __ ,.Alternative. I accept the spe�ifications of the
permi#.
Ow�ne�/i�ag�l �tepresentative: � � "� �� 6
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Authonzed Srane Agent D� '
Syst+em rnmponeats repmmt mppca�ee canaours adp. T7u avarr�cmrmust9sg t6e sysum priar m begmauig tlie iasra�otioa m
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Applicant:
Location:
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a�x Map ' / P�,rc-ei .
S�u,b ci!i v i�s i o n
Phase Sec-t+i�.m ot �
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. System .Type (ln Accordance With Table Va): �
TH1S SY5TE3UI HAS BEEA1 IAISTALLED IM COMPLIANC� WtTH. AP.PLlCABLE.NORTH
C�4ROLI�IA GE3IERAL STATUTES, �RUtES �QR SEiNACE TREATMENT. AND DISPOSP+L,
AND • AL•.1. CONDITiONS OF � T}-�E lMPRL?VEiVIENT PERMIT APID CDi�STRUCTION
AtlTHOR ON. - .
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Authot�zed State Agetrt � Date
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Tax Map #,�� Parc�� # Systern Type (Tabie Va}
Owrier/Appiicant � � Si�bdivision
Address/LQcation SerJPhas� Lot # � �
pct�d rev. 31'13/01
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