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A25 70Aopiir.atlon Date:�/��6 Amowrt Pald• Rec�iot �• -���_.�� I�I�IE�� �� - - , � � � ���-� 11Eaa�.a=��^ -^--� �aa.�.�.71 ��C.o�.Il.�]� 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 _��_�� Date PCi-l�, rev. �6127102 � �� i ,��� �J11d �� �� �� � i + ,, � � � ����� � ���s�� � ���.�.11 II33L��.11� 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 � 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( � � : �e� � � 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 ' • PCHD rev. l l/10/OS A �� �r � � ���. s� I�I�I�� ��T — ������ ��.o.��� � ��� � ����� STTE PLAN n N N� ' Taa Map #��'Parcei # `•� $ Secrion/I.at# 0 Authonzed Srane Agent D� ' Syst+em rnmponeats repmmt mppca�ee canaours adp. T7u avarr�cmrmust9sg t6e sysum priar m begmauig tlie iasra�otioa m '^",.r �rPmP�B�deiamaiauraed ��� . �e o� � �'��� e��� �}�rL � � �, �, � �P �,< <� � l�e �l�edu� �o � l��k � �� ako� S�� � �� ��e<�o• � �O�t� � - �o,cb��o :Q (�`�te ��re. RLc� � , s �r-�e.. �' "�. i�C �r7�/�-f�tES �e � ( �U • _ �, �. �,�,�� � ���� � ���� �� L1 .�� � �• � � � � �� Jl J!. ��.w�.s-�„-„ ,t-1-��s�.��.� ����.�.��a Applicant: Location: � �� -!= ' . � � �-.. � a�x Map ' / P�,rc-ei . S�u,b ci!i v i�s i o n Phase Sec-t+i�.m ot � = of Bedu�oo � � s . 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. - . . ��� � �lr-�u-�� - Authot�zed State Agetrt � Date 1 nstalled. By. v U �(.�JP ��t�� . Dafe�. _ l ��� � `� � _ � _ e-,. � �..� �-. �. � ,7 �, 5'��' 5 ��� (��� ��,, '3 ,„ 52 � S� 20 � ���i' S7- -� S7�r� �-� vr�,� ���� 1; �� � rl 3 �0�2 , PCHQ, rev. 07l29/04 � ���c ���� t�s����ao� �����ss7 ��e �e - � Tax Map #,�� Parc�� # Systern Type (Tabie Va} Owrier/Appiicant � � Si�bdivision Address/LQcation SerJPhas� Lot # � � pct�d rev. 31'13/01 � j ����, �� � �. � ;, � . w� ,� ����.-�s � �e. ��s .,�� c � �� � �, � � � � r � � ' � .� ,�� ��- �r s �,,�-4 . ; � �( �.,� s�,,c ( ���-- � �� � � `� � � o� '�� r � l� � �1/i �d�'�-� � � � �V(; r � �{ a � U'�� �„�"� �1 � �S`rr� •