A26 180,�e�ioiication �;ate• 7""��G' � . .
�mourat �aid• � �— �a � ��� .
��C.?I[3t r%.' :Zo27�J� ��
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J��� : �prson Cauniv �iealth De�artmen�
. : - .p�� ;,;��vironr�;�ntai �iealth Section
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' ��;:. APFCICATION FOR SEi�VIC�S
T�� Ma� �: f� .2�
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IF THE 1NFORMATiON IN THE APPLICATION FOR AN IMPROVf3UlENT PERMR fS FALSiF1ED. C9iANG�D. OR THE SITE IS
ALiERED. THEN THE iMPROVE�VIENT PERMIT AND AUTHORlZATlON TO CONSTRUCT SHALL BECOME 1NVALID.
r!)� Permit requested by: (Owner/a e prospective owne�: � �.i � � bYl �,, I
Home Phone: �• 7•?� �� Address: f KCJ
Businesa Phone. • 7 i � � � ' �
2) Name and address oi` currer�t ownec �( �� 1'1 � I� I � C5 Y�
3) Property Description: Lot slze: Township: '
Directions to the property I dudirtg road names and numbers): B►'UD K j�- � 2� �
�i,2�, _ �( �75�1 �
4) Proposed U and`Sfructure Desaription: swer each of the foflowing questions:
a) Proposed� Existing ❑
b) S�dc Built �, Madular Q Single Wide , Dauble Wde ❑
c) Number of Bedro s. � d) Number of occvparrts or peopie to be served: .
e}. Basemen� . Yes �o f yes. # qf basement fudures: � � ' � ' � � " ` � " �� �
fl � Gar�,aae. Dispc.�ai: Yes �: :;� o-.:.- . _.:-...� ... � .. . a .8. x �� - - -
g) Dimensions of Proposed Struc�: Width: � Depth: �
� Water Sugpiy Type: Private�(new a or e�dsting o), Public �, Community �, Spring ❑
. • Are acry weils on adjoining propert�? Yes � No � If yes, location
fi)" Please Indicate Desired System Type: (sysfiems can be ranked in arder of your prefeience)
�Converrtianal _Modifted Comrerrtional _ Alternati�e. Innovative
Other (sPec�Y).
2
CL�►RLY STAKE a�l.L CORNERS APID LINES OF THE PROPERTY.
STAKE THE CDRNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SlTE PLAN TO THIS APPL1CATtON
I hereby make application to the Person County Heaith Departrnerrt for a siie evaluation for the on-site sewage disposal system for
the above-describerl property. I agree that the corrterits of this appiicatian are true and represent'the maximum facil'�ies to be
placed on the property. I understand if the siie is altered or the irrtended use changes, the permit shall become invaiid. I understand
that as appGcatrt, 1 am responsible for identifying and marldng properry lines, comers and making the site acr,�ssible for the
personnel of the Person County Heslth Oepartrnent to canduct their evaivations. I understand that I am respansible for notiiying the
Health Departmerrt ifi my pro e carrtains arry wetlands as designated by the Amry Corps of Engineers.
� '� � '� �-� �
0 er or Legal Representative . Date
PC}-1D, reu 10l12199
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Applicant:
Location:
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T���x �VI��� i .. � P�rc�el # � �
S��chciivi�s�ioi�
Fl�����se Sect�ion Lot �'
. Improvement Permit �
Permit Valid for �ve Y ars _ No Eapiration � � `�
Type of Facility: `�B S. New r��Addition Water Supply �d�
# of Occupants N�X # o Ij,gdrooms Projected Daily Flow 3� g.p.d. ��
Proposed Wastewater System: Lqvi.1�'' ' Type:
Proposed Repair: �G/tt p (� bv�,1/i ' � Type:- �
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LtS , i�, � ;
Owner or Legal Representative
Authorized State Agent:
c{ Ac���f--s � s��`e-
ufe (�s> C� �
Date:
Date: ' $'a Z
The issuance of this permit by the Health Deparhnent in does not guarantee the issuance of other permita. It is the reaponaibility of the
appllcandproperty owner to in sure that all Person County Planning and Zoning and Building Inepections requiretnente ara me� ThIe
Improvement Permit !s aubject to revocation'If the elte plan, plat or the lntended use changee. The Improvement Permit is not affected
by a change In ownershlp of the property. This. permit was Isaued !n compllance wlt� the provlslona of the North Carollna 'Laws and
Rules for Servage Treatment and Dtsposal Svstems' (15A NCAC 18A .1900).
�' Authorization to Construct Wastewater System (Reqaired for Building Permit)
* See site plan and addttional attachments (�.
Proposed astewater Syatem: ���,�/� �. Type� Wastewater Flow 3 i00 g.p.d.
New .� Repair Expansion Soil LTAR: . 02 � �..d./ ft 2
Type of Facility: ,� Basement _ Yes ✓ No
� .�
Wastewater System Requirements
Tank Size: Septie Tank: l3� gal Pump Tank: � gat Grease Trap: gal
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Drainfield: Total Area: Z 0 Sq ft Total Length �� ft Maa�imum Trench Depth l� in
Trench Width �_ ft Minimum Soil Cover: _� in Minimum Trench Separation: � ft
Distributlon: Distribution Box V Serial Distribution Pressure Manifold
Specifications:1�0�1C� �/1�'�� � � "F-t'�W �� �1 S��-QM _ �i^ �`''`���d�,�'.
Authorized State Agent: �
Pennit Expiration Date:
�
The type of system permitted is ✓ Conventional
the permit.
Owner/Legal Representati : i� �
Date• ���'Sro Z
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Innovative �lternative. I accept the specifications of
Date:
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WELL PERIVIIT�
PI.EASE SEE ATTACHED PLAN FOR WELL SITE LAYOUI'
Tax Map #: � � Parcel # ` �O
gPp�� -�����, � � � � �� � �,
Subdivisiori:
C�
Tvne of Water Suv�lv:
Rec�wirenr�;ents•
Site A�proved bp
Grouting Approved by
Well Log
_ . . Well Tag;
Air Vent �
Hose Bib
Concrete Slab
Well Driller.
Township
dividual
Section: Lo�
Communitp Public
Well Appmved By: Date:
'�°5ee Attached Site Sketch'�
Wells must be 10 feet from propertp lines.
WeDs must he 100 feet from septic systems.
Wells must be at least 25 feet from anp bu�ding foundation.
Other conditions•
PCF-ID, =ev. 09/07/01