A35 126Application Date: D
Amount Paid: O �
Receipt #: ,��
e�.� � ��
0 Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
�ISG.00 (if site visit requiredj
0 Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
�� ) f ��q .�� �l � Tax Map: '�'
�� a Parcel#: �T�_
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Services
for Services
❑ Constructian Authorization
(Fee is dependent on the type of
0 Permit Revision
$75.00
pair of Existing Septic System
Applicatian: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: +�ow�� Phone (home):
Address: rS"SS 1 11���^�s�� � �2n . (work/cell): _
2) Name and address of current owner (if different than applicant):
Name: Phnr.e:
Address
3) Property Descraption: Lot Size: Subdivision:
Address and/or directions to Property:
L�t #:
❑ yes � no Does the site contair� any jurisdictional wetlands?
❑ yes 0 no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
❑ New Singie Family Residence Maximum number of bedrooms: �
❑ Ex�ansion of Existing System If expansion: Cu►rant r•amber of be�rooms:
fd'Repair to Mzlfun�t;oning System Will there be a basement? 0 yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Mzx:m�m number of employees:
Total Square footage of Building:
I��acimum number o: seats:
�) Water Sup�ly: ❑ New well ❑ Existing Well ❑ Comr:iunity Well ❑ Pubtic Water 0 Spring
Are there any existing wells, springs, or existing waterlines on this properiy7 ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional � Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided above is complete a d correct. l also understand that if the information provided is
inaccurate, or if the site is subsequently alt ed, or^ the i e ded use changes, all permits and approvals shall be invalic�
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� Signature wner/ L gal epresentative* D e
* Support' g documentation required.
e Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
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ConnectGIS Feature Report
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Page 1 of 1
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;;�; ; Welcome to the Person County GIS Website. ConnectGlS has been prepared for the inventory of real prope
�-� County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system are noti
public information sources should be consulted for verification of the information in this system. Person Cou
�ssume no leqal responsibility for the information in this system. Grid is based on the NC state plane coordinate s
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PerSon County Environmental Health ��A t�
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Swte C
Roxboro, NC 27573
http://gis.personcounty.net/connectgis_v6/DownloadFile.ashx?i=_ags_map60e 1 bbf49a34... 10/31 /2012
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Applicant:
Address/L
Tax Map: �� Parcel: /Zlv
Subdivision
Phase/Section/Lot #
Improvement Permit
Permit Valid for: Five Y rs � Non-expiring
Type of Facility: �s _ New _ Addition _ Water Supply: ��I.,L
Number of: Bedrooms / Occupants / Employees / Seats: Projected Daily Flow: gallons/day
Proposed Wastewater System: Type:
Proposed Repair: r� Type: _��
Permit Conditions:
Authorized State Agent:
(X) Owner or Legal Representative:
Date:
Date:
"['he issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicanUproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina �Laws
a�:rl Rules for Sewage Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: �C�¢,�;���p (*)Type Design Flow � gal./day
New Repair � E pansion _ Soil LTA� gal./day/ftz
Type of Facility: ,��,r Basement: � es _ No
(*) System Types IIIb, IIIbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
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Tank Size: Septic Tank t gal. Pump Tank gal. Grease Trap gaL
Drainfield: Total Area rpOC� sq. ft.
Trench Width _� ft.
Total Length �� ft.
Min.Soil Cover (� in
Max. Trench Depth � in.
Min.Trench Separation ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold �j'i.+Ir�Qc Li.f� �
Specifications: � ��z. y'fio•, �/�`��P,c1sT �E'���,c//� � .O �LL �'������6n/�.,c0
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Authorized State Agent: Issue Date: % i�
Permit Expiration Date: �
The system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: [.c_ _ Date: /d- �%'/�
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Applicant:
Location:
Operation Permit
Tax Map O 37 Parcel # 1� ;,,
Subdivision
Phase/Section/Lot #
# of Bedrooms
System Type (From Table Va): i Product (IIIg): ��.�,� Z< ,
This system has been installed in compliance with applicahle North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
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(Licensed Contractor)
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Tax Map: � Parcel #: ��
Septic Tank System Checklist (Type II-I�
Notes•
System Type: ���
Pump System Checklist
Pump Tank � InitiaUDate
State ID & Date:
Lapacity:
Riser (6" min.
NEMA 4X Box
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on post
Above grade (12") ,
Tank Components
Pump model:
Block (4")
Nylon retrieval rope
Float tree and attachments
OrJOff �lcat swir�g: in.
Alann float (,6" sep�ration)
Anti-siphon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
Pressure Manifold Su ly Line
Number of tat�s: Size and material: in. s�h.
Size and sch: i,ength: fr.
Contracted Certified Operator (Type IV +Systems):
Notes•
NOTIFIED BUILDING INSPECTIONS: Copy of OP e-mail Date:
(Revised 12/09 BH)
InitiaUDate