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Permit requested by: . �� ,
ner/prospective wner/a �ent
Idress: •
?. Dimensions�or Proposed Structure:
�I Width: .���;_
Denth: 7l•'� � __
� � S� �� 8. Wha[ type (if any, additions, expansions, or I
replacemen[ is anticipated to the structure or facility
tha� this sewage disposal system is intended to serve?
Home Phone #: S��i l"� `�•� g � I v�%/b►
Business Phone #: �L�3'L.� �,��
2. Name and address of current owner: S�{�� 9. Water supply [}'pe:
� ' private�,public❑ community ❑ spring ❑
Are any wells on adjoining property?Yes`L� No �
If so, identify location:
PropeRy Description: Lot size: z��a ����s
Tax Map#: /7'13S �
Parcel#: ��� -
Township: G�/�/�J..t�s.afl•�� -
. Directions to property: State Road #& Road
mes,�tc.
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of structurelfacility: Proposed: �xisting: Q
� Type of dwelling: I
House:� Mobile Home: L� Business: ❑
Type of business:
Number of Employees: •
� Number of bedrooms: �
� Garbage Disposal? Yes No �
Basement? Yes❑ Nc�If so, # of basement fixtures:
. 6. I�Iumber of occupants or people to be senred: %Z -
CLEARLX STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS OF ALL
� PROPOSED STRUCTURES•
I hereby make application to the Pe1CSOn COunty'Health Department for a site evalualication ahe �rue ite
sewage disposal system for the above described property. I agree that the contents of this app
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can b�
issued, I must present a survey plat of the property to the Health Depc. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfei[ed.
�i ' � /' _
Z Owner or Authorized Agent
Signc�
Perm�� Issued l.�"
Permit Denied ❑
plat Observed I�/�
.t
_ _�
S ignature Date
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RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, slreams, gullies, �✓et areas, fill
• areas, wells, water bodies, slope pattems� CIC.� C:V�AttpRV.DOCSNPPSEC.S�t��NCEPC
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B 1450
PERSON C�UNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � � � Parcel # [O
Zoning Township S
Owner/Contractor�;�Ru c� DGt, VrrS Date 3- �� R`%
Location/Address �' r1 �- r � 3 � ,�b s � � 3 3 � -�-� ►�� Q �,.� c� ,- ; � e �sr ✓
;' n.�" � S�Mre o,� r,-�' S.R.#
Subdivision Name
SEWAGE SYSTEM SPECIN'ICATION3
Repair Lot Area �� Gi CYc'.,. Size of Tank � �✓
SFD Mobile Home Size of Pump Tank ,� r/
Business # of Bedrooms�_ Nitrification Line 4 4 D X 3'
Max Uepth Trenches � (, � �
Permits may be voided if site is altered int de use
Well and Septic Layout by
Comments:
Date�i�-��-9� Installed by,
Approved by,
Well Permit Paid � WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab 1�
Public Replacement Air Vent
Site Approved , Required Well Log
Well Head Approved �� Well Tag y�
Comments:
This report is based in part on information provided the homeo�ner or his/6er
representative in the application submitted for this permi� The environmental
health specialist is not responsible for false or misleading in%rmation
contained in the application. The environmental health specialist is also not
responsible for concealed conditions ori the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the �ater supply will remain potable.
c:lamiprolpermit.sam O1/95 rev.l.l
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Building Additions/ Mobile Home Replacements
Tax Map #: A�j Parcel#: �� Address: g 5 2 l�l c G- %/i. i
. o Z75 7
Approval Requested for: �o�bile Home Replacement
✓ Building Addition(5fora�c. bu� td�� �
J
Applicant Name: �u �. � a v� �
Address: 8 Z M���j� Qc�.
QOX�ero �� Z."1Si'�
Phone #'s:
Permit Located: V Yes No
Installation Date: (�-20-R7 Design flow: 3�¢0 (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: ✓ Well Public or Community
Wastewater system shows no visual evidence of failure on: -�-( (date)
(Applicant's signature if site visit is not required)
Comments:
Addition/Replacement Approved
Environmental Health Specialist
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www_personcount .y net