A35 185Application Date: - � Z. � ��O
Amount Paid: '7� . D O
Receipt #: � 7� a 0�
e,te �k � 3�'s
Ap
❑ Improvement Permit (Site Evaluation)
R2d0.�0/�300.00 (if > 600 �pd)
��?, )� �J.ldll�l� �d. �Y Tag Map: 1� 3 5
,,_,: �r. � � ���� Parcel#: ��_
]��awnroaaanacan�.mIl �cca��la
Services
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)__
ell Permit
for Services
❑ Construction Authorization
(Fee is dependent on the type
� Permit Revision
$75.00
❑ Repair of Eaisting Septic 5ystem
Annlication: No Char�e/ CA $150.00 or $300.00
1) Applicant Information:
Name: � Z0.0 I�hone (home): ,r� %�;� � � `•LZ '-� � r'J Cj
Address: ' � ' (work/cell): J'�"� !,� — 5 $ 3 -' [v !0 3 (o
Z'15'i
2) Name and address of current owner (if different than applicant):
Name: ' W � � Phone:
Address: lo
��
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property: 2,21 m c
O yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes 0 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 documentarion) _
4) Proposed Use and Type of Structure:
❑Residentia(
O New Single Family Residence Maximum number of bedrooms: / Occupants:
0 Expansion of Existing System If expansion: Current number of bedrooms:
0 Repair to Malfiznctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixhues? ❑ yes 0 no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any known ground water restricrions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
(Owner/ Legal Representative*)
* Supporting documentation required.
q-IZ-Ib
Date
• Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
���.sf �I��.���
�- � � ����
��ra�nlroaanaao�ra��.Il ����Il¢�in
WELL PERNIIT )
(New_ Repair ) l� � �� `�
�
Tax Map: � Parcel: ��
Subdivisi n: Lot: �
Applicant's Name: r �1 �✓� � � ��^+ � ��`'�'r W � � �
Mailing Address: �� r
2- 5? �3� 5S`3���3�p
Phone Numbers:
Location of Property:
'�Z� �cG���S ,
�<<( ►�C `
Permit Conditions:
1.) See attached site plan, for proposed well location.
2.) A�l ap�licable SFate and County regu�atioyzs goveYning construction and setbacirs apply.
3.) Permits expire 5 years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: ������'^ �'` ����
�Tew FJVetI:
EHS/Date
Location:
Grouting:
Well Log:
Wel! Tag:
Pump Tag:
Air Ven±:
Hose Bib:
Casing Height:
Concrete Slab:
Wel1 Driller:
Pump Installer:
Approved by:
.Additional C�m.ments:
Bate Sampie Coilected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date: ` ����
Cgr�i'fi�at� Qf Compl�t�o�
` �iner:
��' ��� �� � ..,l EHS�Date
�-���{� -Plepth: 3�/4/�s/��v
C� i►�G Z� ' Grout: i�
it�Gr2o�-t�t��
V�a�-�. ���� � :
�4' ��c�- oi-F,
> �Z�- �S'qtti' n�t
$7'
�l3M,P �_"t" � � �
DAbandonment:
Date: _
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-i790 Fax:336-597-7808
11J26/i3
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�olicati� atei ��4��3.
Amount Faid: . l%
Re i
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P e� '
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�1PPUCAT�ON FOR S RVI ES
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... . .. .:...:.. . . ..genrtces:Reqltest�d� :::::..��•:::.°:.::� �:.:::•.:;.'_:_�� .
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�mprovemerds Permit (Racorded Lot} - 5200•00 0 Well Perm� (Ne+ndReP�cemnM) - -
p ConsWctbn Au4hoti�atian for Saptic S�rstems-
O lmprovemer� Permil • i150.OD s150.401520D.00
{Mcbilee Home Replacema�fAddition) Fe� - 375.D0
- - — _-,. ❑ PertnilRCvision _
v.,.�.�....�.. —. - - - -- -
C N TRUCT SHALL BECOME lNYALID.
1) Pem�it reque
Name Phane:
Business Pha
2) Name and a__. _-- - -
3� Propeity � �u c�Wnship:
Descripttcn: tot size: �
Directions ta the prope�tY (�r c�uding road n nQ a�d
�_ nn.-�c�_ � ��
�
C�'J
� ues�ons: Depth:,_
4) Proposed Use apd S cture-DescrlPtio�: answer h of th follow'ng Q W'dth:, —.
a} Proposed �, Existing Type of Struaure:
' Number of occupants paople to be served:
b) Number of Bedrooms: _
c) Basement: Yes_., No VYiil t ere be plumbing in the basement?_ ��
d) Garbage Disposal: Yes _,_, No
5) Wate� Suppty TYPe: Privats �(new _ or existing�, Public� Communily^, S ro mate location an the
Are any w e l l s o n a d j o i n i n g pro p e � l Y? YeS— No , tif Y�. P��se indlcate app
site plan. �
6) Does Your prope�'ty co�ain previously identffied jurisdictional wetlands? Yes� No
�
PLEq NOTE THE F L OWING:
➢ A PLAT OF THE QROPERTII OR s� �US BE CLEARLY MARKEDD �H TM�S APP��CA'�ON.
➢ PROPERTY L�NES AND CORNERS
➢ THE PROPOSED L�AT�O Y ACCESS B E OR AN EVAI.UATION BYD HE H LTH DEPA�tTMENi
D THE SRE MUS7 BE READ{L
STAFF.
ereb make application to the Perso� County Health Department ior a site'� at�naa{ �e a� ep�s��he max mu�m�
t h Y � a ree that the contents of this app � �mit shakl
sysiem fot the rn+e-described propertY• 9
fi2cilit►es to b p ced on the roperty I nderstand if the site is altered or the intended use changes, t e pe
become inv i , � � ���_�3
//)j , � pate
pCHD, rev. 06127fo2
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�':'` T IMOTNY L . W[LIIAMS
cv �, �,�� - .
� m �� ,,,� LISA R. WILLIAMS
� ro YIOOOSDALE T�'P„ PEiSCA ;;(;�NTY, N.C,
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I���n.���.�����.]L 7E-�7L��.Il.�I{a
Applicant: ��� �' L� S a �,J i, � I i Gc m S
Location: CJ' h u b[.cc K c, (1.d- L� l Yl c G
T��x M��,� ' P�rcel # �
Su�hcl'ivi•s•ioia
Ph��se Sect�ion Lot #
Improvement Permit
Permit Valid for � Five Years No Ezpiration
Type of Facility: (i1D�'J � � t� �-�JrY1G New � Addition Water Supply EXiS�a
# of Occupants u.X, # of Bedrooms � Pro'ected Daily Flow �� g.p.d. �
Proposed Wastewater System: V C � rCi, v i . Type: �
Proposed Repair: S V A. ' V G `O 2.�dc.�.c-�i �n Type: ��
Tr15tu. �
Owner or Lega1 Represe
Authorized Staxe Agent:
c,, �G '�✓ �
c �� Fi'
GCt �
Date: ��-�'�
Date: 10' -03
The issuance of this permit by tt� Health Department in does not guarantee the issuance of other permib. It is the responsibility of the
applicanbproperty owner to in sure 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 Permit is not affected
by a change in ownerslup of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). 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 water suppiy will remam
potable.
Autho.rization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional a#achments (�.
Propose Wastewater System: C',onVe.r�-�� ona( G�ci�i'ty Type � WastewaterFlowa�iOg.p.d.
New � Repair Expansion _ Soil LTAR: . o� .p.d./ ft 2
Type of Facility: �1'lOb1 �C I-�a n'1 G Basement Yes �No
Wastewater System Requirements
Tank Size: Septic Tank: �QQQ, gal Pump Tank: N_ l�__ ga
Drainfield: Total Area: �� sq ft Total Length �� ft
Trench Width J ft Minimum Soil Cover: � in
Distribution: Distribution Box � Serial Distribution _
Specifications• ��CQ 5
Authorized State Agent:
Permit Exx
Date: ��-
i Fi c-d ar
1 Grease Trap: �l�} gal
Ma�mum Trench Depth c� � in
Minimum Trench Sepazation: � ft
_ Pressure Manifold
. �Tns-� I 1 on Can�ou.r
Date: j 0 " �"0.3
The type of system permitted is � C entio Innovative Alternative. I accept the specifications of
the permit.
Owner/Legal Repre�entative: - Date: b� �
� PC 7/30/2002
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Nam T'iYl °�' �. i� L•i � � I I Q M,S .Tax Map #�� Paxcel #�`�
Su di isi Section/Lot#
I � -� -0 3 �
Authorized Sta.te Agent � Date �
Syater� c�o��tpo�tents represent appmximate contours only. The cor�tmctor must, flag the system prior to "
beginni�zg the irtstcrllation to insu»e tliat p�bpergrade is n�dintained t t s yS � m �' D F� F c I(,� ro pc r�'/ � i��s
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Applicar� ��tn�, � L � 1..� �-Q-�(.Gz�►.�
Location:��� mc C-� n�-Q-� �/ � � �
. ��pGrat��l'1: �E'�`I'Yllt . �
System Type (In Accordance With Table Va): � �
THIS SYSTEM HAS BEEN IN�TALLED � IN COMPLlANCE WITH APPLICABLE NORTH
� CAROLINA GENERAL STATUTES, RULES .FOi� .SEWAGE���TREATAAENT AND DISPOSAL, ��
AND ALL CONDITIONS OF THE IMPROVEMENT ' PERMIT . AND CONSTRUCTION ..
HORIZATIO. . . . , ..:
. � �d . . . . . .... ..�. � �,�-:�_� � .. . .. ..
� Authorized State Agent � � . � _. � � � ' : • Date � • � � �
Instailed By: �,1 + m n}y L �+..� ti S .. Date: � i— S� �. . .. ...
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❑
S�3�TiC �'�4A1K 11VS�ECTION C�9E��CLlST (Type 11- i�
Tax Map # 3 S Parce! # 1.� System Type (Table Va) 'T-�
Owner/Appiicant'T.�, / �a �Jut.P�.crrw� Subdivision _ �1 / �i
AddresslLocation � � rn� r�<<:.e� n� 2� Ser.lPhase Lot #
State ID/date ST6�4Z/ $-
Capacity. (�00 . gal.
Tee and Fiter
Baffle
Sealarrt
Riser (if appiicable)
Tank Outlet: Seal
Permanent Marker
� Puma Tank
Capacity
Waterproaf /Sealant
Riser �
Water Tight
. . P��rr�n
�heck Valve/Gate Valve .
- fi-si hon o e��.: .
.� �loats/Switches. . � .. . � .. _
Alarm visable and audible
� Electricai Componer�ts
Rate (Qam) �
Ap roved Pum Model
Blocic Under Pum �
Pum - Removal Ro e/Chain
� Distribution System
Seriai Distribution '
ressure an' o
Low Pressure Pipe �
Ap r. Pipe Material and Grade
Valves
1-S Q3 �Tt�ench Width
ft.
m.
' Trench Length ft.
' Trench Grade
' Trench S aci�g
'. Rocic De th and Qualiiy
' Dams/Ste owns etc. �
Pressure Laterais
� F� � Hole Spacing
o e �ze . .
� Pipe Sieeve . � - - �
Tum-upsfProtectors
�Required Setbacics
From Welis �. �
From Prvperty lines �
__ : .Structures/Basements.:: �
� �t es rainage ays �
_ : . _ . �Surface` Waters - � -
Public Water Supplies
Verticai Cuts >2 fi. .
Water Lines
Vehicfe Ttaffic
W Easemerrts/Ri ht of W�
Other
�rt 11-5-�3 Easements Recorded .
Comments
S
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� pcf�d rev. 3113/01