A36 14A lication Data: �O' I�-O ? . Tax Man #� �� G— ��
Amount Pald: Od .�
Reczipt �: � 3 9 3 G f Parca! �#:
�4 G �--���_ �� I��I�� �1�T
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APPLlCATION FOR SE3iVIC�S
IP T�-i� IfdFORnfleATlOid IN ii3E APPL9G.4T➢O�1 Fa�i AOd lIIAPR�VEME�IT PE�dIIAIT IS It�CaRR�CT, �d1LS9Fi�i3
CN�►NGED OF2 THE S1TE IS ALTEi�ED. THE➢V T�IE 1MPROVE�E�IT P�RhAIT AiVD AflITHORl�T10Bd TO
CONSTRUCT S�1ALL BECD�flE IMV�LID. •
1) Pertr9it requ�st�d tny: (Ownerlagent/praspective owner): �' � �= s/�,,;. << � N9
H o m e P h o n e: y r v ���-� c 5 o A d d r e s s: / � v � �- ;.. �! L �,. � ati � I� ✓. I
Business Rhone: ��� ,: _; 5 s- �: S 3 7•+�.� h� n �t �- '��oi
�} Narn� and adc9ress of c�rrent owraer. ��.; � s �-� ,i�.�-Rr �-s i� L v r�, d�- << u S 1�
. , _ ,� L� - J .
�c � .�.� L , .:{,� �
//D � %�r.! 9 (> c.) c.n 4! /-�� % �-<G %.�T-•'-t � '�/ �- 2 ? iG�/
3) Properly Descr�ptdon: Lot size: Township: :�� s� �Subdivision: Lot #,�_
Directions to the property (lncluding road names and numbecs)_
_ . w i . . _� � .
4) Prop�ses! Use anc�. $t�aac#a�r� Descri�iion:. answer each of the following questions:
_ a) Proposed ✓. Existing � Type of Structure: , = Width: Depth:
b) Number bf 8edrooms: 3� �. Number of occu ants or peopie to be served: u� �ra��r � :
-. c) Basemen� Ye� . No . Will there be plumbing in the basement7. .. - .-
d) �arbage Disposal:.Yes � No _ -
5} ifi/ate� Su�ply�'iype: Private ✓(new �r existing�, Publ'�c , CommunityJ Spring
� Are any wells on adjoining property? Yes�/No _ If yes, please indicaie approximate location on the
� site plan. � . �
6) Does yo�r pr�perty cantain gic�vio��ly identifed Jur�sdi�#ional wetlarads? Yesr, No `�
PL�A�� IVO'i'E Ti-!E FOLLO{NIMG:
9,� PLAi OF iHE PROPE�TV OFZ SiTE PLAN i1�1lST HE SLlBnAI'i?�D `1VITH T�IIS �PPLHCAT90P1.
➢ PROPE�t'T4( LlF�IES A(dD CORNERS MUST BE CLE�►RLY 1VlARKED. •,
➢ TiiE PROP�SED LaC.4T10N OF ALL STRUCTU�ZES MUST BE Si�D OF� FLAGG�D.
5� 'fHE S9T�E IVIIlST SE RE,4DILY ACCIESSIBLE FOR �1t� EVALUATIOfd BY THE HE�►L.�H DE�ART11tE�T
STA�'F: �
l hereby make application to the Person County Health Deparkment for a site evaluation for the on-site sewage disposal
system for the above-described property. 1 agree that ihe cantents of this applicatlon are true and represent the macimum
facilities to be piac�d on the p�� rty. I under�ta� ifi the site is altered or the intended use changes, the permit shali
became invalid. / �
Leaal Re
6 �s-o7
Date
FC'rID, rev. �6127102
Application Date: i �� � 3-� � Tax Map:
Amount Paid: �00 Pazcel #: _
Receipt#: � 9 D ��l 3
�--���. .� �I��.$� ��
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�aa�aa�-anaa�ra.aa-�aadmn.Il I�7I ac�au.lL��n
Application for Services
(Sentic Svstems and Wells)
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 �pd)
D Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
O Well Permit (New/Replacement)
$225.00/$125.00
❑ Construction Authorization
(Fee is dependent on the type of
� Permit Revision
$75.00
❑, Repair of Ezisting Septic Syst�
No Char�e
Important: If the information in the application for an Improvement Permit is incorrect, fa/sified, or the site is altered, then the
Imnrovement Permit and the Authorization to Construct shaU become invalid _
1) Services Requested by:
Name: tJ �.c. � G�� r�-t. L�-t'T
Address: �� BDX 1 Z!� G
l2o x ►�02� 1 2-1573
Phone # (home):
(work/cell): 33�- S S -rf - $ % �2
2)Name and address of current owner (if different than applicant):
Name: �'��tEs A� . Lolv �
Address: �� � O 3 ENC�' LEWr�p Av �
i�t 1121�P�1 t�1 G 2-15'7 3
3) Property Description: Lot Size: 3 5 ubdivision: J� t-ON � Lot #: 3
Address and/or direcrions to Property:
4) Proposed Use and Type of Structure:
Residential X� Business/Type: Other
Number of bedrooms 3—� / Number of people served (seats/employees):
Basement: Yes No „� (with plumbing: Yes No ,x )
Garbage disposal: Yes l No
S7 Water Supply:
Private Well � (Proposed Existing �
_..__ Community_V�ell: Public Water System:
.__
e ere on tlie adjoining properties? No Yes (please show location on site plan)
Note: A comnleted apnlication must also include: .�
➢ A plat/siie plan of the property that shows property dimensions and the size and location of all
proposed structures
➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated
I am submitting this application to request services from the Person County Health Departmen� The
information provided is accurate. I understand that if any site is altered or the intended use changes, all
permits shall become invalid.
Signature (Owner/Lega1 Representa.tive): IV,�r'Q � • ��,ti_ _�!(_ Date :
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
���� � �, ���� ��
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� 7ta�Y71 SP' <fD 7L'Il_.ICIL71 <C�=` � �.��.11 .IE�3I �L �a.11 �I�
T�x Map � Parc I #
Subdivision
Pha�Sect�ion Lot #
Improvement Permit
Permit Valid for Five Years No Expiration /
Type ofFacility: �va� (�Qc;c�a„�:e, New ✓Addition
# of Occupants �(� # of Bedrooms Projected Daily Flow ,31��
Proposed Wastewater System: , � �
Proposed Repair:
Permit Conditions: • �,�.�,�, q� �o� aG�CS
Owner or Legal Representati
Authorized State A�ent/
Water 5upply .�l
g.p.d.
�_ Type:�. b �
Type:
Date:
Date: 2-23-oq
The issuance of this pernut by the Health Deparhnent in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicantlproperty 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 ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Rules for Seivage Treatment and Disposal Svsterns' (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
thz water supply will remain potable.
Authori�ation to Construct VVastewater System (itequired for Building Peranit)
* See site plan and additional attachments (_�.
Propose astewater System:� 'n naO �-�le or �br,�,Type�� Wastewater Flow '�Go g.p.d.
New � Repair Ex ansion _ Soil LTAR.' • 3 g.p.d./ ft 2
Type of Facility: Pri���e g<jc�e�cE Basement _ Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: Doo gal Pump Tank: Doo gal Grease Trap: gal
Drainfield: Total Area: �%�o sq ft Total Length 3Do ft Maximum Trench Depth 22 in
Trench Width 3 ft Minimum Soil Cover: �( _ in Minimum Trench Separation: Q� ft �
Distribution: Distribution Box Serial Distribution ✓ P ressure Manifold
Authorized State Ag
Permit
The type of system permitted is Conventional
permit.
Owner/Legal Representative:
Date: 2. -Z 3- 0 9
u
_ Accepted Iternative. I accept the specifications of the
Date:
PCHD rev. 11/10/OS
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�7L3'PIl7L'�wn �r�°'�. �a3.'�.JL ��L'lAJI� , . .
SI'I']E S�TC� � .
Name � I� Taz Ma #/�3 � Par�e1 ��
�Se J p �
Subdivi ' _ � Section/Lot# 3
� 3_3_09 .
. uthorized State Agent . � Date . .
Systesra cvmponess�s �e, presen� a�pmacimate�conto�srs �rdy: The con�ct�r �ra�, fl'ug the sys�tesn prior t� ;
beginning tlr� in,rtalluiion to insure thatpm�ierg�rrde is snaris�tained
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NEMA 4X Simplex Contml Panel
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12° Sappratioa I
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Ta� lYlap: � 6 � Parcel #: � Date. 3"f-OQ
I.irne '�'at� '�'�p (5ci�) Ta� �'iow Liaae �es�gt� �otiv / fooi
# l�ia�a��er(ian) ( m) (ft)
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75% x gal = IN1 g� �er �os� 24 . gal per minute (gpm) = F'iow Raate
PVCfi�e Vslw
P.�fomem�
����fln ���a _ _ `
I.�ss: •� 2% ft per l0d it of supply line x.SD ft of supply line = 100 = •� ft
. ft x 1.2 =�_ ft of frictiorr head . �
IVlani%id Size: �-� „ Forc� 1Rain Size: Z „ PVC.. .
'�mtal i9yn�ac �$ead =�f.t of Elevation head + 2 ft of Pressure head +�_ft of
Friction I-iead = I l TDH � .
�ump Req�aire9taent: Z� � GPM @ �( . ft of Head. .
I3r�wdown: ,��gal per dose ,-` 2l gal per inch =� inch drawdown per dose
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A�p�iean�'s 11a�e: �a
I'���i�a� A�d��s�:
�➢n�ne 11a�aa�iue�s:
����nat �oaardaiion�:
1, See attached site plan for proposed well location.
2� All appdicable State and County regulations goveYning construciion and setbacks a�ply.�
�) Permits e�pire � lears frona the date of issue.
d���er �ondataons/�'c�raaa�nents: ,� ePd �►A��P p Ooo� d� ra Y
- - • �T , .
�'�r�aflg a�sa�e� by:
����: 3 - 3 �
��+ �'�' � + ���+ �I'+ �°fll�/��.,�+ �'��P�
l�i�� '�✓'��� ��n�����ia�a�.
EHS/Date
Location:
Groutina:
�rVell Log:
tiVell Tag:
Pump Tag:
A.ir Vent:
Hose Bib:
Casing Height:
Concrete Slab:
`��� ���era
Pump Installer:
�i3�y�� �ppr�w�d ��:
Date Sarri�?e Coilected:
P�: san County Environmental �?ealth
3�:; S. lYlorQan St.; Suite C
Ro�boro, NC 27573
�n�e� ��s����n��:
EHS/Date
Installer:
Deptii:
Grout:
��� ����do�ffie�a�:
EHS/Date
Completed:
Ivlethod/Nlaterial(s): _
�,a���a�e #:
License#:
���e:
Date Results Vlailed:
rhone: 33b-�97-1790 rati: :30-�97-7808
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