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A36 34�«��«��, �d«: 4 3 v� I o� � _ unt Paid: a , OG GI 1�• ).� Receipt#: -. � � ?� � � 3 �l-J �� ��� ���- ��.�� �� /�/ Lj -- h�-- � � 1L17�G�r`�L'-��r . lV ` r .J.4.�nr7l�ll.'1 �I.]L: K:Y.I[.T_fl'lYT_�1'1;J�T."�.C11..11. Jl„"��`,��L�.:J.YR.I�:Q,;:•ILT. � t�pp9ica�io� %e• Ser�ices � (Septic Systems and Wells) L TmproWement �ermit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) C Mobile Home Replacement or Building Addition _ $1 �0.00 (if site visit required) � 0 Well Permit (Pdew/Iteplacement) $225.00/$125.00 Tax Map: � y 7 Parcel #: �'�_ �e$wices 12e uested C Constriictlon ?.utl�orization Fee is de endent on the e of sys ❑ Permit Revision $75.00 .'. 0 Rcpair of Existing Septic System No Charee 0 Call. �� Me� Important: If �'/ie i�eforsn�rtio�t i�: t/te applicatioit for an I»rprovenieut Permlt is btcvrrect, falsiftecl, or� tdpe site as nlPererl, Pher� 1/le hnprovemes�t Pernri[ a►rrl t/�e Aut/torizRtion to Cnrtsiruct sltal! beconte invalid. . 1) 5�rvece� Re ie�t�d 1��: � � j M M �—C�J� � Name: �- ���� � i Phone # (home): _�3� � ,SQ�^�!�/� Address: (worlJcell): ,3��Q q, /703 �,������ �r� x �s �y . . B)l�da�rne an� ��dress off current ov�ner (if diigerent tEian applicant): Name: Address: �� I�➢'O�)�g'f� ��SC�'9�t10Ili: Lot Size: /, S/I�� Subdivision: Lot #: Address and/or directions.to Praperty: �,,, j ,(�l, ,� T . l� �,v y� /,}�Jd •.��1 di�/ 1��,. � ADli 7�U `�.v�. �) P�•opmsed �Jse and Type of �tructure: Residentjal ri� BusinesslType: � Other . Number of bedrooms �...� / Number of people se�•ved (seats/employees): I3asement: Yes No (with plumliing: Yes No _) Garbage disposal: Yes No � 5) '�I�tea• SuPP'Y: • • . Private Well ✓ (Proposed Existing _) Community Well: Public Water System: Are tl�ere on the adjoining properties? No � Yes (please show location on site plan) I�Ioie: � com�leiecl n,p dicntion mcs�t also inclurle- . � A pladsite pla�z of the property that shows propeYty ditv�en�iotts rend Plae �ize c�nd CocraPiota o,f'�ell p��oposerl strtcctures. ' � A signe�l copy of the `.�vt I'reparation' form ver�ing thr�P t3�e prope�•ty is rerady io be evalisated: � a�a sanba�itien� tl�i� application io e-eque�t seY-vices fpotn the Pepson Cowmty He�9th �e�arta�aent. 'Y'9B� gl[1fOY'1I11�Dgfl0II ��'UWIfICC� 7S �CCiil'�$C. g under�tatnd that if amy site is altered oe- the int�ena�eal use cbare�es, �nH� p�r�its ��a��i lbe�offie inv�➢id. ' �igna�ag�•� (Owner/Legal Representative): p � � ��$�e : �� 06/07 Person County Enviromnenta) Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) , ��� � h � 11. .L1ji.l9. \1. `� � J::. V .y�.a � � �y � +� _.�/ `LJ �� J� � ' ° �71.�'3��m-n-� -*n+'a cC���:�8.1�. �'1�:aE�:1i.t�.lY�. T�x Wla�� � � �rcei Sl'l� � C�!IVI�S'IOtI Ph�s�e;'Se t+ian.Lo�t � Iffiproveffient �$rmit �'Ermit Valid foa� I+'ive �ears ATo� ��iration ' � Type of Facility: �,� � �a+'e. �� eh c,� New Elddition _ 9�ater Sn�piy W e r � # of Occupants �(� # of B�' ooms 3 Projecte3 Daily Flow � jL g p.d. Proposerl Wastewater System: (�en./ �• ' �� � � Type: � Proposed Repair: %env�n-h'Ana � Type: •��. .�.��.� , �I�i�i]�•.�•� • � � - • . ' - • - a� e �rr. � � - � ����I �� ���� � . - �• '� Y. " ' 1 ���-� � S. ' � The issuance of this permit by the Health Department m does not guarantes the issuance of other permits. It is the responsibility of the applicant/property owner to in sure tha# all Person Coimty Planning and Zoning and Bu�ding Inspections requiremeats are met This Improvement P�rtnit is subject to revacation if the site. pl�n, plat or t�e intended use changes. The Improvement JPermit is. not :.�,�::.. affected by a ch�nge in ownersttig.o�.ttc�groperty. This pes-mit �vss issued in.eompliamce with the pra�;sions oithe.Noctli�C�aralina • ��:::�-;:fLuws:-�d .Rufes faY Sewas�.: Treutrn,e:it-�xd..Disnosal Svstenls' (�1�A N���.'18A 1900 . Nrather Person;La g�o�=#he:r;.� �.. ) ...�..�.� . . •��,���n�i�nme�tal �ealtfi: S��i��'�;�r-ra��s:�hat }Che. septic tank.system will:.cum�in : �, �� �,riction� saiisfactoniya�,����,�€t���°w _ ,.:,: the:�eater�.supply will.remain..potable.. . - • ' _ � ,.'� -,� u- ��^�..�:��:�,.,t.�:f :.` Aritlioa�ization io �ons�ct�astev�ater Syste�t (Iteqaire+d�fu���uiidingY�rmit)�"� _. ._ �� � �* See site plan and additional attachments (_). . .� . Propose astewater System: �ie►.vP��nna.� � Type� W waterFlov�r�g.p.d. .- New • Repair F,Ap ion � Soil LTAYZ: •� g.p.dJ ft 2 Type of Facility: �yg� p.�j �ne� Basement _ Yes _ No ']�ank Size: Septic'Tank:� �_ �� g� Drainfield: Total Area: � � Z.00 sq ft �a�tewater Syst�m Reqinire�xen$s Pnmp Tank• —�gal G�ease Trag�:—'—"g�l Total �,ength �00 it � 1VV��a�mnm Trench �epth 32- an Trenc�► Widt� � ft lYginimnm Soil Cover. (,a in �istribnt�on: �/ Distribntion �oa Specificati0ns: t�ntinorizerl State Agent • Permit Exn: 'ihe type of system permitted is Permi,t• 1 (�w�e�/L�31 �e�resEnt�tiv], Serial �istri�nntion � l r"ar�C Minimnm'I'a�ench separation• �� it Pressnre Mani%ld I accept ±he spe�ificarions of the PCHD rev. 11/10/OS ; `� r � '��^ • � ^�: ° `�`'y :������� ������ '��-- � . �° (� �LJ 1 V` 1L � 7E���-•��,.�,.e��.m.B. u33Cm�� � SiTE ��TC� � . . Name .J � �wi Tag Map # /a`�� - Pas:cel ��� a�� - Subdivi _ � Section/Lot# � -�7-�8' . � . uthorized State Ageflt . � Date . Sys�te�a cbmponents s,e�iresent •rrpproximate�contours only: The contmcl`or mustflag the system�rior to beginning the installation to insure thatpm�ergmde is �naintairied � hS�����5:e685 �`� SI �4iQi �L�o�v o� 00'S� �� � � �- ' ���, ��, �-r� , � o� \ � � � , � � �` � r' � � ' � \ � �� � �, � � . � � ' ; \ `\ � � ��, ,1 � \ \ \ SN , � � � � ;,� �, . ��' I � 1 � � o Y � \ "''� `''N � . � I � � 7; � I c- ,r. _ - N � `, � � �6... �},� �j.� ,�, � o ( � ;} ' I ��r ,^` I � ` � � ( J c �' �17' `�'�r • �� _ - � C � / __ .' ;� � � =-z __... .. : :-..---�--^%'^. . .-. _�. .' d _.....,...:.�..-.�.-�-��.-., ` . ., t � � r N � Q r � V\ S� N � '��� �� �.Z. �'_�� �.�� � �. � � � � �_�-,�`= �� � � �T��' � 's T ��-��-m--^ � ���.1i ���.1�. anplicani: Loca�ion: �r� �� g3 � ?�uc�9 � . 3�{ ��.L. � '�no� ��l��s�o���� Y 'N VY � � � d l:JL3t1LFtJ • � � . . , . - . : . . �'. �� � �� � : . � . Syst�m Type (In Ac�ardanca Wi�h Tabfe Va): � THIS SYS�'�� ��S �E�� i�{�'a..�.LL�s7 if� GDP�lFLI�.��� V�i?3-i �PP�ICA�L� . NQRTH C'A�OLliil� Gc���d.. S?�4TUTE5, �iilt.Ej �'t3R Sci�itAC� TREA�'l1�iEi1iT �1�dD D(S�OSAL, • �,i�D -�LL CO1i413[T3t3�dS GF � T�-3� �M�F2f��F��i�:l�T ���i1iT Ai�D G�i�STRL)CTiDN a4t3'I'H��i� i�N. � . • � � .S �0 OS' � . uthorized State Agertt �ate . lnstaile�i. B� • , . • Date: � �`zo -08 � � . ' . " �i . � . _� ��� ���. � �; Z�' �,� �j� � � � � . ��� . �'1� � , 3 . � , 2 � Z . '�!a' � . � �u1' � � 5,� . . . i . �v . . o Q �,�� C �� C �� L��� 2� � �C�-?L', Cc3/. � i r���/r.,n ��:��� ��s�� ��5�����0� ��E�"�� a � ���� �9 � 1�� : a; Ni�� f�� r 2�C2� ��_ Sys�e� Typ� (Ta�I� Va) �Q O���erlApplican� : . . S�b��uisot� A.ddress/Lo�aiior� Se�; Phar� Loi � � ���ue�. �'�a�� �nia��dB��„� �oz�a�o��a��a� �,��� �ni�a� ci� � , State�(D/da�e �- - T - a re�cfi 11V�d�� � 3� �. 5-1a- Capaci cral. � Trer�cf� Depti-� 32 in: Tee and Fiifes - � T,re�c�t Le� �. � �af�e ✓ � Tr��ct� Ga�ade � � � Seal�nt � Tre�ci� S ac�� Riser it applicable � � Roc:� De and Q[��i" �'an�C Outiet SeaL � DamsiSt� downs �#c. Perman�srt li�arker Pressa��e Laterls � � . €�a�m� �'ank • � Hal� S�acang - c8.,+a n�a-�,�,o _ i ^ n . �-�o ISe�lan� Ris�r Water�Tight � � , � � ���� Chec� ValvelGate �«1ve �larm (visable and audi�i�} �ieciric�! Camponents Rate (qpm) . . Approve� Pump i�ode� Blac� Ue�dec Pump � Purnp Remova! �Ropel��ain . ��Dis�gbuti�r�.: S�s�rn Serial Disi�bution �°ressure U6�ntrod Lnw Press�re Pi�� Ap�r. Pipe Ni�te�iai ac�d ��ad� ilalves � Siea�e �qui�d' ���a�� From� �JVeits � Frorn Prope�y lines ��-�.-�-,n--_��-� .. � • ' �Surfa� Wat�rs Pubiic V1�a#er Supplie Vs�iicai Ctias >2 �t. a V1�a�r Lin�ss . lle�ccie �Traf�ac � � ���esne��igh� ofi O�e� �as��rt�t� R�a�d� I ��m�e�� � CC:IC c1. �i'i�/{�i� :..:f• .. . ::.�.+...'. ::.... ,.� .:�,. ��/ 1���!:.}•�4��:: .� • .�:��1LlJ•��.'•:�..•:..:••..•• • . ��,�-`y •. •::,;::...,.... •. .... . �. .� +':�`:�.:�.�.�:... ' . •..;.....';'•.'•%%:::::,.�.��,.�. :.:�... . . � . ..........:,.•:::.,� .:� . . : •:;:.�.n:.,,:•. .� .�:. .,�...,..�..� ......:....:...., . .,...... . ;.: .... . . , . . . ..::. , � .,... � ,., . � : . .. . . .... �i"T'.•-�9:9't]L�!�CD�lZ7'�'� i.,�'^'*"A��7L:�:�9i' ';";�. 7�� 'i1� . . ..., � : �.c�'�-1L"�-�rn•.'. ri�u�.,�, ����' _ ���'�'�; ��;�' .f'��'��'�.,� ��t� �`Q��'a ��� �'��',.�1��� Tax Map � 3� Parc�l #�� Township: Applicanf: � i mm�/ L.�ew�'S Subdivisionh -,T, , _ . I.ot # � � of �a�en�,5u � : Individual YP pp y_ ._ Commumty Pubhc l�q�ar�aaaen�: Site Approved By: � � Grouting Approved B- y� Well Log. Pump Tag: _ Well Tag• au v�t: Hose Bib: Gasing Heigh� Concrete Slab: ���a � �a���r: � �S�a 3 Cj�� �Installed by: � - �S Depth set: I a-o • �} � Grouted: � [3 W r� S /�o � � -o � nat�: _�1���?�� . Water Sample: Well Driller• �/1r2� l� Well Approveci by: � Date: �***�e�.At��c�aed �it� 5ke#c�*�*� Wells mt�st be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at ieast 25 feet from any buiiding foundation. Other canditions: PCI3D rPv 0�!27/0� Owner: 11 n.� Location: �F � K 5 Subdivision: � Or�� � � - 3�( 61 � � � � �rn! TR' ii✓��� ���ll rf D� O�c�! S —�z —o � . -: -- c�rout I,og . " Taut Map� �6 Pa�el # 3 `I Lot # s - Wea ConstracEion Disfance From ne�st Propeity Line (Miuimum 10 feet) t o r Distance finm Septic Sysbem (M'minuum s0 feet) 1 b-�o Tota1 Depth: -3 �� ft Yeld: �� GPM • Static Water I.eveL• ?,� $ Water Beazing Zo� Depth �r,.� ft 1 �� ft 2 SS ft & n� ro�n . 1� to 6 3 ft. niameber: 6'�y in . Z�+pe: Cralwani�ed Sbeel ./ . Weigh� Thictaiess: ��� Height above Cmound: .� Z in - Ihi�e Shae: • Yes No Any problems encotm�ed wh�e �g casnng? If `�yes" give reason: - _Yes v� Grout: - / , • . . Ne� SandlCe�t ✓ C.ancrete GraveUCemeut . '. �ular Space Width • mches Water in Aimular Space. Yes ' No .. MeBbod of Cmrn� Pum�ed Pressvre � Pouned ,� Depth l� to �� Ft Materials IIsecL• � - Liaer: No. Bags Portland cement ' Weight o� 1 Bag � Pounds . If m�ure (sapd, gr�vel, cu�ngs) — Ratio fio—�� . ID plat,e� ./ Yes _ No 4 a 4 slab V Yes _ No - - . �: ! z � � n� �ea: � :z..z -�y cm� �nea�: - Drilling Log Lacation Drawing From fi'o Rormat�ion � � y� �� 2 �' � J l . �-- �Z �3 � , s Q � �� . . . 5 3 3�� - �..� 5�.� - C . ' : _ . .c4 �- . i .- . �-� �,s . ��Y �► t�t �e above� iafa�ti� is coa+acc ana �ax t�s well was c�a m�oe wi� ��gulatia�s �t f�h by tt�e Persou Coimty Health Departmart. , � - 5�re oiConiritc�or ID# J� � Daie �=2 �• o� - � ( ✓ Pamp I�t • - Pum� Installation Contractor_ � Gt iVl � CTc ��.. ���//l �!� State I��sh�tiOn Number: ��y -r-- � nept�: Z v $ � 2� $ '�mp Make & ModeL• /� �� �a �e- �. Pump S'rr.e and Ratin�.�hp l b gpm � herei'+Y certify that tins pu�m�p was �Ied and the well I� �co�l�ed acx�rdmg to the Peisa�n County'Well Ruies in eff�t xi t�is date and tl�at a capy of ttns record has l� i��e well ownez . �p � �.e ,�: � ' Date: � �� � � `'YPC�ID rev Ql/27104 IS N —� � , ' �_.i , �,�. C)��! ; �. � , 'l •,� - � ,�� j � i } �- / _. s1,� ;? �IS i5 A [;;;', SALES LONIE DUNCAN IRREVOCAELE t r'.UST D.B. 2b1, P. 65i .��''ca.� ,.�ti . ,... `J ;c„SS