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Recai�t�: � �3 �-�� � ParcQl�:
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APPLICATION FOR SERVICES
IF'i�-1� INFOR9�i�Ti�N IN THE APPL9C.4T➢O6d F�R �►Pd l�fiPR�VEMEi�T PE�iflAIT IS fP9GaRi2�CT. F�1LS9FiE33,
C�iA1VGEif C3R THE S1TE IS �►L?�i��D, THE9V T�-ilE 1MPROVE�E�IT_P�RI�i9T AND AIJTHORI�►'i'108�9 YO
COh�STiaUC7' SNALL �ECO�flE IMV�►LlD. �
'1) Penvait reqvest�d �y: (Ownerlagera#lpraspec#ive owner): `� R �= s/�. << r� ivy
Home Phone: 9� v ���-�� 5 o Address: //v � �- ;�5,� d I� ✓. I
Business Rhone: _�-; �. .s-�; s- �; S 3 .i •1 FC {� � N r� c 2��o;
2) Nam� and ad�9e�ss ofi es�rreni oweeer. �-1�.'� s�z-� ��-,N zs i� L � N y� d � e� u s t�
' C ;.� �n i s.� �� .a c^ .
// 0 �, ��! v l> c.� ,; n cfT � .✓7 �_. ,e. Lt.-r•�-t , '% � 2 ? 1 d /
3) Prop�ety Descr��tion: Lot size: Township: :��s� �Subdivision: Lot # v
Directions to th� property (lncluding road names and numbers):
'Tn �.�s r c ?ie-�c � �� 4� L,a.� �d � '�6 �. ctic � = oo .7
4) Propos�d �3se and �t�aac'tvr� Descr�piian:.answer each of the foilowing questions:
_ a) Proposed ✓. Existing , Type of Structure: sC�� Width: Depth: �.
b) Number of Bedrooms: 3� �. N�mber of oc�up nts or people to be served: u� �o�..��c �
c) .. Basement Ye� , No �, . Will there be plumbing in the basement? - •
d) �arbage Disposal:_Yes �� � . No _ -
5} if;Ja�er �upply. Ti ype: Private �(new �r existing�, Pubiic , Community� Spring _
Ar� any wells o� adjoining property? Yes�,/No _ If yes, please ind'�cate approximate locatiori on the
'site plan. � . �
6) Does your progaerfij cantaire gireviau§!y identified jur��dic�i�nal wetlar�ds? Yes_.., No `�
PL�SE IVOi'E THE F�LL0INIMG:
9� PL,A i OF 'THE PROPEi�TI OFd Sii'E PLAR{ Ml9Si BE �UBI4A1Tf�D �1UITN 'rl-iIS �PPL9CAT60�f.
9 PROPE�ZTY L1NE� AMD CORNERS MUST BE CL�►RLY MAR4CED. -,
➢ iHE PR�POS�D LaCATIOfd OF ALL �TRUC'TURES iViUST BE ST�►6CED OR FLAGG�D.
� THE S9TE IViUST SE R�►DILY ACC�SSiBL� FOR d1N EVALUATIOId BY THE HEALTH DE�,�RT11iE�1T
STAF�: �
I here5y make application to the Person County Health Department for a site evaluation for the on-site sewage disposai
syst�m for the above-described property. 1 agres that the cante�ts of this applicatlon are true and represent the ma%cimum
faciiiiies to be plac�d on thi%pr6g�rty: l understand ifi the site is aitered or the intended use changes, the permit shall
became invalid. � � i
Legal
� -��`U
Date
PC: iD, rev. �6�27�02
Application Date: � �`� � 3`�U � Ta.x Map:
Amount Paid: � b6 , 0� Parcel #: .
Receipt#: �- q o a q 3
���.ss" �I�I����T
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T�_ �rn.w n u-ca nassaa �� �ca �.r_n, ll 1�-� a�.cn.Il 1£. �I�.
Application for Services
' (Sentic Svstems and Wells)
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225,00/$125.00
❑ Construction Authorization
(Fee is dependent on the type of sy;
0 Permit Revision
$75.00
❑. Repair of Existing Septic System
No Char�e
Important: If the information in the app[ication for an Improvement Permit is incorrect, falsified, or the site is altered, then the
Imnrovement Permit and the Authorization to Construct shall become invalid
1) Services Requested by:
Name: 1-1 �EPt t_ L.-%�a n� ��rr
Address: P D Bo�C I Z G�
� o?� BbR.o , fJ C_ �--t 57 3
Phone # (home):
(work/cell): 33� - 5 �i9 - aZ � Z
2)Name and address of current owner (if different than applicant): „
Name: Sp�MES A . �►J4
Address: � l p 3 E �.14 � E ul�o v/.Lv E
D U Ra-t P�M ti 1U L. 2. Z� n 1
3) Property Description: Lot Size: 1� 1��4Subdivision: S/�. (ro IJ G Lot #: 2-
Address and/or directions to Property:
C(-lU B t�.I�E (� o� RoP� u 5��' /�?T�C�I� GT S
4) Proposed Use and Type of Structure:
Residential �_ Business/Type: Other
Number of bedrooms 3—¢ / Number of people served (seats/employees):
Basement: Yes No � (with plumbing: Yes No �
Garbage disposal: Yes _ � No
5) Water Supply:
Private Well �c _ (Proposed Existing _)
Community Well: Public Water System:
_ ----
re ere on the adjoining properties? No es
(please show location on site plan)
Note: A comvleted anplication must also include:
➢ A plat/site 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 ver�ing that the property is ready to be evaluated
I am submitting this application to request services from the Person County Health Department. 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/Legal Representative): , Date : o � 200
06/U7 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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� l `_.7La'tY717r" <CD 7T"Il.Il7�71 <C�� 7L��.2.A.J1 1L Jl c� �iLl1 �� lrW�°IA�l:31CaJl3l5lSU � 0 �' �
Permit Valid for Y Fi
Type of Facility: Pr;��
# of Occupants rv�ux G
Proposed Wastewater S}
Proposed Repair: ��
Improvement Per it
e Years No Expiration
,�L��,�;dQn�� _ New Addition_
# of Bedrooms _� Projected Daily Flow 3(eD
Permit Conditions: �air►-�g� Q �% S�b��s
Owner or Legal Representative
Authorized State Agent: �
Water Supply �%I f
.p.d.
I Type: ���
Type:
Date:
Date: 2 - z 3 -a�j
The issuance of this pernut by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicant/property 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 a�id Rules for Sewage Treatment and Disnosa! 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 supply will remain potable.
Authori�ation to Construct Wastewater Sysiem (Required for �uilding Permit)
* See site plan and additional attachments (_).
Proposed astewater System: n�c J� nM�vt EZ i"loW er �n�M���YI�e �.tl��. � Wa�ewater Flow 3�6 g.p.d.
New � Repair Ex ansi � Soil LTAK: , 3 g.p.d./ ft 2
Type of Facility: �rl�p� e�j�er,ce. Basement _ Yes }� No
Wastewater System Requirements
Tank Size: Septic Tank: Od0 gal Pump Tank: Doa gal Grease Trap: `----gal
Drainfield: Tota1 Area: � sq ft Total Length �oo _ ft Maaumum Trench Depth 2-Z, in
d . C.
Trench Width _� ft Minimum Soil Cover: __� in Minimum Trench Separation: �_ ft
Distribution: Distribution Box Serial Distribution �/ Pressure Manifold
Specifications:
Authorized State
Permit Expirati
The type of system permitted is
permit.
Owner/Legal Representative:
Date: 2- Zi�-09
Date: Z-2�{-/�F
✓ w%Pu"�
Conventional Accepted Alternative. I accept the specifications of the
Date:
PCHD rev. 11/10/OS
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sy�r�m �o�po�� ��r��� app��� ����ou� � y: The con�ctor snrrst fla� the systerra prior to .
begirsnirsg t�ie installu�ion to i�s�re that pm�ierg�ade is m�i�tained ,
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���pnit �ondaiion.�:
1,1 See attached site plan for proposed well location.
2� All appdicable State and �oainty Yegulations governing construction and setbacks apply.
3) Permits ex�ire .5 years from the date of issue.
�f3�3�er ��nda�iara�/�'a��aaaazents: �_� w.� ai,L�' Oaod �Oaara,c� /
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I��� '�J��& I�n�����noanc
EHS/Date
Location:
Grouting:
Well Log:
tiVell Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
`�Y�� ��ll�r:
Pump Installer:
'�I�1� t�ppr���d �w:
Date Sam�le Coilected:
Pe:son County Environmenial �?ealth
32:; S. Vlorgan St., Suite C
R�aboro, NC 27573
�.,n�e� ��a�g������a:
EHS/Date
Installer:
I)epth:
Grout:
�e� ��aa��onffie�a�:
EHSll�ate
Completed:
IvIetl3cd/Material(s}:
�,as�sa�e #:
License#:
���e:
Date Results Vlailed:
rhone: 336-�97-1'90 rat: :30-�97-%808
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