A36 47Application Date• ��, 3Q (o ��� S f ������ Taz Map: I�-3`
Amount Paid: 0 0 ��0 • ✓" Parcel#: 2N
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Receipt #: I 7 71U fi" -j'o
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Services
Permit (Site
' � $200.00/$300.00 (if> 600 gpd)
❑ Mobile Iiome Replacement or Building .
$150.00 (if site visit required)
� Well Permit (New/ReplacementlRepair)
$300.00/$200.00/$75.00
1) Applicant I format}on:
Name: �Ii�YIU(�i, �%`�`i�(1ir1
Address:
for Serv�ces
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
❑ Repair of Ezisting Septic System
Application: No Charge/ CA $150.00 or $300.00
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): � 3�—� � 1 I 35
(work/cell): 3 3 — — 3
i�l-3�e�t���
Phone:
3) Property Description: Lot Size: 2 Q C�ubdivision: �I �
Add ess and/or direcr�'ons to Property: �P ��_���
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❑ yes �6.no Does the site contain any jurisdictional wetlands?
❑ yes 19.no Does the site contain any e�cisting wastewater systems?
❑ yes 15�no Is any wastewater going to be generated on the site other than domestic sewage7
❑ yes �Sl 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 documentation)
4) P posed Use and Type of Structure:
s�dential
ew Single Family Residence Maximum number of bedrooms: � / Occupants: �
❑ Expansion of Existing System If expansion: Current number of bedrooms:
� Repair to Malfunctioning System Will there be a basement? i�yes ❑ no With plumbing fixtures? es ❑ no
❑Non-Residential
Type of business: Total Square footage of Building:
Maximum number of employees: Maximum number of seats:
5) Water Supply: �New well � E�usting Well 0 Community Well ❑ Publie Wate � Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes �no
Please note any known ground water restrictions or sources of contamination:
� If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ ConvenUonal ❑ 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 irrvalid.
�gnature (Owner/ Legal Representative*)
* Supporting documentadon required.
!2 �d /�
Date
• Permits are valid for eit6er 60 months or are non-expiring when accompanied by an approved pla�
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tag Map: �� Parcel:�Z
Subdivision
Phase/Section/Lot #
Applicant: "
Address/Location:_�G�-,c�:s� � L �Z�_ > L- ���T�2. 7 E,�i�c� ,�'a11�-%
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Improvement Permit
Permit Vatid for: Five Years � Non-expiring
Type of Facility: New �/ Addition _
Number of: Bedrooms / Occupants !o / Employees / Seats:
Proposed Wastewater System: �
Proposed Repair: ��.�
Permit Conditions:
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Water Supp;y: WY-Lt_
Projected Daily Flow:�.,� gallons/day
Type: T,"
Type: �
Authorized State Agent: __ Date:
(X) Owner or Legal Representative: Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is th� responsibilin� of
the applicant/property owner to insure that all Person County Pianning and Zoning and Buildina Inspections requirements are met. This
Improvement Permit is subject tu revocation if the site plan, plat or the intended use c6anges. The Improvement is not affected
by a change in ownership of the property. This permit was issaed in compliance with the provisions of the North Carolina `Laws
rutr! Rules for Sewage Treatment and Ilicnosal Svstems'(1SA NCAC 18A .1900). Neitber Persoa County nor the Environmental
Health Specialist warrants tha+ t�e septic system wiil cantEnu.. to function satisfacto::ly in thc future, or that the water suppfy wiil
remain potable.
Authorization to Construct Wastewater System
a�ee site plan and additional attachments (�.
x
Yroposed/ Wastewater System: ���%��,,►1rT/Di1(�iL�' (*)Type �� Design Flow _=� gal./day
New t� Repair_ E, pansion _ Soil LTAiZ: •� gal./day/ftz
Type of Facitity: ,� Basement: _ Yes � No
(`) System Types Illh, Ilibg, �Y, crnd V, requireperiodie systsna inspections by the Persorr Corinty Health De�artment.
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Wastewater Sysiem Requirements
Tank Size: Septic Tank �OD�i gal.
Drainfield: 'Total Area L2�0 sq. ft.
Trench �Nidth �l' ft.
Pump Tank gal
Total Lengtl� �_ ft.
Min.Soil Cover _� in.
Grease Trap gal.
Max. 'french Depth � in.
Min.T'rench Separation 9 ft.
Distribution: Distrihution Box� / Serial Distribution ! Pressure Manifotd _�_
Specifications: Dd ��G'Or✓1� D�iL�� � �� � '`rJ' �/11���1) ril�
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Authorized State Agent: Issue Date: ;
Permit Expiration
The system permitted is: Conventional /Ac te ' Alternati�e / Innovative . I ac�ept the conditions
and specifications of this permit. �G
(k) Owner or Legal Representative: , Date: �–' J�
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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System Type: �
Septic Tank: 10G� gallons
Pump Tank: �1A gallons
Total Linear Feet: �GG
Max.Trench Depth: Z�"
Name:
Subdivison:
Site Plan
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Lot:
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Tax Map: �
Parcel: ��
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EHS:
Date:
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Scale: < H�Sb �
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Health with any questions (336) 597-1790.
Additional Comments: /y ��'r� OD�T.�tJ�� /���� i��iLG� �� � 1 �
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Taac Map: _�� Parcel: _L��%
Subdivision:
WELL PERNIIT
(New �Repair _ )
Lot:
Applicant's Name: �p�,�na � '' G,. ��� � �.3
Mailing Address:
PhoneNumbers: ZL��-�41�'-7y'�5 ��G�-SD�-d�5�v
Location of Property:
Permit Conditions:
1.) S'ee attached site plan for proposed well location.
2.) All applicable Stat� und Counry regulativ�rs gove-rning cdnsiructian and setbacks apply.
3.) Yermits expire S years, from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: Date: �
�"•Tew WeA:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Ai: Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer: _
Approved by: _
A�di+i�nul Co.mm�n!s:
Date Sarriple Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
tZoxboro, NC 27573
Certificaie of Completi�n
- 0%iner:
EHS/Date
Depth:
Grout:
DAoandonment:
Date:
Method/Materials:
L�cense #:
License #:
Date:
Date Results Mailed:
Phone:33o'-597-1790 Fax:336-597-7808
1ij26/13