A39 43Application Date: �0 �
Amount Paid: 06.0
Receipt#: t� %
c� �
a���
�I�� �.�et- t C ��- �' 7--�-i
� O� Ex%olGd-`�l Tax�M #: �l - �'3
� �� 01�'O � Parcei #: �
� � �tN �� y-c�c-l��7��
�____��.s � I���.� ��� P���: � ���d�
- - .-,_ ������
�L_����� �.�na���_,�a�.�.0 ����..�����.��.
APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requ ed wner/a ent/prospective owne ): � e` S ci. V�T
Home Phone�� � i-� °' ?�(p Address: � ( 1 ��I.�X �l�-�
Business Phone: l —�� 13 Q
2) Name and address of current owner: �,nS�vi (��S. �-1-� _
-' (�i-�-Z1 1�.� � (i(L,+.��e.�^
3) Praperty Description:
Directions to the propei
Lot size: y�•��! Township:
y (Including road names and
�e! 1 � �� f1S"�'-2Q� �`}1-r
�
�T�
�Q-nciSCsi��!' S�i�i�F.Q� "
4) Proposed Use and Structure D�scription: answer each of the following questions:
a) Proposed 7t , Existing , Type of Structure: %n, U�-s � Wdth: �o (7 Depth: 3 p
b) Number of Bedrooms: � Number of occupants or people to be served: 'L`
c) Basement: Yes , No X Will there be plumbing in the basement?
d) Garbage Disposal: Yes _, No X
5) Water Supply Type: Private �, (new _ or existing�, Public , Community_, Spring _
Are any wells on adjoining property? Yes No _ If yes, please indicate approximate location on the
site plan. t�v��f /c,�o��, �1 o���c� hC�%PiC(pS�'— f D
�'�c�'as�zP kv:.�s� S .•-F�
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No�� >
d vl. � �
PLEASE NOTE THE FOLLOWING: � �� uPp`�r �`�"`�`G�' °�
�'lc•-� R , v v-r
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITfED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF QLL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid.
���L� P. g -- 6 � D�
Owner or Legal Representative Date
PCHD, rev. 06/27/02
� ��� �� ���� �� � i
�`v 1�.c
� � � ������
�IL�.�a. ��t�'TIT TTTT_ CL�.���.� 1L ��ia�.� LL�1L3�-
T�x Ma� ,�. � arce;l �
Su:bd�ivisiari
Ph�•s�e,Sect,ian:'La�t �
Parmit Valid for 1' �ave �E
Type of Facility: V` I�� '�"
# of Occupants �� # of
Proposed Wastewater System:
Froposed Repair: �e�
Permit Conditions:
Owner or Legal Represe
Authorized State Ageat:
�T ., . �praveament.�es�mii,
Water Snppiy J��
g•P•d-
Type:
Type: �
The issuance of this pemnit by the Health Department in does not gvarantee the issuance of other permits. It is the responsibility of the .
aPPli�Pr�P�Y owner to in sure t�hat all Person County Planning and Zoning and Bu�ding inspections requn.ements are met This
Ymprovement Permit is snbject to revocation if the site plaa; �pl"�r'or the intended use changes. The Improvement Permit is no�
a�'ected by a ciiange in owner"stup of the property. This permit was isgued in compliance with the provisions of the North Carolina, .: �
`Laws and Rules fnr Sewaee Treabnent and Disposal Svstems' (15A NCAC 18A .1900). Neither Person �oun#y�: �or��t�ie-` �� =
Environmental Health Specialist warrants that the septic tank System w�31 continue to fnnction satisfactorily in the fntnre or�#liaf .
the�water suPP1Y will remain potable. _ � -- -'--- --- - -- _ -- -----
� Authorization to Constrnct'9Vastew�ter System (Required for Bnilding Permit) �
* See site plan and additional attachments (�. � -. .
25�1�� .
Proposerl ter Systezn: EZ •� o Ty�pe W�Stewater Flow �g.p.d.
New �/��Rep • Exp ' .� Soil I�� ..-.� g.p.dJ ft 2
Type of Facility: �� P Si'� �. � � Basement _ Yes • o .
� �i�Vastewa�e� System Req�rements .
'aank Size: 5eptic Taak:� 0p gal Pnmp Tank:�--gai Grease Trap:
Drainfield: Total Area: /.20v sQ it Total Length DU ft � Ma�mnm Trench Depth % g in
� a� .
Trench Width �, ft NYinimnm 5oi1 Cover. �g_ in M'in'imnm Trench Separation:
Dista�ibntion: ✓ I;istri'bntion �oa
� Seri�l iDistribntion
Pressare 19�ianifald
���%�irl�cl"�
The type of system permitted is Conventional � Acc�pted Alternative. I a�cept the specifications of the
P�- � I
�er/Iaegai �taprrs�ntative: '��`'�''� ��``-� Date: o� • 1 � • �
. PCHD rey. l l/10/QS...
� .. .
. �
�
'�''�wo.
i
i
Sf,�,E..L � I''� Z,ob� ,� �
r e
,
_
r
�
.��-,�,5� I��I�� ��T � �
� � �:���� �
�m���� � ��� ����.
. � SIZ'E S.�TCI� �- . .
Name � Taz Map # �'3 `i . P�cel #_ �' �
Iiru ��a�rn_�
�rn
Sub , _ � Sectian/Lot#
_ � q 25 �
uthotized State Ag�ent . � Date .
System cn��ionenis m�is�se�n a�ipr�x�s�co�t+vra�� only: Tha confiwctnr must, f�Csg the system prior t� .
�n • �f
beg�m�ing tlu i��stalk�ion to i�sxre that. pm�'b•��e is �raintair,ed
� _�� 4 �� �� _�
—�-� .
. -1—�.t�a�� S Sfer,n
U —
���o � �� j � ��.
— �6p' /-�-r.�e�ea(l. 3 L71?f'-
_ �g �� �-e,�c� �aff�y►'�
� i�'t�OX O1� S�ei�a � eh'.
�-� � �looX 4�aiil�+.c,� @�ua�
�
�� ��� �� ��
��y'� .
w
�� �
� �
� '��
� i �
',�(fe - in5fk��a%a� ��e��r�
/'V�An�a � �
C � 'r'm hcust S j �'e �
���_ SePf�c are� �
ApplfcaEfon Date• � /� �
Amouet Paid: . �
Receipt #:
`—.�� ,f �Ad��l'� T�A�ap:�1���
� � ��„�...� Parcel#:
]�mvia-�o,as.xzn.�aL�ml �1[e,aIl�.3a
Servioes
0 Is�pravement Per�it (Site Bvala�tiosj
5200.00/5300.OD if> 600
obik Hum eplaeemeat or Bufld�g Addition
$I e€siDe visit
0 We� rmit (New/ReplAcemontlRepalr)
$300.00/$200.00/�75.U0
for Servicca
0 Ceu�traetiomA�ctpor�rat�oo
(Foe is dopen�nt oa tbe tYpe of
❑ Perwft Revfa�
❑ Repsir otS�ti�B Se�lc S�nEem
Applicetiw: No ChargeJ CA SIS0.00 w$30Q.00
xl) Applicant Iafor�ation: .
Nsme: C.s� r"r C.' , S G, rx, v�� S r
Aadra�s: : �_ ��'v''.d'1:��-�C=i r` c•�
� Gk�''' C'! �_ r�'� NG � 7 5,�'�
2) Name a�d addr s of curreot owaer (if dt�ferenf than appttc�at):
Name: �
Address:
P6one (homs): 9/? - IF�o- /,� �S'
(wo�dcetl}: 9/2 - 9/� - �%/6 ��
Phone:
3) Propert�r Deacription: [.ot 5ize: c� li Subdivision: Lat #:
Address and/or diractions bn Property: 70 i<--ew, c lJ� .� �-} ��•-��'
CZ�,:�� v: r� �"�<._' -'-7 S` 7� :" s"r� ,��s.��1� r��E'v.�% �� cii=�' o f 5�:" G,� /-�'�� �i
�' D yes r'��p Does the site �ai aay j','dianal vretiend9? �, r:.:�. �.. J1 �G�.v_ /c��� �o r�..z So:.��, ,
[7 yas � no Does tho sioe coirt� a�r exiatmg � systems?
❑ yes �"no Ls eny vrastewa�er goiag to be geoarabod am the aite otfior t�►►an domeatic sewsge?
� yes C7 ao Is mo aile subjeat t�o approval by► ao0' oth� pnblic e�r B�, y�i, .t� ,�w s� ;.f o N;s P � a H M, a� /; ��, f
C] yes �no Are the� aay easao�b or iight of ways on this propr�ty't %����✓Cj
(if `yes' is c�ecloed, pl�ase provic�a suppoiting docume�tion)
� ��-�e��/�s
4j P�posed Use and Type of &ru�tt�re: `�,u�f �oi� C�t/5J'e��f�
❑Resident�! y•
('3 New Singie Famiiy Residenca Maximiun number of bedtooms: _� �
❑ Expanaioa� of Existing Syatem lf expan�ian: Cunent aumbar of badroom�:
� R�air to Malfunctioning Syst�em 9Ji11 tha�e be a basement? ❑ yec ❑ no With plumbing fixaaas? Cl yes ❑ ao
❑Non-Residential
Type of businass: /'=��. rr� Totat 5quara footage, of Buildfng: '"�(>6'f �'�5�,.�•��sG��.�i�
Maximum a�mber of emplayees: Maximum netmber of seats: "
5) Water Suppty: ❑ New aell ❑ Bxisting Wall ❑ Cammnnity Woll ❑ Public Watar CJ Spring
Are thete any existmg walls, eprings. ar exi9ting watetlines an �is proParty? � yes C] no
6) If appiying for `Authoriz�Hoa to Conitrsct', pleese iudicate pre�rred ey�be� type(s}:
❑ Convor►tional � Accepted � Innovative � AlteraatEva ❑ Other 0 Any
I cert � that the information provided above is com,plete and carrec� 1 also understand that if the infon�zation provided is
inaccurate, or if tlie site is subsequently alterea( or the i�rter�ded use chweges, all perrrrits caed approvals shall be imalid
ti
� .�''C��-
Si�nature (Owner/ Legal Representative*)
* Supgorting documentation require�.
ii �' v�
��
Permits are vaqd for either 60 maaths or Are noo-eapiring w�eu accgmpsinied by an approvec! pla�
A rmm�leted �l.nt Pr�armtinn� fnrrn nluftt aCcnm[foIIV sIIV ZdDi�CBt�on rennirino n Ritn av�la'Nnn
��� J �� i .:�:� ��� �.��
� �_ v � � � �✓ � � � 3. �
JL�'T�"r1.��.T�O'Y'��.'n"n ��11_¢�.� ��'�LL.���
�� ��� .� �� ���� �� �- 3
�1 t:iLJ�Y:i! 1! LL�4N{l
U" '�,Q��'o'r'yt,'S� o o {� `t�
� o� o^ n o 0
A�plicanf: � �/' � x�► � .
Location: '�9 S o� L�-.� `S w�^ S�Pa �� R,� � o�- o�
.. �
P�s� # `t �7
������ � �� �� �-Z
� � � � �-J
Syst�m Type (ln Accardanc� Wifih Table Va .
_T�ilS �'�S�'�3i� ��� �E�t'� �SVST�1.LEi� 9r9 CflM�'Lls4iVC� VlftTii �►PQ�3Cra�L� .I�ORTH
C:��C3Li%II� GE���►L ��'a�,T�lT��, F`U��S �t�R S�i►It�CE TR�►7�PIIEiVi ,4�ID DISPaSAL,
,��iD �1:L �t�Ni�ITiOiVS t�F � i�3E 914�Pi�O�r'E�Ei�T PE�Vl63 AND Ct)i�5 � RUGTION
:�Li�'3-�OI�l�►�'30N. �
, -
. � �-/�l /o �' �., �;
Authorized State Agent Date
lnstailed By; %� . L� w i S Date:. c� �-�)I �O 9 .
:- � .-�
�
.� `�
� : � =`�
� . �-
�
- PvC �s��
SvPPL�( ��
' L�N E r
SGt?-� �: iV T S
y��� fy,.
�t'�i'/�.
� H�
' 1�
pRo�R�'Y L�iV E �ti ��'
C, �. , o �
� �. ^ so'
�3 = ��o' -
L, y- - 1 f �'
L S = � �o �
-?`'o�� � = 400 ' � 2. � �. o w `•
i � lo `�/08
�TS - ��ov
5-r 6— 3��- -
�
�� v E
� �e- .
-� Co�-•� Q � ��� � s a-, / y
�o rP�s P-�i" Qi' y-� .�., � o-� 1 � S.p� �`� iv�, ,
c
FC; �D; re�. �7!29IQ4
�
��:r�i� ��1�� �����'� � ��� �°�i�'�'��S! ���� �� � �����'
Tax Nlap ��. 3� Parc�! � ,1-�3_ Syst��a Type (iabie Va)
Ovvner/Applic�nf C�4 ��r S,L-,a �Pi' SubdiVision
AddresslLacation ��� ; s w��s��r) Se�fPhase Lot #
God,o Rr�, . �
Se��c �'�ea� �ni�sa Q���� �i�a�dc����ra 'r�� ��a�#�a a� �
State�lDldate ��-3ay i�,b�i/� Ts�/oa.l„/� Tre�cf� Width 3 fi �'a�,. oa/r�/
Ca aci (o�� _ al. � � Trencf� De ti� /S in.
Te� and F�1ter � � Trenci� Len th 4� ft.
� Baffie Tr�nci� Grarde
Seaiant Trencfi S acin
� Rise� ifi a Iicable � Roc�, De t� ar�d Quaii i4
- Tank Outiet Seai Dams/Ste dovvns �ic. ; r��.► oa-/��/v�r
Permanent Marker Pressure Later�als � N �4-
P�am� �'��k � iiJ / A Hoie S,�acir�q � �
Ca ac'ri � gal•
Wate 3roof /Seaiant
Riser
V1/ater Ti ht
��m�
C�ec�C ValvelGate Vaive
,Alarm (visable and audib(e)
Electrical Camponents
Rate (gpm)
Appraver� Pump 1Vlodei
Blocic Under Pump
Pum� Removal Ro�oelCt�ain
. ���is�t�abu�aon. Sys�rra
Serial Distribution
ressure Man� oi
Low Pressure Pipe
A�pr. Pipe i�ate�iai and Grade
Vaives
N,
S1e�ve
F�qu�e�s�� Seibac��
Frorn� Wells n�o�t ��; I(Fj
From Prape�iy lines
Stru�tures/Basetnents
�tc es / ralnage .a}�s
Surfac2 Waters
Public Water Supplies
Verticai Cuts (>2 f�.)
Water Lines
Ve�iicle�Traific �
� �Easements/Rigi�f of
� �9�es�
��.i���� �asesnenis Rec�rd�
�e�srn�n�
�c:,d rEv. �/1�/O�i
� J J
�, �,� f
�.,..., �-�- � � �T���
I���n�-���.����.11 IHI��.Il¢Ik�.
Buiiding Additions/ Mobile Home Replacements
Tax Ma}� #:�'�_ Parcel#:_t��_ Address: �O/ G��� Gv, sf �R�:i�
axt���'-�. NL 27S"�`l�
Approval Requested far: Mobile Home Replacement
_/ Building Addition 2$ur.�,Q '��� f-r-c�y s
oh, z. �%� /e 5 �
Applicant Name: � ,,r,i/£,�
Address: /y5� fi� , l-�c� r�' � rLl`'� --
�= !-�n�z. l (�'/<,N!'.� 2 75' t �o
Phone #'s: �1 � - �E.<� -- /�G ZS2'l ,ul .�-- 9iy - � � � � �� z!/�
Permit Located: ✓ Yes No
Installation Date: �,p . Design flow: �(gpd)
Current Contract with Certified Operator on file (if rcquired): �,�-.
Water Supply: ✓ Well Public or Community
Wastewater system shaws no visual evidence of failurc on: 11/� �i �. (date)
(Ap l�icant's signature if site visit is not required) _�'C � �
Addition/Replacement Approved
Environme tal e Specialist
J/—�%7'
Dale
Person County Environmenta! Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 ww��.personcounlv.net