A39 51Application Date: _��, �� � Tax iVlap:
Amount Paid: ��-�.,� Parcel �:
Receipt#: � ,.,� �-�
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. Applic�tion for Se�-vices . � :
lSevtic Svstems and Wellsl
L Improvement �ermit (Site Evaluation)
$200.00/$300.00 lif> 600 end)
C Mobile �-Yome �t�placement or �uilding Addition
$150.00 (if site visit required) �
Q Well Permit (Plew/Replacement)
$225.00/$125.00
�ervic�s I�e uested
���'onstruction Authorization
(Fee is de endent on the e of s s
❑ Permit Revision
$75.00
�. ❑ 1Zepair of Existing Septic System
No Char�e
Important: If t/ie iriformatian in t/ee applicatia►: for nn Imprnvement Permit is incorreci, falsified, or• ihe site is altered, d:en 1he
Improvement Permit and theAuthorization to Cn�istrucishall becnme invalid � •
fl) 5ea�vices R uested b: `
Name: .�.�ri� �/
Address. / �o -� �
����a . ,n.�. �
Phone # (home): �9g ,� �!�
(woriJcell):. ���,_ �g1-/..5�
2)1`tame �nd acidress oi current ovvs�er (nf d�erea�t t�an applicant):
Name: � � U., � / J�. �{ _
Address: /,��i, �;,,t ��//� �,
�, , T ifi � •
3) P�operty Description: Lot Size: S-/,,►�,��1 Subdivision: Lot #: �—
Address and/or directions. to Property: y� � U4 ,v �vc, r4 /2� �
���i5 � i'L�-.�1c�.r�h�� 42d .
4} �'roposed iTse ancl Typ� of Sta�ctear�: �
Residential �� Business/Type: Other
Number of bedrooms � -3 / Number of people served (seats/employees):
Basement Yes No ✓(with plumbing: Yes -� No �
Garbage disposal: Yes No i� .
5) Water Supply: • � .
Private Well .✓(Proposed `� Existing _)
Community Well: Pubiic Water System: .
Are there on tlie adjoining properties? No
Yes �— (please show location on site plan)
NoPe: A comvleted annlication fraust also include: �
9 A plat/site plan of tfie property that shows property dirraensio�ts and the size. and docation of al!
prvposed structures.
➢ A signed copy of the `Lot �'�eparatio�' form vea��ing thag the property is reudy po be evaluated.
��li S11�iYIIllttiHlg ��Y19 a�D�DI1C�$IOYI $O E'BC�li�S$ 58Y S�flC�9 �Y'Offi $�� �BpSOYI CO19Y11� �I�alf�! DC�I�Y'tffie➢1�. The
�nforffiation provided is ac�ur�ie. X ugader�t�nd t�aat �f any site fs altered or the antended aase chan�es, afll
per�iis �hal� beea�e invalid. �
�igs�a�ure (Owner/Legal Representative). � ,l, ��#e ; !� ,3� I��
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06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-�97-1790)
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T�x �Vla� : � �rcel »
Su;bd'i��isi,an
Fh�:S�e; S�ct+ian.'Lat +
��rmit �alid �or
Type of Facility: .
# of Occupants �
Proposed Waste�
Pmposed Re�air:
i�'ear�
� .
2 # of
System:
�prave�eut �ermit
I�Ta �piration /
New �/ Addition � '6�ater S�Pp�Y �% 1 �
,s Projected Daily Flow ��,b g.p,d
� � � � Type:
, , z r Type: �
PETmIt ConditioIIs: � n, ,n� J, CA �� 4��a r' KS ' -: _ .
Owner or Legai Representativ '�e: � Daie:
Anthorized State Agen�� � -. � � Date: /l-/3 D7
The issuancs of this permit liy t�e Health Department in does not guatautes the isanArrt of otl�es pennits. It is the m��pons�i��lity of the .
aPPli��P�Y owner m in sure that aIl Person. Co�mty Planning and Zomng and Bu�ing Inspections requsements aie met This
Iffiprovement I'ermit is snbject to revocation if the site plan; �pla�'oi� the intended use changes. The Improvement Permit is not
a$ectesi bg a change in owner"siup oi the property. Tlus permit was is�ued in complianca with the pmvisions of the North Carolina, ..
`Laws and Rules for Sewa�e Treurinent and Disnosal Susteras' (X5A NCAC 18A .1900). Neither Person �onnty�:itor�;tlie-'`'�
Environmental Heatth Sgecialist warrants that the septic tank systetn w�l cantinue to fnnctian satisfactorily in the fnture�or:tliaf.
the-water supply w�l remain potable. • �
� Anthorization to Constrnct �astew�ter System (]teqnired for Bnilding Perrmit) �
* See site plan and additional attachmentr (_�. ' � . -�
Propos aste�vater System: �;an�����io�;r+ I .. Type�_ Wastewatez F1owL'(�h. �.p.d. .
New � Re}� �'' Exp �on _ � , � Soil LTAR: . �.S g.p.dJ ft 2 �
Type ofFacility: Nr�� P�i�nhr� � � Basement_Yes No .
. � _ _��
� ��Vastewa�e� Syst�m Res�iairements
Tank Size: Septic 'Taak:' l0 �1D ga� PnmP Tatik: -gai Grease Trap: � ga�-- ,
Iaraiafield: Total Area: � sq fii Total Lengt� $0 ft ' Nta�mumn Trench Depi� ��an
' o�
Trencii Width <� fi lYYini�um Soil Cover: �g_ in 11Tinimu�ri ZYencit Beparation: �_ #t
Dist$�ibution: ��ist�'bntion �oa 5erial �istribulaon ]Pressure l0�ianifold . �
Specificaiions: t"i�2c� • is'�-�„ Q�-�ana � St1� ( C'�ver ove�r �'��S,�w► .
The type of system permitted is
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�e�l���i �8}�a��ntatave:
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I acc�t the spe�ifications of the
Date:
pCHD rev. l l/10/OS_
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Subdivisi n . � Section/Lot#
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Authorized State Agent . � Date .
System cn»rjlonessts m�»'esent a�b�iroxrmats�tontoras only.' The cantmmct+or must fiug the system prior to .
beginning the insta�on ta insrsre that pro�iergmde is maint�ned
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Tax Map �_ P�l # �_ .. Tovvnship:
Applicant: �n,r% ua , es
Subdivision. �- r „+ -�
�ype �f �Yatea- 5upp�y: _ Individual _ Commnniiy Public
�equirements:
Site Approved By:
Grouting Appraved By �
Well Log. •
Pump Tag: .
Well Tag ' '
Air Vent: ` �
Hose Bib: �
Gasing Heigh� '
Concrete Slab: � � ` �
Well Driller:
Well Approved by:
*�**�ee.At�ac�ed �i� Sketch***�
Liner:
'Installed by: _
Depth set: _
Grouted:
Date;
Water Sample:
Wells must be 10 feet from pmperty lines.
Wells must be 100 %et from septic systems,
Wells must be at least 25 feet from any building foundation.
Other canditions:
Date:,
PCHP rev 01.�271Q�