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A40 167Ap�lication Date: o ���7 Amount Paid: ,�GCI. Qb Recelpt #: � I ��� d o� �3��� �� 11 � �� Tax Ma #:���� �o�j --_`--��_��" �I�I�.� �� _� 3 ' -- � � �l� "1I'' �Y" ����a� .m:��-..�.�..��.,��..0 ��ma.��-a ��� ��� � .� APPLICATION FOR SERVICES Parcel #: ,Fi-1 �Yw�.�,�� Cali o� ��� i ��� � �,.� � '�Q /Il� IF THE iNFORMATIOId IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED. CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHOFdIZATIOM TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: (Owner/agent/prospective owner): ���� S fl�j �� a y�j � Home Phone:�336) 54�t- lb 8� Address: 3!'-� �� t-�� 5 f� D. Business Phone: a ti� o� o�NC Z'� 5� N 2) Name and address of current owner: �� �r-�- : s �'� 1\ :��s o� l�o� 1� CO.��..��� {3fO.:.K2. 1..��n�. RokbOra� �'`'�G 3) Property Description: Lot size: 7._ �l L� Township: �1� (�:�ar Subdivision: Go�N�-� y�t'�k�. Lot # 1� Directions to ihe property (Including road names and numbers): G�^ �- o F c o a d o� ('.�, �� �-r v � f o.� 1z�.- 1., c._ 2 ���' a�' Nn � t„ {�� �: s fl. o� _ 4) Proposed Use�d Structure Description: answer eacll of the following questions: i a) Proposed ,, Existing _, Type of Structure: Irlo�sa- Width: �'� � Depth: � D b) Number of Bedroom� : 1�_ Number of occupants or people to be served: � c) Basement: Yes ✓, No _ Wiil th re be plumbing in the basement?�qLS d) Garbage Disposal: Yes _, No � 5) Water Supply Type: Private �new _ or existing�, Pu ic_, Community�, Spring _ Are any wells on adjoining property? Yes_ No �If yes, please indicate approximate location on the site plan. . 6) Does your prope�ty contain previously identified jurisdictional wetlands? Yes_ No� � PLEASE NOTE THE FOLLOWING: � A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. y PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. _ ➢ THE PRUPOSED LOCATION OF ALL STRUCTURES MUST BE STAF(ED OR FLAGGED. T- THE S�TE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEPIT STAFF. I hereby make application to the Person County Health Department for a site evaluation fo� the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and rep�esent the maximum facilities to be piaced on the properly. I understand if the site is altered or the intended use changes, the permit shall become invalid. _ Representative g � o� ate PCHD, rev. O6I27/02 , ) . � ������� �������� ' ��' � � �-�.L�i � J!. ' � rs�s�� -*-�-, <e�.�.�.11. I��.s�.�-�1�. Applican� Location: ���at �alid �o� LG �ve '�e� Type �of Facility:_ S i ` ## of OcLzzpant� 1(g � of B� Praposed Wastewater System: _ Proposed Repair: ACCr�c��c1 ( Permit Conditians: � . l�, . � U1C'� ► , �x Map ' a.rc� � Su;p.d!ivis�ian '� . Fh�s•e S�cGian Lat ':' � Inaproveasent �'�rmit �+Io �i��tion IwP 1\ �� New �o Addition -- s -3 ��� D�y �ow �(�a _. Uwner br Legal Represen tive Signature: AuthoTizerl Si�te�Ag�ut: � � ` -�. �ate� �n}��iY Well _ g.p.d. Type: ��� Type: `� Date: � The issuanca of tUis pemiit by. the Health Department in does not guarantee the ;a�,a„�s of other pe�its. It is the responsi`bility of the" aPP��P�Y owner to in sure that all Person Cou�y Planning and Zrnung and Bwidmg Inspections req�uiements are mei B'his �mproveffient �'ermit is snbject to re4oca4ion if the site pIa�, pl�t or the intencded use ci�ges. The Ymprovemeut Pers�it is not a�e�te� by a c�►�nge in ovr�ersiup of the �roperty. i7�is permit was issned in comoQliancx.with the provisians of #he North Carolina `Zaws and 3�ules for Sewage Treutment and ]Disnosal Svstems' (15A NCAC 18A .1900). Neither P�on �Connty nor tii� Enviran�aeatal �ealt3i Spes.ialist'w�rrants tha�. the septic tank system wn11 cantiaiue tn func#ion. satisia�ttoriip in ths fu#m�e or'that the water supply wi71 remain:pota�le. - --.. _ � . . . A�thori�ation � Cons#r�ctct Wastewater Systean (�tes�ire� for Bt�ciing Pe�s�mat) * Ses site plan and additional attachments (�. Proposf d Wastewater System: `��/Pn'i�` c�� � Type �a � Flow �:p.d. �tew J Reaair ExQansion� . . Soil LTAR: � g.p.d1$ 2 Type of Facility `� � � i nalQ �i �t..t (i w�C�Q-i r2Q Basement �Yes _ No � ' - . —7- .. �astewa#� Sg�ste�a I��nareynents � '.�ank Size: Se�ic Tank: ( O� g� �p Tank: -- gal �rease Trap: � gai �rai�iadci: 'Tot�l Area:' � Zob ; sq � -7'otal I.engtL �Dv ft � 1l��nm �r�nch 3�t� / �, an Tre�c�'PVid#� � ft t�'in�uffi Soil Cmver: �Q: in lY�i��am Tre�cii Se�aa�ation: / ft �istrA�ataon: spe�iffica�ons: ��tribu�.ion �o� �0 Se�ial �ist�ution k°ressaire Manifold u� za 1��SilP n�n�►-, 1�-i`►►„ ?�i ii��i-i`�n� n:-,�,-�-r���- Env- �JQ� DU�f -�-597-/7S� A�aorizeri St�.te �.g��t c 't1 �1 Pernat ExQiration Date: The type of system permmtte� is � Canventio � Permit � � i ���1��ga1 ��prese�ialive� a ' �� � Date: Alternative. I ac:.rpt the spe�ificatians of the D�: ll�� lo y PC� rev. l v10/OS Applicatiou Date: � ;� 13 Amount Paid: Receipt #: � ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) 1�.Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 ��� � �" ������ Tax Map: ti`O � • ��.- Parcel#s 1 rn� .�..,, � � ���� 7L.�ma an-��,��.�.a;�..11 7L—iC��.11�:::tr. Services for Services ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: /Q, j�. .11��r�� Address: � 6? �o� F,.� rir�o (/.e l�,.� �oXbora /V � a-7� 7N 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home): 3 3G -�9 R- S� I 6 (work/cell): �36- .s-oN-o3 �8 Phone: 3) Property Description: Lot Size: a.�6 Subdivision: ��...-� L3�.ke Lot #: I�f Address and/or directions to Property: k9 S-/�1��., 1Jo••� - Lo,_.,-4�•i B �u�k� L�.e - lof5-� �.,o..1N o„ rrc�lni" � yes ❑ no Does the site contain any jurisdictional wetlands? �"yes ❑ no Does the site contain any existing wastewater systems? ❑ yes � no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes I�"no Is the site subject to approval by any other public agency? ❑ yes 0 no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no on-Residential ypeofbusiness: dc�}Q��c� qo�,e Maximum number of emp(oyees: Total Square footage of Building: /O� Maximum number of seats: 5) Water Supply: ❑ New well � Existing Well � Community Well ❑ Public Water � Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. 1 also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. ��;(/L S a t �3 Signature (Owner/ Legal Representative*) * Supporting documentation required. Date Permits are valid for either 60 months or are non-expiring when accompauied by an approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/I 1) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � �. � J � � i � V�. ► � � � �J ��� ��L�TIl��IL�Il�[n,c�IC�¢�.JL �c��.11'�lk� Building Additions/ Mobile Home Replacements Tax Map #: y0 Parcel#: 1 l0`1 Address: lt� $ Coil�,�.� �c� La Q.�x�b�Yto ta c. �'1 S � Approval Requested for: Mobile Home Replacement X Building Addition Applicant Name: � K �v�v� Address: Sqr� As �a�r'e. Phone #'s: 33b� s q�- 53tb 3'�b - so�1 - d3$� Permit Located: Yes No Installation Date: 2(�o o Design flow: 3b'G (gpd) Current Contract with Certified Operator on file (if required): ��1 Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on: (date) (Applicant's signature if site visit is not required) Comments: �1�cc.avEO �R- �'tAc�.D �nAb� �'32� X3'L ) �� �° Pwn���� �x�.v�s Addition/Replacement Approved �.�....� Q -�� � Environmental Health Specialist � a� +3 Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcounty.net ���� �� ���� �� � �v� ��— � � ���� �aavas��.aan�oa.tE�.� g��.m���in �•�� B u r�,� SITE PLAN Name '�+�� ^ � Tax Map #� Parcel # / � 7 S�b 'vision �ke Section/Lo ��� �� Authorized State Agent Date System campoaents represent appmadurate conmurs oaly. The conrractarmusr tlag the system pdor begmaiag the lasrrl/ariaa m insurr that pmpergrade is maintaiaed. . 29�.3�� �c� -�� � ` �g��k°''� . � �s, 4,� - _. � � � �� in, �-;� �D�g� N r '� c� c�nv. �inQ 1�'�-, -},--�„�.., d��-h o' I • �o , 80 ' .�_��S i �o,. � . � VO � � � Q,r � � cr�ek �� \ Acc.�P�d �as��a i'-eciLcCT1'V� �-z �/pw U Y ��_ ���, �' '� N�a,n-�c�:�n e�l\ �� bc�ccks � � �a���� � inS�Ql1 S�S-ien� on C�-�r '� � n��- d � S-4uri� Sui I� n�a�n�`,'e ld . a Y-es� �r� c le�.+ri r� 4�e ( o-k- . �� An,� c� U�-f��o� C;�r�+ac-� En v. I�PaL� � � 5�7-� ��� n ���� �� ��.1��� �� Vr �� `�•-''j�. .`�/ ����� ��n�a-ao�-++ TM� �s�.��.� �-���.��� Applicant: Location: �x M�p � � � �rc : I - ub � ivision �� a�. � ' � Ph,ase Sec .ion: ot # # of Bedraoms . . � �' �� � � 9� I� �Z ��o�,J System Type (in Accordance Wifih Tat�le Va): �L.� THIS SYS'i'E3VI t-flAS �EEN 1MST�►LLE� 1�! COiVlP�iANCE 1dVlii-9 �.PPLlC�.BLE . NORTH �i�ROLlR[A GEi�E�L STATiJTES, RU�.ES �OR SEINAGE 3'REAi'ME�lT AND D(S?OSAL, AP1D - AL.l. COIVDITIONS OF � THE 9iVIPROVE�EIVT PE�flfIdT At�ID CaNSTRUCTION ,4UTH0�?t T1ORl. � . � �e�/ �: a/to/o � . � ufhorized State Agent Daie lnstailed Br �` � � o�t�: � z «l0 9 . - C1Q�s�1D �1� , IS _ Pv� ����i� �1 �g'� t 16 � � r r� - � �� . � ,��61� � lo'!� � �� ��9 c � , ii� tt,. �fis l�� 57��1�z ,; lD � � . � �,��5 FCHQ, rev. C7/2Q1Q4 � (f� ����G �'��K �NS�'�'���OR� �u'�E��.l�7' �'9�e 99 a I� Tax f�a� # �" Parc�! �� Sys�terr� Type (Tabie Va} Owr�erlAppiicant � Sui�division AddresslLocation Se�fPhas� Lot # � State-lD/date S.e.� 5�2 Capacity � 8c�o .gal. Tee and Fiiter � • Baffie Sealant Riser (ifi appiicable) �F'ank Outiet Seai Perrnanent 1Vlarker Pum� T�nk 1Sealant Riser ChecSc ValvelGate Valve Ant�-sia on o e �11arm (visa�le and audible) Electrical Compo�er�ts Rate (gpm) , . Approved Pump iVlodel Blocic U�der Pum� � Pump Removai RopelChain . �Dis�abu�ion:Sys�s�a Serial Disfribution Pressure N1ani oi Low Pressure Pipe Ap�r. Pipe l�ateriai and Grad� Va[ves � 0 Trenct� �dth� 3 ft. � Trench De th in. T,renci� Lsn a-� ft. Trencf� Grade � Trencf� S ac�n � Roc� De th and Quai' DamslSte down� etc. Pressure Laierals � Hoie Spacing � o e �ze Pi e. Sieeve Turn- s/Protectors et Requi�d' Setba�9s� From� We!(s " From Property lines StructuresBasements itc es ! rama e .a � Sur�ace Waters Pubiic Vilater Su iies �le�tical Cuts >2 ft Water Lines Ve#ticle �Traffic � � , �Easements/Ri ht of 1t� �es� � . �asements Recae-ded e e erator oi Tri-Partate A ressnen� Comenera� . . � pc7d rev. 3/1�JQ1 ��.'.. ���';>..`::.'::..,::,;.:;.', .'.::'''':.. .�.. .+.._.�,�' ,...,,..;.�.... �.:,�.�,�.�... ., �, ...� . '. �''�;�:►;.:1 .�� . .���� ��� .�.T,^.�.�.; ;. � : :�!:�.•'�m�.� � . �.]TS?::�P:71a]L:,dA'�f�''� .r„»r.n�.�4!L,231.`�:�:'v,T.�:It'�-':ll:":+.:LA_'cEr'9Z'���'�1L�:�: 3'Y3J�L Xa•���Y111 � �9���L' 17i:r�.t'A311"�'L.�9:�8J gn•tA�� ��A1 Wl'L'9�Y.! �7d1JL'i L�Z�CJ�& Tax Map �c'� Applicant: � Subdivision � �� Location: �-1 q s - Parcel # l� Tov�nshit�: � Type of'�ater,5upply: � Individual �.tequirea�ents: Community Public Site Approved By: � � `'`�! �� � �"�" �� � Liner: Grouting Approved By: � ' �It�stalled by: Well Log: �_�/ l� �,; 5� �( p J Depth set: _ Pump Tag: T c.,J a`����/� 9�' b'� Grouted: _ WellTag: 6�.J � oa- �a� �o,,,�eo��c�,Date: _ Air Vent: � Hose Bib: � �JlTater Sample: � Casing Height: Concrete Slab: � Well Driller• � �I � /1 S Well Approvec� by: '�d�1�� �� ****See Ai�ached Site Sketci�**** ���ells must be 10 feet from property lines. ells must be 100 feet from s�ptic systems. � Wells must be at least 25 feet from any bui3.ding foundation. Other canditions: Date:,'`����0�' an� PCHI? rev Ol/27/04 03/04/2009 15:34 336-388-5940 EVANS WELL DRILLING PAGE 01 .._ ..�,.. ...,,��.,,,. .. ,. \`�°�-•`� �'�.�'" � �.°�.!1�`�!��.' _� �:� sAJ�li�l�" ull� �" � 1 �' I �J / / � . ���.�.'�' F � � �� . �- � �� ��R ��.''� �,14�.�. �2 `i � ��r t' / �K'" / �:�..,uac-�.�o�u��.,.��:.�r.D. �E-iiC�cn.�l�:ik,. ��I�C� � " � `Z �1. �. - �i'dC�ll� X�O�' ,,-. 4wt�er: _..� _%i � a � k �.____....,,._ _._._.....�._ Tax, Axari �.:�,�� P�r�nl '� �. � ' / �:c�;at�on; � — . ,.�_.---. T_� -� -- _.�,.�,.--- �u�'!�'�`�tiIQ.G: ��.-•Y `-�r ` r'u C li��. �.At #� � W��1 (=QAS�"ACtjOp I�Di�►C� �'zom nessast Pr�'�; Li� (N�7zimum I O feet) Ir✓ _ T7ist2uar,e Froxn Scptic �y�m {Miuimum 6G feeC) �✓' Tar�,i Dep�i�: �. U f� Yi�ld• f�pbi Stat�c W�te�r �.evcl: ft ....�. �? .�.- V4 ater ]3earix�� ?.'c�nas: �� `��� _ ft j�,,,� ft ,,, -�.�.-'�„ � f� �.�...,..�„�_ f� Gao.sin�: �c�p�i: Fa'�a]x1 ,,,,. �, Q-- #0 �_-•-- �' Di�17CUeT': �_/�._ in T'y��: +ra�3�ssz�teel �„�,,,!_,_ .,:� ( �ei�iat 'i'�ucknea�: fi�iglax abov� (3xott�ld: .,,L,�. t� Drive ulxoe:: ,,,,_,r� Y�s �! Na Any proi�l� asieorssit�-ed whila secc�ug es►aizxg7 .. `rea „�'�To [f "yn!s" gi.v'b i�eit5�i7.' ._.�........__ -,�.,.� �ruut•.� I��t:: Sa.*►d/Ccanenx Cox.��r.te C�►vellCe�mr�t ... , _ . Annul.ar ap�c�'W'icltti ,�__.__ �ches wAr•r iu 1�utu,��t' S�a�aa� ._._._Yea .. l.�l a M,ctJu�d ��x` Grou.: �'umpe:c,i ,^ _._ Pres�ixrr,,..... .. l�'r�red t/ L3c�pth ,�„�_ tu ...,,�.,� Pt ;1� at�lr�ni�n US��: . Tva- �3�t�� f'ortlan� cenurit,,,„_, W�aght of i�3ag �Ps�anad� If mix�ar� (at��3, graa�cl, cutti.nge� —�tiu 2� tn �_....�. :l;L;� piates: ,'!r Y'�x __ Na � x 4�lab ,�'ea „�_ Nr. 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Raxin�: _ --._._hP ._.�—__ �P� 1 t1r,r�by c�r.ti;,=y tt,tit Ckais p�unzp '���s �r.��i��a Zna t�� w��� n���. �a��p�ncct ������ng t� �C ��$o� r,�„��Ty w�t� �.u�� �� e��e� �7u rhiF dgr� and that s aopy cf thi� re�:or� has bear: p�rovidQd ta �i�� we11 o�vza.ar. ���p ftnstail�r Sl�ns�tur�_—....,.., _.r..�,._.____....._..._.._...�.---- A$te: ,,,w_.�,..�.�.__ :�'f,:i�D �r�v O1/'e"•04 _ ..,.,�, , , �.,�..�.. ��.�.--�-� , G�aG� �LL�IC': 44:!11 F.f•lGl;; �,J�%1iC� 03/62/2609 00:09 336-388-5946 EVANS WELL DRILLING .�,_ ,��,�,,.-•.,'»».. • 1 1 .._�1_r ���y�� �� � y ��� � 5�� y W�',�.�, A��3AN1)ONMrN'1' 121:C'.t)RD Nnrth (';�rulin�i I)crr�rtmcni u1'I;uviro�lil�Cilt:inJ N;Iti�r�] RC�ouPCr�-1)ivisiun i�! Watcr I�u,ilitl� Wk:l�t. t'ON�I'RAC"1'OR <.:i:R'1'IFIC"/�TI()N # .,,,,� � �3 � t. wr:�.�, t't)n�r�t.1c "rUK: �� f�. ( �1 �_!...�..'t �': '� ! ��.�_��...� .. .__ ..__ ............ . 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