The URL can be used to link to this page

A40 181.. Person Courity Health Department . � Sewage System Improvements Permit � Date:1�:�1.This Perm't Void After � Years �err�it # E�� , Owner: w . C' o_n�t� .,,�_�� SR# � � Location/Directions: _� S� y.�-'`, Subdivision Name: �� " K vP,. i l�u �:{� ��, Lot # Lot Size: `�r..33 G't C�-�_s Type of Dwelling: Water Supply: Priv �• �� Public: Community: Bedrooms: �. ge Disposal Basement Baseme 'vc $ INFORMA BY � � ' $��: ��,.� owner or represaitative REPAIR: REEVALUATION: Size of Sepdc Tank: �,�� •. &,illons Size of Pump Tank: ---- Nitrification Line: ��7� 0 � .,; Depth of Stone: 12 inches �/ Maz Depth of Trenches: �p« Altemative System: Conv. Pump LPP Pump Remarks: Date Well Approved: Well should be 100 ft from any sewer system BY Sewage Sysce A roved: �' �� B G Sanitarian � TIFI ATE QF COMPLETION ,.� Contractor. � „vq,,� � ------------------------- � Sewage System location. installation, and prote�tion must meet state and Iceal � regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained by owner in such manner as not to create a public health hazard. Septic tank and nitrification line must be inspected and approved by a member of the Person Counry � Health Departrnent before any portion of the installation is covered and put into use. If � ihe site plans or inter�ded use change this pemtit is subject to revocation. (G.S. 130 A-335F) � oQ � L,ocation of sewage disposal sewage system sketched on back. (OVER) ,r' r �� oun�y Health Department Well Permit �iSate: '�'�! This Permit Af�ter 3 Years ,,� i .� of�� .:10� �`9 Locadon/Directions: � ' - - Subdivision Name: � ` " Lot #�► _ Drilling Contractor. � �J .�.,r. s ��!'.J..1/Ca- , , Distance from earesf Property�Line� Distance &om Source of Polludon d � - Total Depth: � Yield: �.��d GP dc Water Level �� FG Water Bearing Zones: �De �th '�� F� ��FG FG F� Casing: Depth: Fro�n U to _��Ft Diameter: ' Inchcs TYPE: Steel • ' -�- Galvanized Steel ff Steel, does ownec'.approvei ' Yes No • Weight �_'!`lncimess• > ��-Height Above Ground:; T�-�nches Drive Shce: Y�es No � Were Problems Encountered in Setting the Casing? Yes No ` If "yes" give reason: Grout: Type: Neat Sand/Cement —Concrete � Annular Space Width _ . ? Inches Water in Aruiular Space: Yes No_s� Method: Pumped Pressure Potaed� _ Depch From �� to �C�F� Materials Used: No. Bags Portlan Cement � Weight of 1 bag lbs. If ' re (sand gr8vel, cuttings) - Rado• '� to � � � ID Plates: Yes �o � 4 x 4 slab Yes No � De th p From To Foan 'on Descri don � n� ✓ • `'d I HEREBY CER'I�Y THAT THE ABOVE WFORMATION IS CORRECT AND THAT � THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS S�i' ,,, FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. `J`� � _i . Signahae of Date Issued I � Sanitarian's Signature Date Completed Sketch well locaaon on reverse side. . APPLICATION FOR It�ROV'EHEPZT PERriIT DAT�: 1. Permit r/eque ted by: Addr.ess -IOL 2. flame and address of current owner: Home PhoneSb�-�� 6 Business Phone �' 3. Property Description: Lot size �� . Front Left Right 4_ Tax map No.i� t�"�� Toanship: �� Block No. 5. Direct Dimensions: . Rear is to property: State Road No. b Road Nasnes, etc. L 1 S'1 Lot No\.S, 6. Psrmit requested for: New Installation�_ Repaired Additional Renovation re-using present system 7. Number of occupants of people served 8. Di:nensions of Proposad Structure: Width Depth 9. What t�•g�.(if any) additions, expansions, or�replace..��ent is a.z�icipated te the structure or facility that this seWage disposal sys�em is intend . to se�ve? � •10. Type of Water supply: Well V yes no: supply: . Are th� property?� �If so, identify location._ 11. If r,o, name source oi �.rater any we].�s on adjoining Type of structure or facility: Proposed� Existing Type of dwelling: House Mobile Home Business Type of busine �s Number of Employees_ Number of Bedrooitrs�_ Number of automatic appliances Sasement . Number of basement fixtures z a 3 � 12. Clearly stake sll corners of the property snd the corners of all proposed structures. I herebp make application to the Person Countp Health Department for � a site evaluation or existing system evaluation for the on-site seWage disposal spstem for the above described propertp. I agree that the content of this applicatioa are true and represent the maximum facilities to be placed on the propertp. I understand if the site is altered or the in- tended use changes, the permit shall become invalid. Permits are valid for 60 months from date of issLe. Permission is hereby granted to enter the propertp for the evaluation. G.S. 130A-335(F) .. � Signed Ocrner or Aui+�i rized Agent 0 �3 a x � a � � � 0 � � r 0 ct � � N 0 � x � ro c� n 3 w rr FACTORS�- SITE EVALUATION l. SLOPE (X) 2. SOIL TEXTURE (12-36 in.) (Sandy, loamy, clayey, Note 2:1 clay) 3. SOIL STRUCTIJRE (12-36 in. (Clayey soils) � 4. SOIL DEPTH (in.) S. RESTRICTIVE HORIZONS (in. (Impervious Strata, rock) 6. SOIL DRAIIQAGE/GROUNDWATER (F�cternal � Internal) 7. SOIL PERMEABILITY (Percolation Rate) 8. OTHER (specify) S PS U s PS U S PS U S PS U S PS U S PS U S PS U S PS U AREA AREA 2 I AREA 3 S PS U S l PS I • PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U • S PS U S PS U S PS u s PS U S PS U S PS U S PS U S PS U S PS U S PS U AREA 4 9. SITE CLASSIFICATION (See below) SOIL SERIES S- Suitable PS - Provisionally Suitable U- Unsuitable RECOr4�1EENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill.areas, wells, water bodies, slope patterns, etc.) Application Date: ��"�%� Tax Map #: �� O Amount Paid: l� t O Receipt #: Parcel #: � � I �� ,s� I��II��T �a � _ --�- � � �-�� .��,..-�-.. ��a ��.�a.��. 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. �) Permit requested by: (Owner/agent/prospective owner): v fC`�b r�c��C'�_ �e rl�lQ.i/��2 Home Phone: �3(�- S�i''7— zf'1 Y� Address: 18�t �N-�iS�b ri c Ui l(G�A� YC� • Business Phone: 420X1;-hc�� N.0 2r( ��3 2) Name and address of current owner: V� de z , � n 1�� a�-` �/'i �� ` 3) Property Description: Lot size: �Township: Subdivision: �� a� Lot #� Directions to the property (Including road names and numbers):. 4) Proposed Use and Structure Description: answer eac of the fol'l qwing questions: a) Proposed ✓, Existing Type of Structure:_�Ol'�lA,l�1t/ i�lltMf� W-'Idth:� Depth:�� b) Number of Bedrooms: � Number of occupants or people to be served: `-1 c) Basement: Yes , No � Will there be plumbing in the basement?_y� d) Garbage Disposal: Yes _, No � 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. � Does your property 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. ➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. _ ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAF(ED 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�ced on the property. 1 understand if the site is altered or the intended use changes, the permit shall become invali � ,� , L"egal Date PCHD, rev. 06/27/02 T�TNL � / �ti ,rj � . 3C.�,.�� :. .Y' . � , � , � �°�' 31 "6� �40. OG � i� L 30.Op. 0 � �.✓v e--,�s, ��____��-�__� C2`�t =L `_�� -_ � `?� � `�� V Q �� 3° � o � � '_ ', ' � � i;.00. �.Q..� Q,�. �, �, � , 6 ' i � �,, � n ` � � �y F / � � ,` s` �j � � S84°40'4�„E i � ° E � �� 220.p0' 333.00' roTAL ;o.9z�—. I.�'2 AC, z3o. oo• , �: ,.� ,, '�c� �i�� :V"�� `. } J � �.� , Q . ��, �''f .✓- �. � �,� "' � � 6 � � U ' 9 37 ��.��,;:�,� �'� �' �� o i.fo� �,G. � � .. _ `^ � °' . 1.45 AC. , `,� ao �o , '�`� �`�� v� r„ o �E38° 03'41 "E '� \ N '� � 0 457. 01 � �� m / ��. N . � � PLq f�T�1Tl � o -- " `. O(�f 30.0 i o � , , ' - - --- - _ _ o. q ° _ _ DRI� ' 1�1C. •''/�� p�o / `\� C3 N84°40'45••W � 220.U0' _, _ ` -- -� ._�o�_ •� �� _ � / �� - J� 115.59' ;�, ` " 229.f3t3' Nii.�� i �n ; ' —�' �. N84"4U'45"W 14 'U`45".61 ` � � �� 22.93' � �--------r— - E.�6' 1E�4. 06 • 1 � � / C. � 31.54' ., ! 30 03' 1 -._ . _.-�_ .._ _ '_3G_� __ . _ � f � y. � � .. , {`y� i ;::,� , `, c..{ � : - -- - i�' �° ,� O� / ,� �Q� 5 �''�"° " � '1 , � j � 4 ? � -� ; w Q �J - �°� �� 1.63 AC. �, � ; j; __ � o o �',`( ` / ��- �. �� m \� 2 / ', � ��o � o o '. i;�� c � / � ,h -� r � So.R � v h'� 4 v, o (. l. . � v . S�o � _��`�� 1.64 AC. � ~ `� "� " �,, , o. J ,., o �.�.i � �. ,:�-, � __ .. � � ._� �;�. ��,y, �c �� %� ' � ��=t"l��y 6 Q� �'�. �_J_/ . .r� t 'v� '4,�,�� , S �, \ Z Q _ 6-1� 1� .3'c . � '�� ,� `i � � . 1 O ,� �� U� m :� �,�� ,!r ' �o_�S ,' ; 't^� -� \} NP�°OFS'43"�� . � � T�� "�. � ;,1 �" `' , .� ww ._�.�� ` .� ' 17 4. 81 °� � 9 � ^. j' � ( V `ti'�ti.�� `} �" � �,°' .>= N3Q°26'31"W ' �O �`� �.f''�' 50.00' ' �� p• tu `� n"� v N � n � � o � � aa n � � � � � � 1.03 AC. � � � . �� C� �= �-=�" 7c "\ v� 891��". %a W 5�5oO�,pO`u 4 2��, �?6- �� 1�.�� !-�� Hu��-�L �v�,-r�_=�:�� ?�� N86°30'11"W • 23G. 00' �. i�'Bb°.30'11"W ;'; _ '�; U59. 64 ' OMEG� ��':;��;t� Application Date: �� 3 /.� �� S l` �� Tax Map: �� Amount Paid: � �0 • � � _ ~. � • �- Parcel#: � Receipt #: �0?�2 5 I � � � � �� —^—^ )�"J.un.�s-�isaa�cn.�ra�:�rntLra� 1I�Ia-en.Ilt(:)in . �.._.._-_.:-._..._..__ Improvement Permit (Site Ev: $200.00/$300.00 (if> 600 Mobile Home Reulacement or $150.00 (if site visit $300.00/$200.00/$75.00 -- -- AAplication for S�rvic�s — -- — — Services Re uested Construction Authoriz; (Fee is de endent on the ition Permit Revision $75.00 of pair of Existing Septic System Application; No Charge/ CA $150.00 or $300.00 � _ ) Applicant Inforj�►ation: Name: �l I GT'D�Z �Si4. Address: /89 1��ST'o,�IC V/� t_��,�- �D. R�� a� rl. C � �_�- 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: I g Phone (home): (work/cell): � � q— q 3 7— I�3 Phone: Lot #: �� e �/ ,�—S2 � 0 yes � no Does the site contain any jurisdictional wetlands? 0 yes O no Does the site contain any existing wastewater systems? p yes Q no Is any wastewater going to be generated on the site other than domestic sewage? C7 yes C7 no Is the site subject to approval by any other public agency? p yes ❑ 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: / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes O no With plumbing fixtures? �Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well 0 Existing Well ❑ Community Well O Public Water ❑ Spring Are there any existing wells, springs, or existmg waterlines on this property? ❑ yes ❑ no Please note; any known ground water restrichons.or sources of contamination: ' �o v � 1re o� F ro � �i- DeCk �g' X �7'� ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): 0 Conventional � Accepted ❑ Innovative � Alternative � Other ❑ Any � �eN d �� e dec� —i�o C �J�-�ea I cert� that the informati n provided above is complete and correct. I also understand that if the information provided is inaccurate, the s�s�equently altered, or the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Legal Representative*) * Supporting documentation required. Date Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � � �� r �/ � � . � !�[ \l� � , I 4\ !!'�i� 1 I 1 1 e• 4 1� ii ( � � c� 3! 1 1 Building Additions/ Mobile Home Replacements T� Map #:�� Parcel#: � g � Approval Requested for: ✓ Mobile Home Replacement Building Addition Applicant Name: Address: Phone #'s: � �rT��'� :' , . �,. .. . . � :� Permit Located: `� Yes No Installation Date: "t-30 —R3 Design flow: ��D (gpd) Current Contract with Certified Operator on file (if required): Water Supply: ✓Well Public or Community Wastewater system shows no visual evidence of failure on: � Z—( Z-1�,� (date) (Applicant's signature if site visit is not required) Addition/Replacement Approved E ironmental Health Specialist 11/15/OS �--�f �� Date !) .� �� T � J \ � � � �,� � � ,I. �. .�. ��.Il�. Building Additions/ Mobite glome Replacemeats Tax Map #: `�� Parcel#: C� Address: � � S�n� ' � � R ✓1°� � C S Approval Requested for: Mobile Home Replacernent � Building Addition . Applicant Name: ��C� -Sa S °� Address: �� S Q �� . Phone #'s: Ql � �?- S 1 �l3 _ � Pern►it Located: � Yes No Installation Date: 3 0� � r-BnS•i �c�� Design flow: �� (gpd) -Zr-Zf�—ng"--P�C'��rS'i o � Current Contract wi±h Certified Operator on file (if required): �_ Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on: �� ?a"( S (date) (Applicant's signature if site visit is not required) l�ddition/Iteplacemen� t�pprov�d � � �v�'►� � ironmental Health Specialist ��Z�� Z Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www�ersoncount .y net :�1��• �� `�.J� ' '`..- ��'l+, "'~•��•�..�� 1� ]E��,rn ,�,.,, ��.m.]l ]E�T��.Il,�ll� ��. ��'.��. Name V j �i� SoSa �¢f n2vs�� z. Tag lY1a.p #..��Pa�cel # l8I Sub ion I a �8R 1{�'s{�r � c `�e�tion/Lot# 3 ` • villa�,'�� ' /Z -l2 -D � �J Authoriz�ed State Agent � Date . `� System com�ionents re�bresent it�b�roxissaate �cont�urs only. Tlae contractor sparQst, flag the sys,terox prior to beginning the installation to isasrar8 fhat j�ropergrxrde is »saantaassed �� . � � � New L�r,� � _ �. � . � Ul(!�� Scale: ��'" �-n �C.� [� 0 I'G�, rev. 09/L/01 � I . �� 1:� y ..'. �� 1 � n/��.�. ' \�1. q' . . � � � ..� '.. 3 . ., . .... . �, . i . � ,� . � . . iYL�,.�\'1.�i�/ �.. ..� . � ...:..: . '. '�. � . . �.,.r.., .bY ~�: d ' � �� . . ` .�^ : � `�% �� .. � � � ' . .. '�, n.�-a� <m �n.�� <c �t�:,�z.�. �"'� � �in, �.�� _ � \.:. . - . � ' � . � . .. Applican� Location: T�x Map � / ' �rc�el � : SU�� f�IVIS1011 i 1 r� irL. � i c15 E S t+.l 0 t1.' � t� ��rmit Valid for t/��ve �� Type of Facility: # of Occupants ,�� # of Proposed Wastewatez System: Proposed Re}�air: Permit Conditions: � . � �.,.«,u,� � "7"—Owner or Legal ] Authorized State Ianpravesnent ��rmit �To �xpiraiaon , / ,, / / New Addition 'V �ate- Sup�� . �(�t/�iG s Projected Daily Flow � g.p.d. -�� iol�ll � _ Type: �q Type: . ,� Date: Date: / Z� C�� The issuance of this permit by the Health Department in does .not guarantee the issuance of other permits. It is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are me� 'I'hi� �mpro �emeut ��rmit is subjec�, to revocaiion if the sife plan, plat or the intended use changes. The Improvement Permit is not aife,,:terl by a change.in:ownership.oi the pa-op�rty. '''�is permit vcras issued in compliammce with the pr.ovisions of:the:�Torth Car�iinc: •_. `Lr�zs:s a�id IPules :far:sSewa�e.:TreQtment and I�iSF�sal Svstems':'41SA_NCAC 1.�A. .1900). .Neiiher.,.:�P,erson:.�ounty nor the ,.�� nviron�entai�•�ea�tii��S;aer,ialist warrant� tha� :he se�tic t�nk sy.stem=wilt.rontinr�e to function satisfac#oxaly:�in:thE::futur�. or th<:i �. ; the.water supply:.will remain potabie:: .:.'. �: , , ._,;. ...:_ ��.. _.. . . .. . >.... . .. _ . , . ... . . � _:,., - ' Aaathoa-azation to �onsta-a�et �astetivater ,�ystem (.�equireai �or �uilding ��rmit) " . , . ' * See site plan and additional attachments (�. Proposed Wastewater System:�e�j � l Type � Wastewater Flow _�g.p.d. New Repair E�ansion Soil L'TAR: •$� g.p.d./ ft 2 Type of Facility: �ry'��e Res��o.nG� Basement _ Yes o T� Size: Se�iic 'Tank: �S`�a�� 1)rain�ieirl: Total Are�: sq ft Trench Wiaith � fft �istrii�utio�a: Specifications: '�aste�v�.ter Sysieffi �2eqaa�effie�ats �mp Tanflc:—''—gafl �rease Trap: g '�otal �,ength 5� �t I�a�muffi Trench Iiepth � aaa 1�i�um 5oi1 Cover: � in �isiribution �o� erial �istribution �. ., _ / .. ^_i • s/�_ / t�ut9�or�er� State Agent: Permit Expi �ate: l Z �Z /l� � /J o.G. 1Vlinimum �reaac� Separa�ion: �__ fft I'ress�re l�anifold /' . , Date: ]Z � The type of system permitted is Conventionai Accepted Altemative. I accept the specifications of the permiot. �w�e�/�,eg� �epres��ta�ave: -�.. Date: � "3 � rU rC r�v.11/10/05 �. 4 ' � �� y 1 ,� '�"�'�'�— � � �� 1� I��.-z�-m�:-,�-� ��.IL - ��.�.�.� Anpficani Locaiion: - � . . � � �� r i� . � . Syst�m Type (in Accordance With Table Va): �� iHIS SYSi'�� F�AS �E��9 iR�STA�Lc� Ih! Ct3�#It'Llr�NC� l�lti'H APPLIC�.BLE . i�IORTH CAROLINA Gci1�E�L ST�itJTES, RU�.ES ��R Sci�iIACE TR�AThitE�T r1�ID DtS�OSAL, � AMD • AtLL CORlY3ITlONS �F � Tl-31E IIViPR01/�i�tEi�T PE3�111T A�ID CONSTRUCTIOf� .4tlTHVRf�T1ON. n � �� 4�ID ��o � � 18J 0 0 �� f►�rVP.r P�a�� o� ° � "I�C�C'�`s�O�i L�% ,"�M 3 �o� o�o 00 � � . . Z-�2�—ofl - ed State Agent , Date _ � lnstalled. � Date: � 2-ZG D 1� � {�7 ` 't m 'c ��,:�� l��'a�� '�.95 0 � ��l�� ax IVia� � �t� i�arc�9 � 8'_ j I _ Sys�e:� Typ� (T�ble Va) -�-Q Ow�e=lAppli�n� Su�division �(a�"�i�r f N� . Address/Lo�aEion S��/Phc�� Lat � � � �e�g��. �'��s� �ni��a�/�� ot�srac��ivr� ��n� [n�� c�a� � Sta#e �ID/date Tr�ncf� WWid#h � 3 fi. S Z� ZG -d Capaci - Q �. al. � � Trenc� De #h S� 23in: Te� and Fiifer - • � Trer�c� Len th �t. Baf�e �� Tr�nct� Gtade � � Sealant Tre�ct� S acin .� � Riser iT ap�licabie �� Roc� De tii and Quali � -�'ank Outlet Seal Dams/Ste downs etc. Perman�rrt �Ilarker Pressure Lateral� � ' . �aa�a� '�ank • � Hole Spac�ng � . State Qldate � . o e izs � - Ca ac� aL Pi �. Sienve � Wate roof ISe�l�nt � Tum- slE'rote�tors ' - Riser �qui�d� Se�ba�� Water Ti ht � From� vllei(s -� �'�na� From Prope�ty fines � . Che�k ValvelGate 1ialve S#ructures/�as�inertis � �� Anti-s� on o e � �c es I ra�na �.a FioaislSwitches � � � �Surfac� Waters Alarm visable and audi�ie Pubiic V�later Su iies • Elecirical Cam onenis � Verticai Ctais >2 �t. .f � Raie m .. V14ater Lines A roved Pum iUlode! VeFiic�e�Traf�ic �� ,/ ' Bloc� Undes� Pump � Ad'acent stems � - � Purn Remova! �Ro elChain • �Ease�ients/Ri ht of V�la s . �•D6s�rBbu�a�n: S��a� . O��r _ . � Serial Distribution .� -2�- Easements Re�arded � �ress�re �VBanrtoa e e erator ontract �aw Pressure P� e � 7r�-�ariate A re��ne�t Ap r. Pip� 11��te�ia� and G�d� �' � . Vaiv�s . • C�ma��a� . . . �c:�d r�r. 3!'13/C'1 DEPARTIV�NT OF ENVIRONMENT �,� f%.td 1 Z Z" 4.� PROPERTY ID #: AND NATURAL RESOURCES . �, ,n / DATF, OF EVALUATION: /Z "IL--d TIiVT.cTl1N (1F FNVTR(1NMRNTAT. HRAi.TH I � �1 / L, C l_ ` _ � . ' /l COUNTY: -- • ----- - -- -- � � V � � I ' ,'tU f tG V I I1 Ql'') �, - �jYz - � -. � t � � � ��. �: � r� . � � s �Y � ' - £ -, � s �f ' � ; � � t . y % x S i�t E y,£ 3 �.yV i�S h� k a. 1 � � Q_ 7' s�� C��G1d1�RPlB�i�I,�� .� r El��: > F � ,y k.� <s ; �.,��y� � �,,�_ �w� (.]9�1�a� � �''=�Y; 't f� �.�,x ��;i's.�i�l��A�+�� ;" 5,� �x < ,[(� N � . 'st £ ;. ��1lFF � 3 f `tt.. � . L. S 5 f :: "'� k : y66. , . -. : S . . . { S Y5 . t 4. .. 4. �'�x s % i . "3� ,�t N 3 � �� t "w� r^x � r ` . : f � �-n i �as �: z� nS_� .c ��`0 . �,� �.. ,� - .�, F>�s w�. ��¢� A� � t �tf �� y � r �. �s�.<' � °s ?i c i �'�3 ��7��i�,5 t x. xr raY' av rt �'d � i e.. TZ" Ls z:,?N''' t ��r f x��,k� � # cs t@ a� � n� � � �. }. .,<. �� ` � ...s:��f �'�� ) E, r;,_..eyyt ��_ .� �, sxJ 4..]�<f�'�' '� : �"s.i� ..-. s � . 3�j'j�...�,��y 3.y ,s��+'�a: f - ,S �c ��L' u , a-. �7�4�iF � -„y �.Q:Ri � Rr� � a ��{#d �. s e �l7!T� $r � s zl�� i 3�f. y F . � F x r h 7fi 3 �� . i +"i+ w �.x^F' K�. �� . � �; - a��s.��tr2 �,.�� ' � ��`��r� � �v ��'��` f � �� c�xi� � � t�n��4 �. ; =��R� � h�� : ,," {�� Q (�'{�j 9� �` � `� sl: �., 'ST; f �;t�� -.r.�� j:� � � Yfa : r�y;Ey�''��' $y Ps 4��13 r �7^^'^� z5 17G �� .. 5�,�?%� 1� �� ,� £ _ � ,� � £l..L1 � z � � ; ci � ),�., u»A..>r lisi ... ' Ki<.v. S �r.' > -�\. J �.:/..n.r.>)..�z.�� .::) Y.. »..�:uYa..i.,.� y'...Y>N ��.. � i �nF�� h C � ,. 1� ... .... .....a.,.r. ..n ..... '.a... .. ... x .��.. .v .'.... ..a.' �...... :.:iv.. . .. . . .. ' t . '' � � ` x� SS 4 d� . , . � � . . ,, �°.S � � : � �1�. , 3 , �S �� L Sl3 SEXD Ss sP � �—S � S� � � , ., r+na,n�,r��rre. • " a ___._.�_.__ � Xls n� �,z� 3 � �f b� v�rm .� . 2�l � ' o U��.�vt an u� J �y� � 11 � . t� � 5� — i �'. �" _aai ,' .��r:--�_� _ ....^ ' _ _ ��} �� . '� , _ ';� • . _:.-"'. •. • . • '. . - • . ' .. . �� •� , ��Ll.� ��. V �YLl � �''Q ��'y' � � `L/ �•�T�� J'L ��YTf �`RZ [:`3:.�Y�GWL • ��'� 'I u..�;..• LOT PREi'ARATION IlVSTRIICTIONS I. You must suhmit a�te pian with your applicaiion. A samplc site plan arid site p3� war�si�ert are � atmched.- Be s�a to read what yon ner.� ta siiow.in the site �lan. Checic them of as yau draw tfiem on • the sitc plan Z�1a� al�, p�operty lines,. ,Ali pmpecty lines �within 250 �t of the proQoaed honse site must be ci�► mar3zed and and� readii�r ident'rfiable as PmP�Y �. If qou are prc�posing to sni�divide your PmP�'� �YQm m�st indicate the proposed Iocation of aIl naw P�'QP�Y �- 3. If the lot.is too ttiic�iy cove,red witfi tre�, fallen trees, underhrush, or other �al then you �il need �to. c,iear to tite exbent that a person can get anto the Iat aad move amund fr�iy. $�+ Yiii3 CI� YO� PRt�Y°�'�Y� �E C� NOT RO DIST�� a'� �ICa St��! � This cauld adverselp a$ecLthe outcame of your evaluation. If you have any questions, please call the � . Persnn Cannty Envizvamental Hcalth �f� at (33� �97-�790. :. 4. Mar� the propose3 honse site. The proposed house site c�ners must be staked ont nn tf�e P�P�Y .�•� � and it mnstreasonably maiei� ttie site plan submitted with the appiication. � 5. Post ti�e brig�t oiang� sign with your name on it neai ta the road sa that wre can identify yonYr PmP�Y• . ' . 6. �Phen you have complete3. t.fiese items, sign the statement below and retun� it to Person County ' Enyaonmental Health at 20-$ Court 3�, Rnxi�om, NC 27573. This statem�nt w�l.serve as confi�ation thatyonr lot�has been prepaz�ed acmrding ta.these ins�ons. Onca we x�e�eive this canfuma#ion, we will :�ve it to active stauis. Applii�tion. wt�l be processed in the order that . cnnfnmation �vas received. - 7. I� when we azrive to evaivate your proprrtp, �ve find that it is na� pra�azed acxarding to ttaese insiziictions, we w�1 place your application on inaciive stams. We w�l reiurn your apglication to ar.riye status when wa have canfi�ation that the proPerty, is prepar�si propeiiy. Yoa will be notified if this oc��s, and yon, w71 be required to aotify Environme�tal Health Sxtion u�on campietion of site pre�azation. Yo� application.w�il be handled in the order that the canfumadon was re�aived �. If �ou have aay.questions about what is experxed, You shouid caII our affic� at ya�iest � canveniencs and aek for assistance in order ta avoid any possi�le deiays dne to improper site pian or Iot �aration. An environmeutai hesith spe�ialist can be reac3ied betwezn 830 and 93U a_m. and. between 4:30 and 5:00 p�a. at (33� 597-179Q. � - Ma� or deliver tiiis fo� to: Peson Connty Env�nmental Health . � 2U-� Couct Strezt � . . Itnzbom, NC 27573 . � , I, - - - • b�Y �Y � �Y FroP�Y� I�catad at , has been prepazed fc�t sit� and sail svaluation in accardancs with ti�e lot preparation instrnctions listed abo�. I imderstand that fa�iiu e t� �. prepax� my graperty ia ae: ardancx vcri these inshvctions w�l rasult in piaeement of my applieation on ina�tive sratus unul ti�e P�Peri`J � P� ProP�Y• � � Sig�atnre of Apaiican� ace: