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A27 61�.' `�.tiv'� LJU 1�E ' �- The Dis�rict Health Departmenf i ' CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMEWTS PEAMIT No._� te �i- i%< Owner. � �ti�o�a I� Sh�1�1�0,� � . Location: - � . _ ` } � 1% � � % � ,iJn ,'l_^_,y ,I - -�v-�c`�' J •' 7 �C �T'; ; Contractor: Water Supplp: Private ' Public f� , . � , -� + ~ . . r - " ' � `� �?�C.-\ '� ` � � '�'�f �'� ._y�� \ �` \ \ ��` ^,��. t�'t ) j Sewaqe Disposal Facilities: No. bedrooms � Dishwasher, •--------- washing machine, other automatic appliances — r '� Size of tank: ��_ �' �� Nitriflcation line: Other disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE Ii�STAL�rfIQN IS COV- ERED AND PUT INTO USE. / 1 ' t �'� fb . 1 t�;' �f,i.,� �'v �-"=_i � � Date approved: Signe�`� Sani,tarian Well: , ry ir ' % ri` ' � 1 Sewage Disposal • Count�ec-; ' ;s' ;�'%� '� �' �' 1 aigne � ^ ,�, ..; , !! ,; :;� '' f BY� ,(Owner'or'hi� repres�htativey / � Certi�cate of Comple2ion �: Date Approved: �� By: ` a itaria (O Location oi well and sewage disposal facilities sketched on back. NOTE: I � sketch of installation showing lot size I shape, location of house, septic tanks, �ies, water supplies, etc. Note special problems existing on lot. Wra� in measurements in order that installations may be located � at later date. Note location of water supplies on adjacent lots. , � �� f. i �; �. i, o �1 � , t � : �i� ---..Lr:::;�. �2� �,� �� I�� d Application Date: � � � Amount Paid: � � ('� .0 O Receipt #: �P� �'� Ct a� r�C ❑ Improvement Permit (Site Evaluation) $204.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition _ $150.00 (if site visit required) 0 WEiI Permit (I�'ew/IZeplacemer,t/Repair) $304.00/$200.00/$75.00 ��,?,)f ��1 V Tax Map: �� ,�� Parcel#s _ !�p/ �.navna-�+r*..+Y*¢�aa.d�m.� �ao�.Il�.�a �lication for Services Services Re uested � Construction Authorization ee is de endent on the pe of ❑ Permit Revision ❑ Repair of Eaisting Septic System Application: No Cnazge/ CA $150.00 or $300.00 �Applicant Information: Name:�ua, p {� �t-}�'R�� Address: l� I F,�� -rc �p. �o �.��C1' 21S7y 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property D�scription: Lot Size: �_ Subdivision: Address and/or directions to Property: (4�� Cs�1,.� Phone (home): �� S�j1—�t 5`7 (work/cell):133�� i� �22Co7 Phone: Lot #: l2 ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? O yes ❑ no Is any wastewater going to be generated on the site other thar domestic sewage? � yes � no Is the site subject to approval by any other public agency? ❑ yes ❑ no Are there any easements or right of ways on this property7 (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and T3�pe of Structure: . ` ❑Residentia! �`�LE ��i � ) ❑ New Single Family ltesidence Maximum number of bedrooms: �(�,�`Qv�� Xl f0 � Expansion of Existing System If expansion: Current number of bedrooms: 0 Repau• to Malfunctioning System Will there be a basement? ❑ yes B nu With plutnbing fixtures? ❑ yes !�'no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum numUer of seats: 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well 0 Public Water ❑ Spr�in Are there any existing wells, springs, or existing waterlines oa this property7 C�]"yes ❑ no 6) If applying for `Authorization ta Construct', please iudicate preferred system type(s): C1 Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any I cert�� that the infof•mation providecl above is complete and correct. I ulso undzrstand that if the information provided is inaccurate, or if the site is subsequently altered, or the 'ntended use changes, all permits a.nd approvals s all be ' ti�alid. � s' � Zr G Signature (Owner/ Legal Representative*) Date * Supporting documentation required. Permits are valid for either 60 months or are nan-expiring when accompanied by an approved plat. A completed `Lot Prepa�ation' form must accompany any appIication requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morsan St., Suite C. R�xhnrn N('. �7i7� !�?�_�4�_� �om r � . � �-. J� f < �.i�.- 1 <: • :. ... .... ... ,.:. .:•:..:'' . :... � ''s. � � �1.J �� aIl��T]1.7t°:��II.]C7YIl,�ICI1..��.11 �c.��.J1�� Building Additions/ Mobile Home Replacements Tax Map #: Z�J Parcel#: �e� Address: I�[. 1�2A.+.� �-lya �?� • Approval Requested for: Mobile Home Replacement _ /� Building Addition y-�x � �l�A,,,�� Applicant Name: �o,�.,,,�,�� 2� c� c� Address: f �'t /� �o.� �� ' 1�� _ ��(o,��_..a _ ►.� 2 7�'7 +-� Phone #'s: ��7� 3;1�7 ��I�- ��G� Permit Located: ✓� Yes No Installation Date: �S Design flow: �_ (gpd) Current Contract with Certified Operator on file (if required): _�('� Water Supply: ti/ Well Public or Community Wastewater system shows no visual evidence of failure on: ��T �date) (Applicant's signature if site visit is not required) Addition/Replacement Approved , Environmental Hea pecialist � �/�� Date Persan County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-17901 Fax: 336-597-7808 www.personcountv.net ConnectGIS Feature Rzport '�' _. _. �.. i !`_ � L-?;__ : .{'il5 �,veR r.�;srr��. ��j��/ � 15382 5' � J t t�� , N G't � i� ,—,-F �'J �� Person County F�vir�a�men4al Heaith 325 S. Morgan Street SUI�@ Ci � � Qv� � �Di✓S G'D,✓f?G� �Gi-%l� � S�i7-i�y'D �� 5as� • a r \ ', 5'� �jf � 1 � � � �� 5:385 l�aopo5 E�p � � � � �\ 'g� t �-.�A `� �\ / Sr}-Ec� , q �� \ \ � �� Page 1 of 1 Person Printed May 24, 2016 See Below tor Disclaimer � 27 '" �• � f' �. :3689 f ;� _,;� � � ��SaQ-� � •"Y,�; � �i Y/�, /`:' M1�'� � /� �� .� ~ �`-� � f� �I �83 ,;;:, � � �� , :� � =� � � �� zso �' ' u : 50 Feet � , — IOTICE: Recentiy, we have had several users report browser compatibility issues when tryiny to attess our GIS website. Typicaliy, the prooiem stems from users who ha =cently upgraded to the VJindows 8 operating system or a new version of intemet Explorer. We were abie to resolve this issue py directing users to the internet Expior ompatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US/intemet explorer/products/ie-9/features/compatibility-vie this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectG[S has be� repared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other publlc records. Users of GIS system a otifed that the aforementioned public information sources should be consulted for verifcation of the information in this system. Person County, Mobile 311, ConnedC ssume no leqal resqonsibilitv for the information in this svstem. Grid is based on the NC state plane coordinate system, 1983 NAD. i� ' , .:l�' .1 .,.��1A ll�: . .7: � 1(��1� 7 r ��1'�r � �li�(�:;��,?i>.}�CC.`;i)IlC(;�llliA.Ilii��llllilC�l��t.�i .viiCi��illl)�i�ii il.'..15�1'�.i �I�� t�l�l�;-�_�-r;��-i;_�C)... >,��_�� ,