A27 76� _
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' �� � Ttie District Health Department
�(� Orange, Perscm, Caswell, Chatham; Lee Counlies.
. � Water Supply�and-Sewage Disposal �
' — IMPROVEMENTS PERM�T No.
; � _ __ ' \�� ate ' �
.. x Owner: � " " �� �F1 C bn,;.�
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` Location:
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` � Contractor � �
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4:�: Water Supplys: Private ' Public
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, Sew- sa Facilities No bedrooms Dishw�sher, Disposal,
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ther aufo A atic.. ap�liances � '
r Size of tank = • � NitrifiCation 'ne: � ` , '�
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' Other disposal facility: � �
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;; ..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-
��. � PROVEB BY A MEMBEft' OF THF,.pISTRIC.'� AI.TH DEPARTMENT'`'. .
, STA�F BEFORE -ANY'POIi,TIQN: OF', �TI�E.< TA�LATION.• IS COV- "=
` ERED AND PU1` INTO USE ` ' _ •." .
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Date ap�roved�: - _ ' � � �$igriec� . - - -• --
' t . - 'Sanitarian - _ .
; Well: - _ _ `
.. : : =- - y.
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Sewage Disposal: � Counter- � ��� � � �
� • � signed � ��
.By: _
(Owner o� iiis representative) -
f� _
� ` Certiiicate of Com Ie!' ti' � . � " - .
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• Date Approved: � • � B :
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� .. COVER) - .: . ^
� Location of well:'arid`.sewage •disposal facilities sketched on-back. ,�
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NOTE: Make sketch of installation showing lot size . and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Wrste in measurements in order that installations may be located
� ;� at later date. Note location of water supplies on adjacent lots. •
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Application �ate: - �¢' I
Amount Paid: , Op
Receipt #: �
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 d)
obile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
'��`j. ) f �J.t��� �l V Tax Map: ,� Z7
� � �.�.�� Parcel#: ��_
IG aavn.n-�v.as.xas�sn4':aaIl IHI �.ai.Il�I�a.
lication for Services
Services Re uested
Construction Authorization
(Fee is de endent on the e of s stem ermitted)
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: �'��►C. �5
Address: �s ,� 1 d •
, IJ� a � t'l a--
2) Name and address of current owner (if different than applicant):
Name: � � sv
Address: ;�,1 � �fi� "l� iu-c_.
c�r � . N� a� 51 �
Phone (home):
(work/cell): f �( - �$ a -- � � 0�
Phone:
3) Property Description: Lot Size: oter� Subdivision:��u.x.� �<<5 Lot #: ��
Address and/or directions to Property: '7 cn.- �a�+ 'l� ��- - Pti . -+ � _
❑ yes no Does the site contain any jurisdictional wetlands?
�s 0 no Does the site contain any existing wastewater systems?
❑ yes � Is any wastewater going to be generated on the site other than domestic sewage? 1� l� -�-p �%i��
❑ yes Ca'� Is the site subject to approval by any other public agency7 �
❑ yes 0 o Are there any easements or right of ways on this property? ��� Q��
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
C�tesidential
❑ 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 ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well LyExisting Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
3�b-17
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.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
ConnectGIS Feature Report
3�0�7 Page 1 of 1
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NOTICE Recently, we have had several users report browser compatibility issues when trying to access our G15 website. Typicaliy, the probiem stems from users who hav
�ecently upgreded to the Windows 8 opereting system or a new version of Intemet Explorer. We were able to resolve this issue by directing users to the lntemet Expiore
�ompatibility vew tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-USlntemet-explorer/produ�e-9/features/compatibility-vie
f this does not solve the probiem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGLS has bee
�repared for the inventory of reat properry found within Person County, and is compiled from recorded deeds, piau, and other public records. Users of GLS system ar
�otified that the aforementioned public information sources shouid be consulted for verification of the information in this system Person County, Mobile 311, Connect
3ssume no leaal resoonsibilitv for the information in this svstem. Grid is based on the NC state plane coordinate system, 1983 NAD.
http://oldgis.personcounty.nedConnectGIS v6/DownloadFile.ashx?i= ags mapba68b23889... 3/9/2017
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Building Additions/ Mobile Home ReQlacements
Tax Map #: a7 Pazcel#:�_ Address: ��l ,' �--•
C
Approvat Requested for: Mobile Home Replacement
� Building Addition .
Applicant Name: - .. � � � !S'��, �{���e �T4. �
Address:
Sa'�-2 a S � av�
Phone#'s: Q(9 ��J-39os'
V
Pernut Located: Yes
Installation Date: - ( -
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Design flow: � 6 0 (gpd)
Current Contract with Certified Operator on file (if required): v� ll�
Water Supply: __�__ Well Public or Community
��,� �. ;��e��Y ��� v� � =��
Wastewater system shows no visual evidence of failure on: `3 -(9 �! �(date)
(Applicant's signature if site visit is not required)
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Addition/Repiacemea�t Appr6ved
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E iranmental Health Specialist
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Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net
4/15/2017 �'� TaxParcelvewer
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