A28 11Application Date: 3 � 7 �O o0 ���,�` ������
Amount Paid: � 00 � O d � �,��- � � ����
Receipt #: ^ 18� 3 3 5 j 8' 3� 0�1
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Application for Services
Im ermit (Site Evaluation)
$200.00/ 00.00 if > 600 d�L ) ___
Mo e Replacement or Buiiding
$150.00 (if site visit required)
Weli Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
Tax Map: � � � �
Parcel#: _�_
Ca�l� ��
N e�` �
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Services Re uested
onstruction Authorization
ee is de endent on the e of s stem ermitted)
Permit Revision
$75.00
Repair of Esisting Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Infor ation: J
Name: f��fvGv �� (�t/.y`rIG� � . Phone (home): 3 3�` 5��' s�- �ig� .
Address: (c (� � o�'i9 sr`a/3{ �°d (work/cell): 33G, Sa y`16 �/�
�o,��o�o �v c. ��S'`7y
2) Name and address of current owner (if different than applicant):
Name: Phone:
Address: �
3) Property Description: Lot Size: r06 � Subdivision:
Address and/or directions to Property:
Lot #:
❑ yes y�e Does the site contain any jurisdictional wetlands7
❑ yes G�a"n� Does the site contain any existing wastewater systems?
0 yes C�n� Is any wastewater going to be generated on the site other than domestic sewage? -
❑ yes C��� Is the site subject to approval by any other public agency?
❑ yes CiYno 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: .
❑R idential '
ew Single Family Residence Maximum number of bedrooms: �_/ Occupants: �_
� Expansion of Existing System If expansion: Current number o bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? es ❑ no With plumbing fixtures? �es �. no
❑Non-Residential
Type of business: �`
Maximum number of employees: _
Total Squaze fvotage of Building:
Maximum number of seats:
5) Water Supply: Ld` New well ❑ Existing Well ❑ Community Well ❑ Public Water O Spring
. Are there any existing wells, springs, or existing waterlines on this property? ❑ yes Ct�'��
Please note any known ground water restrictions or sources of contamination:
6) If a�plying for `Authorization to Construct', please indicate preferred system type(s):
�Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. 1 also understand that if the information provided is
inaccur,c�te. the site is subsequently 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.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applicant:
a1K-��
Permit Valid for: Five Y ars
Type of Facility: ✓312 1�F
Number of: Bedrooms 3 / �
Proposed Wastewater System:
Proposed Repair: �v��/'Q.� -�
Improvement Permit
� Non-expiring
> S, New�r—Addition
�ccupants�/ Em,Ployees / Seats:
�0'►�tv'�v►�i �cQ. (
Permit Conditions: �j2-� 5��� Sk-2'��
Taz Map: P'r �g Parcel• ��
Subdivision
Phase/Section/Lot #
Water Supp;y: � � �
Projected Daily Flow: 3 6 p gallons/day
Type: �Q
Type: .�q
Authorized State Ageni: w� �;. `"��" Date: 5—
(X) Owner or Legal Rep esentafive• �-,� � � n _ Date:
The issuance of this permit b f the Health Department does not guarantee the issuance of other required permits. It is th� responsibility of
the applicandproperty owner ±o insure that all Person County Planning and Zoning and Buildina Inspections requirements aze met. This
Improvement PerQiit is subject tu revocation if the site plan, plat or the intended use c6anges. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolin� °Laws
rrnrl Ru[es for Sewa�e Treatmen� and Dlcnosal Svstems'(15A I�iCAC 18A .1900). Neitber Persoa County nor the Eavironmental
Health S�Cecialist warrants that t�e septic system wi31 continu� to function satisfacto: i7y in thc future, or that the water su�pfy wiil
remain potable. — _____—_— _
Authorization to Construct Wastewater 5ystetn
See site plan and additional attachments (�.
x
Yroposed Wastewater System: 1�11�1✓Q� �i`oKa (��, �Otv2 � (*)Type �Q _ Design Flow 3 6 O galJday
New � Repair _ E:cpansion _ Soil LTfik: ��?.S— gal./day/ftz
Type of Facitity: ��� �S� Basement: � Yes P:o
w� � lu►� b�.z�
(") System Types Illh, liibg, �V, �nd V, reyuire periodic system inspertions by the Person County Health Deparhnent.
- Wastewater System Requirements
Tank Size: Septic Tank f a d � gal.
Drainiield: 'Total Area �3 z'O sq. ft.
Trench Width � ft.
Pump Tank — gal.
Total Length �f Y�_ ft.
Min.Soil Cover �P in.
Grease Trap ^ gal.
Ma�c. 'french Depth ��,� �m � `S / ��
Niin.T'rench Separation � ft.
Distribufion: Distrihution Box �/ Serial Distribution K/ Pressure Manifold �_
Specifications: a' �° ° K o✓� �Pr; Q( ► S d-�, '—' �� � b o K 1�S �� ��PC� u a( ��Q y y�t,, � i�-� S,
Authorized State Agent: �ti"� � C�ti�� [ssue Data: 5 r Y1 �'7
Permit Expiration Date: S'— " 2'Z
The system permitted is: Conventional �/Accepted i Alternati�e / Innovative . I accept the con�itions
and specifications of this permit. �
(k) Owner or Legal Representative: Date:
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
�� (f �llell�1���T Name:
~.�•�� l� Subdivison:
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Site Plar.
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iress:
Lot:
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30 �'�30 �
EHS:`
Date:
Tax Map: 02�
Parcel: ��
s'-9^c
Scale: �l ' = l00 �
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Enviro menta Healt with ny questions (336) 597-1790. /�
4dditional Comments: �v � � ti 'e a�t ✓LIQ+-I�X Wi��� �✓1 r� �i�Q+c -1��� S •
Tax Map: �g
Subdivision:
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lE�rn.�nu-,��n.a�a��ra��o.Il �33C�mIl�lla
Parcel: l�
WE� PERNIIT
(New Repair_)
Applicant's Name: .f� 0y (,JQ ��(-Q r
Mailing Address:
Phone Numbers:
Lot:
Location of Property: � Sbu�q �� -� �I��/i Q cl a„�v� }Qo.C� —� PY? p � SaaQ
�ta�se ►� � 4 �, e �� E�> OoK�
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by:
ew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmentai Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
�
Date: � ���
Certificate of Completion
OLiner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13