A28 119� � j�
C�P
Person Count� He�lth Department ;
Sewage System Improvements Permit �'
Datc:I�2��C;�This Permit Void After'S Years';.. ��! �
Owncr: - SR# .����"`—
Locauon/Dircc:lio s:
� / �
Subclivisio Namc: � ' ' Lot # � �
Lot Sizc: • ype:of ; welling: .
Watcr Supp • Private: Public: Community:
Bedrooms: _�— Garbage Disposal
Basemcnt BasementFixtuies' �
INFORMA IE BY. �
Sat11t�1i'18A: - • ,. owncr or representativc ;
REPAIR: EVAL �ATION:
Sizc of Scptic Tank: ' gallon� Sizc of Pump Tank:
Nitrificauon Linc: �
Depth of S�onc: 12 inches
Max Depth of Trenches: �
Al�emative Syst : Conv. Pump LPP Pum �.
Remarks: Ma� h�c P,.Q� W� Y
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Date Well Approvcci: _� Well should be 100 f� from any sewer system
BY Sanitarian�,Q�
Date S• ge y m pproved: �•-� r��
BY Sanitarian
ERTIFICA'I� OF COMPLETION
Contrictor. � + 1ri n . � � � c'
_ �
Sewage System location, installarion, and protection must mcet state and local �
reguladons. Septic tank should be pumped out every 3 to Syeazs and shall be maintained �
by owner in such manner as nof to create a public`health hazard. Septic tank and'd
nitriFicapon linc must bc inspccted and ap�oved by a member of thc Person Counry �
Health Dcpartment before any portion of the installation is covered and put into use. If
the site plans or intended usc change this pernut is subject to revocation.
(G.S. 130 A-335F)
L.ocation of sewage disposal scwagc systcro skctched on back. �
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(OVER) �
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Application Date: � �" I 3') .2 ��� �S ���� (�i�
AmountPaid: ��� j-�d� � �, ,�•� ��
Receipt #: q y � 0 3� Ca r ��� ������
Jf?:�rn-s-nn-an4r,.,�„ aaan.ti,�n.11 1C-3L�a�.l�d,�.
Application for Services
Services Reauested
❑ Improvement Permit (Site Evaluation)
_ $200.00/$300.00 (if> 600 �pd)
�Mobile Home Replacement or Building Addition
� i 50.00 �if site visit requiredj
❑ 'Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
❑ Construction Authorization
�Fee is dependent on the type of
0 Permit Revision
Tax Map: �
Parcel#c _�_
��v PerM; �-
Fov��1d
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Inf rmation:
Name: �a tl v1 i e v1 (,��- � � c�c 2
Address: � o Q(� I F �o
o►� 7�1C i
2) Name and address of current owner (if different than applicant):
Name:
Address
Phone (home): 33 (o �9 �( (� y3 �J
(worWcell): 33(c� ���'- 330 Z.
Phnr.e:
3) Property Description: Lot Size: ve�- Subdiv;s�or�: Lnt #: _____
Address and/or directions to Property:
❑ yes 0 no Does the site contain any jurisdictional wetlands?
❑ yes 0 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 ❑ no Is the site subject to approval by any other public agency?
❑ 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:
❑ Ex�ansion of Existing System If expansion: Ca;rzrt r«mber of bedro�ms:
❑ Repair t� :�lzlfunct;oning System Will there be a basement? � yes ❑ no With plumbing fixtures? ❑ yes ❑ no �
. S�1-� r0.
�1Von-Residential o, � � S d �
Type of business: Total Square footage of Building: 1 UC7 � �
M�ac:mu:n number of employees: i�z.�cimum numb�; o: seats: 3 p X 3 O
�) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water 0 Spring
Are there any existing wells, springs, or existing waterlines on this properiy? � yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
� Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
1 cert� that the information provided above is complete and correct. I 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
I�("�i2�Lu-e LIJ�� �J��KQ // l.�—Lo 1 Z
Signature (Owner/ Legal Representative*) Date
* Supporting documentation required.
• 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)
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�Im�]I.7��IC71.IC1YI1cC�]1.ZL'��.1L ���•�'�x�
Building Additions/ Mobile Home Replacements
Tax Map #:� Parcel#:�,_ Address: �� i DC'� �4�� '�(�
e C
Approval Requested for: Mobile Home Replacement
� Building Addition
Applicant Name: 0 r '(a�-
Address: ..Sr?'�2 �� ��
Phone #'s: �� Q- 6�f39 Sf2- 33o Z
Permit Located: � Yes No
Installation Date: 4' Design flow: 3C'o0 (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: f< <6 (date)
(Applicant's signaiure if siie visit is not required)
Addition/Replacement Approved
✓ti "`�,,�
E ironmental Health Specialist
I � 92.
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
28.14'
RONNIE D. WALLACE
KOT � 28
S89`24'S2"E
(TOTAL)
366.36'
�,�'
EXISTING STORAGE BLDG. �;���
� T- �S V QI� •�'LL^ � �(1 � V
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�-61.95'--� / \\�oL� �/�Z!' l
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\� �p � � LOT 29
� � 0.92 ACRES
PROPOSED GARAGE
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EXISTING CARPORT
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CURNER
30.10' � �
EXISTING HOUSE
LOT LINE TO BE RE��10\iED
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�� � �?�� LOT 3 �
j��t,��-�" 0.94 CRES �
" OL
N89°24'39"W CORNER � -- -
- — --- 293.95' � 30.OU
(TOTAL)
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ROBERT STOX
D.B. 638/49
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