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A28 12A�pplication Date: O b ��� a� �/ q- � � TaY Ylap: �� A�nount Paid: % S. pa GQ S c/! rarce! #: �) �,4 Receipt�: a � % --r � I,---� �� , � -;� ,� ���� � � ��� ' �---�--__ �� ��> �lL� ;�,, �' .-�� 7 7��u��-�-.��s-.���3.._„_„ <trr-�,L:,�zIL iE�L��..-n.,!���z ����gc���on �oa- �e�-vac�s (Septic Systems and Wells) Seavie�s �� uesred � Improvement Permit (Site Evaluation} 0�onstruction Authorization �200.00/$300.00 (if> 600 � d} (Fee is dependent on the tyne of system permitted) ❑ l�Tooile �ome.�3epiacesnent or Building ��dition �J Permit Revision I $1�0.00 (if site visit re uired) �75.00 � �'sil Permit (Pdew/I2eplacement/ll2epair) O Repair of ��isiing Septic System � $300.00/$200.00/$75.00 No Charse �) Servic�s R�y31eS�e�l �. : / Name: ��Oe � � CY i^ Phone # (home : ,3 �� � .�d.3 �Ol � Address: / n S (tivorlUcell): �/ 4' �� 3�� — �s -� OZ i)l�t�iu� a�d adalr�ss of �ur��mt awa�ea� (a�' dif'ff�er�n# �han applaca�t): Name: Address: 3} �r�g�erdy �3escrfl��io�: Lot Size: ' Subdivision: Address and/or dire�ftions t'o!Property: L r4SS <<� o�� %,� �7� D� �%!�V'r NF T�P% �, �ea r� � 4) �roposed Use aud 'T3�pe of S�ructua-e: Residential _G� Business/Type: Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes � No (with plumbing: Yes No _� Garbage disposal: Yes No 5) �Vater Supply: � Private Well �oposed Existing _� Community Well: Public tiVater Systein: Are there wells on the adjoining properties? No Yes �ot #: (please show location on site plan) I�I�ote: ,4 cornpleted c�v,�licalion mus� t��so incluc�e: � A�ladsite pl�zn of'thg ,�rapeyty lliat sJtorvs� prc�er� tli�r�en�aons c�nc� t,�e size �ra�l ?ocr�tion af �11 �ro�osed structures. � . 5� A:sagned cvpy of idie `�ot �'r�p�sration',i'�r�aa ve���an� �haf tlae �ropeYry �� ready �o be. ev�alurate�. � area submiiiang thos .��p�inca#ioia to raquest 3ervic�s . iff th�e info��na#ion ��-ovide� is �s�eorrP�# or i� t:�e ��#e periraats and appravals shat� �ecame inaalici. / t�e �'Qr�o� �our��y �ealth �epa,r#pneant. � uncersta�d �tha� i�s�e�ue�n�ly �➢�e�e�, or �f i;�Q �mtendeal u�e charge�, a�� �ab���u�-� (Owner!'Legal Representative): �a5� : � �( O _ 10i�8 Person County invironmenta! '_-?ealth; �"'S S. �iior?an �t.: Suice C; R�Yboro, NG ''757 ;�33b-�Q`1-1790) A lication Date: �/g 0 7 Amount Paid: O �� Recaipt �: ���°��Ls�. ��I� . g °� �� 6// Tax Map #: � � � Parca! �!: � � �- •�����__�� ��Jld� �� ' —= tC � �J 1�T'I� � �a.a-�+-s.a-aaaa-•�•,�•• oa-a.�m.]l. ��m.m.7L�I�a APPLlCAT10N FOR SER1/IC�S � IF i'HE iWFO1ZMATiOid IN TFiE APPL9C.a►TiON FOa2 AN lMPROVEME3�T PE�ZflAIT 1S INCaRR�CT F�1LS7�3E� C�i�►idGE�. Oi� THE SfTE IS ALYEitED. TIiE�! T1iE 1NIPROVENiEAIT PERIlAIT AND AUTH06�IZi4TiOf�9 T� COtuSTRt1CT SH�►LL BECOAAE IMVALID. • �ermit requested iay: (Ownerlagent/prospeclive owner): � a < � � � Home Phone: ���6 So_3 / D! I Address: .� • Business Phone: , � � G .2 2) IVam� and addr�ss of c�rrent owr�e� �Cc Y"I f C� S G�c �D U`e 3) Property Descr�ption: Directions to the prope; 4) S) re Township: 'd " � Lot # F�roposed Use and Structure Description:.answe�ach of the foliowing questions: , , a) Proposed . Existing Type of Struciure: r�df�a �'9 ¢' t�� �/ir�y Width:� Deptt�;.2 .� � b) Number of Bedrooms: � �. Number of occupants or peopie to be served: c) Basement Ye�_, No _ Will there be plumbing in the basement? � d) �arbage Disposal:.Yes � , No _ - 1Water Supply 'iype: Private �new _ ar existin Pu '_, Community , Spring _ Are any weils on adjoining propetty? Yes o,�f yes, please indicate approximate location on the 's�te plan. � . . ' �'aYDoes your property cantaln previ��asly identifiec! �ur�sdictional wettands? Yes_ iVo�� , PLEASE NOTE THE FOLLOWIMG: 9� PLA? OF THE PROPE92TY OR SITE PLAid NlllST BIE SUBMf'CTED WITFI �HIS �4PPL9C.'�Ti�N. 9 PROPE�ZTY LlNES AND CORNERS MUST BE CLEARLY MAR1��D. �, ➢ iHE PROPOSED LOCATIOPI OE �4LL STRUCTURES MUST BIE STA�D OR FiAGGED. �'fHE SITE I�iU$T SE RE�►DILY �►CCIESSiBL� FOR AN EVALUA►TIOPI BY THE HEALTH DE��►RT11iEi�T STAFF: � I hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposal system for the above-described property. I agre� that the cantents of this application are true and represent the maximum facilities to be piac�d on the �operty. ( understand ifi the site is altered or the intended use changes, the permii shali became invat�d. , .// ' Legal Representative ��r��6. Date PC�iD, rev. �6127IO2 . �� � � s � �ti � 4� 1 � � �/ � �� � � JJ�..K��i.��.�. ��.�� �G.i��� � ,�i��LNLJi ���an� Ad�itio�/ �obi�e �o�e �eQi�c�ffi��a#� Tax Map #:��_ Appmval Requested for. Paresl#: Ot2A � Mob�e Home Replacement � Buiiding Addition � ' F :: i ' Applicau# Name: � o e � (�rn dS�� r � Address: ' ' 1-r'i 1 Rory.� c f�] . � . 1Q2�6o�e • 1�1�C 2751� � ' Phon� #'s�: _ 3 3L � So �- �o�[ _ - . � . . ' - �--� � 1 Peanit Located: Installation Date: Y �'Yes No 5- 4- 73 Design'fiow: Cu�ent Cantract �vith Certif�ed Operator on fi1� (if requirec�: Wa�r Supply: � ell � Public or Community (gpd) Wastewater system shows no vi.suai evidene� of failuce on: �' 1 g"a 7 (date) ��. tAPPlicaIIt's signature if site visit is not require� Comments:_�Ain�riir► Q f � S�ef�acKs" - �bcdro� lacer+enf-/baf�.ovw, n,J,�,f�+en � ' � A 'tio�teplac�n��t Approeer� � - � G -l8'0� Enviro ental� Heaith Speciaiist � Date 11/15/05 � . ���.�� I�I�I�..�S�� . � --����� . � ��s��,. �.-.. ��� ��.w:��. SiTE PI.��1�7 - Name � e�P,� %j Sh er Taa Map # 28 P�zcd # �� Su�� � / Secu�u/I.or# • '� � r -►s-o7 � oflzed State Ageut Datt System campaneacs repnscat app.ca�are caaooras anly. The caaaacrarmuartlag r6e sysnempa°ar m bgmanug rhelns�aa m ;••°""'r6atPt°Pergsadelsmamtsuaed - . � . . �jSi , U�� D � � J t i � ' / _ _ . �._. { _:'_� - , `��z � " �. � �. b ��. � �� � � �x J � � Z y � � : �. x �. �, :r b y o y � �- � � y O m � x. �, _. � � - aa �' o � � �. o � e�r y , � N• m � m � ... t�. � � � w � � c ' �! � � o � � m � � o y � � o O „'�' a � ro o . � � w .�. y' ... �p � � � � " i � � � � o � ; y .. � � � � e� 1 (� �A/1 � O � ; n � w �, � �. CL y .1 � � _- . -.__ .. � ,� The District ��Hea�,�h � Department �Orange, Person, Caswell, Chatham, Lee Counties � �� �� Water Supply and Sewage Disposal ` � /s�9�� � � ate - `' '. ^ � Owner: ` y ,o �� pq oc�tion: � � , . _ _ ". a � Contractor: � Water Supply: Private Public Sewage Disposal cilities: No. bedrooms � Dishwasher, Disposal, ashing machine other autom tic appliances Size o an i: • � Nitrification line: ��.� ��� , Other disposal facility; Water supply and sewage disposal facilities location, installation. and protection must meet state and local regulations. Above recommendations based on information received and observed , soil condition. Septic tank and nitrification line MUST BE INSEECTE,D - AND APPROVED BY A MEMBEft OF THE DISTRICT HEALTH DE= � � PARTMENT STAFF before any portion of the installation is covered and put into use. ��vF+R� Location of well and sewage disposal facilities sketched on back. 1 �� � �, a � �-` � � < � � �1 � �� � � ��L1,�7"ID.�"QD� "�7Y:�.��.'t'�'�f.� ����� �u�a�n� A�a���on�/ �o��le �offie ��piac��a��a� Tax Niag #:�_ Approvai �tequested foz: Pazcei#: O��A_ 11�Iabile Home Replacement � Building Addition ' A�plican� 1�Tame: � o Q � � rn � r Address: � ' 1.�', t 1Ze,,,,�„c Rrl. AeXbe/'d NC 2�%S�T Phon� #'s�: _ 3�� � Sa3- �a�! . � Pexmit Located: " �'Y'es Installaiion I?ate: 5- 4- 73 Desigri'ffow:. (gpd) Cusent Contract �rith Certified Operator on %1� (if required): Water Supply: � ell Public or Community �Jastewater system shows no vi.suat evidence of failwre on: (o -1 g-0 7 (date) �� {Applicant's si.gnature if site visit is not required) COIDII1�Ilt'S: %�Ain�ctt+n aJl se�l-baGl�S _ ��C.alrodM rer.i�aGer+en�}-�berhrvaw+ a�r��finn . — " � � itioa�ep�ac��nt A�pro��ri . � � � -�8-oy � Enviro ental� Heaith Spe�iaiist � Date 11/15/05 � 0 . �~�.+r�� , �,��T.�.J �� . ' ^� � '�l `T� ��T�� . . �3Z'o�'3TO'I^'T..'w �@3a.�L 1L 1L�0��� ST'� PL.�1`�i Name �� av ! ljr»�1 S� � r Tax Map ,�. 28 Parcel # O.� Sub ' ' �/� Secriou/I.or# � �lr/�� _ _� — �e�18 a7 � tliko�2ed $ta� a4geIIi , DatC Sy9tem campaaeacs represear sppms�a� caararas anlp. T3e canuacormu�rslag rlte sqsrem p�car m 6e�iania� rhelas�i� m msucrtharpmpergradtJsmvamined • 5�� �fD�l� u ��� )� �� ���� �� �_..� � � � � � Jl � I�; a.-��� � � �. �-�: � �. � �.11 IH L � � ]l -� I� Tas Map: � �� Subdivision: W��� P�RMiT Parcel: � � � (Netiv_Repai�\� Lot: Applicant's Name: ^�P � `�/'Q �Sl�(� % Nlailing Address: ) S / /�O�-,G.,S /zd. Rd xba�a /[�G TS Phone Numbers: � `3� -SD ,� -10 1) �I � q - '�� �-�'i S a Lacation of Pro er i S 1 1�`°"��nS C��- P tY� I'ermit L'onditions: 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply. 3) Permits expire 5 years from the date of issue. Other Conditions/Comments: - Per�nit issued by: ,��=������t� � I�aie: ��/� 3( �/ C�R'�'��i�ATE OF C�NL'PL�'I'IO1�T New Well Inspection: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Gasing Height: Concrete Slab: Well Driller: Pump Installer: Well Approved by: Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Liner Inspection: EHS/Date Installer: �}.Q,,k,n 1,�����ar�s�� Depth: �5.('-�' Grout: -� �2�� �oR � Well Abandonment: EHS/Date Completed: Method/Material(s): _ License #: License#: Date: Date Results Nlailed: '' Phone: 336-�97-1790 Fax: 336-597-7808 siiio8