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��
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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 - .
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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
�� �
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�-` � � < � � �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