A28 159Application Date: (� o�� � � 3
Amount Paid: ��
Receipt #: I 7 IaZ
�P
U Improvement Permit (Site Eva[uatio�)
$200.OU/$300.0� (if> 600 �pd)___+__�
D iV;o�ilE IIome Replacement ar Eaildiag Addii:on
$15U.00 (if site �isit require�
D �'Vell Fermit (Netiv/Re entJltepair)
$3�0.00;�200.0 !$75.00
`-•�,;,�,� ll ����1 V Tax Map: � 8
�,.: �r- Parcel#: 1 S `1
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I� xao-aa-cD�*+�*� �3nc:aPi iHL�e,.a,IL�
Services
for Services
tequested
❑ Construction Authorization
(Fee is d�endent on the type of sysiem permirted)
� ?ermir Revisiun �
$75.U0
❑ Repair uf Eaisting Septic System
Applicatic►n: Nn Charge/ CA �150.OQ or $300.00
1) Applicant Information:
rr��: �a i 3a n e E
Address: ' I n
oX ol0 27 �
2) Narne and address of current owner (if rlifferent than applicant):
Name: m en �larsh G il
AddrEss: 3� q I li�r �nc� 1��
Xbp �/Ir L 7 � S'1 �
Phone ('nome): ��3�- �� 3� O��Z9'
(work/cell): �
Phone: k/ 1' 3 Z�" 6 2 Z Z
3) Property Descrnption: Lot Size: Subdivision: Lot #:
,�ddress and/or directions to Praperty: 3 r� hnuSG c� n �-��- pa �C ��dc lh�c�ula^
❑ yes � no Does the site contain any jurisdictional wetlar.ds?
❑ yes ❑ no Daes tiie site contain a�iy existuig wastewater systems?
❑ yes ❑ no Is any waste�e�ater g�ing zo be generated on the site other than domestic sewag�?
❑ ��es u no 1s the site subject �o approval by any oiher public agEncy?
❑ yes C r.o Are there any easements or riaht of ways on this pi�operiy?
(if `yes' is checked, please pro•ride supporting docum.ntatioa)
4) Proposed Use and Type of Structure:
❑Resiriential
L, Ne�v Single Family R�sidence �-laximum number of bedrooms:
❑ Expansi�n ��f Existing Sysieni If expansion: Cerrent number of beasooms:
❑ Repair to Malfunctioning System Will tiiere be a basement? ❑ yes G no With plumbing fixriues? � yes � ne
❑Non-Residential
1�pe of business:
Maxinium number of ernplayees:
___ Total Square footage ofBuilding:
Maximum n.imber oi seats:
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community V��ell ❑ Public Water � Spring
Are there any existing �vells, springs, or existing waterlines nn this property? ❑��es ❑ na
6) If applying for `Authorization to Construct', glease indicate preferred system type(s):
❑ Com�entional O flccept�d Cl Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the infornzation provided above is complete and co��ect. I also understand tltat f the ir formatior� proi�idec,l is
liTGCC2lYQiC, or if the site is subsequently alte••ed, or the intendad use changes, all perr:its and �z�provals sltull be invaiid.
�� a� `-z S - l3
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
Date
Permits are valid for eithei• GO months or are non-ezpiring when accoinpanied 6y an approved plat
A completed `Lot Preparation' form must accompany any application requiring a site e�aluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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1�.���- � �a-�. ����.11 .IE� � �.11 -�]]�
W�+ �,I, ]PERNIIT (New Repair ✓ �L i n.�� �
Taz Map: � 2$ Parcel: � 5�
Subdivision: Y�nt:
Applicant's Name: �a �f M e h. IV t a�rSl,a I�
Mailing Address: I 3 q �a � r�g d,
ox o,�o !�l C, 2�57
Phone Numbers: �( i q- 3 2 3-(�22Z
Location of Property: y q S 7�I�> o n (� � a� o� K (�a ��-u �� . 7
,,� ��; ��� l�.� _l �.J . 7 t�bf ,�� ('�.�
Permit Condiiions:
1) Se� attached site pdan for proposed well location.
2) All applicable State and Counry regulations governing construction and setbacks �pply.�
3) Permits expire S years from the date of issue. �
Other Conditions/Comments: P�er n� i-{�e� .�(�.f �� j �n e,� -
r --- � � ��
P�rmit issued by: _ �� �ate: (,Q 'Z Ce - � 3 . VJ�< < �"� —
� � �,f,�� ;�g8
C�1�TIFICA7'� O� CO1dIPY�E�'i+DleT �
New �`dell Ins�ection:
EHS/Date
Location:
Grouting:
"'ell Log:
We� Tag:
Pump Tag:
Air Vent:
Hose I�ib:
Casing Height:
Concrete Slab:
Liner Inspection:
E S/Date
Installer: , �e � W i zctr�5
Depth:
Grout: �S - 212.-1
Well Abandonment:
EHS/Date
Completed:
Method/1liiaterial(s): _
Well Drill�r: . ( � �a�,+� l� � `LQYdS Lacens� #:
Pump Installer�^ Lieense#:
l�ell Approved b�:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date:
Date Results Mailed: ' �
Phone: 336-597-1790 Fax: 336-597-7808
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8/1/08
ConneclGlS Featurc Report
Pagelofl
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