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A28 168T � _. - _ y z Person County Health• Department � Sewage System Improvements Permit �' `��.'� � �} -�30 � I :'L�'_L`7�This Permit Void After 5. Years Pern►it # Owner: �� Location/Directions: Subdivision Name: Lot # " Lot Size: � � Type of Dwelling: Water Supply: Privatc: Public: Community: Bedrooms: 3 Gazb e Disposal Basement Baseme ixtures INFORMATION CERTIFIED B ' Environmental Heal[h Specialis[: o��f qr r res ive REPAIR: REEV ATION: �� Size of Septic Tank: `� allon Size of Pump Tank: Nitrification Line: � X � � Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remarks: , • Date Well Approved: Well should be 100 f� from any sewer system BY Environmen[al Health Specialis[ Date S age ys m pproved: — - BY Environmental Health Specialist ._,.� CERTIFTCATE OF COMPLETION ,� Contractor: �_� L �,.� i c � -------------------------- � � Sewage System location, installation, and protection must mect state and local � regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained by owner in such manner as not to cieate a public health hazazd: Septic tank and nisification line must be inspected and approved by a member of the . Person Counry Health Department before any portion of the installation is covered and put into use. If � the site plans or intended use change this pernut is subject ta revocation. ' N (G.S.130 A-335F) "� + L.ocation of sewage disposal sewage system sketched on back. � , � (OVER). _ r NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located at later date. Note location of water supplies on adjacent lots. � (1) (2) ■� ii� �����i�r�����■■��■ ■■����■����■ ■����i�i���i���■�■ ■���■�������■ s��■���iwi�u�����■ ■�����������■ ■�����7rIF������■ ■��■��������■ �■��i:ii���■���■ ■�����������■ ■■■�■�■■.I■■■■. ■■■■�■■■..■. ■����l�i� 1�'iiii�l����■ ■�����������■ �,, ■��i�'iii�������■ ■��0��������■ �l���■�������■■ ■�����������■ - �i���������!��� ■�����������■ .�ii�i��il.��C�l,�!�����■ ■��������n�■ �G�'�=� :�siii�■ ■��■����■�■�■ ���� -rr ---� _-,,.. ......... �—l�-{�ci Amount Paid: 1 � ; . UD Receipt#: 5 �� � � ��,� S �". ��.�� �� „_` " � � ��°�c`� � �,, � � 7� �;rn.�s+n�c-.c� -n.a.�s-nQ,:n.)1. (',U/ _� i O 7F.' 7C �:�.rn. Il,t:lla. "�� Application for Services _ (Septic Systems and Wells) ❑ Improvement Permit (Site Evaluation) $200.00/�300.00 (if> 600 apd} ❑ Mobile Home Replacement or Building Addition � $150.00 (if site visit required) ElWell Permit (New/Replacement) $225.00/� 125.00 1 ax 1v1ap: �_ Parcel #: I (�g Services Re uested ❑ Construction Authorization (Fee is de endent on the e of sy; ❑ Permit Revision $75.00 0 Repair of Existing Septic System " No Char�e Important: If. tlze information in tlte application for mt Improveme�:t Permit is incorrect, falsified, or t/ie site is altered, tl:en the Impro �nt Permit and the Autl:orization to Construct sl:all become invalid. ) Service�equested by: Name: � �, � � � �/-�� Address: ' a,�f�.-�� /l/ C, o? 7�� 7 � Phone # (home):33Co ���? S93l� (work/cell): 3 3� :� �3� •'7 5~j I x I� ��Il 33c. 59�3-- ��S�S 2)Name and address of current owner (if different than applicant): Name �e j�ccc r�, C,�C�r;-�v�, Address: _l 2�' fRe d-Fox L� ��ht�v��� I� � �']� '1 � 3) Property Description: Lot Size: ubdivisi Address and/or directions to Property: 1,J � C..o vrh v�. v e P Lot #: ct.�-t- � �t� I 5 �s Svy�� l / ,D» �.ct�2 �f /_�-�- � X�ec� Tc ar ) .�rr''N G�3 'v [7v� 4) Proposed Use and Type of Structure: C � J � � E C� I'� %� �� �'c�Y /' 6l u� .:./, k 4�r� Residential �/ Business/Type: Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No _(with plumbing: Yes _ No � Garbage disposal: Yes No Approximate size of buiiding foundation: Length Width j: . .'�) Water Supply: Private Well �(Proposed Existing _) � Community Well: Public Water System: Are there wells on the adjoining properties? No _ Yes (please show location on site plan) Note: A comvleted annlication must also include• ➢ A plat/site plan of the property that sltows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' forna ver�ing that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representative). `J Date: �� s/d � 11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) -----_ --- - - - —__ _ _ -____ _ gs� sn ol �;;�, - - - - r 5(�' ACCE�� E��EM�NT � F_XI�TING ~ ----------- cn S07' 06' 50"��=a-`--`- _ - � S 0/° �W�_ 6�..5��� .��...�-�s-"�"�ti��-- 9� _ _ _ _ - - -�'y"`Y.._,_.-:_,___. 1 67 .9.8' � �� �uLb�S�oOUN —v- — - — � J ' -' O � � W I- Z Z � o C U U . , . - . .. :.S F ���A y .; . 3 i � :1. t ., _ � - 1i f )`�: Y :7�1!N.g K �,45 •���� J�� ���� �� . . ' r� �! � v7� i V �y J.4�T �713^YII]['�� v'*'� �33�.La.Y ��B.ID.JI�IC�, SITE ��TCH �� Name i�e �ecCQ �.(Q a Tag Map #�.P�cel # 1 �nl _ Subdivisio . � Section/Lot# � 2-IR-o� � . tho�ized State Agent . � Date � . System cumponents rrepr�esent u�iproacimate�contours only: The coniractor must, flag tlae systemlbrior to beginning the inrtaZlation to insure that ps�opergr�ade is maintained � � P �'� Se��'` . S�S�w, :. ii. n 'I �o�— }� Sc�-c�' 5-� ra e �U��� � �iQ��rT�'Ct� n L�-' Crn'n� / -�"►"om �j t,Er �Cil h �C{�'1 c��i� C' YI � ��� � � C s S�iyls Q nd . -�d� s�p� y � l� �1 jl ('� b �oyv� . �r�Qr�%l � �I� �e5�io��S Co��aG�" / � � �nv. ��1-� � � 33t� - 5q'1-17�0 � � :�p �MZS� k T � PA. � ,..�..,:.. � . .. . .`� ;��,: .:�;:.: :..�...,.' :::�.' <; . � ��� . :::1:"�"�:: .� �• ���.�i/n,.�•'•�•�••� ..��.' '• • ....�•:..�. , .. .�.r.�.� . • �.. " •Y . . k':�:� �.•�.� -� ... .......;....:::.�n::: �..:..v�::..:::.:..� ............. �'L . ...�. ., �.., , "." ' ...:;:::,-:;.. ,. . : .` : •'..a. . .�T1 ... 7. �- :: : ... .. . .. .�1J��7�Il;.'S9"-31'e7L;! 4�F.71�L�.:9Gi�+:ffiriJL' .:' �L';.li.�:uB'p29t..�L' � ', � WT�L'��.3�8<lY9.g1 • ��JV' L'"r17L:� �8�� tA� il'i�.1Q1d:r3y �u •r il �1�� �1 �� �g1JC! n '���LyYJ $ Tax Map �,(��g�� Applicanf• Subdivision: Location: 1 SSC ln1 Parc�l # �_ Township: �I�.,i-I�n Lot # L►; . --� Type of �ater Suppgy: �dividual _ Community �eq�aire�nents: Public Site Approved By: �S . Liner: Grouting Approved By: 2- Zlc�� �� 7nstalled by: Well Log: � � Depth set: ` Pump Tag: � Grouted• Well Tag• ' Date• Air Vent � ` Hoae Bib: � Watea� Sample: Caeing Heigh� ' . Concrete Slab: � � ' � � Well Driller: �ra �n5 Well Approved by: ****�ee.Attac�aed Sit� S�ce#ch***� Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems, Wells must be at least 25 feet from any building foundation. Other canditions: Date: � PCHr rev 01!2?/0� 12/0 �2�0? 10:17 33� 5977� 8 � ON COtlNTv EAI-R1O p� .'`''�,,��� � ��..� ,..�'°r.n� �'�.J� \ 1�� li�i � �._.,,�F.�t� � � ...,._...�.....-. `' � � .;�.�+� ,�T"�'°�' � u11t.���- �irsar.�x�o'saara�a���w.�L' �`�«.r�]I,� ��� �� 3-3 -a �,......r�..� Cs�'0�t i.0g Owru: �E, hP c c �- � /a ,. � ����y n ,�_ . �_.�.__._. T�� � � +�,.1.�� i�41�fiDii: Cr ii L �✓ �/►Il.� � IA�+�"��� ar.�. �.�rri .w. �.�.�� �ti�tvlli011: j„� � �r . . w� � DLt�o� Fram a�t �rogerty L'ma (Miai�um• IO !bu?y._____,__,__ �a lfr�a S�ao 3ys� (�m �p�c ) Toe�1 Bspa�; ��� !t Yi�id: i� S�i�mit L�vs{: _,,,_,.y !i ws� H«�i�� �+.�,�. � � � _.,,_.._ n,.__,..._ t� c,�= � �__s�..___ m,�_-- t� n�: ��_''¢___ � '�p� c��.a swi w�i� L,3,.,.� Tbioi�m�ee.� ,�� _ iiea�iae �ba.e c�rmmd: ,.,�,� � Ikt�v SLoe: Ya �,,, No Aay probl� �o�oomtai+�c! wMI�s �a* ayia�? ,_„Ya � Ido If "�a" giw swweY: � Mat�rlaM Lbotr: %t.�L' .�_ s�arce�i „��c,"OaOnm ,_„__ c�ll,�arc.�.� „_.__.,_ A:mutar Spavr Width �,_ t�c�e W�c ��_�� ,�Yea �� I�atbod of C3rott� Pur�d ,,,�,�, p� � p,� +�.� �F,�, ��� p� UMi: No. Bag� Pio�nd c�a�t���, Wa�t ai 1 A4g �bu� If mixRoaa (��� trst, �tin�o� _ � -�2.��,� ID P�� � Y�a _ No � s 4 �dab �es ,_, P1e QS �� Dwe h�el�od: ,�„�,�,,, C3tou� Isu�lled by. _....� ? c1 �� � ; H r.' ns,it � �C's�_J Q„�,` /�+-v� ` R��� �_t ,�- . ,- �•-• Loea4i� 1l�wln� I hareiyy oatl�jr tbat tbt abo�+�c tetfc�t�iarc� it oor�ect �d �t t� �eQ tr�� oo�r�toe�d in �ecc��� with r*auietiOrur sat fartb bp tMr P�e�eoo Ccwmty i�ie,a�!► �art�� ffiissst�n o! Costraretor I iv �r 2 d� b.a �,_ �:� � �■R �+mv �ali�eion Coaasc�or: Sd�e Rs4��C�lot� N�btr: Pu�pP D�p1►� .-.....���,.._-____t4 Si�tb liVqer Lavdl• R Pump Iidab � l+ded�1. ' "�--�---- �p �i�e �tnd Radn;: _eY_„�yp � I 2mreby cortiij' tlxt t,� P�P a�u fnnelkd ad tbe w�U i+e�d compl�ed �►eooedfa� to tbe Per�or, Cowaty Wall Rula 1n etlect o» th{� dsta �nd �at a oopy of t�i� recotd bau beet� pcavid�d bo tt�o a+et1 awstar. �ta� �taWr Slpatar� DaW: _,_, �3D rav OU�7� .