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A28 203d �7�'�0 � � ��� � Application Date: � �� �� � � j �0� � �eJ�� ���\ Tax Map #: Amount Paid: O•60 � a�.' Recai t : ParcE� #: �� �� .� �I � � �--__- - - � I�1�I�.� �1�T � � � ��-��- ��?�. �� �s�.vaa-a�xrs� a�xm.�..s.Il 7�-1Lo.m.Il.�]La � / �%'�• . APPLlCATIOM FOR 8ERVIC�S � IF THE INFORMATION IN THE APPLICATION FOR AN IMPR�VEMENT PERMIT 1S INCORRECT, Pl�1LSIFIED, CH�►NGED OR THE SITE IS ALTERED. THEN THE INIPROVEMENT PERMIT AiVD AUTH�RIZ�TION TO COIVSTRUCT SHALL BECOME INVALID. � �ertni# requested by: (Ovmer/agentlprospective owner): � 1� /�" 2%l� /,�- A-J l�F %/=�21 �%) Home Phone: 3 3�—�4 4- 3� 4�/ Address: , 6d �� s Business Phone: oac b�, ,e a � .._}:,,.2) iVame and address of current owne�: S'�4 �rt � .,..�,.. ) P P �� Townshi O 1 r v�. � 3 Pro e�ty Descri tion: Lot size: p: FL� I l Subdivision: Lot # Directions to the property (I,ncluding road names and numbers): • � ��— sr �r) A��ct� ��(' �cs � lo, a � 1 0, � t�-.r 4) pruposed Use and Structure Description: answer each of the fol wing questions: a) Proposed �/ Existing , Type of Structure: � Width: v(� Depth: �� b) Number of Bedrooms: 3 Number of occupants or people to be served: � c} Basement Yes_, No � Will there be plumbing in the basement? d) 6ar6age Disposal: Yes , No � . . . 5) Water Supply Tbpe: Private V(new ✓ or existin9� , Public_, Community_, Spring _ Are any wells on adjoining property7 Yes ✓ No _ If yes, please indicate approximate tocation on the 'site plan. fiDoes your property contaln previousiy identified jurisdictional wetlands? Yes_ No_ , PLEASE NOTE THE FOLLOWING: . � e4 PL.d1T OF THE PROPEi2TY QR SIT� PL.AiV MUST BE SUBMITTE� 1MTH THIS APPLICA'ilORi. ➢ PROP�RTY LINES AND CORNERS MUST BE CLEARLY MARKED. �, ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE ST�►6{ED OR FLAGGED. 9 THE SITE MUST BE READILY ACCESSIBL� FOR AN EVALUATIOPI B`I TFIE�HEALTH DEP�►RTiVIENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposa( system for the above-described property. I agree that the contents of this application are true and represent the maximum faciliiies to be piaced on the property. I understand ifi the site is altered or the intended use changes, the' permit shall became•invalid. . /1[� Owner or ! 0,5' Date PCND, rev. 061271U2 �-��, ; � �� ���� �� �. - "^ � � ��� 1L I��.�aa-��� ����.]L IL--3C��.Il�11a T�x M�� , . � Farcel � � � S�uihclliv i s�i o ii Ph:�s�e`Section Lot # Applicant: IXr�-�q �Q � i 1� Location: ,� � � _. , . � - _ , n ., . _ Permit Valid for Type of Facility: _ # of Occupants � Proposed Wastew Proposed Repair: � Five �'ears � # of: System: �: / " `J �` - i v�i�t1 �y �� , � ��,�1� - �`cctis Improveinent I'ermit � lG�� r 5��o{,.e ,, No Egpiration �, . New � Addition R�ater Supply �� � �nnmc `� Projected Daily Flow `� (00 g p d • Type: ��i Type: Permit Conditions: ��� a l� l�ir`�-� c�-t- SP)�s�i� Sc.f��/�-� G?-� (r�s1 S�' %d � � wt Owner or Legal Representative Authorized State Agent: _� Date: Date: - -o s The issuance of this permit by the Health Department in does not guazantee the issuance of other pemuts. It is the responsibility of the applicandpropezty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement P.ermit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rule�or Sewage Treatment and Disposal Systems' (15A NCAC 1�A .1900). Neither Person County nor the Environmental Hea1tL Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. �Authori�aiion to Construct VVaste`vater Systeffi �Required for Building Permat) * See site plan and additional attachments (_). �.� WastewaterFlow ��o� d. Propos d Wastewater System: �vt,��.� d� � l��v 2� Type _g.p• New � Repair Expansion _ Soil LTA�t: .�� g.p.d./ ft 2 Type of Facility: � '�?�R' �o S• Basement Yes �No Wastewater Systeffi Requirements Size: Septic Tank: - C9� gal Pump Tank: gal Grease Trap: ga1 field: Tota1 Area: �o2p0 sq ft Total I,ength �b� ft Mazimuffi Trench Depth o�oZ in zh Width � ft Minimum Soifl Cover: � in Minimum Trench Sepazation: � ft �• C• Distribution: � Distribution Box � Serial Distribution Specifications: "��2 S �� S�� � Authorized State Agent: _ Permit Expi Date: � � �-E— LD Pressure Manifold Date: �� �� S The type of system pennitted is � Conven 'onal ovative Alternative. I accept the specifications of the perinit. � �� - 4� r Owner/Legal Representative: � Date: PCHD7J30/2002 0 0 `���,�� ������ . . - - �' '" �. � ���� . . � 3E�-������m�.Il.'I�-�m��]I�. , S7'I'F' PI.AN Name /"di�� �1 �(� � -- Tas M�p # !T Z�Parcei #� Sub ' ' Secrion/Lo D Authosized Scate t�geat D� . Sysm� rampaaeans represear appnn�ne cantouzs �aIP• The cant�aormvsr9ag t6e sysaem priar ro be,�g tlie ms�a�on m a.,•:• thuPn'F�sgnde is maiar�iae� Tn"'ACT A ?P=P,OX. 52.5C R=MAl� °cRTHA KAY -it�rRt,^,H C'.'r.S'. �Q��?S% :J' . :. �k KD PVG t u. ^� l�lo`— �BK ;��Mi►! � I 1 � �� .�,: t � Well �� M�a �\ `2 � - Z •' ���T � v`.i.- J�.. . . I �W � �� � LeaSbu,� ��. ♦ V �v�a��u�' Tr�ie- , � , � � __ � � �s� � � ��g�x: � Wl �� l�� . (� ��s �} ZZ,� ��P � �� sa-a.�� x �, �� ��� - b�+�n a � �.anK �' A-�o1L• O N _ �, � �1u5�` �� n`'� � ��� �Qr � s _ l„ N �(`� s�o..tr �0�.�� ' . `lyr��'�' ' I V15� l� 0.�-i Jn • \ ��� ��g���s '�� �.�C.�-�-Y o�.1 q,-$-a5 �� � — � /�v`�- ��2 � 1: u _ lDc� ' . <\�'� / s �.��� �� ���d� �� `� = • •�T � � �.J � ►!. 1L , ' �mm.�-�a-���� �s�.��.� �'���.���a Applicant: �'�� ��f��'�� Location: w /►n �. _ �../J A A • . �,n. • . a ax M�p / � � . �rc ' � SubdliviFsion Phas - Sec ion? ot # af Bed�roo � � s �` + _ _ .J . � . . .. �, � .:� � ��.,, . � ��'�tl�i� .�� 1� � � � �.. . . �, . , System Type (ln Accordance Wiih Tabie Va): � THtS SYS?E3U1 �--IAS �EEi11 I1VST�4LL�D IN COti11PL1AMC� WtTH APPLICA.BLE . NORTH G'�,ROLd➢�iA GENER�►L STATUTES; RU�ES FQR SEIiVAGE TREATME�T AND DIS�OSAL, • AND -/�Ll. CONDITiONS OF " TI-lE !luiPROVEiViE1�T PERI�IIT. AND COi�lSTRUCTION AUTI-( R T10N. . . � � . , h,i'e,/ -• � � (-� S' • Authorized State Agent � Date � Installed. By: ,,� 1��► s Date: � ,�� 7�.�� � . .- U � ( ' . .. � . , �Q . . ��� _ ,S, �� . ,' ��,,,e� 1� �� . e � �x� . �, j �����- ��.x.�,� � � .�; ... . r �a ��G� �� �, �,-`w,� ✓`raP� : i���6 � � ��L�� 9��« .,,, �0' -?-o �y� ( ( �l L .� , � 6' , ��r i� � za- �" s P�� ����� �a��� ������S�a�� �,���"�..��� i���� �� � � Tax Nlap #�.2 � Rarc�! #_� Sysite� Typ� (Tab�e Va) Owezer/Appiicant � Subdivision Rddress/L�cation Ser,/Phas� Lot # � Se���. T'ara� ni�saU�at� a�t a�on nes_ In��a d�t� � State�(D/date e '� S� Trencfl �dih� '�r ft. S Ca aci B al. � Trenc� De th 2 in: Tee and Filier - � � T,rench Len o ft. � Baffie ✓ � Trencf� Gtade � . Sea{ant � � Trench S ac9n -.� � Riser 'rF a licabie � Rocic De �iii and Quali • - Tank Out(et Sea! DamslSte down� etc. �- Permanerrt 1Viarker Pressure Laterals � � -- . Purnp T�nk � � Hole Spacing � -- State /date - o e ize -^. . � Ca aci al. Pi e. Sieeve ` -�•- Wate roof /Sealant Tucn- slProte�tors -� Risei- _ _ ' . Recguered�:Se�a�� � Ct�eck ValrrelGate Valve � � Anti-sip on o e F#oatslSwitches �larm visable and aurl�le Electrical Com onents ' Rate m .. A roved Pum iViode! Blocic Under Pum � Pum Removal Ro e/Ct�ai . ��Dis�'sbu�ion: Sys�n � Seriai Distribution ressure fVlan o Low Pressure Pi e A r. Pi e i�i�teriai and Gi , �-,--_- .. From� Welis From Prooettv lines Surface Waters Public 1Nater Suppi Verticai Cuts (>2 ft Water Lines Ve�iicle �Traffic • . �EasementslRi hf ofi �er fi- Easemenis Recarde . , ,. Co�aav�en� . � pchd rev. 3/13/01 _ _. � 7 : l . ���� �� � ..�,: � _. �;�. ..° � � ���� _ _ _ J��.�a�-����:��.��.IL ��, �- WELL PERMIT PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map a� Parcel # v2o� Township: Applicant: ,- � Subdivision: Lot # Type of Water Supply: � Individual _ Community Public Requirements: Site Approved By: 9 ��o� Grouting Appro d By: 9/ o� Well Log: - Pump Tag: Well Tag: � Air Vent: ✓� Hose Bib: Casing Height: - Concrete Slab: Liner: Insta.11ed by: Depth set: _ Grouted: Date: Water Sample: Well Driller: � Well Approved by: , /� Y�� ****See Attached 5ite Sketch**** Wells must be 1:0 feet froin property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: Date: 3 -10 -(�(� PCHD rev O1127/04 j'1'• �--.-��� � �f .� � f �� �J �,.i �� �`�°�. `�y Q� /. � f _ j� r� ' // '...�.. ' �✓"' •� `� ••f� T 7'i \ :�►' '��J,�'(iay;un U�� V f! �I�C ��.�^-' I � � �' S '�'!��"`�� "�""� �.� `�.% L., �.. '� �� �j�,�� �ft���p��� r -- v � 331ir•:i 1L" O JT i 1'1�1,!!'1 :� I11 1 :: ��. �`. c7c:. J Q". � :i ���/ C'Y f�i� � �..r� 1�'ell L�g o��: �r�"�i.�._..��-�-�.� L.�.�._..___� T',�x .�iep��� �Lcc. ._�v �_;x;�[ton. �. � .�O ....._,L c,.f1-S_.. b �r ..!__.. _____..__... _.�.__ ... _ .. 3 . � �_. Sut�ti�:u;un: �� L:;tr� 1�'ell (+onurucdon I?iscaar�; 3=ro,x nctc:�; ;•r�7p��y t. ine ;�i;nunwr. i�) feet; _.�_.__.._.-- Di�tiu:ce t':JU1 S�','SCC S}•,:e:*i (h"�ni:A't1�I1 OV ECC:; `--'� ._, Toca: De;��ii �c7 t} �':rlc:: ._� .._.__.._ 'v'��' 3taLc 4L'atc_ L�v�:. __,� . . ��3iCT �CtLCL'lg %C'LCS' .J�p'.i3 --�&CIL i :� T�. 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U�'P�l _.. _'�_ :o . _.�: 0 `:. :viitcrial� l.'�c�ct: � \�o. 3.��s r�rt�a.-�d ::.,�:.tcr:it G�%cic;.tit uf : Bu� .._—.r'i._ {�Paun;ls ;i �nixture �tiar, :�.� ra�:�i, ,:utt;:�Y�} �- l:.�it�o ��, / ✓ ?ia:e�: . .I/t �, . .. ti a » x 4 Siab 7�'es ~ � � ' llriLin� I_a� Lc,cYtrc,n Dra�+ing ..._ . . 1--�..._-- - -� —_..__...__.._.._ _._._. . . � _.. ... _. .. . .._ .._ . . .__.. ._. _ .._. . ►� F'rom ' T� • b'urtn�ilon ._._. . _ . .._.... . .. .._. � ��-�6=_ -_ _.,._ . � � : ...___ _::- �- _ _ . _ -_�._:� ; -.�_- _�._.T_�����.. f� �.�r�� ,�a�� �— % � ___.... .-- �� _._ _._ ., - -.�1 �.�.�...� �d� �---.�-� � .. ..__:..� a- ... . _; .. �r�a-Y .%.o �•.- - -.-..-. _ a-J v_. � � �p c� _ .t. � � rn.� ,C' f�r� M ' --a" 6 `� . - �-�� .._ �' L�= _� G_.G�._�� i ---� ----. �_ ....__.. , __., _-- -�-�.._-----...... , ; . �`.�. �L... ... ...�. � . .. � �...���.����' .. ..��. ��..�� ��.�� ' . ._ _ _.. . ....... ._ ... i_ _.�__.r. _ . __.. . I.... _.. .. _. .. _ .. ____._w_ _._"_� .. _.__._ . _ . .. _ . . ... _.. . .. _ .....�,.�__ . _..�__�.�__.�. _. ..__ I 1C7CC�� �C.77i'�' 'hai •!�►r ��b01 : :i!.'.� .r;-:� • .a'.:t��. .4 C� 'iCI L^.V � ;!•, � � '�i'iL•' i i SZI f7:it::!` t��l 1��.',li�i:'..i:l.11l'i �'1�.�.L� CJu:' .. -- -. I.��Z'.:t'i:�.:fl .i�:�:J'::�ifi:: '.�:!:��':1'U::�ii 'lL� Stb,natztre oT Cuutntctur _— —_ ____....� � * __� 0.3 / Ef.�te � �/ _9._._.��� . .:3:: :. , . . . � w g ,�p 3 �� PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant ��� /iL���l�,�.h Address � �a �r d • County ����,o}� RoxboYa , 1J C a. 7� 7�f Collected By_'�� Date Collected ��25"' � ? Time Collected °� // �Qj� Source: ell � Spring ❑ Other Location: House Tap pWell Tap . � Other ❑No Charge Charge **���*��������*�*�*��*��****������*�**����*�*���*�*����**���*��****�**�**����* *�����**�**����*�������������**���**�*�*�����*****��*���*������*�*�����*�*���� Total Coliform FecaUE. Coli Results Present Abse t D a � Reported iiC..�7 '�Z 2 � bactreport �p.� �� �o a�.0� 'l '