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A28 3Application Date: � � a� yv� Tax Map: �mount Paid: Parcel #: Receipt#: �� 1�'��$�t�� ' .e,v�-4�,� — c� � �� 1� `� I�c� k .� 1L�aa�a>i�u-.calc-n�rna.c:.�ra�.�en11 1[ JL<c=mo.IltGl�n Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if> 600 d) (Fee is de endent on the ty e of s: ❑ AZobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired) $75.00 Cl Well Permit (New/Replacement/Repair) Repair of Existing Septic System $300.00/$200.00/$75.00 No Charge � 1) Services Requested by• , Name: ' `6— Address: �3 b � ,,��('.� �.1�.: /ve . � s-�/ �a 1( �" � ,+� M e �`�" a �,�� Phone #(home): 3 3� :5�� i�d Z (work/cell): 3 3 6 — �5�3 ' �� %� 2)Name and address of current o��ner (if different fhan applicant): Name: Address: x 3) Property Description: Lot Size: � Subdivision: Address and/or directions to, pProperty: S ZS"� o�e.�,�,�-c �'�,✓Iitr% , 5 G d �/%� T� 0 7S�(i.�[ o�...� 4) Proposed Use and Type of Structure: Residential � Business/Type: Other Number of bedrooms ,� / Number of people served (seats/employees): -- Basement: Yes No �(with plumbing: Yes No � Garbage disposal: Yes No 1/ � 5) Water Supply: Private Well ✓(Proposed Existing _) Community Well: Public Water System: Are there wells on the adjoining properties? No _ Lot #: — Yes '�(please show location on site plan) Note: A completed anplication rnusf also include: ➢ A plat/site plan of tlie property that shows property dimensions and t/ze size and location of all proposed structures. ➢ A signed copy of tlte `Lot Preparation' form verifyii:g that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. �� ,, �� ,�%� c� ;y,a� l�` Signature (Owner/Legal Representative): � /Lti�� . � Date : �J2.3v�/ 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-] 790) 1,. Application Date: ��T7 Amount Paid: � Receipt #: ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacem $300.00/$200.00/$75.00 ��, ?.�,� �� l V �� 7G��mm�b�¢�,Il ]HC��.A;� �lication for Services Services Re uested 0 Construction Authorization (Fee is denendent on the type of ❑ Permit Revision ,. $75.00 Taz Map: � b Parcel#: ,� �R 11 � �o �,�e� Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Inf rmation: , Name: C - � /!/ r Address: /C L ' �/ 2) Name and address of current wner (if different than applicant): Name: 5 - � � ,�-� .� Address: � �n Phone (home): 3 3�rS l9� �c�� 'Z" (work/cell): 3 3 � .�b'"3 � S�� f Phone: 3) Property Description: Lot Size: _� Subdivision: Lot #: Address and/or directions to Property: ��'S ) - ' ❑ yes � no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? ❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency? ❑ yes ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structurei ❑Residential ' ❑ New Single Family Residence Maximum number of bedrooms: �_/ Occupants: � ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? � yes O no With plumbing fixtures? O yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no Please note any known ground .water resfictions or sources of contamination: 6) If applying for °Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. � ` _ � �� /�'� �� % . Signature O r/ Legal Represent ve*) Date * Supporting documentation required. • Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��'-'�z�� i�_.. �� ! Tag Map: �f Z� Parcel: 3 �� y � 1 � � � �� Subdivision �—� – � � � �'� � Phase/Section/Lot # ICs �-yn a-��-��.I1 IL�L � �.11 �7� Applicant: ' Address/Location: Permit Valid for: Five Years �_ Type of Facility: Number of Bedrooms / Occupants Proposed Wastewater System: Proposed Repair: Permit Conditions: Authorized Staie Age • (X) Owner gal Representative: Improvement Permit Non-expiring New Addition _ 11Vater Supply: / Employees / Seats: Projected D�i Type: Type: Date: Date: gallons/day The issuan�e of �his permit by the Health Department does not guazantee the issuance of other required permits. It is the responsibiliry of the applic�nt/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Luws and Rules for Se►vaFE Treatment and Disnnsal Svstems'(15A I�TCAC l8A .i9U(1). Neither Person County nor the Environmental Fiealth Specialist iv�rrants that �6e septic system will continue to fanciion satisfactorily in the future, or �hat tne water supply will remair potable. Authorization to Coostruct Waste�water System See site plan and additioMal attachments �_). � Pro�osed Wastew�ter System: ��p�� (*)Type��-_ _ Design Flow _.yAr _ gal./day New Repair Expansion _ Soil L'Cf�R. Q P�/�- gal./day/ftZ Type of Faci lit-,�: Base;,ient: _ Yes _ l��o IY, and [; require periodic system ins�ections by the Person County Health � t��t� Wastewater System Requirements � ��,�,g�� /U��-i �.sc� �� Tank Size: Septic Tank 1 gal. Pump Tank gal. Grease Trap gal. Drainfield: Total Area^- e�D sq. ft. 'fotal Length - 3Eie� ft. Max. Trench Depth f2� in. Trench Width ft. iVlin.Soil Cuver �`3� in. Min.Trench Separation ^-� ft. Disiribution: Distribution Box�� '� / Seriai Distribution� / Pressure Manifold Specifications: Authoriz.,d State Agent: 7'he system permitted is: Conventional /Acczpted _�/ Alternative / Innovative . i accept the co��ditions and specifications of this permit. (X) Owner or Legal Representative: Date: Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) ConnectGIS Feature Report � C�NI�ECTGIS WEB HrfStING � i�� 2 - W` � � T �' t. � S�Sv L � P�5 L.�..��.-��'j �%,+,X � � - �� . 1-� �� Page 1 of 1 r^_J--�� Person f"'�•' Printed January 26, 2017 �, Yy � See Below for Disclaimer ,1�d�� - �� k'�/Y�/� ��jF�G'� .:� /S �� , . �? � ��✓ 5 0 � i�j ,Soi� /��s h�.✓5 ��rr e�l�� .��' . �20►',� ,f� !��►/� �f,��cf ' �vna�/. �,c. �-1 ��i�� ';�R ��/Z Gr%3'�D�!'Jj �%328$ .i�G��/ �� i' �.'%':.:: ..-, >:''! � � a�' c��✓yv�,��/y �.�w� ,��r��.��:�,,�,,,.� �,��i�� -3 1�'� ��, ,��r��-..J�f�� _ �. y:�,�i! . � '� saa � `� .�.^_";y�°v � ��$ f__ / ..� __....-___-. .-.�.__ ��..,_-..._.__.._,-. N ��p .v.—�_�_ 1� r'� � N ,� �,,,• 5�5�� 612 `� 83 .. 1_ �— '� � f .; /�r' � i ,',:;: . � �,) v� t1 '� 4 ft 6�� /��/ � �:�v�i N � l �' 'a E . �rty C� J£h+t c�.� : is,��.h� x' fi�«-}-� �: `�` � f ? . , <�,.�,� � r � � r. 1 40 Feet . � . ��t� � ` t �i �;�: � . ��f,.-�-� ►�i rj � t-'"± ! 5 � �- �-1� �,,; _ : IOTICE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who hav� �cently upgraded to the Windows 8 opereting system or a new version of Internet Explorer. We were able to resolve this issue by directing users to the Internet Explore ompatibility View tool. 7his link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US�nternet-explorer/products/ie-9/features/compatibility-viev this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGlS has beei repared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system ari otified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectGl' ssume no legal responsibility for the information in this system Grid is based on the NC state plane coordinate system 1983 NAD. http://oldgis.personcounty.nedConnectGIS v6/DownloadFile.ashx?i=_ags_map95aflc2a4... 1/26/2017 � ' PERSON COUNTY HEALTH DEPARTMENT � 355A SOUTH NIADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant� � W�� e �� Address �, 25�1 1..enS 6.ra � County �P,r�o,n Collected By �S Date Collected /U-29—o`7 Time Collected �'3p Source: C'�'Well ❑ Spring ❑ Other Location: ,C'House Tap OWell Tap /��e - Sa��, C�3I�10 Charge �Charge ❑ Other ��*��****��*�***��*,�*��*****��*��*�*�:�**��*��*��***��**��*��* ***��*��x*��**�**�**��*�*��X*��**��*****��*��**��:�:��*��* Total Coliform FecaVE. Coli Results Present Abse�}t ❑ Lt�� ❑ CN' Reported By � �� MT bactreport ,