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A28 75.,� � ` z C�,�^' � Person County eal�h Department � Sewage System Improvements Permit Date: -� i ermi Void After 5 Years Owncr: SR# Location/Directions: °'`� Subdivision Name: Lot # Lot Size: � Type of Dwelling: . Water Supply: vatc: �— Public: Community: Bedrooms: � Garbage Disposal Basement Basement Fix[ures �j INFO TIO C TIFIED BY ' 5�� owner or representative g�pp�; REEVALUATION: Size of Septic Tank: � gTlons ize of�Pump T�ilc: -- — Nitrification Line: Depth of Stone: 12 inches � Ma�c Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remarks: Date Well Appmved:�� Well should be 100 fG from any sewer system By S_ �� D Sewagc System A ro d: �'- � `� gy Sanitarian � CER FICATE OF COMPLETION - - • —�--- — ---------------- � Sewage System location, installation, and protection must meet 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 create a public health hazard. Septic tank and`d nitrification 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 permit is subject to revocadon. (G.S. 13U A-335F) Location of sewage disposal sewage system sketched on back. (OVER) „ 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 ,t at later date. Note location of water supplies on adjacent lots. (1) f� � (2) . r" e' � � The District Health Department CASWEL �¢IATNAM - LEE - PERSON COUNTI �!N % )r' � o'� �% � � l� '� Water u r dnd�ewage�isposa PP Y IMPROVEMENTS PERM�'� N�� - ��_ Owner: � �� Location: `� ;,i lsl/ ;✓�" , Vvdlt%�5�,�� ,� � _� a` t r _.; Contractor: � � Waier Supplp: Private Public Sewage Disposal Facilities: No. bedrooms _ washing machine, oth�rvauto�natic appliances t Size o�#a�l�j ;r' "' L'� _�`�-� Nitrification ' �R ' d �' " � ; � n facility: Dishwasher, Disposal, line: ' ,. .,�t,{,j.l �'S�KY KU''t y� Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard.: Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE,.F�STALLATION IS COV- ERED AND PUT INTO USE. - jj �� j� /" ` rJ;�� S j � � � ! �T-^+�.« � t S e i'`��;'L•'i �. 'I:�y''��Y}. Date approved: Sign �cl �.�=� " � �-� � Sanitarian Well: - Sewage Disposal: By �. I �ertificaie of Completion Date Approved: ' ' Counter- aigned (Owner or his representative) �� /�� .� ../: (OVER) Location of well and sewage disposal facilities sketched on bac:�. I4 'ea Application Date: � � � Amount Paid: 0. 00 Receipt #: 1 q � `1'� ' ' � 13 �� Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 �2nd) or Building Addition $3 00.00/$200.00/$75.00 �� l ) f �� 1 �y Tax Map: .� � � ._...: ► • j..,r- �. � ��,� Parcel#: %�� J��.aava n•caaiaaaa-anff:uIl :E-:� c�raIl4:3a tion for Services Services Construction Authorization (Fee is dependent on the type of Permit Revision Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Informatio : Name: Address: � C� U �2- 0 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: �� Phone (home): 3�5��3 l� 1 (work/cell): � L 1 (0 27 3 Phone: � ��c�l-� �a IPv.lo.� �,ot #: 1 C� � � v�� v � _ , . � � � ❑ yes no Does the site contain any jurisdicrional wetlands? � r n �, � h�— on �A-�—_.� ❑ yes [I�yi Does the site contain any existing wastewater systems? �� ❑ yes m'no Is any wastewater going to be generated on the site other than domestic sewa 0 yes G�Yn/o� Is the site subject to approval by any other public agency7 d e��eG� qar c��R. ❑ yes �'no Are there any easements or right of ways on this property? •v U (if `yes' is checked, please provide supporting documentation) �j.� X�. �/ � -� ., 4) Proposed Use and Type of Structure: ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: C�urent number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? O yes ❑ no �Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Ma�cimum number of seats: S� Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any e�cisting wells, springs, or existing waterlines on this property? ❑ yes 0 no � If applying for `Authorization to Construct', please indicate preferred system type(s): O Conventional 0 Accepted ❑ Innovative ❑ Alternative ❑ Other � Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccu�qt�, or,i�'the site is subsequen�ly altered, or the intended use changes, all permits and approvals shall be invalid. �wn�r/ Legal Representative*) documentadon required. �-rz� � Date • Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat. • A completed `LotPreparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) . / . � � x � � : �:.�� . �� ,�na��.11 1�C��►-�-¢� . Building Additions/ Mobile Home Replacements Tax Map #:__;�� Pazcel#: 7� Address: ��A�vlcy��`,PD • c�� _ �G �z.�r7� Approval Requested for: Mobile Home Replacement ✓ Building Addition G�.�c{ � c�-o,c � S' Applicant Name: L � �,�iLI�C� Address: Phane #'s: .�9 �>'— 7?,ls�! � �� 7 � Permit Located: ✓ Yes No Installation Date: � O �r2� Design flow: �(gpd) Current Contract with Certified Operator on file (if required): �� Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on: ! 3 t 7 (date) (Applicant's signature if site visit is not required) Addition/Replace�ent Approved � / . Envirorunental Hea th S cialist 9.j�.�7 Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net Tax Parcel Viewer �� :� � ,,.t � � � .i t ., � n https://gis.personcounty.net/TaxParcelV iewer/ Page 1 of 1 .q��_ �� , �C; �,��.�,z� ' �Z�� _� : ��iqt�. ,. g �- ' t ?: d :< -:' �xi �.•� �. � ra: ti� �. v�� `��:�:�<3�,. : �-s PPrson County EnvironmrM��.! '--'�alth 325 S. Morgan Stre��i Suite C Roxboro, NC 27573 `��i ��l 7 ,, �� , � 9/12/201 %' � � � U i� CCS a ` Tax�lVlap #. � � t� �.��, f A 001072 PERSON CO HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERMIT Paxcel # I ,Township Owner/Contractor �� p /� F.t l% Date x/U- �� Location/Address „ , __, I .� , � . � f � , Subdivision Name SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area Size of Tank •�?Ct .I�i",:, � Clw,lr�l,-�, SFD Mobile Home Size of Pump Tank Business # of Bedrooms Z-- Nitrification Line ��( 300 ��<,3 ° ��— Max Depth Trenches Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if s Well and Septic Layout by Comments: �i Y�.,�- Date Installed by Approved by. WELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Slab Public Replacement Air Vent Site Approved Required Well Lo� Well Head Approved Well Tag Grouting Approved Comments: Date Installed by � Approved by This report is based in part on information provided the homeowner or lus/her repres�itative in the application submitted for this pernrit The environmerrtal health specialist is not responsible for false or misleading information contained in the application 'fhe environmcntal health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Petson County nor the environmental health specialist wazrants that the septic tank system will continue to function satisfadorily in the future or that the water supply will remain potable.� c:�amipro�pecnutsam O 1/95 rev.1.0 ► ----�-; . ' _ _ , '� , r � r m , -�--� .� � PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT Tax Map # Parcel # Zoning Township r� X.b�� (Z� Owner/Contractor e � Location/Address L � -� L � 1 „ , _ � _ � � 7 rYX ,-.,.,, lJ i ..1, � � a� U � a Date � -� � - 4'g � Q � ,�� S �p � S.R.# SEWAGE SYSTEM SPECIFICATIONS Repair 1�_ Lot Area Size of Tank e��`��-! r'lG'i� SFD �/ Mobile Home Size of Pump Tank �/�► Business # of Bedrooms�_ Nitrification Line ,�'1b' X 3� M� Depth Trenches �y" �� Permit Void after 60 months. Permit Void if not in compliance wlth zorung reguiations. � Permits may be voided if site is altered or intended use hanged. � Well and Septic Layout by � � Comments: Date (o �1a-q 'A Installed vidual Site . Well Comments: ;Q Approved WELL SYSTEM SPECIFICATIONS i-Public Required Slab �cement Air Vent � � _. W.ell on Date Installed by Approved by This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in ihe application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resutted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic tanlc systetn will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro�permit.sam O1/95 rev.1.0 ORIGINAL ��