A29 124� Amou�t paid
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?ersor� Courny F,Uaitn C�ri
V;J 5. �Sofgan Sire�i
Roxboro, N.C. 275T.�
�;qitrier �?2-33•15
.IU-1�-99
Date
Improvements Permit.(Established/Recorded Lot) I_ Reinspection of Existing System (Loan CIosing)
_ ImpFovements Permi[ (Unrecorded Lot) I_ Repaic/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _. Permit foc New Well
Improvements Permit (Addi[ion) _ Replace Existing Well
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p �, _?� �2 ry ��.,Y�.��;>..<-r,�>��K�,��,�`a����,W,aterSamplet beCollectecl = .
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$acteria _ Chemical � Petroleum _ Pesticide
_ Lead
l. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospective owner/agent: �m e� N�1� " Wrdth: �i ��
Address: P � i3o)l -] I(� i y _ Depth: 30 �
�, � N� c_ a� � g, 'What type' (if any, additions, expansions, or
� replacement is anticipated to the structure or facility
a that this sewage disposal system is intended to serve?
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� Home Phone #: y �I -�10 c� � �
a
usiness Phone #: Ll �I - ��6 �'
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Name and addre5s of curren[ owne'�: � 9. Water supply type:
T �+,C_. fi-s sc, c z n c _ private �: public ❑ community ❑ spring ❑
' Are any wells on adjoining property?Yes ❑ No [�.
' If so, identify location: ) n I<now n -
: Lot size:
. Tax Map#: A. -.a 9
Parcel#: 1 ,� �
Townshlp: OL ►.v� .�-i �._I j
. Directions to propercy: State Road #& Road
iames,�tc.
r ,� , � , , „,> �. a c,. ,-4-1„ .. o , �.�,.-�- �.,
Number of occupants or people to be served:
10. Type of structure/facility: Proposed: �Existing: Q I
Type of dwelling:
House: [�Mobile Home: C� Business: ❑
Tyge of business:
Number of Employees:____—_._
Number of bedrooms: ,.,�_ �
Garbage Disposal? Yes, �❑, �o �
Basement? Yes ❑ Nol�d'if so, # of basemenc fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AI�ID THE CORI�IERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Person County Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the con[ents of this application are tcue
and represent the maximum facilities to be placed on the property. I understand if the site is� altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the propeccy to the Health Dept. I understand that in the event I have not
delivered a survey piat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this a,pplication shall become void and all fees paid forfeited.
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Signcc� �wner or Authorized Agent
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PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: h1' 2"1 Parcel # 12 �
Zoning Township d L��E � 11�i-
Appiicant: �1 A(Y1£S N t LL
Location• `�f`7 cS T1� ��cl �+.i�S c�{� � r �I
Subdivision: �d���il\-�-� ��G� Sectlon: Lot: �_
Improvement Permit
A buiidinq permit cannot be issued with onlv an Improvement Permit
New � Repair _ Addition _ Type of Structure i��4�Water Supply U� �L�
# of Occupantsci��X b# of Bedrooms 3 Other .
Basement? +�o Basement Fixtures? hlo
Projected Daily Flow: 3(�(7 g.p.d. Permit Valid For: �ve Years ❑ No Expiration
Proposed Wastewater System T pe: Cot�E►�TIO�iR(.
Pump Required? Yes � No
PermitConditions: �tiSiAl.L 0'vJ C���Du� �EEQ S�►\C-s Si�M I� �lfnl►Mur�'1 �r SD�`T'O
0�1 t`'i�P4�t2 C�fZ� —� �� �o � n1�� PRR��Ac� mP Co+JvF�lrroNh�-
Owner or Legal Representativ� S,�gnature: Date: �1 `"�-� `� �
Authorized State Agent:
Date: � �-20 - Q.°I
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit
holder is responsible for checking with appropriate goveming bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Perm(t shall not be
affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Buildina Permit)
Type of Wastewater System C..Ot�i�l En11101�{�l. Wastewater Flow: 36d g.p.d.
Facility Type: la New �Repair DExpansion ❑
Basement? 0 Yes � No Basernent Fixtures? O Yes O'tQo
Wastewater Svstem Reauirements
Septic Tank Size: 1000 gallons Pump Tank Size: �� gallons
Total Trench Length: ab� feet Maximum T�ench Depth: `da inches Aggregate Depth: So2 in.
Maximum Soil Cover: � inches Trench Separation: �l Feet on Center
Other: �"�SiAU, On1 %oNiO�(Z ,StE �m��o����r P��m�T I
Permit Expiration Date: ��-?-CA�O�
Authorized State Agent: s Date: �� 2�" �l
The type of system permitted O does ❑ es not differ from the type specified on the application. I accept
the specifications of this permit. D f�� Z Z-� F
Owner/Legal Representative Signatur .
� � Date:
PCHD, rev/ 10/12/99
❑
Application #:
Tax Map #: f� - q _
Parcel #: 1 ��
Person County Health Department
Environmental Health Section
SITE SKETCH
JAm�S 1��LL '�Zos�v�u.� R�e��'._�oT ��1
ApplicanYs Name Subdivision ection/Lot#
.Sbd�1 �; . rpW t-KES
Authorized State Agent
1�-2o-gQ
Da#e
System components represent approximate contours only. The contractor must flag tl:e system
vrior to beeinninQ the installation to insure tliat proper grade is maintained
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Scale: l �� _ (00�
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WELL PERMIT
PLEASE SEE A'ITACI�ED PLAN FOR WELL SITE T.AYOUT
Tax Map #: � Parcel #/?� Township OG��f �//%
Applicant• 1%� � �li l/
Subdivision: �!l ��� Secrion: Lot: � _
Location•
T�e of Water Suvulv:
Rec�uirements•
e� Individual
Site Approved bp �
Grouting App o ed by
Well Log _
Well T
Air Vent I - 9- �Z
Hose Bib . � -4-�z
Concrete Slab �,� / - S'-a-�- �
Well Driller.
Well Approved By:
�'►`�
Community Public
Attached Site Sketch**
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septic spstems.
Wells must be at least 25 feet from anp building founda.tion. .
Other conditions:
PCi-ID, rev. 09/07/01
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I��c)lt�l�ll liY "!'111. I�I;1z�;c>i l c'c:�l)�J�I�I� Iit:nl.�I�II 1�L'l���It�1�t��tt:rJ�l�.
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Person County Health Department
Environmental Health Section
Tax Map #: h`�4 Parcei #: �04. y"
Zoning: Township: /�,��i.� .'�f
Subdivision: .�2 ' ,' Section: Lot: �
Appiicant: �,�.o s �'�/ -
Location•
Operatifln Permi��
System Type (In Accordance With Table Va):
THIS SYSTEM HAS BEEN tNSTALLED IN COMPUANCE WITH APPLICABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
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Authorized State Agent ate
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Tax Map #: �029 Parcei #: /a��
PCHD, rev. 10/12/99