A29 131Application Dat�: � . �l
Ar-�o��.nt P�id: O �
Receipt #: ►� 3 j b Z
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❑ 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/Replacement/Repair)
$300.00/$200.00/$75.00
tion for Services
Services
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Tax MI�p:
Parce!#: �—
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: �` , � � �
Name: � e� �� \ t i ��1 �%t I � Phone (home): �� ��"�.� � � � � �
Address: � ^ � Q � Y � � � ,.,.� �' n � ;� 17 . (work/cell): � a �� �
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2) Name and address of current owner (if different than apphcant):
Name:
Address:
3) Property Description: Lot Size: Subdivision
Address and/or directions to Property: ��,
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Phone:
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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 P posed Use and Type of Structure:
esidential -7
❑ 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 ❑ no With plumbing fixtures?
❑ yes ❑ no '
❑Non-Residential
Type of business: Total Square footage of Building:
Maximum number of employe s: Maacimum number of seats:
5) Water Supply: ew 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 restrictions or sources of contamination:
6) If a ying for `Authorization to Construct', please iudicate preferred system type(s):
Conventional 0 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 sit�is�ubsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signatu e (�r/ Legal Representative*)
* Supporting documentation required.
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Date
• Permits are valid for either 60 months or are non-expiring 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)
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Applicant: �1�
Address/Location:
Tag Map: f�� Parcel: /� /
Subd�visior_ �✓i//.� � �1�
Phase/Section/Lot # �/
Improvement Permit
Permit Valid for: Five � ears ✓ Non-expiring
Type of Facility: New �/ Addition _
Number of: Bedrooms �/ Occupants (P / Employees / Seats:
Proposed Wastewater System:
Proposed Repair: ���� W�`��'►a P
�-- s� r T
Water Supply: V1r= l_L _
Projected Daily Flow:�� gallons/day
Type:
Type:
Permit Conditions: a -
Auth�rized State Ageni: __ Date: � / /
(X) Owner or Legal Representative: — r Date: _
The issuance of this permit by the Health Department does not guarantee the issuance of ather r:.quired permits. It is th;, responsibility of
the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject tu revocation if the site plan, plat or the intended use changes. The Improvemeat is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of t6e North Carolina �Laws
«nd Ru[es for Sewa�e Treatment and Uisnosal Svstems'(15A NCAC 18A .1900). Neitber Persao County nor the Environmental
Health S�Cecialist warrants that the septic system wiil continue to function satisfacto::iy in thc fature, or that the water s�ppfy will
remain otable.
Authori�ation to Construct Wastewat�r System
See site pla�n and additional attachments (�.
Yro osed Wastewater S stem: ��� ��'� ���/, i*)Type � Design Flow " r�ta gal./day
P y 2
New ✓ Repair _ EYpansio Soil LTA.�: .� gal./day/ft
Type of Facility: � t3��QG�M-1 Basement: _Yes �P�o
(``) System Types IIIb, Ilibg, IV, crnd V, require periodic system inspections by the Person Coiinty i�ealth Department.
Wastewater System Requirements
Tank Size: Septic Tank bD0 gal.
Drainfield: 'Total Area DD sq. ft.
Trench Width l� ft.
Pump Tank �i/ � gal
Totat Lengtl� � � ft.
Min.S�il Cover _� in.
Grease Trap ga .
Max. 'french Depth in.
Niin.T'rench Separation 9 ft.
Distribution: Distribution Box �✓/ Serial Distribution ✓/ Pressure Manifold _�_
Specifications: � ! /�i✓E�_ � �d � ��"1y ��'-�� ��7`��� -
Authorized State Agent: Issue Date: /��//� �
Permi� Expiration Date:
The system permitted is: Conventional /Accepted }�i / Alternative / Ini�ovative . I accept the conditions
and specifications of this permit.
(k) Owner or Legal Representative: � � (J Date: � 1� _
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Person County Environmental Health, 325 S. Morgan 5t, Suite C, Roxboro, NC 27573/ph: 336-597-179� (rev 5/12)
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Name: �
Subdivison:
� ��N�� Gd /DD �
System Type: �.
Septic Tank: �,���allons
Pump Tank: �//�gallons
Total Linear Feet: DD
Max.Trench Depth: �"
Site Plan
' Tax Map: ,��
Parcel: /J/
iress:
�ot:�
EHS:
Date: / �3l �/4�
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Scale: �� �
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Health with any questions (336) 597-1790.
Additional Comm�nts:,��%!J� �,�G'�%�701�% /%�����/ / 3T � �