A29 155. � ��.
� t �
�{ � • �`
. � �� �:J ���
�.�n.�Il.�.cIDIl�L7C�t��Il.�a�. �
I.l �[. �.��
Suilding Additions/ Mobile Home Replacements
� j�
Tax Map #: �— Pazcel#: 1� Address: Q� �i ►� U%"Q�
•. �,
Approval Requested for: Mobile Home Replacement
� Building Addition .
Applicant Name: - . . � G( �-C,� � �� �tic�rf�
Address: �'Q� p
Phone #'s: �a�7- �a r{ R'C
Permit Located: � Yes
Installation Date: — ?�
No
Design flow: 3% � (gpd)
Current Contract with Certified Operator on file (if required); h l�
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: �' '� "���� ate)
(Applicant's signature if site visit is not required) �%�%�'%�t,4, ..A /��� ,
Comments: Y�YM� �5 �a� � Sp �� (� �
Addition/Replaceme�t Appr�ved
�
'� �. ,,,,e✓
En ironmental Health Specialist
2 zl-�
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
ut,,,�A• zZ�_So�_t�onr�",• �z�_co�_�QnQ „�,�..------.. . .
�Q:a.ii�tl07 -'�a'�8: ���`—�� a � i IM ��i .\� i .a� �'���l: �
���,�� ��e��e����
Amount Paid: �� ..,: � � ��,�� Parcel#: ��
Receipt #:
]Eaa�asoaa�a���ml[ IHl�mll�]!n
Services
! 0 Improvement Permit (Site Evaluatio�
$200.00/$300.00 (if> 600 �}-�
�bi1e Home Replacement • Building
� $150.00 ifsite visit re uire
� l,VglH�evf'�,j�Tew/Replacement/RepairJ
for Services
❑ Construction Authorization
(Fee is dependent on the type
0 Permit Revision
� Repair of Existiug Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: �
Name: q r •
Address: �L.� ►► W r
_ .
o r
2) Name and address of current owner (if different than applicant):
Name: Sw +'►�t �
Address:
3) Property Description: Lot Size:3.0 �wGSubdivision:
Address and/or directions to Property:
Phone (home): .?3 ` �5�' % —,? O 0 �j
(work/cell): �'/� — G � Q —,,,�/ 9�
Phone:
Lot #:
❑ yes ao Does the site contain any jurisdictional wetlands7 �
�yes �❑� o Does the site contain any existing wastewater systems? � y�
O yes �9 no Is any wastewater going to be generated on the site other than domestic sewage? gX ��r
❑ 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? � r� O t�"
(if `yes' is checked, please provide supporting documentation)
I� C�4) Proposed Use and Type of Structure: :
OResidential �
❑ New Single Family Residence Maximum number of bedrooms: I Occupar:ts:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? � yes ❑ no With plumbing fiactures? ❑ yes ❑ no
Noa-Residential
f business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well �xisting Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, pri s, or existing waterlines on this property? �yes ❑ no
Please note any knovm �ound water restrictions or sources of contamination:
� 1n��6) If applying for `Authorization to Construct', please indicate preferred system type(s):
�"l ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that tf the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
��n��,�L- _
Signature (Owner/ Legal Representative*)
'� Supporting documentation required.
�-�i-�o��
Date
Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
A completed `LotPreparation' form must accompany any application requiring a site e�valuation.
(10/I S) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N� 27573 (336-�97-1790)
� f{ �
� � � � � un
_ , ., .
� , �. ..
„,
, ,, a � � , .
. s'�.�C s�_ s * � , � � � �'� �����#'+1�y: �� ' `� O � �
� ' `��; � ���; , .t
/ - '' . s a � _
�" .
�►. . •y * iit-, �� y�' . ' -* - � ti,�Y'` ,
4` �� ��
. , .
. � p' '.
� . • y .. = i . � L+
�
ti
$ � ��
. . , � ti
... �-..� � f�
� L �A y
I .•/ . . � 1jy� . _ - � i' � t:,,p�,
�7. � S Z �§y � �� 'NQ ^� lT � �� �0 � � ..�.,� � � .
..,. . . . . ..
;
` � ~
...�y, �. �- :a �y��,. �.. �� '. . „ , _
t :
�,Y � �y r,�,+�'ri � a � _.
,. r � a . ,�, ��: f , ;� -� ` �. .,,
y� � ;�_
� Fr �� r � 5 �' � d �4 Yl��'�F ��' � � � � t _ r _
.
r � ,
'�
' 'f�' , . .�`
: . ` ,,. 'x � �,�1� ' �`�, t � .wr' • ..r *�I!+ ,� L
`
P�v �
. ,� � . 1 � .*� ! ' �
..��. � �i. y •+:. .���.rT � c rS ' � � � �-` � � A Vi. `'_
H�Y
�r' 1 ..�`s � '`�' �A � 1� ��+
/ 'q � � ^ �`* � ��r s�'� ,�
�� � � � �' � .�.� -� " "'� "°, y ,�j� "`�.i
� . .l .». pt ���� `;�, .. ��.. e m . ' '�,
� , • � „ _ �. � . .�. . r . 2 . -� � . ` �
q_'. t, � * r:'� � '..t M�. '�h' �d r �
� �� � � "� '" - e � ( �' �'$ # �` � �� �' � �' ` �� �� +t
,
_:
.�'� � ��T�' ' 4 y ��� '� ���; .�g, �� � � � • � �..p �' -r °'�'�t,
,
;. � � � n�� �� � - � � •'�'�,� . � � , �,�� � �
` �, � � �� ,, � � � � ,
. � . _
.
, . .
_ � �� �� �� �
, - . r� . �y � .w..a�,y.� « _�, ,.". E ��P��p r ,.� :��- � Y � 6..
� ' � �� r i��. �_ ��' ���`t��� ��, � � ,��„x. �'y� .
�
4 y�,
� � ,�N
' �, . �; ' � -. � �' �, , i . ��
�S. � , ..�� : �i R .' ; 3k "`. �. � �is� �'d . , � �..
/ . �,� .po ..1►. ' t-,
# y� * . � a y! �t' i ;� A �z q �� :�
. 1 � �' � F �. C!�. ' ... , � r �i: � . ` i, �. K �.
F{ � "� 4 �x, '�
* " v�,. . � � 1�
la .
. . . � . . � -n . w' � e a�'ah'„-� �f..
t } t. � S � �� �,.
a « .
• .. ry k`�, q � � b� �
. ' , � � . ��. � . . . y � � � -.�, � _
t : 1- a � �i. �..
` � ' ^' � �k �+ , .
, �, . �a °'` . � � .'s � - � ' � �`'�1 - ' '. "
� � ' � .
� ` • "
. � � .
",4 r ° �- :> '. a ' � . . . . �,�.�" �- v �
_ ,
,:� . e ' e ."",.,.x p �� , k, �, ^ � %' ..'$. '�; , p� �.. ' •,� �, ' .�,4 t „ �'r
y �
� '• ,.. Y ' s • � ' � " + , �,! 1 � z i� �
t
�� . - ...,� .. i v ' ll�� .. i . . � # , ^� . \ � . . �S4 * � � -
. � A�
� . + 1(y� a . � ' .� J. ,
t�ii� � � � �Y • 7F �� �.' � H �. � u�- .
, ..
,, � �� ,,�� A�_s . . c .� , .� � . ,
���� :� �
. � � � � . ,� ' �
, .R . � �,,. . , y�= * { 4 ��
..
.. �
,
,
� �.. f r _ .� , . - . . . <.� � � . `.: �� -� -.t�,;,,P' � - .
. rt r � .. . Q.'- #,�:
� . ' � ' ,,;,� ' �+L�R, ��: � �' �+ a i?YCSD � � y- } �
;Ki' � �� J's� 'Go ��y'�IS, C ���xbo�o
:,�,
LE�E�Id ?J � � / 2018
� � � � ` � ���� .5f'� CI1 �'�AI° '�'
E-911 Addresses
Easements ' �� Pd�fB�.��sh ���G���� �
Feet
Conservation ���� ��•�� B� � S, ��� � � 120 180 240
Easement 0 0.01 0.02 0.03 0.04
Uti I ity (VI i les
RII Other
�� l
�, 1�1 f
�. � �l/ � �1./ � � �
��nn�-n��1m.�rnrnc�n�n��.� �c��.���
Building Additions/ Mobile Home Replacements
. � ' .r �i � w ' � � ♦/ � !L� /
' � � L�
=ii� // � �.
Approval Requested for: � Mobile Home Replacement
Building Addition
Applicant Name: __1ti����p���
Address:
Phone #'s:
Permit Located: �/ Yes No 3�vo S/����,��c�
Installation Date: � ZZ Design flow: y� (gPd) `�"�
Cunent Contract with Certified Operator on file (if required): ,
Water Supply: �/ Well Public or Community
Wastewater system shows no visual evidence of failure on: Ei����f� (date)
(Applicant's signature if site visit is not required) �—
J
S%/i � - f���� s,�r �'�� � i1 o�.to���srr�,4 • �c/� �,/d�v Sr.2 � ��
��� ,�-Co�/.�/�c,tio�/ Crs�/�/��,BL 9d�24r�T'� �
Addition/Replacement Approved
�
Environmental e Specialist
�?`��D� ��
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcounty.net
� ConnectGIS Feature Report
k� ., V'�
: £�.0 � ai!'J�,,.
Person County Environm2n#al Health
325 S. Morgan S'aeet
Suite C
Ro�oro, NC 27573
2'I 5 �
�a
�/�/s
�����
Page 1 of 1
Person
Printed April 30, 2015
See Below for Disclaimer
Pdreels
❑
Pra�re�s �:reas f1�
i,
�rogre�s hreas �;?�
�
�
�arcei �,ddeess Poir:��
�areel Carr,er �c+ir::s
0
�ercei �irE Cim�r;siar;s
� i�' ,�����P
Lakes v�i:
\ � �'�::�! a r�
/ �
� �.r„ F`?
—i— � .
� �,
� :c.
24=�7
R�,ads
� �d' �'1Q'es.1,��irQ
�,falur�ar;l.�aric�:l:�:ral Gis�ri�es
��,z-p�n� T��L
�
''�PT'�JC� K.Ar��
�iZ�i3 �,1� L.�
�C-;�,�-� �' � i
s�.�;�;�.r
—� 1�-_� : tif/hn/�'�-ii✓ �D �
_'�_��_� --- �✓'E�,��G i'� T�J�(iG
� fp �1a✓�lf�n GJ n�
���y1�r�/ W%zLl.s .
' � : 5� F��t
. Nf/j-i�v�iyi�t/ �✓r'�
� �ril�j�,��rtlT
• f��.l�t�l��t/l,� �.t�r�i�/� ti''/h�ilG.
_ , _ __ __ .. � _, ,
OTICE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who h
�cently upgraded to the Windows 8 operating system or a new version ot Internet Explorer. We were able to resolve this issue by directing users to the Internet Expli
ompatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US/internet-explorer/products/ie-9/features/compatibility-�
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. ConnectGIS has b
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
otified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, Connecl
ssume no leqal responsibiliN for the information in this system. Grid is based on the NC state plane coordinate syctem, 1983 NAD.
http://gis.personcounty.nedConnectGIS_v6/DownloadFile.ashx?i=_ags_map4cc03 8cfa4cd... 4/30/2015
v$
� M
� �
3 �
��
,5 ,�,
.a �
x�
� �
.� �
� �.
i+ y
d �
N .
_�
N r
� H
x�
b
o.o
�
O .y
.�
SE
� �
�
N
� °'
y � O
b.�^
�
� � v
'ti u
.ya�
.� '-` ,
� � a
to o v ,
� a
x � �
n k y �
� � �.
o ::
� � �
°$
� a
• oC
w ro ...
u. vQ,' 'G,
d N :+
y � Fr
�, z
w
� � �
� v ,b
v �
� ^ °�'
a�
xN (d
�
V '
� z
Person County Health Department �
Sewage System .lmprovements Permit �
Owner: �
Location/D'uections:
Permit Void After 5 Yeazs Permit #��-���
�-Yr�_(.J✓e.�r SR# I1��
Subdivision Name: Lot #
Lot Size: Type of Dwelling:
Water Supply: Pnvate: Public: Community: �
Bedrooms: � arba Dispo�`
Basement Basement FyC �
INFORMATION CER'TIFIED BY ���
Environmental Health Specialist: o e� or �ep�e uve .
REPAIlt: REE - O : -- --
Size of Septic Tank: ��F�Q(� gallons Size of Pump Tank: ---�
Nitrification Line: �/'��I P Y? /'
Depth of Stone: 12 inches
Max Depth,of Trenches:
Altemative System: Conv. Pump_ LPP Pump . ,
v�.s�--v
Date Well Approved: Well should be 100 ft fi+�m any sewer system
�Y Environmental Health Specialist
Date Sewage System Approved: 9— a 7�
BY ��� � D��._ Environmental Health Specialist
CER �TE OF CO LETION
Contractorr��
� � � � � � � � � � � � � � � � � � �.� � � � � �
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 maintaine3
by owner in such manner as not to create a public health hazard. Septic tank and
ni0rificadon 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 pemrit is subject to revocation
(G.S. 130 A-335F) '
Locacion of sewage disposal sewage system slcetched on back.
(OVER)
APR. 28, 2015 4:21PM BIOMEDICAL ENG.
N0, 5974 P. 1
Application Date: �7� r� � a%� ��� j)� ����� Tax Map: �_
Am�ount Paid: , d f� c�� � .�, * Parcel#: �_
m �. � ����
�ecei�tt #: _ ���Lt� �ffi���m��fl ]E����
Impxovement PeCmit (5ite LvaluaL�oq)
�zoa.00�300.00 �� 600
Mob��e Home Re,�lacement br Bui�dir�g Addition
� 150.00 fif site visit reauic'ed)
$300.00/$200.Od/$75.00
I�1CA�OI1 �O�' ►�. �I'V1CP9
Sexvices Re ueste�
Cansiructian Autbori�atian
(Fee is de endent on t�e e
Pex'mit Rcvisian
pair af Exisiing Septic System
Applicatiou: No Charge/ CA $150.00 or $300.00
1) Ap�lic.�tnt Information:
Name:
Address:
Z} Name anc� address of current owuer (if dit�erent iha�a applic�nt):
Naxue:
Address:
3) Prop�rty Descri�ption: Lot Size: Subdivisiori:
Address and/or d�z�e,ctions ta Property: � q S---�
Phone (home): ���— ��� � �p��
(woz�lcall): �d�_� -,�j`j�
Mhh�uKe , edK
�'hone: �
e w�a � I ('e ce i p-f' ��P('°'�`''�
� �ba�e e�na� (
#:
,`�0 es ,�nb Does the site con�diu ai�+ jurisdictianal wetlands7
yes ❑ no Does tkae site contam an�► existing wastewatea' s�►Stems?
L1 �as �go Is any rvastewater goiu� to be generated on the site other than domestie sewage?
�� �no Is the site subjeet to approval by an� otk�er public agency?
0 no Are there any easez�ents or right of ways oa this property?
(af `yes' is checked, please provide supportin.g docum,entatian)
7
4) roposed Use and Typ� o�Structure:
e3ide �ial �(a� X �(p �
New Single Family Residence Maximum number of bedrooms: ��
L] Fxpansion of Existing S�+stem If eacpansion: CurrEnt num6er of bedrooms:
❑ Re�air to MalfunCtioning 5ystem Will tliere be a basement? �yes � ao With ptumbing fixtures? 0 yes �no
�Non-Reside�t�a1 '
Type of busincss:
Maximum t�umber of employees:
Total Square footage of Building:
Maximum number of seats:
5} �Vater Su�pl�r: ❑ New well �Bxi�stiung Well C] Communi�}+ Wetl Cl Public Water ❑ Spring
Are there any existing we11s, spris�gs, or existing waterlines on tJais plrop�rry? �yes q no
6) Yf �lying for `A�thori�zation to Construct', please indicate preferre� system type(g):
�Conventional ❑ Accepted C] Innovative CI Alternative �'Other d Any
I cert� that the information provided above rs complete arrd correet. I also wzderstand that if the informai'ion provided is
inaccu�ate, or if the site �s subsequently attered, or the mtended use changes, all permits and approvals shall be invdlid.
Representative*)
* Supportin� documentat�on required.
�.7 r�� .�C�/.�'
�Iate
Pe�nits are valid for either 60 maz�tl�s or sre nQn-expx��mg w�en accom�anied 6y aa approved plat
A completed `Zot �'rep�rem'on' form mast acxom�any any app�ication requiring a site evaluation.
' vr�/iy6�CC � �� �'Gr.��l
o . — iv 1�`J�"c�l' ��' `i� °,,� (,� �
��� �S ��iit�'�i' `,lrl/t,f� •, �'l�`a� fZ �c� 2�'r�'� '
�?iJ� l� Z�� � ��,L�1" `oG��L,U �
�s,�,�
�, f����, 'ql� � d �'�"�'�� ����
� ���� �
� �l
e ,��.�� � ��`�'�'
��
� �� �
-�<����� .
� � �l�, ,G�, ,�����
' �,� � i�/ ��/� y� ,� � T`"�,�,� �,��,���rr
��i� �r� '�
� i�'�¢' '��"� �'.P� , I o . � �, .,.�-�--
������� �% � rs ��✓'�'� ��'�`�'� ��'
��,�,� . di�%G ���
� � �,/,����� .
>� �