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A29 19Application Date: cj-Q � � � � Amount Paid: � Receipt#: -��`�,5.� ���..��� �.. _�_=-_r = c� � 1:���"IC"`�Y" J� ',�. aa�v-ii .ic-.cn zi-n�rnT_.E � n-n. Q:.rs..11 7E`-'7r"ar�.en.11: ti: i�a . App�ication %r Se�ices � (Septic Systems and Wells) G Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) C Mobile Home Iteplacement or ]Building Addition $150.00 (if site visit required) � C Well Permit (New/Y2eplacement) $225.00/$125.00 Tax Map: A � � Parcel #: �I �' _ Services Ite uested G Construction Authorization (Fee is de endent on the e of sy; ❑ Permit Revision $75.00 . �epair of Existing Septic System No Charee C�-�` �-� e -� �a � � �.�1(� � ��C' / a ��� � Important: If the information in t/:e application for an Improvement Permit is incnrrect, falsified, or the site is altered, tleen tlie Improvement Permit and theAuthorization to Construct sl:all becane invalirL � 1) Services Rec�, sted by: Name: / L. Phone #(home): ✓`�`'j' S� 44 7,3 Address: �2,[� � �� ���, }Q/� (work/cell): ��� � - ���,��� �, � r� 2)1Vanne�aad addres� f curren o�idiiferent than �pplicant): Name: Q Address: 3) Property Description: • Lot Size: 2— Subdivision: Address and/or directions.to Property: 4) Proposed gTse and Type oi Structure: Residential L/ Business/Type: Other Number of bedrooms / Number of people served (seats/employees): 4� Basement: Yes No (with plumbing: Yes No �—) Garbage disposal: Yes No �`"� 5) Water Supply�:� - Private Well (/ (Proposed Existing _) Community Well: Public Water System: Are there on the adjoining properties? No Yes Lot #: (please show location on site plan) Note: A completed a,�plication rnust also include: ➢ A pladsite plan of tlee property that shows praperty dimen�ions and Phe size a�td docation of all proposed structures. ➢�4 signesi copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluaied I am subaniitang t�is applic��ion io request seY-vices %ouy the Person County Health Dep�rtment. The anfor�nation provided is accur�te. � under�tand that if any site is altered or the intended use changes, all perflnits shall becoffie invalid. � � Signa�ure (Owner/Legal Representative): � � � D�t¢ : 9 - 4- - v � 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) Page 1 of 1 � ..�' � � �� ,' � , �-; . �� „ �, �,`� .. . ;. 4 .... � . .. . . . . x 9e .. � . .. . . . . . ; .. �� � � � IQ n ��`�Q (J v0 � � Y�-�`r""_ _ i ,.�,� � P:J� J I ��� �� � �. � � � �� ',�� ,�� ��: � � � r--� �-p� c p-e,�� � _. � �,� � C? . �� .. . r -.% � o�: � � < . , �� :: u: � ,, �... .: .. . .. .. . . � �o �� � � � ��. i i I �� s ` � �.� 11 > g! 1 �T . , s.. .. .. . ,� �; . ^ Vv � . i t V � Q v z; , � — j�� �����. � , ''7 '+� i, ,.� ��� � 'P� � F� C' �E .� . .. t . . �'� � y �� . . .. � . �, i .°�' S a� K �� � � �i "✓„ :: '�� �� '3 � . y °,�� . �`�` � � � � ' �{yc �9�uY., ���. � •.a - � ^�z��'"'' �.a a� . �'`,� `� f �' ', t � . . � � w'.,,, 2 � �' k ° r �� `'; �� � ia , � � �� � � � g � , ��t'� �, . �'7� $ � ;# a � ;` ,'�'�� ' �'� � � .;� � ?�. �`m "`tn- ^�.,v�a � 4 a�„ �:.-dt � c�... �'Se�, � � � . � -� � � r.� �A „�� � ,,��`.>;�1� ���. � �' e, : �, �` ,� � �� . � � �w ..x �' m� �"� � dq � �. , � � F'a . a '� � - a �'� �"�� ' r � � L sE �� �`' S � . �� � � > �°' d "�.�, . � ,� � � . e .. y�. , tt � � ��: . � : � � �� k` a� s� � � �, ^� ' , _ � �, � ' ��� � �:, � � � �� ;, �« � a• � � � , e �, � ; �. � �, � , �� `� � o. � n° i '�, � � � B 3 � . . "�: � � � � �� � �� � °� ;,� �. � �'°�, � � ,_ � �� � . � � � � $ � " ,�, ` a �;� �, �� z � � �:= � � '�� � �� � � ," �a� � � � �, � �° �: �` � _ �," � �" � � �, � �•_ �� ° �� � �� � ����- �� � � � � � � � � �� ... . .R g � � � Y#� . ,�.�s . _ �,.. ,..� „ r-r � �. � � .;� . �k , x ' . . � � ��� �£ � �� � . � : � .. . �-`.� �... �� :��.:. �� \� ..+�� .. '^:3 . � 3� �.�_ � s � � - �.x ` : � . � '� . . � �r�t , .. � � ��. �� � �j �� � � �� � . �� a � � � �� � � � � � `� �., � � '�� . � . _, � _ x . ,� �,. .. � , � _. ._ � � �• �. __ s��i�: i• �i3 http:!!gis.personcounty.ilet/connect�i si M a��/connectoi-.aspx 9/12� 2007 �� , . i �� � ` � �� �.J �� � y� � � � � y ��'^ � � ���� � 1. _� �i�.�'iL�i' fi�: TT "fY'}Y11_ �'r 7����.JL � �' a�1L� U�L�l . . Applicant __��� Location: _ Q P�rmit `�7a1'ad for _ ave 3�eaa-� _ I+To Type of Facility: # of Occupants # of Be ms _ Proposerl Waste�vater Systenz: Proposed Repair: P�rrnit Conditions: iffiproveuYeat,�ermit Tax {41a� ; � ' �rcel t � Suibd,ivisi�an P'h�,se,Sectian:La�t � �� New Addition _ � V�ater Supp�9 Froje� Daily Flow g.p.d. Type: Type: Owner or Legal Regresentative Signature: � Date. Aut3iorized State Age� � � Date: The issuancx of this per�it by the Healti� DeparGment in does not guaraatee the �����*+�e of other permits. If is the �espons��7ity of the aPPli�a�rt/proPert}' owner m in sure that aIl Person Caunty Planning and Zo�g and Bw7ding iaspections re�r�ments are m,et This Improvement �'ermit is snbject to revocation if the site plan;�pTai''u'r'the intended use changes. Tiie Ymprovememt Permit is no# a�ffected liy a c�ange 9n ownership of the property. This permit was is�ued in complianca with the pmvisions of the North Carolim.a. .: 'Laws and Rules for Sewa�e T`remdnent and Disaosal Svstenis' {7.5A NCAC 18A .1900). Neither Person �Caunty:�or°:ttie.`'�� Environmental Health Sper,ialist vvarrants tha# the septic tank.systeut w�l cantinue to fnnction satisfactorily in the futnre`or:tliaf. thewater suppty wiIl remain potable. � • • Authorization to Constrnct Wastewater System (dtequired for Bnilding Permnit) � * See site plan and additional attachments (_�. � � � . • r��os� w�c���� Q ��.�1 �EZ-F(� �or C�►��,-� z�,�e 7� w�� �Qw 3�d g.�.a. New Repatr Expa�nsian .� SQiI LT -,� g.p.d1 ft 2 Type of Facility: iivc+�c �2S? �nct � � Basement _ Yes _ No . �`b��te�va�e� Systean ��rements � . T�nk Size: Septic Tank:"�al Pnmp Tan➢�: � Grease Trap: � Draiafie�d: Total Area. Ob sq it Total Length 3d � fit 1Vta��nu� Trenc3i Dep#h .l g i�n ' v� �renc� �Vidth � ft lY�nimaim 5oi1 Cover. i_ in 1N�nimnrri ZYemch Sepatation: �_ ft� IDisfxibnt�on: ✓ D'istn7buiion �az Serial �istr�bntion Pressare l0ianifold . Specifications: Antlaorized State Agefi � Permi.t Expiratiq Date: Date: The type of system permitte3 is Conventional Acc�ted Alternative. I a�cept the .specifications of the P�• o � �e�Ce�/���1 �8��pa�saatatiye: ���`—P Date: � ��- ` + PC� rev.11110l05.- ,. .. . . . tl _ ,: • M � • . . .•L . . • .....��. . . �. . . • , `���y �� ��G�{�� ��' • . • , ... .. ' . .� Y -,_. • � V ' �+ "i. V� JL . .. � ����� �tf11 t}�t}'LI �i�� ���� . ���•���1� � . . N�me �rHos 13ea . Ta� # Qz9 Pa�c�l # Suli . • � � ,� �/9 � . ' ' ' � � ' '9_�?,d7 � A.�ori�ed S:tate A.geut � � . � � D� � . . f .- • '• Syst�ua crr�mraeasts r�s�es,e� �i,�ir�e�ca�o� o�i,3r. The cra�etr�d�or �ra�astjZag t3ae s,�s�rn�iazrer �o .� be�ng. �e �rta�a���s io i�as��se �t, prr�ergrade is s�rmintrai�ed - �� �. ���� . . . . ,� }�,5 �s ;E r� . �2�c�ov� renn Scale: � l�o-l- -�-o Soa(Z � � 0 � p�'_'�T: �. �9/7'?/�1 Y ) '� � +: - 5'r�c G�r �9 p�l � � /9 �.,�� � � �� i � � ��� � � - � �i1 J� . � `._.._' ' i--- �-. � V � �L. V � ��T ° L4 a�r J����m� -*-**-„ ��u.-�.�. I�-3��.�]I.�.'.� ��r �.� . � A�P�icarrt �3 � . . . . Lncation: — � o o ' z � �- - , . . - � � . �'�`�� � �� �.� . . . . . .. . . . . S�St��n Typ� (ln t'�cx�rda�c� 1!�!'dh T�1� 1Jaa: �— � Z � 'i'�315 sY� : � �� IAt�T.�.i.� � t� Ct��Y.i�C� �!l1TM A���.l��IL..� N�� .. ' C�,ROi:.d.�. G��i 5'%�'�UT��, RLdL.�� F�� S���G� TR�4T�E�'�'�' �[L7 L�#S�S.m,}.,; � • - .p]�iD �,a;i. � ��31iii34�S � C�F '� ii�E t�lE'�fl��i'�' ��1T .�1►� Ct�fi�S'i1�1JsGTlO�1 • a�U"f'�� � &3f�i. . . ` . , . . - - . q.� ��-6T - � - � � n�a s ���� � � . r.r� ' . �n� .,Q,�ue � �: � �-��'��? � • ' . � � i2 '�� ' . . � � � � . � � . 0 . . . . 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