A29 211�pnilcation Daie: 4 - ��� � .
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Psrson Cauntv iiealth Deaartment
Environmentai Health Section
APPLICATION FOR SERVIC�S
- iUnreco�ded t.aq -
Improvernerda Permit - s10Q00
(Moblle Home Replacement/Add�lion):
Ganstruc�ton Authortzatlon - 5100.00
�'ax iY�ao �: �� /
ps��� #• � i �
vrcu re��uu ��v�nuccn�ua[�71��[J - � 147.
Existlng Syatem InspecSon - $100.00
RepaiNReplace Exlsttng System Petmit
t
Redraw SiGa Plan _ S7ri(10
7) Permitrequeatedby: {Ownedagent/prospective�iwner]j �
Home Phone• ��s• c�
Busi�ess Phane: f'" �- �, j�
2) Name and address of cument owner. _����,��__�����
L
3) Property Description: l.ot s� /�� wnshi�x � . ,L /��
Diredions to the prooertvllnduiilna road nam anes� d nurubersl: f711.���"i
�� � --�-� � I
y�
4) Proposed Use and Structure Description: answer eact� of the following questions:
a) Propos F�cisting ❑ .
b) � Sbcic B i1t�Modular �, Single Wide 0. Dauble Wtde �
c) Number of Bedrooms: .�- d) Number of occupants ar peopie to be served: n�
# of basement fixtures: �
_. e) . Basemen� Yes �. N Yes, - - - - _ . _ __._ _ ._.__. :...:. .. ._ ..__ .. . _. _
fl Garbage Disposal: Y O. Nd�- .
g) Dimensions of Proposed Sbuctur�e: Widih:� Depth: �
5� Watier Supply Type: Private ewl�orexist3ng �, PubUc �, Cammunity �, Spring ❑ �
. Are a y�wells�on adjoining property? Yes ❑ No 0 If yes, loca�on /%?/�y
�
�6) PI Indlcate Desired System , i ype: (systems can be ranked in order of your preferenca)
rrtionai _Modifled Carnrentional _ Altemative lnnavative
Other (specity):
/� ee+ e '�
�
.} � • �-.�'�.
���
� CLEARLY STAKE ALL CORNERS AND L1NES OF THE PROPERTY.
STAKE THE CCyRNERS OF'ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY P�AT OR SITE PLAN TO THIS APPUCATION
I hereby make application to the Persan County H�atth Department for a site evaivadon for the on-siie sewage disposal �system for
the above-desaibed property. I agres that the '�anter�ts of this appiication are true and represent the maximum faa�ties to be
placed on the property. I understand if the site is aitered or the irttended use changes, the permit shall becnme invaUd. I understand
that es appiicant, 1 am respansible for identIiying and mariring property lines, comers and making the site accessibie far the
personne! of the Pers Courrty Health Departmerrt to canduct the�r evaluations. I understand that I am responsi6ie fo� notifying the
Health Departrn y property co i any wetlands as designated by the Amry Corps of Engineers. �
, ,�L iQ� -
wnec ar entative � D��`--
• PCt�1D, rev.10!'12199
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PERSON COUFVTY E�fVIRONMEN�'AL HEALTH
PLEAS� SE�E A�i'ACHED PLAN F'OR WELL SITE LAYOUT
Tax AAaP �:
,��.R P�,# a � �
Townshlp �
Zoning . . _ .
APPiiCant � �V'^�- _�-.�k"� 3 � '�--�. �
So ��,. �, ✓ ""• ' ' !- � _ "" _ � �t�^N ✓' —
�.001tI00: _ . _ . �
Subdivislon•
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Well Permit '
i: V Individual Community Public
Tvpe of Water Supp v
Reauirements-
Site Approved by
Grouting Appro by
Weli Log
Well Tag t �
Air Vent
Hose Bib �
Concrete SI b�C
Well Driller
Well Appro
�� Z�
_ -�_ �
Date: � `'S`b�
**See Attached Site Sketch**
Weils must be 10 feet from property fines. ,y�
���ells must be 100 feet from septic systems. �1��
Welis must be �at least 25 feet from any building foundation.
Other conditions:,
�g�- �s` �
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PCHD, rev. 11/29/99
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Applicant: �,�1i��a � � �
Location: , . _ ,
I
T��x M��� . � P�,rcel # .
S�uibcllivi�s�ion
Ph��se Sect+ion Lot #
Improvement Permit
Permit Valid for i� Five Years No Ezpiration
Type of Facility: New� Addition Water Supply � �
# of Occupants et�t� # o Bedrooms Projected Daily Flow � g.p.d. �
Proposed Wastewater ystem: Cg1.�,✓• Type: �`
Proposed Repair: �. Type:
- - �
Permit Conditions:
Owner or Legal Representative i
Authorized Sta.te Agent:
� ��� �� � s�
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoni.ng and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewa�e Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (�.
Proposed Wastewater System: �'�IJQh�� � Typ� Wastewater Flow �.p.d.
New � Repair Expansion Soil LTAR: •�>� g.p.d./ ft 2
Type of Facility: o�� �zc� . Basement Yes � No
Wastewater System Requirements
Tank Size: Septic Tank: C�OOgal Pump Tank: gal Grease Trap: gal
Drainfield: Total Area: �.sq ft Total Length �� ft Mazimum Trench Deptli`_�.�—'�3 in
Trench Width � ft Minimum Soil Cover: �D in Minimum Trench Separation: �_ ft�•C-�
Distribution: � Distribution Box Serial Distribution Pressure Mazu o
S ecifications: `trl l o � �` �' � s �� � �p ����
r
Authorized State Agent:
Permit Expiration
Date: ' 1' � �`C��
The type of system permitted is �LGon tional ovative Alternative. I accept the specifications of
the permit. �
Owner/Jl,egal Representative: - Date: �
PCHD 7/2003
I•'I , 1 \ ,, ��� � p � � P�rcel ,;
� T��x h1�� T
Suhefiivi�s�ion
� < <�� � � � � Fh�:�e�Secti:o�a �La�t �
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Oper��ion Perrnit
� �
� � System Type (In Accordance With Table Va): .
THIS SYSTIEM HAS BEEN INSTALLED IN COMPL' IANCIE WITH APPLICABLE NORTH
CAROLlNA GEAIERAL STATUTES� RULES FOI� SEWAGE.TREATWIENT A(dD DISPOSAL, . ��
AND� ALL' CONDITIONS ,.OF THE IMPROVEMEPIT PE'RMIT AND. CONS'�RUCTIOfd .
�AUTHORfZAT10N. � � �
. l : . .. .. .
� �!/�L� ��3 ` �
Au�horiz d te gent � � . ' Date � � � � ;
Instaited By. Q•�P�..>�.S . . . Date: // �T��d � . .
� .. _ ___.�� �. ���� � _ . . .
. ' . . _ . � .. . _ . .. . ..-. .� : -: . .'�." �, . �, ��� -.� . �:'.� .:._ '.-�.' ... . '....
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PCHD, rev. 07/29l02
SE�T�C �ANE� DMSPE�TI�iV C�iE��l.lST ('iy�pe i9 - iiJ'j
Ta ; Ma� #� F res! # Z!/ � System Type (Tabie Va)
Owner/AQpiicant� � Subdivisian �
Address/Location SecfPhase Lot #
p�d rev. 3/13101
Application Date:
Amount Paid:
Receipt #:
� �?.2 -' � J `�� ) f ���� �J� Tax Map: � � I
� �•� Parcel#: �
.__._ �� ������
IE":.�ros n.n-anun_m�ra�c,.2T.dan.Il 7L�r�.�,,.114:1a.
A
� Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 d)
obile Home Replacement or Building Addition
$I50.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
tion for Services
Services Re uested
0 Construction Authorization
(Fee is de endent on the e of s stem ermitted)
❑ Permit Revision
$75.00
� Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Info ' n•
Name: Phone (home): � ���
Address: (work/cell): �
�
2) Name and address current wner (if different t an applicant):
Name:
Address:
3) Property Description: Lot Size• Subdivision:
Address and/or directions to Prope
Phone:
Lot #:
❑ 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) Proposed Use and Type of Structure:
❑Residential
� New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? 0 yes ❑ no
❑Non-Residential �-1�� �� 2 Y .a�
Type of business: p Total Square footage of Building: L� �/ /��_��
Maximum number of emp oyees: Maximum number of seats: �X �,�,� I
� 6
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring ��/'/'�
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the info ation provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if e ite is subsyq�rently altered, or the intended use changes, all permits and approvals shall be invalid.
required.
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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
:: � l
`.�
\ 1 � .
�r� = ► 4 '. . ; � � �LJ � � �
�J
�
�n�n�n��lrnn�cn��n.��.�. �c��.���n.
Building Additions/ Mobile Home Replacements
Tax Map #: .2 Pazcel#: �_�_ Address: � 3 1'-� �S� �"� '
�
� u� �C 7S'7�
Approval Requested for: Mobile Home Replacement
�_ Building Addition .
Applicant Name: �G ►� �
Address:
,'Lt-e S C�` ov-�
Phone #'s: S�� —� a �� �` 2 q
Permit Located: Yes No
Installation Date: Z—o Design flow: '2 �� (gpd)
Current Contract vvith Certified Operator on file (if required): ��
Water Supply: �_ Well Public or Community
Wastewater system shows no visual evidence of failure on: � '�� (date)
(t�ppli ar.t's signature if site visit is not required)
Y,.� `��s�- s��
k, , ���� % i3c`�s. � ��
Comments: �'( l(�4�I /� X( Z�/ 1 Z�/� L� .Pj(+ S�'� ��n, SZt� P��'`'�
v.
��''
Addition/Replacement Approve�l
�� � ���
nvirorunental Health Specialist
�`�Z 2 j �
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www_personcount�net
o � �� 1'�
Application Date: �3 � I�Q 0 �� S(' ������
Amount Paid: d _ l
Receipt #: �! 0 �' �/ `l q 2- �� "• �' � ����
��`l'� E.�� G IE��ndnn-��**,.,�„���,m..11 ]HI��..11�.
Aaalication for Services
Services
Improvement Permit (Site Evaluation)
$200.00/�300.00 (if> 600 end)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
0 Construction Authorization
(Fee is dependent on the type of
0 Permit Revision
Tax Map: � � 1
Parcel#: ,� 1 �
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Inf r a't'i�
Name: /� . �%i
Address: �'
�
2) Name and address o current o ner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size:a.������
Add�es� and�or directions to Property� _
on:
0
Phone (home): ��� ��o�
(work/cell): �
Phone:
�:
C3'yes �no Does the site cQfitaih any jurisdictional wetlanSs? "'
�es ❑ 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 properiy?
(if `yes' is checked, please provide supporting documentation)
��� ��
�o�'d
4) Proposed Use and Type of Structure:
❑Residentia! 3
O ew Single Family Residence Maximum number of bedrooms:
xpansion of Existing System If expansion: Current number of bedrooms: 2-.
❑ pair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes � no
❑Non-Residential
Type of 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 ex�sting wells, springs, or existing waterlines on this property? � yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the in o mation provided above is complete and correct. I also understand that if the information provided is
inaccurate, or ifi��i�ja�ubsequen� altered, or the intended use changes, all permits and approvals shall be invalid.
�✓ r
ate
documentation required.
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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
���. sf ���.� ��
' �- C���CJ���
l[Ns��n���-�.-TM-� ����.11 IE���.Il�1�
Applicant: 1�/AY��E �
Address/Location: $03
5� Arcn� 7 Fcr.�.�ov
�
7 "�"►�cu,
Improvement Permit
Permit Valid for: Five Years x Non-expiring
Type of Facility: 4-�vvSi�. New _ Addition �
Number of: Bedrooms �/ Occupants i�"^�`/ Employees / Seats:
Proposed Wastewater System: e,o..\vt��`.
Proposed Repair: C,or�vEa�.�►A�. P�rQ G�ve.�hi,�a,1��,.
Tax Map: �.q Parcel: ail
Subdivision �►�ms�aE �av.�r.
Phase/Section/Lot # 3
ti
Water Supply: l�v�E WEv..
Projected Daily Flow: 3�� gal(ons/day
Type: Zifi
Type: �
Permit Conditions: `}�l�E, -3.am�a�csw� ��1,. �,���t�,-�c� w� S��i1c.. Cv��cz�' p� �� �a��
Authorized State Agent: �CtR.�c.V� • �� Date:
(X) Owner or Legal Representative: x, Date:
The issuance of this permit by the Health Departm�'"nt does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperiy owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws
an�l Rules for Sewa�e Treatment and Disposal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmentai
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: (;oti.\v�rlrnoaAl. (*)Type Design Flow 3l�'O gal./day
New Repair _ Expansion X Soil LTAR: 4. a0 gal./day/ft2
Type of Facility: �-(�p�o�a� -�ei�,� Basement: _ Yes � No
(*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank ��a�o gal. Pump Tank —"' gal. Grease Trap � gal.
Drainfield: Total Area �4� sq. ft. Total Length "L04 ft. Max. Trench Depth �Z. in.
Trench Width �_ ft. Min.Soil Cover �o in. Min.Trench Separation i ft.
Distribution: Distribution Box / Serial Distribution %� / Pressure Manifold
Specifications: $-10��
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Authorized State Agent: DEsFSt,�tx. A. sM� Issue Date
Permit Ex�
-1
The system permitted is: Conventional i� /Ac pted / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date: � �
�
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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' Name 1/WAYt�E R.aSS
; Subdivision ���5 E
i)ES�cx h• Ss'�a1�1
Authoazed State Agent
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SITE PLAN
Tax Map # aa� Parcel # a� i
Secrion/Lot
S �t i
Date
System compooeats represerrt appmximate cantours oaly. Thr coatractormustl7ag the sysrempdor ro bee nn: a rhe instal/atian ro
iasure tltatpmpergrade is maintained.
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Applicant: ��� �
Location: 803 �i�s�
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Tag Map �Aa Parcel # �1 �
Subdivision ���s� t�.r�.
Phase/Section/Lot #
# of Bedrooms 3
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O�eration Permii
System Type (From Table Va): I.tIG Product (IIIg): E.'L �ww
Type V& VI Expiration Date: —' Type V& VI Renewal Date: --�
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
Dr.Rw�� A . s�►�
(Authorized Agent)
-�,�.�.� �,s � �aS
j (Licensed Contractor)
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Scale l�S
PCHD, rev. 12/14/12
l,��alt�1
(Date)
b�a��
ate)
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Tax Map: a�i Parcel #• a1�
Septic Tank System Checklist (Type II-I� System Type: � E,
Notes•
Pump System Checklist
Con�racted Certified Operator (Type IV Systems):
Notes• �
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BOX# 7
New Document
9 21 1
Cape Fear Public
Utility Authority
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