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A29 26The Districf Healfh Deparfinent Orange, Person, Caswell, Chatham, Lee Counties SEPTIC TANK PERMIT ���- Date in — 11 � "" � � Name of owner: f�%I �� t � I� rn n-1'1,-- Name of contractor: �,�� � � Address and Directions �h� �'7' f�-n x F�." r�� t , �: � f � i? G� �t'��V���e — %���;�-�� ��`nr� }'2�,. Person or firm doing installation: � Address No. of persons to be serve� Bedrooms 1, 2�4. Additional ap liances to be used: Disposal, dishwasher, washing machine 1�,�� � Recoxnmended: Septic ta � � I� .� �/ � (�' Nitrification line: �� ,ls� � �+ ' r � Above recommendation based on information received and observed soil condition. Sentic tank and nitrification line musi be inspected aad approved by a member of the DistricY Health Departmeni staff before any portion of the installation is covered. Countersigned Signe� Sanitarian O. David Garvin, M.D., M.P.H. District Health Officer (Over) �. n A��al1� . . '��� �i ,4 �: � i. � `y . '*fi�'p�: Make sketch of installation showing location of house, septic tanks, privies, water supplies on %�;p .r Application Date: ; .�._� " o��J��d`�� . , TaY tilap: � �'� Asnount Paid: 1�0 .Ov � e� rarcel �: �(� Receipt�: � 9 0 C�C C � 6'�� d`t 1 I=�� AVe ba.��2 �'�� C� � � `� ' � ' � ' 1 �� _ � 1���.� �� ____. _ ---�-- �� � � � �� �' �� 7�'.ax�i•ti-sL�*r�s�•,-•-„ .er r �E:..cn.11 1E��,t::-..ro.�jti�z 1�����c����� �o�' �e�'vie�s (Septic Systems and Wells� Sea-vic�s �� uested � �mprovernent Permit (Site Evaluationj ❑ Construction Authorization �200.00/$300.00 (if > 600 g d) (Fee is dependent on the tyoe of sys iYTobile �iome.�2eplacement or ,�uilding Addition �J Permit Revision $1�0.00 (if site visit re uired) �,-� e�,k add i� �` $75.00 C�'Qil Permit (idew/�2eplacement/b2ep�ir) O Repair of ��isiing Septic System $300.00/$200.00/$75.00 No Char�e � �� �ervic�s R ueste�l 'n G q Name: G�, (� Phone #(home): � I 1'�� 1 Address: �{ 2 (tivorklcell}: Q j - S l�0 - O'� � c ,r-o N c a1 � 336 �9�-004� i)l��m� ar�d ad�r�s� off ��arr�ut aw�e�- (9� (Iig�29'�91� �ha�a applaca�t): Name: ��� _ � r�c�as C�-1 � Address: C'..0.1 � Y'Q� ;``" � µ e 3) �rog�es-�ty �escr���no�: Loi Size: � Subdivision. �ot #: Address and/or directions to Property: 5� 2 �.��.o � 4) ��-oposed Use and 'Y'ype of Structure: R�sidential ✓ Business/Type: Other�-�-�� l ZX 1�}- Nur,iber of bedrooms / Number of people served (seats/employees): Basement: Yes � No (with plumbing: Yes No _� Garbage disposal: Yes No �"Y d'Vater Supply: / Private Well � (Proposed Existing 1�� Community We11: Public Water System: . . Are there wells on the adjoining properties? No Yes (please show iocation on site plan} 1'�I�te: � cornplefe� ccv�licaiion mus� nlso incluc�e: �.4 �lat/site pluac of ihe ,�ropeyty �iiat sJaorvs� �: c�er#� dir�ensao�s cu�td the siz� n�rel �ocr�tion of rall p�•oposed sfructures. . 5 A sagried capy af idze `�at �'r��araPion'�'or�aa ver fyin; that tlae �ropeYry i� re�cdy io be. ev�alu�te�i � arra submittang #hns ��polncatioia to rEqaaest 3�rvic�s �rocrs t�e �Q; son �ou�n�y ?�e�lth �epa�-tQne�nt. � uneersta�d tha� i�' th�e in#'mr�ation pravide�l is i�earrp�t oa� ;y #he �fi#e :s s��s�e�ue�nt3y a9�e�-e�, �r �f i;�Q ;ntendea1 ��� char.g�es, a�� per��ts as�d �ppravals shaP� became inval:d. _ Uag���ur� (CwneriLegal Re�resentative)� L.I ���� :�t 2-9 O 10i08 Person County Lnviron�7enta! Hea?th; ��5 S. iiior?an St., Suite C; Ro�boro, NG ^%57; (336-�Q7-1?00) ConnectGIS Page 1 of 1 ��, � � , l� �« -��''ti " 773"� � „�;,�—""' '��� �- �; � �� ' � ,,•.. � i �, ��,� , � �", � }, — _— -" � � ;� � � a: � � � -� �'s19�22 � �, , � 'ir � C �.�, � � �� � .� �. '' , � � ' i ��� � '� � ° ��' � � z �� { a ,. � � , = 3281 � p � ,. , � „ �. i . �� `.�, �� �� � �� � 1 � � � � ��; ��� . � � � h � � ° � �' f ..a`�. . _ , � �' � i � � � —. 8 �. :. �.�' i � �� � ` � �.�+����� � ��" �,� � ��" � � � � � <� � . � � � , � _ _ ' �4�� � � . . . � ��.��i a __, ����� � �. '.'�� . �� ��� � � � ��z % �' � .�:^� � .J . � � � q ��� _ �, i� ���� s � � � � . � '�,�� . � ,, � � �� � �� '� ��� o�� , � � � � i �� � ��� � • �. � � �� "" � � � � ti �^" � � ' �� � � -� - � ^� � � 3237 � i� � � � � � � � � � �� � 1�8z�� � � � ,�. ,�, �,�� � �; r,' , �" � �"� � � �,.� � � � � �:' �i � � � �,= �� i, .� � � � � � � _� � ,� <� a�;, _ I� � � s: � � �,, _ � �� � ( r _ _ __ � � � � , _ � _ �, . , � � � � _ � --' _ _ :r � .� �... ^Y��! .. — A ��.. . a _ . ;: . y.—'s' .. . _r- '- �.� �c j����i4 _ � _ �..-�,«� `""'�'-^" _ - � �_ _ ;�-�-- � -��i � ' -� ��y____---~ � _ M��. ___---- x » �— ___ , � - _ - �-_ . � -'� �, - ;� .. .�_--�`"' � �- � - - � , � r �.�.� - �� i � .t�� �', � _ - � � � + � � s'` � -_:'.--""� - P � , � i � , � t '3 i � �� ��� � � � , . . . . .r� . . � � � . „ �, '�. � > �� 2s'isi� � e � � r � . � S,� � � ,� � � �� �� 26'1$G � �� � ,� 3� a� � �4g �� '� ' � ,,. �,» , � �� �' F ��. � � � `� � 2fs't €t`�� � a ,� �� � � ���, '� � � � � � � } � � ` � � ti � �y� ,, <��� � � � � ``�,,_ � �� � � ; � ,,. .� ��� � � '' � 3� a- .� ' . •.. . .. ,,.. . ' ,� , .. � � � �_ �- � ti �: - . _ �_ _ �... t �� � � ��, . 1:78 feet f �ly C(7tfN1Y ..' ��� ��1�r � � �� i Q5 - �4 �r ;'� . y 1* � ..�� �� .� �„ � - '� m Y � �` '� y "`- Ts '� N. / � �Jf Y . .t "�""" * it .�,.� �4� �`" >i� q�y l �� �' f y �,�. -�._ t.�� �, ` S �P V o/ ��cuNt� s� �C�txrl��' �I � Frs � c_c� � art r nt.�Cr i ;t*y 'S '17 '3'1 .13t sf ���.Ii:h ft t"' '�'tt -� se �tes: s€ arc t s u�ts _< t� ane �?a3� � �'t c" ma� :rp n i� 9". =. C it .• s1a < a- ac rrr t r e�eatt� .e � 'rS�i9 Gt C9S1 Ui �"` S �31{ ( 1R< rY �n37k> � c� S� * n�Ya s P^_o] � or�j a..u0'a.iC xQ 1 C��l: ��lfttSf.c 1.�.�..y {7nt11At� Cr : 41�5. http://gis.personcounty.net/connectgis/Map/PrintWindow.aspx?Map=http://gis.personcoun... 6/29/2009 Application Date: 2'��-� 3 ���+5� ���� (�� Tax Map: Zq Amount Paid: � 0� ._.. . y-'' Parcel#: 2(4 Receipt #: � �_ � � ���� �,��nn-�,�,.�.,, ��, ��.Il IHI��,.11�.lr. ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 500 gpd) ❑ Nlobile Home Replacement or Building Addition $150.00 (if site visit re uired) ' Well Permit (New/Rep��l �ent/Repair) $300.00/$200.00 7/$ 5.00) �lication for 5ervices Services Re uested ❑ Construction Authorization (Fee is de endent on the e of ❑ Fermit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant I�ormation: Name: _ �G✓� � 13a�ne�p' Address: 7 n 6� 1/� �9 i I�� �� 1Zo.X �o(o NL Z7S��( 2) Name and ad�,ress of current owner (if different than applicant): Name: �Sfen �ti �2� �� Address: Z �(_� t�_ , ROX60fp n/�, 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: ❑ yes ❑ no ❑ yes ❑ no ❑ yes ❑ no ❑ yes ❑ no ❑ ye� ❑ no Phone (home): 336' �R3'" 0�/2 `% (work/cell): Phone: 33�- 5�9� S �J91 Lot #: Does the site contain any jurisdictional wetlan s? Does the site contain any existing wastewater systems? Is any v�rastewater going to be generated on the site other than domestic sewage? Is the site subject to approval by any other public agency? 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: ❑Residentiat ❑ 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? ❑ yes L7 no ❑Non-Residcntial Type of business: Maximum number of employees: Total Square footage of Building: _ Maximum number of seats: Sj Water Supply: ❑ New well I� Existing Well 0 Community Well ❑ Public Water � Spring Are there any existing wells, springs, or existing �vaterlines on this property? ❑ yes O no 6) If applying for `Authorizafion to Construct', please indicate pre%rred system type(s): ❑ Conventional ❑ Accepted O Innovative ❑ Alternative ❑ Other ❑ Any I cert.� that the informatian pravided above is complete and corf•ect. I also understand that if the infornzation provided is inaccurate, or if the site is szrbsequently altered, or the intended a�se changes, all permits and approyals shall be invalid. �-- �2--� Z-/y-�:� Signature (Owner/ Legal Representative*) Date * Supporting documentation required. • Permits are valid for either b0 months or are non-expiring when accompanied by an approved plat. • A compteted `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) ���1'" � �f� �� �� `�' �"� C� � t�T � °� � 11�.�]1.�Il.7Pammm rmm �a.'b'��.�L ���L��.IYb � W�+ ��, PERMIT (New Repair� C� l,� er� Tax Map: �� Parcel• 2 � Subdivision: Lot: Applicant's Name: t Maili�ag Address: � �, � 2 Phone Numbers: - S Location of Property: ��2 �r � � �ermit C'onditions: 1) Seg attached site plan for proposed well location. 2) All applicable State and County �egulations governing construction and setbacks apply.� 3) Permits expire S years f�-om the date of issue. Other Conditions/Comments: �i n � V � ✓n., �.,� - P�rmit issued by: Date: Z �l/=,I ?, CERT�IFICATE �F CO1dIPLE'�'IOToT New Well Inspection: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller• Pump Installez: �Vell Approved by: Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 � Liner Inspection: EHS/Date Installer: '�i�w+s Ba���. Depth: !es' Grout: p��,�.,�r� c��.,� Well Abandonment: EHS/Uate Completed: Method/Material(s): _ License #: License#: Date: Date Results Mailed: ' � Phone: 336-597-1790 Fax: 336-597-7808 8/1/08