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A29 274Application Date: �' i'� 7 � �� � Tax Map #: l'� � O Amount Paid: d� • C) , %' Recelpt #: � � d� � � � �'� � � '� � Parcel #: ��~ _��� y r / ����i.J �� � �� ' -ti- � � ���� -��" aavaa-amaa�--�-�- .D��m11 1�3L�m7L�]�b dPPLICATION FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFIED CHANGED. OR THE SITE IS ALTERED, THEN THE 1MPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. � 1) Permlt requested by: (Owner/agentlprospective owner): �ti �^ �e �ir y Home Phone: � 3,G-- �",��— lF�Zp Address: Business Phone: � 2) Name and address of current owner. / _ c= �s�l 1.J1� ��-�� e\ � 3) Property Description: Lot size: �, � 0 Township: 1. H v� kSubdlvision: Lot # Directions to the property (Inctu�ing ro_�d names a�i numb�rs): __ __ _ �����.`.'o�o-°-� ,��. � " � .��- ' ' . ' ' 4) P'roposed Use �a3�'Structure cription: answer ac of the #ollowin u ali o s: a) �Proposed�_, Existing � Type of Structure: ' Width: � Depth: b) Number of Bedrooms: �_� � Number of occupants or people to be served: _� c) Basement: Yes_, No _�Will there be piumbing in the basement? d) �arbage Disposal: Yes . No ./ 5) Water Supply� Type: Private _(new r%r existing�, Public_, Community� �. Spring _ � Are any wells on adjpining property? Yes_ No _ If yes, please indicate approximate location on the 'site plan. � ' 6) Does your property contaln previously identified juHsdictional wetiands? Yes_ No� ,_ . PLEASE NOTE THE FOLLOWING: � ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APP.LlCATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. - ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STA{CED OR FLAGGED. ➢ THE S�TE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF: � � I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. i understand if the site is alte�ed or the intended use changes, the permit shall , � � �07 Date PCND, rev. 06127/D2 � ��� `� i � 10. /1 �V.. � V � �'7L1'���� � � q `r~ w ^^ ' � �' �� Ji � �rs���m„-„ ,�-•�-, <e��.�.71. I�-3L �a�.�.¢I�. Applican� Location: �ix Map . ' ' a.rc�l . . S U!p.G{;I V I S�i a:n '�h�:s•e S�ctia�n:Lat '' i�aproveu�eat �ermit - ��s�i�i �a�ad fo� �c �ive �e� _ �To �giration . Type �of Faciiity: ' New �c Addition �ate� �ap�%�_ # of flc�upants �, of Bedroo _�_ P=oje� Daiiy Flow 31�0 g.p.d. Praposed Wastewater System: ' Tyge: �c� Fropose3 Repair: �r'��►2r�i � � Type: .�� Permit Conditians: -��1lO�,v S��te �lan Owner br Legal Representative Signat�re: Authorized Siate�Ageu� c�.�Y► i � \ � ' Date: 9] The issuance of this pe�it by. the Health Deparnnent in does not gaaraatee the ?��,a*+�s of other pe�its. It is the respansibility of the � aPP��P�Y ownes to in sure that all Person Caimty Plannmg and Z.anmg and Buiid'mg I�spections requixements are me� 7�his �mproveme� Permit � sai�ject tu revocation if the site pian, plat or the intended use e$aaiges. The Ymprovemeat �ermit is not affes:#e� by a c3�nge in ow�ershap of the property. This permit was issned in cmmpliance.vvith the provisions of the North Carolina `Laws arid Rules for Sewage ?'re�nent and �isvosal Svstems' (15A NCAC 18A .1900� Neither Person �onnty nor t3x� En�ironnaental F3�alt� Speeialist' warranta Wa#. the septic tank system v�3I continue ta func�an. safisia�ton'ly in tiie fu�znre or'that the water snpply w�11 remain:potable. - --.. _ . ' �. Authori�ation tu Constraci W�stewate� Syste3m (Res�ire� for �nilding Per�aat) * SeE site plan and additional attachments %/ j• . . Proposed Wastewater System: C'�I"C�i�roO � Type� Wastewater Flow3�Oa -g:p.d. New � Repair Expa�sion� . . Soil I,TAA: � 27� g.p.d1$ 2' . Type of Fac�7iiy: ��, '�r� M_��C'��2�i n� Basement _ Yes � No � • �.s - � . . �aste�vat�s Syste�a� R�n�e�nen#s � '�ank Size: Se�tac �ank: l �1 g�fl �p 'Tani�: �' gai Grease iraP: — gal �rai�f eld: 'Tot�i Aa�ea: �c�, s� fit -Total I�eng#h "5�3�n ft � lY$a�um Trencit �3e�t� o� in Tre�c3t ^vVidtll� �_ � 1�'in�aun� Soil Cover: (D : in 10�1inimnm Tre�ch Separation: � ft �istas�nt6on: � Di�€ribu#i�a �ox ' ' Sesial ��stan'i�ut�aon Rressure Manifold . spe�i�ca�uns: -� llv�.� ��� d o,r-� �A�an . v7 � �; ��rn C'�,�c-lcic � Env. �le a.c�� � c.54 7 - � -19 p Ant#ao�izeai Si�.te r�.g$nt Permit Expiration Date: Date: l��vt�-�v � The type of syste:n per�ri.tte3 is '� Conventionai Acr,�te3 Alternative. I ac:,rpt the Sp�cations f the P��- � �Ow��r1���1 �BE�rese�iive: C� ,� Date: � 7 0� e�� . pC� rev.11I1Q/OS ���� 9 � �J.��� �� V �'_ � �-r- �: � ���� IE�-�-a��-,-�--,.....���.]L lE,I�.o�ll.�]la. �u.Y �u.1�Y� S�',� PI.AN Name ~ c� T�x �p #� Parcel # a� `� �lon Searon/Lor# �a � �ilblo-f �t,\%15�� Authoazed Srste Ageat �u �/1 �! O i� Sysrem campaneacv rrpiesece�ppm�zm coaraeua aaly. Tt�e eaa�cmrmusrtlsg rhe sysrem pQoc m be,�aaing tkeiusr�wbn m msrue rh�r p,mpergxrde is mamramed (\ * N,L�c��a�n U\l ��bO.C�5 ` � lyh C-�1 �,,e.S-�'i �S �L �0��,� � �tns�0.\\ �S'�� �C-� Ch�. fle4.l`� �ri c�.rYtz�..�r �� � � �� S - ''~ - -'� ` � �'1- 1`ICiO � � �v ' `�-�� � NO� � �n 3.$¢7t�51'15nE �l�Qh ��,�� `1_` j �-� $ �� ��.62� � ��`_� ` � y + � �F 567�44'S7n� , S�4• 16 _ �20•43, � 5Q-: '►��I �� C�,�.i�i OnS ��`� F �� IS �� _ idF NF �� � �� � �� , . v`'� � 'o �� �ip.�(�- � �� ` o � ���1 �� TG �` �-�, tF _-- _ ' � 0 s� � � ' n113,� jr' �• � S ca1�e - 1 � 50 � � ��� , � �p. ��� T� " L� � wJ t„� � j ~`�1~�� � •lY __�,_ �.' �� ^` , ��/ -� � � `'' �a � �?� r 1k ( � : � �r A �--�� - ��-� . �� / 17'4.2 / � i V72•21 �32N�q o. IF —�- n'y� � � ���� ° � �� � � �, b�oM �� -�-1- � C�v_ 1 i ne .� ry �3�n -�nG� c1��}h 86� � �r C�7��. 360 ��3 �r• -��P�'�� ..��'+:/!:••�.:•• +. :: .. yt:•• �}� .` . . . ''�:. .. yr ,�. .`:���� . �•�' .}';�..� �•�'r.�.:1=� , ��`., ti t;.;ri:: � „ � � . "�i �;r' :: ... :' :..:; :::- ••' �:.,.. :•Yc.:,.s;":,. i;�,�'�,.��� .li���.]TLr?�Y.•73i:�,TA'�rn'• ry*"^"++���1L'.�...:�:JLM1':'��'atil-.1L•'�L� . �L �.LUd1.LY-l2 S ' PI.EAS� SEE A�`I�A�D ��.IV F4�t W�g,L S�'Y'}� I,Ax��JB' Tax Map �� Parce3 # �'� Township: Applicant: �y�--� '�� � '�� Subdivisiun �� - " r Lot # • _ Location: {lq S�r ���r, fJ�4�1i r�vi� (zd �s Lai- �1 i.,.�b �., '�'ype of �ater Suppby: LG Individuai � Comxnunity Public Requirements: . . Site Approved By: . Laner: Grauting Apprnved BY: b 7nstalled by: � Well Log. ✓�� �i�3oltt� Depth set: _ �Pump Tag: '�k � � la� �,� . Grouted: Well Tag: ' Date: Air Vent: � � ' �iose B�b: ✓ � Water Sample: Casing Height: Concreta SIab: � . Well Driller: �aK,� . Well Approve� by:��, rt� 011�a1�;- *�**See Aitached Site Sl�etch*�*� Wells must be 30 feet from prope�zty 1in.es. �� �.�Weil� must be I00 feet from septic systems. �� Wells must be at least �5 feet from any building foundatian. Other canditians; Date: l I � ( �o PCHD rev 01/27/0� •���J�� ',��,����. • �Y�WIi� � l� ��, Y _-- ' . ,.. . ...�,��,��'''�'-�-. . �. [� - � � � w�. . . .� . �i:�a^�p,�i-ma�a���r��.�.IC�• �r;��� o� � � � ' . � ' . � .� � . � � �� G�raut Lag � � . � � � �: � � � � T� MAp parCeI # �,ocation• �� � � �� �ubdivision: • � � � � • . . . Lo ' . � � . � � , . � . • . � . . . � . . . �. . 'WaU Constr�tqu. � ' .� Diatancb ,�am ncarest Property Lirus (Miuimiir�' 10 f�ct} �/ t7 ,,,,,,�„ � . �istancc �ram Scptic Systcm (Miniu�um 40 f ) • iD �, - . - � � .. '�otall�ept}i: ',,,�,��ft Yield: �' <`' �M statia Wra�te.r r,ev�1: 3S . ft � Waur Scarin� �onae: Dagiil - QK°- ' - ft r� �7 ft „�,�,�, ft � ft . � � . C�aiag: ' � � • . . � � � � ���: � �_� � .�_ s. ��„�: �.� rn � � . . � . �rpc: Galv�a�ized Stc�1 �dL � . . , . . � � � . � � � . . . 'GVeig� �x I 'I'hiC�sa: s��2a 1 _ �iaight abnve �mund: ;,��� isi • � � Drive. �hac: Yes ,�,�,No Any prqbl�mms cucountar�d vvhilo gettimg oss"vng� Yes �a Tf "yes", girva reasa�: . � � . � . . , . Gront:'� � � � � . � � � � � � � � . � Nrxr „�„�,_;" Seaid/Crnn�ent ✓ • �Conorete C�vaUC��eat '� � �� . . . �u�� s��� wiacb ,,,,,� a ��� � w�r� � �ul� �tCo � � Ye� ✓ Np, � . � M+akt�od of Crai� Pt�m�ed _„� . l�ssua�e,,,� Pouncd • ✓ .'Dapth ,�,� t0 � ��. riYata�iax� Uped: • � � � , � . Na. aag� Pnrt�d ci�e�t �a �. �Veight Qf 1 �a� �,��ound�� . �.. . . � � ' I.f �aixwrc:(��a�rel, � cuttin8a? , �tatto ��. _ . _ to -/�• . . ' . . Ip plat�9: �XCB '�4 4 7� ti 6�! �' Y CS �O •' • i�n�+r: � . � � . � � � � � . � . � Dept�: � � bsfs Ip,�t�ltea; ' � � Crts�t� � . Installed by: � � � �, � � , � DY'3III�g J.a� � � . . . , Luc�tWn D�x�twiug . . � heraby catify ti,�t the abave mforination i� aarcect aad that this vrr�I was cnn�tru�ted 'ns accardaitca va�th regutatione �cst fatt t by the Petaan Coutity Ho�ttt, D�attm�nt. . � . t : � � . . . � . . . wre at Calot7l'ittxat � . . , . . . Sigaa. /C:. � �rd D) # � �� D r � Dstte 1 � � - � .. � . • Paatp Ynatallment Pu�p �tail�tioal Caats�ator; � � ' � � • � 5tata Re�eicatic>n NuSuber: � . . . F'uutp Deptf�: � � �tabio WaterLevel• � � g� ' ' � � � Pump M�tca & l�adet: �� � � � � � � � ��p si�c anct Retlr,g: � .�: lm � � � �� �,m �. Y he�ebp c�tify tbat tIii� puuip w:u installed aad tbe we11 haad aortz�lctc�3.accat�ding t� khe �cX�on �aunty Wei1 Rtttes (n effnat on ti�is d�ta e�d that s�apy af thi� raaord has becn provided zo thc wcll oaner. �� �' � � � P�rtp �as1�dler Slgwtture . . . . ' ' � � � p�te: � � � PC�O r�v Di127/D4 � . . ���,s.f� ���.��� �,�, �� � � ���� I��.�a- � �.,•-,�„ ����.11 IFZL � �.Il �]� Operation Permit Applicant: ��r �'`e � �K � Location: , , �G Tax Map .� Parcel # 2� Subdivision Phase/Sectoin/Lot # � # of Bedrooms . 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. System T e: (In Accordance with Table Va):�"` R Product: f� � Initial: � Repair: Expansion: . . __._.... ._. --- -- - ---�- - - --- --- --- - - -- . - - - --.--.. . . --- � - _ �1�' _ _ � �O- � U. __ _ . M. S/REHSI Date ���� ���Po -e,�°�e �� S Licensed Contractor Date � � i� �� `.1�� � ��a�� � �a�-; d . ,g, �� �� , � � �� �� �`� �� V r �S' , g'�'' �7" i �°� $e��� s,9 �� t i _s. ���+ q�s � � r��t Scale IV��- �,�� 1 ,�n 0 ���� � z s�� � , << � s_ �� � Tax Map:b'"i �� Parcel #: �� �C Septic Tank System Checklist (Type II-VI) System Type: ��� Se tic Tank InitiaUDate State ID & Date: S'7Y� !�(Z, �Z —l0 Capacity: 5 � Tee and filter ✓ Baffle l/' Vent ✓' Riser Outlet boot Perm. Marker Distribution -D=bbx=levels set)__ : _ --_ -- .: 5erial Pressure Manifold LPP Notes• Pump System Cliecklist Pum Tank InitiaVDate State ID & Date: Capacity: Riser (6" min.) NEMA 4X Box Model: Piggy back plug Hard wired Alarm functioning Mounted on post Above grade (12") Conduit sealed Pressure Manifold Number of taps: Size and sch: Contracted Certifed Operator (if applicable): Notes: Tank Com onents InitiaUDate Pum model: Block (4") Nylon retrieval rope Float tree and attachments On/Off float swing: in. Alai-m float (6" separation) Anti-siphon hole Check valve Threaded union Gate valve Conduit sealed Outlet sealed Approved and secured riser Su ly Line Size and material: in. sch. Length: ft. �� Application Date: a 1 Tax Map: Amount Paid: Nt(� Parcel #: _ Receipt#: � �--���, ).,� ���� �� '�'' -�. �C � �� � 1� Tr" ; arnwn u—�ca a-a+�-,.-,• �� � �E:,�a.11 IL�t «��.�..11 �71-n Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if > 600 d) (Fee is de endent on the e of s stem ermitted) obile Home Replacement or Building Addition 0 Permit Revision $75.00 ❑ Well Permit (New/Replacement/Repair) 0 Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Services Requested by: ' l Name: ,e. �" ` � N /u � Address: (�,��_L v ✓'1�,� �.c� � � �c �e_ ���_ 2 � s-h� Phone # (home): �1� —�'� g,3 (work/ceil): 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Address and/or directions to Properly: � Subdivision: � Lot #: � -L. � 7 S' '2 4) Proposed Use and Type of Structure: Residential � Business/Type: Other —�-� �. v a� Number of bedrooms / Number of people served (seats/employees): Basement: Yes No �/' (with pl �bing: Yes No � Garbage disposal: Yes No � 5) Water Supply: Private Well ✓(Proposed Existing _) Community Well: Public Water System: Are there wells on the adjoining properties? No ( Yes (please show location on site plan) Note: A completed application must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be eva[uated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is su6sequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Ow r/Legal Representative): ����% �(,�/ r �.�.�-�„ �Date : � _ ,�� / 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) . � , � �� � �' (, '' � i• �`; 1 i ' `�! �.� 1 ,� � �,, , ; � �� � �..�..� �. � � ���� �� ' �� ��� �� � 1 � '' ' �Is.z.tv-�.�><r��r�� J ;�.<ca�-z.�La�n,.� �.�`����<�n..I �..1� �a�a�d��a� ������m�a�/ �'��b��� ��a�n� 3����z����a��n�5 Tax 1VIap #: .A� Parcel#: a7�- Address: Approval Requested for: Mobile Home F�eplacement �_ Building �Addition Applicant Name: �i�rl��, ��1 �Y1Yl Address: `-� • ��_ . .. . : Permii Located: �,/ Yes Tio Installation �ate: �o\a1i� Design flow: ce, (gpd) Current Centract with Certified Ope:ator on file (if required): NI� Water Supply: � Well Public or Community Wastewater system shows no visual evidence ef failure on: — 2�— {date) (Applicant's signature if site visit is not required) ��, Oe � t ��r1������l��p�������at ��p�r��r��l ��n�.9: i��-�E�S Envirorunental � iea th � neciaiist a �a�i� Date Person C�unr� Environmentai :� eaith,- 3�� S. �ior�an St., Suite C; RoYboro, NC 27� � 3 Fhcne: ��6-�47-??9C/ ra ;: ����-�9�-7�0� � �v�:�^ai.�ersonconn�tv.i,e: