A29 275Application Date: �01-9'�� Tax Map: /� � 1
Amount Paid: 0200 .00 Parcel #: a,7
Receipt#: .4. g d 3 3 3
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Applieation for Services (Septic Systems and Wells)
Services Re uested
Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 g d) (Fee is de endent on the e of system ermitted)
❑ Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Char�e
1) Services Requ��d �, �
Name: D ' � � � �
Address: ( �? !N►c. � � „ � �
X A NG � ��
Phone # home): �°� � S 4 7�`J � y �
(wor ell � 3 �,
/h� �iV �o L c.-,
2)Name and address of current owner (if different than applicant):
Name: _�a �
Address:
3) Property Description: Lot Size: �� � 0 Subdivision:
lress nd/o directions to P�oper�yt :
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M /�X
riex �-o� -F� �1�� 01�✓� c��,t ��
4) Proposed Use apd Type of Structure:
Residential I� Business/Type: Other
Number of bedrooms �/ Number of people served (seats/employees):
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 wells on the adjoining properties? No � Yes
Lot #: �
et�t/
(please show location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of t/ie property that slzows property dimensions and tlze size afz�l [ocation of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifying tlzat tl:e properry is ready to be evaluated.
I am submitting this application to request services from the Person Couniy Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid.
Signature (Owner/Legal Representative): Date :(Z 7 v�
10/08 , Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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T�x M�p ; _' Parcel # �„
Subd'ivision
Ph�se Sect�ion Lot #
Permit Valid for
Type of Facility: .
# of Occupants po
Proposed Wastew
Proposed Repair:
Y
# of
Improvement Permit
No Expiration
New ,� Addition
Projected Daily_Flow t(.So
Water Supply n�.(_
g.p.d.
Type:
Type:
Permit Conditions: MA� ih a��SetbacYs
Owner or Legal
Authorized State
Uate:
Date: f7 -/S-og
T
The issuance of this pernut by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspecrions 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 a�:d Rules for Sewa.ge 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 (ltequired for Building Permit)
* See site plan and additional attachments (_�.
ProposedJd�astewater System: M e ,�� Type1� Wastewater Flow 80 .p.d.
New 1� Repair Expansio Soil LT .' 3a g.p.d./ ft 2
Type of Facility: �l•�� S;d�y�,P. Basement _ Yes �
Wastewater System Requirements
Tank Size: Septic Tank: IOd gal Pump Tank: _�gal Grease Trap: -----gal d�r5j��
Drainfield: Total Area: �QjZ sq ft Total Length � ft Ma�mum Trench Depth �'� in S
Qr C r
Trench Width �� f� Minimum Soil Co :�_ in Minimum Trench Separation: � ft
_= �. � .
Distribution: ' ilistribution Box Serial Distribution _
Specifications•
Authorized State Agent:
Permit Exp
The type of system permitted is
permit.
Owner/Legal Representative:
Pressure Manifold
Date: ,Z � /��b�_
te: 2 -
_ Conventional Accepted Alternative. I accept the specifications of the
Date:
PCHD rev. 11/10/OS
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Subchvts . '-�-C Section/Lot#
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. Au o�ized Sta.te Agent - l 2-/�Q � o__ g+______
Date
Systesn cnm, ponen�ts re, present a�ipra�rim�rte�co::tours o�i1y,' i'he con�'mctor �rarrst jT�sg �the systesre prior to
begir�rii9ag the i�rstallniia� to i�sure thatpmperg�aa% is muir�tained
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Tax M�p: �ar��l: � � 7�
Subdivision: Lot:
Applicant's Name: �
1Viailing Address: ��
Phone i�lumbers:
Location o�f Property: s -�l
.�,.., n�i.�vr � n.,n A�,f —�'7�
I'ermit Conditions:
1) See attached site plan for proposed well location.
2) All appdicable State and County regulations gaverning construction and setbacks apply.�
3) Permits expire � years from the ate of issue.
Oi�ier Conditions/Comments: o
.�f /�i_ 11 L --,._1, _�r,. _ ._ r __�1 t
P�rmii issued
�a�e: l2-/S-o8�
CE�'�'��CA.,�E OF ��Vd�I.�+ 7CI01�1
l�iesv �ell Inspectnom:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
�ell �riller:
Pump Installer:
�Jall r�ppraved by:
Date Sample Collected:
Pe:son County Envirorunental Health
32� S. l�lorgan St., Suite C
Roxboro, NC 27573
�,flner I�spec�ioan:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonffie�t:
EHS/Date
�Completed:
Method/Material(s): _
License #:
License#:
I)ate:
Date Results Mailed:
Phone: 336-�97-1790 F�c: 336-597-7808
8/1 /08