A29 290Application Date: � � 3 %
Amount Paid: � �
Receipt #: I % G q .(,
�I�GG � �L0.1r�
�l Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
� Wetl Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
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l�.an�a*as��* n*�* �oaa�mIl IE�camll ��la
for Services
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Taz Map: �i-Z4
Parcel#: i�
Services Re uested
❑ Construction Authorization
ee is de endent on the e of s stem ermitted
0 Permit Revision
$75.00
� Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name:'�,�„� �;�ynn
Address: 2�� 5ou�+-h S�
�',ds..%o.LF, �IC: �"1�'13 -
2) Name and addr,e�s� of current owner (if different than applicant):
Name: �ho,�r��e�iU�r� d.¢,�
Address:
C
3) Property Description: Lot Size: �+ Subdivision:
Address and/or directions to Property: `�O
�
Phone (home):
(work/cell): �Iq-�Z�/-9527
Phone:
L t #:
„ � ,. Va� n � ,o �/ � '�' 0
❑ yes �l o Does the site contain any jurisdictional wetlands?
❑ yes �o Does the site contain any existing wastewater systems?
❑ yes �}�o Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes LI o Is the site subject to approval by any other public agency?
0 yes Ja 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 ' 2
New Single Family Residence Maximum number of bedrooms: / / Occupants:
❑ 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 ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there an exi ing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) �applying for °Authorization to Construct', please indicate preferred system type(s):
�onventional � Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is sufasequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signatur�(Owner/ Legal Representative*)
* Supporting documentation required.
0
ate
Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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SITE PLAN
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Name �� � ��1 Tax Map# �( Parcel# �� � i
Subdivisio Section/Lot# �i
uthorirze^d State Agent Date
System companents represenf approximafe coxtours onJy. The contractor nsuslJlag lhe system prior to beginning the
installalion to insure tho! propergrade is mair.tained �
Note: An Accepted system may be used rn p/ace oja convenliona! system without permrl authorization or modificalion. !
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"REFERENCES"
DB 781/635
PB 16/843
FILED in PERSON Count NC
on Du 02 2018 at 10:59�� AM
bg: AfIANDA N. GARRETT
-REGISTFA OF �EEOS
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CHARLENE DRAPER HORTON
DB 781/635
PIN 9974-00-81-9467
' RECN 6963
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\ IXIST. MAG NAIL
CONTROL CORNER
NAD 83/2011 (GRID)
N- 940507.53
E- 1978549.67
N g6'17'48" E
1184.36'
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S 87'41'27" W
1 123.31'
JASON L & CHRISTY STEWART
DB 916/180
PIN 9974-00-90-1432
RECN 28157
EXIST. REBAR
- COIJTROL CORNER l
NAD 83/2011 (GRIO)
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E- 1979704.63
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Tax Map: ft"�
Subdivision:
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IE �rn�n �r � aa �rsn o�ra ��.Il IHC � m Il�l�a
Parcel: � �b
W� PERMIT
(New_ Repair_ )
Applicant's Name: �J (�Vii� �i �(o,.l
Mailing Address:
Phone Numbers:
Location of Property: �. � S�
1
Lot:
r� r
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and Counry regulations governing construction and setbacks apply.
3.) Permits expire S years, from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by:
�Tew WeU:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Iustaller:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date: �—'l—1
Certificate of Completion
QLiner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 fax:336-597-7808
11/26/13
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