A29 291� q/� �/i7
Application Date: � ���—�� p0 ��� � ������
Amount Paid: __�QO=, ��6 "`
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Receipt #: _1.8,3�—�,� �9 �2v,, �,:: - . ..:_ ._. . . _ _ � ��¢�.]L ]E-���.A;�
C, �ccY . i'1C��.��mm .
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Permit
' $200.00/$300.00 (if> 600 gpd)
� Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
ID Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
tion for 5ervices
Services
�Taz Map: a ��
Parcel#: �_
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Inforaration: ,I
Name: � 12 {J `b� � � �'J 6�
Address: 1 � ✓�
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2) Name and address of current owner (if different than applicant):
Name: `�'�Yv�--
Address:
r�� ,f ^ � (
3) Property Description: Lot Size: ���1 Subdivision: /' rm�
Addre$s an�/or directions to Property: , � C.C7Y(,�
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Phone (home):�'z� � `'�i �c� �JZ
(work/cell): 37i2� 5 � (c�'1�2
Phone: ��'C� ���' —��'�Z
#:
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❑ yes � Does th site contain any jurisdictional wetlands7
0 yes ��-�t�� Does the site contain any existing wastewater systems?
❑ yes t.�tfo Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes G�l�i�io Is the site subject to approval by any other public agency?
❑ yes L�i►o 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:
�R idential '
ew 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-Residentiat
Type of business:
Maximum number of employees:
Total Squaze footage of Building:
Maximum number of seats:
5) Water Supply: L9'New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes 0 no
Please note any known ground .water restrictions or sources of contamination:
6) If a�plying for `Authorization to Construct', please indicate preferred system type(s):
��Conventional ❑ 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
inaccura e, the site is subseq en alt ed, or the intended use changes, al! permits and approvals shall be invalid.
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* Supporting documentation required.
• Permits are valid for either 60 months or are non-egpiring 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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System Type: ,��i�g � L
Septic Tank: 0 D –gallons
Pump Tank: '— gallons
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Total Linear Feet: � �0
Max.Trench Depth: /5 "
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Site Plar.
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Lot:
EHS:
Date:
Tax Map: � a�
Parcel: a� I
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Scale: �¢
Jote: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Envi onmental Health with any questions (336) 597-1790.
�dditi�nal Comments: �� I Z� � �i n-e $
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Applicant: / �.���''� k' � v ak'
Address/Location:l, _ �
Permit Valid for: �iv
Type of Facility: �
Number of: Bedrooms
Proposed Wastewat r
Proposed Repair: �
Tax iviap: �i�� �arcel: o�� (
� u'OCai viSit�n
Phase/Section/Lot # _
Improvement Permit
Years � Non-expiring
� �eS . New � Addition _
/ Ocgupants Employees / Seats:
System:
�
Permit Conditions: � ��� S wa�✓Sl''.� (��—
Water Supply: �eG�
Projected Daiiy Flow: � gallons/day
Type: -
Type: �
Authorized State Agent: r►, v�`� Date:
(X) Owner or Legat Repr entative: Date:
The issuance of this permit by the Health Ueparhnent does not guar�itee the issuance of other required permits. It is the responsibility of
the applicanbproperty 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
a�:�! Rules for Sewa�e Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply wili
remain otable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: ��QP��' ��' � (*)TYPe�b � sign Flow /a � galJday
New � Repair _ Expansion Soil LTAR � S Y
Type of Facility: ��1� � j��P S. Basement: _ Yes �, No
(*) System Types Illb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Sizz: Septic Tank � 0 e7 gai. '" Pump Tank gal. Grease Trap 1 g�l. =
Drainfield: Total Area � � sq. ft. Total Length �� ft. Max. Trench Depth �� in.
Trench Width � ft. Min.Soil Cover 6 in. Min.Trench Separation � ft.
Distribution: Distribution Box '� / Serial Distribution� / Pressure Manifold
Specifcations: �2�� r►�t�P p' °1C b'� �P"q' �S D•�.
� so�'( e u' 0 �- ;r �-�C
Autllorized State Agent:
The system permitted is: Conventional
and specifications of this permit.
(X) Owner or Legal Representati :
- Issue Date: — z� �'
Permit Expiration Date: �l Z— 2 2
�/ Alternative / Innovative . I accept the conditions
Date: � �
� � � �.:
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-179�@ (rev 5/12)
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"1�° �rn�n�r�aa�rnca¢3�cn.�m.lL I�ICca�.Il¢Ila
Tax Map: ��� Parcel: �� (
Subdivision:
WELL PERNIIT
(New� Repair_)
Applicant's Name: �R��tq% �/�L� G �q„
Mailing Address:
Phone Numbers:
Lot:
Location of Property: � � s• � �(CvuS Yc�s �— �r �
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County 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: w� �
�Tew Well: �
EHS/Date
Location: SS - ��( `�
Grouting:
Well Log:
We(1 Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller: �Ah�
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date: � � Z � �
Certificate of Completion
OLiner:
� 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