A29 294Appllcation Date: %23-� 3/`�<� � ;���1 V
Amount Paid: ?1�o,ao CI?S!� � ��
Receipt #: �_ ! � ���
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Application for Services
Services Re uested
0 Improvement Permit (Site Evaluatton) ❑ Construction Anthorizi�tlon
_$200.00/$300.00 (if> 600 �d) (Fee is deoendent on the tvne of
� MobIIe Home Replacement or BuIIding Addition
❑ Well Permit (New/Replacement/Repair)
5300.00/5200.00/$75.00
❑ Permit Revision
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Informatlon: �
,
Name:
Address: '22�
2
2) Name and address of current owner (if different than applicant):
Name• C,0�1(D I i� P_ 1aJ i IG1 �
Address: �515 I-{ �urc ► P i I �5
�2oX�rC). N�G 215-1d-
Phone (home): QI I�I • q'�'3 '2��0
(work/cell): 3�(� - S�h - 33$f�
Phone• �??(� - `�J� - �JC}% 2
3) Property Descriptlon: Lot Siu: t�C:� �ubdivision: Lot #:
Address and/or directions to Property: '�.�¢� t-���5����� �.
O yes no Does the site contain any jurisdictional wetlands?
❑ yes �no Does the site contain any existing wastewater systems?
❑ yes no Is any wastewater going to be generated on the site other than domesGc sewage?
O yes �(no Is the site subject to approval by any other public agency?
❑ yes ]�,no Are there any easements or right of ways on this propert}+?
(if `yes' is checked, please pmvide supporting documenta6on)
4) Proposed Use and Type of Structure:
❑Residential
�Tew Single Family Residence Maximum number of bedrooms: �/ Occupants: 4
O Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioaing System Will there be a basement? ❑ yes O no With plumbing fixtures7 0 yes ❑ no
❑Non-Residential
Type of business: Total Square footage of Building:
Maximum number of employees: Maximum number of seats: _
� Water Supply: � New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines oa this property7 0 yes ❑ no
Please note any lrnown ground water restricrions or sources of contamination:
6) If applying for �Authorizatlon to Construct', please indicate preferred systear type(s):
❑ Cottventional 0 Accepted D Innova6ve � Altema6ve ❑ Other �) Any
I certify that the informaHon provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner% Legal Representative*)
* Supporting documentation required.
5 23 � �]
Date
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved pla�
� A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/i5) Person Couuty Environmental Healih, 325 S. Morgan St., Suite C, F�oxnoro, NC 27573 (33b-597-179�)
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Applicant:
Address/L
Permit Valid for: Fi`
Type of Facility: ��l�
Number of: Bedroom:
Proposed Wastewater
Proposed Repair: �
v Improvement Permit
Years ^ Non-expiring
; (��o , New � Addition
�_ / Occupants /,Fmployees / Seats:
Permit Conditions: �Q� �+�'1-'c Sl���
Tax Map: � Parcel: 2 Q
�u'udivision �
Phase/Section/Lot #
Water Supply: �� � �
Projected Dai[y Flow: �v allons/day
Type: �_
Type: �
Authorized State Agent: wt v�'P� Date: S—(
(X) Owner or Legal Representative: Date: 0 1 /
The issuance of this permit by the Health Uepartment does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty 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 [mprovement 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�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 will
remain potabte.
Authorization to Construct Wastewater System
See site plan and additional attachments (� j.
Propo`s�d Wastewater System: �— �` � (*)Typ ��_ Design Flow i"� � galJday
New l� Repair _ Expansion _ Soi! LTAR: ��� gal./day/ftz
Type of Facility: ��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 Size: Szptic Tar�k �(id gai. -" Pump Tank � gal. Grease Trap — gal.
Drainfield: Total Area ���{O 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
Specifications: � ( i � ) l20 � li`�cs "i� �'�,/�^� S�"-���oi � i.S�t.�►-bkK
� „_ _i �.��
Authorized State Agent: ti• vUE;✓ Issue Date: �' S— !�
Permit Expiration Date: j-5 —2�
The system permitted is: Conventional ccepted �_/ Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: 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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WELL PERNIIT
(New� Repair_)
Tax Map: / � � � Parcel: Q
Subdivision: �
Applicant's Name: /�t�v-��t �" l�trud �Ge � -e �
Mailing Address:
Phone Numbers:
Location of Properly:
Lot:
�S
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:
�Tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
c Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date: l— S—1 g"
Certificate of Completion
. Di.iner:
• EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
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Phone:336-597-1790 Fax:336e�597-7808
11/26/13
LPS
Site Pla�
��.:,�f �����A.V Name: �Ui✓1
`-^: �-�' ������ Subdivison: _
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Tax Map: ��
Parcel: ��
dress:
. Lot: � �r
EHS:
Date: �^ �'l �
System Type: � �c'C •
Septic Tank: 0 gallons
Pump Tank: �- gallons
Total Linear Feet: �� I,
Max.Trench Depth:1�" �
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Scale:
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Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmentai Health with any questions (336) 597-1790.
Additional Comments: ' .
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