A29 35Application Date: - l��y' �--3
Amount Paid:
Receipt #:
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Services
❑ Improvement Perinit (Site Fvatuation)
$2�0.00/$30U.00 (if>�d)----------------- ---
� i�lobif� ilome Replacement or Eaiidjng Ad�itian
$150.00 (if site visit required)
Q �'4cil Permit (New/Replacement/Itepair}
$300.00; $2Q0.00/�75.00
for Services
equested
J Construction Authorization
ee is dependent on :he�e oi
� Permii Rer•isiou
�75.Q0
pair oi` Existing Septic System
Application: No Charge/ CA $150.00 or S?OQ.00
1) Applicant Information:
Name: �
Address: v
�
2) Name and address of current awner ��f different than applir.ant):
Name:
Address:
3) Property Description: Lot Size: �, �3 Subdivision:
Addrzss and/or directions to �ropet�v: �J� S--�
Phone (hom2):
(work/cell): _331� ~'�O�i— 4�L1S Cc,�.�, ��
Phone:
#:
❑ yes ❑ no Does th� site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existuig wastewater systems?
❑ yes C7 no Is any was.ewater gcir.o io be generated on the sitc �ther tha�-► �omestic sewagz?
❑ yes Ci no Ts the site subjcci to zpprovai by any oiher pul�iic agency?
❑ yes z7 no Are there any easements or right uf ways on this property?
(if `yes' is checked, please pro�ide supporting documentation)
�
,,,_�4�) �P oposed Use and Type of Structure:
.�Reside�teal 3
� D?�'ew Single Fa:nily Residence nlaximum number of berlrooms:
�+�f C�3 �F Pansion of Existing Systeni If expan�ion: ��:rreut number of bedroom�:
'��"Repair to MaJfunctioning System ��Vill ihere be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes 0 ne
❑Non-Residential
Type of busir,ess:
Maxinium number of empiuyees:
Total Sqnare footage of Building:
ivTaximum number of seats:
5) VVater Supply: ❑ New well � Existing VVell ❑ Community WeII ❑ Public Water ❑ Spring
Are there any existing �vells, springs, or existing waterlines on this property? f�yes CJ no
6) If apgl3�ing for `Autborization to Coastruct', please indicate preferred system type(s):
❑ Cons�entional ❑ Accepted C] innovative 17 Aiternative ❑ Other ❑ Any
I cert fy that the inforntation provided aFovP is complete artd cof-rect. 1 alsn u�rciersta;id ths�t � the inforrnation pr•uti°icierl is
inaccurate, or if�the site zs st�Gsequesttiv altered, or the intendad �2 changes, all pe�•r�ti�s and ap�rnvals �lrall be invaiic�
Signature (Qwner/ Legal Representative*)
* Supporting documentation required.
(n-1�'13
Date
Permits are valid for either 60 months or are non-egpiring when accoinpanied by dn approved plat.
A completed `Lot Preparatioi:' form must accompany any agplication requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map: � ParceL• 3S
Subdivision
Phase/Section/Lot #
Applicant: C.�1AW�S �r A►�aA �4-�►C��L.
Address/Location: � 1�{� Fc����. 1,a� (L� • k1�„j�: y g s, -a (� a�.� !�� stpR� 1Z.p �
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Improvement Permit
Permit Valid for: Five Years x Non-expiring
Type of Facility: $ti�j�,�a. �.�� Q�. New _ Addition _ Water Supply: Q�v�- 1�a�v..
Number of: Bedrooms 3/ Occupants�►^�/ Employees / Seats: Projected Daily Flow: 31,o gallons/day
Proposed Wastewater System: Type:
Proposed Repair: Act�pt€O �•,� ��,, QrFo�c..-rtv Type: �"C�.q'
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Permit Conditions:
�
Authorized State Agent: OIJ.,�1 (� , „� „ Date: �t
(X) Owner or Legal Representative:�X ��/� _�,�1 e� Date: �
The issuance of this permit by the Health Department 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 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�id 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 potabie.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: �Cc��t€(� tno� 0`�5`lc, �A��at� (*)Type � Design Flow 3b�i gal./day
New Repair X Expansion _ Soil LTA Q,�� ` gal./day/ft2
Type of Facility: 3��p��.-` }��s� Basement: _ Yes � No
(*) System Types IIIb, Illbg, IV, and V, require periodic syste`n inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank �rc��iit��, gal. Pump Tank "' gal. Grease Trap '— gal.
Drainfield: Tota( Area lch S� sq. ft. Total Length ,014�0 ft. Max. Trench Depth Z� _ in.
Trench Width � ft. Min.Soil Cover �a in. Min.Trench Separation � ft.
Distribution: Distribution Box j( / Serial Distribution / Pressure Manifold
Specifications: 3 �►t�1ES , FS �
0
Authorized State Agent:
0
Issue Date: I8 13
Permit Expiration Date: lo� C8�
The system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions
and specifications of this permit. �,^ �
(X) Owner or Legal Representative:o< 7��4`���J.� Date: `J �' �
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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SITE PI.AN
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Subdivis' n Secrion f Lot#
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Authorized State Agent ate
Sysrem romponents reptesent appraximate contours only. The coatractormust tlag Jie sysrem prlot to begianing the installsticn m
fasure rhsepivpergrJde is marintafned
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Tax Map %} Zq Parcel # 3S
Subdivision
Phase/Section/Lot #
# of Bedrooms
t���ra�ti�n .�erm.�i
System Type (From Table Va): Product (IIIg): EZ
Type V& VI Expiration Date: Type V& VI Renewal Date:
This system has been installed in compliance with applicable North Carolina Generai St�tutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Fermit and Construction
A nth nri�atinn _
Scale N
PCHD, rev. 1 /1 /12
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(Date}
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Line Lengtr
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Total 2 p �
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Tax Map: � Parcel #:
Septic Tank System Checklist (Type II-I� System Type: �
Notes:
Pump System Checklist
Contracted C�rtified Operator (Tyge IV Systems): �
Notes: �