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A29 45BApplication Date: �' / � Amount Paid: / Receipt #: 29 37 Improvement Permit (Site Evaluation) $200.00/$300.00 if> 600 d Mobi e Replacement o� uildin 1 0.00 if site visit re uire3j�� Well (New/Replacement/Repair) $3 00.00/$200.00/$75.00 �� ) �� l V Taz Map: �� ( �✓' � Parcel#: � �� IE��a-o��¢�.Il IE-�m�.Il �]Fa Services for Services Construction Authorization (Fee is dependent on the t�pe of system permitted) Permit Revision $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: �oivr-��,-�� `? � l ( � Address: 3q S 8 h�. t� Lak. ��f �o x 1�c�.v 1�(.0 _ 2�5? 3 2) Name and address of current owner (if different than applicant): Name: �" i rn l�or(-an Address: _ /S((s H.�s-Z-z� sav�L ,2,� 7Zo x U wo � r�l _ c. 2'7 �"7 L( 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Phone (home): � 3!o - 3 Z Z-1 g p Z. (work/cell): � 3 c, - s'oy- 37 3� Phone: Lot #: � 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 domestic sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency? �/' .(),,� �(p S'i n� eDcr ��v-� ❑ yes ❑ no Are there any easements or right of ways on this property? 'T � (if `yes' is checked, please provide supporting documentation) � jf1 �� j �(�� r0�� (U � 4) Proposed Use and Type of Structure: .Q�t �Cf✓�P,�P.�,� esidential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? O yes ❑ no vl(� ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well �xisting Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes O no (� 6) If applying for `Authorization to Construct', please indicate preferred system type(s): _ l ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ pny I cert� that the information provided above is complete and correct. I adso understand that if the information provided is inaccurate, or if the site is sub�uently altered, or the intended use changes, all permits and approvals shall be invalid. �. � A / I Signature (Owner/ Legal Representative*) '� Supporting documentation required. S=1q-1 S Date Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-17901 � Y � , , •• �=' � � �Y �� >��.1� ��.Il¢l� Building Additions/ Mobile gIome Replacemeats Tax Ma #: �f' � Pazcel#: � 5✓j Address: l Sp S� �� "'�' p � S7 Approval Requested for: Mobile Home Replacement —�' Building Addition . Applicant Name: iM � d`� � �� Address: San,,P �?s .�'�o� Phone #'s: `32 Z� 1�� Z 5 d –`3? 3 CP Permit Located: Installation Date: Yes � No Design flow: ��ow�(gpd) Current Contract with Certified Operator on file (if required): �_ Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on: S� Z�' l� (date) (Applicant's signature if site visit is not required) N ,ssio� 2�c i ' S � cs-2 4' : ' 1 � Q r'�� /(� �� a,,, r�-F S�-► C e�'� S� � ( Q' � CQt,- � o ►-�4� �- .A,. (oU-�e � `'h ��''�'�i'I— (.��CC° �i(� Q'(��',� C�,y Qt�9�i�{�`ovcSL� �DE�1-av+-hs. � Addition/Iteplacemen� t�pprov�d � � �� -24-(5 nvironmental Health Specialist Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 33b-597-1790/ Fax: 336-597-7808 wwwpersoncount .y net ConnectGIS Feature Report �� 1�� •• 5��. �r��.. _ �� ' � � °� : N� �� z� � � � � �� ` � y �; �� . � ` . �: • �. �. � , � � � «�^ �'�� &� � " � �� ;�� _ � � �,�e � � � � � � � °� �: � �M, t � n��' �. a �'"�� o �(� _ � � � � �� m�� z � ;. � \� �� ,\ �\ �" y � �� " � � � . � � � � � ��'. �� ;. . � � � � � �. �: , �' �� \ � �� ,��e, u,� r � , ��. � � � �. 1 � �Y"�'� �� `,' . � � . � e � ,� _ � ` � Y � $` \ b' �: \� .a�. � �E �� . � � ��. � � ! ��. - � •`� � �..�---� .� L.0 t� �: �\. �° � � < s � � � C�'i✓: Page 1 of 1 Person Printed May 18, 2015 See Below for Disdaimer ,� � � � ° � - �.� � �� . 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Typically, the problem stems from users who have =cently upgraded to the Windows 8 operating rystem or a new version of Internet Explorer. We were able to resolve this issue by directing users to the Internet Explorei ompatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US/internet-explorer/products/ie-9/features/compatibility-vieH this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGIS has beer repared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system arE otif ed that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectGI' ssume no leaal res�onsibilitv for the information in this svstem. Grid is based on the NC state plane coordinate system, 1983 NAD. http://gis.personcounty.net/ConnectGIS_v6/DownloadFile.ashx?i=_ags_mape68644020e3... 5/18/2015 355 A South Madison Bivd • Roxboro, NC 27573 May 28, 2015 Timothy Horton 1516 Hester's Store Road Roxboro, NC 27574 RE: Variance from Person County Well Regulations — 1516 Hester's Store Road, Tax Map # A29, Parcel # 45B Dear Mr. Horton: urturing'a healthy community The North Carolina Division of Public Health, On-Site Water Protection Branch has issued a well setback variance for your property at 1516 Hester's Store Road. The variance allows you to use an existing private drinking water well that is located less than 25 feet from the existing carport which is proposed to be enclosed. Person County well regulations also include a minimum well setback (25') from a structure. Based on the variance issued by the State and the accompanying conditions, the Person County Health Department also grants a variance with the same stipulations. Please feel free to contact Environmental Health at 336-597-1790, if you have any questions. Sincerely, . �� J net O. Clayton, MPH, REHS Person County Health Director phone 336.597.2204 fax 336.597.4804 Application.Date: � �9-U� Amount Pa.id: ?_ �• � U _ Receij�t#: 4 6£ � 7 2 , �p �� . � � ��l.�.� �� Gj ��L/J � � ZC.T�'�C� " � IG :ra tv-n a.ras ii�..:irna�� na. �zn..Il. IE'�I.c�.m, ll. d�.:Ev_ Application for Services lSeptic Svstems and Wellsl Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 if> 600 d) Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Tax Vlap: �� i Parcel #: � ❑ Construction Authorization (Fee is dependent on the type of sy; ❑ Permit Revision $75.00 0 Repair of Ezisting Septic System No Char�e Important: If tlze information in the application for an Improvement Permit is incorrect, falsified, or the site is altererl, then the Improvement Permit and the Authorization to Consrruct shall beco�ne invalid 1) Services Requested by: Name: T` r,� J�o f'�D n Address: 15 /(o hlP 5�� S-�z.. 2 ��cbcL�, Nc. �5 �y Phone #(home): 5 q�- 2/ Z 3 (work/cell): 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Lot #: Address andJor directions to Property: 4) Proposed Use and Type of Structure: Residential Business/Type: �o�.c�c� — 1� �'�ra��v� Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No _(with plumbing: Yes _ No � Garbage disposal: Yes _ No _ Approacimate size of building foundation: Length 3 D, Width 3 O' S� Water Supply: Private Well (Proposed Existing _� Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A cvmpleted annlication must also include: ➢ A plat/site plan of the property that shows property rlimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evalua�ed T�m submitting this application to request services �'rom the Person County Health Department. '��e information provided is accurate. I understand that if any site is altered or #he intended use changes, all permits shall become invalid. �( � •Z�-D� Signature (Owner/Legal Representative): -., \ I9ate: � 11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-�97-1790) ' � ' �� ` .� . ...� , �� 1 �� '� r� � �� .��,�.<��.�;.�.11 ��.�,�I��. �an��i�a� f��fl$Il�Ilfl�% P�Ol��l� �I�IDII�Il� ��I�`a��E�'IIIl�';.�'�5 Tax Map #: Q 2q Approval Req�ested for: Parcel#: SB �Mobile Home Replacement Building Addiiion � Applicant Name: Address: r G Phone #'s: ��17- Zl2,3 Pemut Located: Yes �/ i�o Instailation I�ate: ? Desi� flo�,v: (gpd) Current Contract with Certified Operator on file (if required): Water �upply: V Well Public or Communify Wastewater system shows no visual evidence of failure on: q-�-Og (date} (Applicant's signature if sit� visit is not required) Comments: � . :u� Aa��Il�o�3��la�� s�de� � 9-2�08' Environm tal Health Specia ist Date 1 ? /15/OS 0 � .\��J� / �es �.��./�� • f �p ,�+� y `�... 7 V V �../ i V� Jl. I��.�u-��mm ��,��.11 IL3t�.�ll� � 5I7'E SI�E'I'C�-I .� 1 Name / �nn �ir-ian Tag Map #�Pa:tcel #�� Sub ' ' 'on _ � S�ctiou/Lot# . . 9-2-vs Authorized State Agent . � Date . Syst�sra cmr��imare�a� re�resenP u�i�ir��cispsat� �contoas�s o�a�: 3'la� con��s8os� �ss�, fBas� the .s�us�e��!frtor #� , beg�nning tdae i�astaTlrat�osa io srasuare tdraat ps�n�lier,g� ss m�intassae� � �t i� � ConnectGIS � `� � �� ' � � � . e, �:�4 , , � �, �: . ��. � ,, � ` ;� ��..' �� , � ;. �._ � � ,h � �,�, �- � �� -� �� _ � �� : , _ � ' � � � � �.-,_.� .,� .... ___--- � �;. , � � � �� . � � � � �� `'� y` �f r � � .. � � �� • � . � �� ... �.. �� .. � .. _ � '� �^'� \�. �, '� �� a . .. . '*?0� . " » . ... � Y � � �'�, �� ,� � � � �'. � � °�� ..� � � � � r' � ,- , � � � � �, � �' �. ��. � �� .; � � � �_� � �� '�� s� �, � �,. , � � , � "� �,� :��. � � .. ' �., E � �;�' � �� t!��iEi?'S�iGI��__ � . .� �� . ..._.�—� � �. _ ._—___ _ � �� ---�_ ;��,�I�a �r', , .L___ _-.,.-.. .. . . . � ,�:s� . _ . :� �"�L � �Cut��sA#J� �i� �� e�r '�MM► ��ii �` �� ,� < ��. � � � ~� � � � ' • '� � � � '. 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