Loading...
A29 5Application Date: � � � � Amount Paid: — Receipt #: � 12� 0 Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 d) obile Home Replacement or Bailding Addit:on $150.00 (if site visit required) ❑ Well Permit (lvew/Replacement/Repair) $300.00/$200.00/$75.00 '�..��'j� ) f ���� �l V ������ J�nnwnraa,•*,•,�*e��n�.ai.� )r���e�.]�4;;.�a. Tax Map: /� 02 I Parcel#c �— Cc�l I C'. e C� �, � �lication for Services �h e'`� � � � ,,�- Services Re uested � ❑ Construction Authorization (Fee is de endent on the e of system ermitted) ❑ Perr.�it Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $I50.00 or $300.00 1) Applicant In�rmatio�p► � Name: � !/o � �^� Phone (home): Address: 5 � ' (work/cell): � a %7 2) Name and address o current owner (if different than app icant): / Name: Address: 3) Prap�rty D�scription: Lot Size: Subdivision: Address and/or directions to Property: � Phone: ����Gy � � �2 �3zZ"7 ❑ 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? ❑ yes ❑ 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: �.��i ����� ❑Residential � �� ��� �% ❑ New Single Family Residence Maximum number of bedrooms: <<' ❑ Expansion of Existing System If expansion: Current number of bedroo . ❑ Repzir :o Malfi.�nctioning Sys:em ��Vil] there be a basemeat? 'L� yes o Wit�'� plumbing fixtur;,s? yes L' 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 any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If applying for `Authorization to Construct', ptease indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other � Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate,�r �the site is s�eauen j?v�rzltered. or the intended use changes, all permits and anprovals shall be invalid. ive*) * Supporting documentation required. �� Z D te Permits are valid for either 60 months or are non-expiring wben 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 (336-597-1790) ► � �� ���. � �+y: 4 . ���,�- � ,. , �.b �� V..J �L..! �.b. �1 �� ]�:�,.��{��.mrn.«�.�C.�zJI �<c.�a,l�t�� � �u�fl���a�� �6�6�fl�Il�IIfl�I P✓g�l�D�flc� ���9� ���D�at�!f;'�HIlc2�Il�5 Tax Map #:�_ Approval Requested for: Parcel#: Q�,� Nlobile Home Replacement �- Building Addition Applicant Name: r Address: ` Koxboro . PIC 2�S1� Phone #'s: S0�( - 3�{(Qa -T Permit Located: Yes V No Insta.11ation Date: ? Design flow: 3�e. �(gpd) Current Contract with Certified Operator on file (if required): Water Su 1: V Well Public or Communi PP Y tY Wastewater system shows no visual evidence of failure on: (Applicant's signature if site visit is not required) 3 - 2 2 - ( 2 (da.te) ���fln�a�����z���a��a�� ����°���� Enviro ental Health Specialist 1 ? /15/05 3 — z 2 �z Date . `���, �� � ilGf �� �� � T� ��\ �7►y \.�� 71 �� � V ���7� 11. � il'�'JLIL'�lT'17I•�1rn�tmm�OilL��.� u11�L.�.��rlrn SI'TE ��`T��-I I��. Name VR Pi:jr1 x�2.r Ta� Map # 2` Pa:tcel # S Subclivisi Section/Lot#. y. , _ _ _ _ _ , _ _ _ _ . _ _ _ � '3 _ z Z -/ 2 A tho�ized State Agent Date System cdmponents nepresent iapproximate�contours only. The contractor must, fdag tlae syste�ralbrdor to begir�ning the instadla�ion to ansure that prolbergrade is rnaintained -- — -- - - -_ � - ,� . ��� � ,,,� � �,�� � _ � ; ; � ����`� a� _ �. ,%.:` i ,,�, . .�. �: �. : �, .Yy- . ;; i,, ,� ; . _ . . .�,'�.'�F° . . e N .. !, ji,�, v, �`i.°' � ,� %,�, i , / f ,; � � ;� -, �� , � �` j � �a �,- ; ., : . �� � � r, ,, a, � � , ' i � - � ' ',� �'� �" i . �,i: ii/ ;%/�. ,,,;, �, ,,, '�'i�" ..� , i`:� 'c^ � � z . ��� ". , � , � .�, , �;, � i . .� "y'� � . ; �; �f � ¢� � , � * Tt�t �y,'; �i . . . � ���`-�" � � , � . � ' , �:: s%r �,F � ' . � . . . . . . . f yt �4d$ .. � � �' � � ',' � �A . � � � � � �� 9} / �� � ��� � � � _ � � � � ��� ; __...-- �� i , tA � �� �''#� � � 3 t �4� � � ,a t A , L'�f Y � ! ', �, �- _ y w � , � k �� s� �i ,£����.� � �' � . V � N% ji lc., -..� Di � �� :: d'iw✓' . "� .'.,E,�' °f"''�"° �r'* � �-`o.`�, _ � � �. x' � � � 5 Y � , -,' 1?' � ro g r £ " � u` �"� ,����`' „,a�,'F � � � � A � � . �5 ^'. � � F� & � � � . �' . �� � � � ., � '• �. � S � ^ � f ��yQ.' � «Z �- �. � �j, .� �'�•n ., � :, �,..' , „_ . � . �y � � ;., � " '� - � . _ � - �F �� � . :�' P >, a 3 � S � � v'�.,'•lk r°�ff°��. t y"� � a�" .,: �s �� : ,, �,�f.` ``"+:: cY . • . � 4 � $t � - . x �'�.\�� ��� �� :� � � � � � '� �� �� � ,� ,,� `>; ! � : � �� � � i �`s� '`r, , ,� �� �'�.� �'.�a�,.: �.�C."� � ,€� .�� u � '` .e s � � �" '�1 .r. � � � "t . � �¢ [ � �' . _ � . �' �-�. �' � � a � '�- .. � 3 � ^^„ap . 4^'i ,. _� �.�� '�� � ..��" �Y3��h � '' Y � l�'p �' �° . ,€ �rt' S � �a a.'1 Y� �' Aa� . Qr,� e,�. � '�.�'� � ,.��`��y,, .x � � i`+�r,�k;� ��'•: �s„�` �� z �,'�,�:� �-�,.; ' '�,� . : � �� r��-��-.}>: "� �' � ��r � � �� � -f�� � ti� �" �s�'��� � ���� �' �� �� � � � �. �"� � ,�''�+'"� �M �� � � � �� � _ $ ' � ��� � � �:x ��a 3� � ', �^ �+' � , � � � � >wv '•�'`ti �"�fiw� ��� . : ,.� a a '�� , � ��y �� � � � . � ��a . ��� . t,�` � +q ky �J � `� � €n, �� � � . . � � � '`` . . �' ~. . . � � , "�*�°� . �. � �� '� " �� �.��ri� � �� � - _ � . � � �� �� ,���� � �b � �,'a"� .��'' s� �� � ��5 ''8 �. � .� �' ,�„ � ,,� `� �`��` � : ''�� �`�, i � ` �$ ' �-- �, � � �i �„ � �' � ,��'"� �u �� ,�� -� � � � , � � a���F ' � �a� �3 . �. '�� : � h• � � �a' � � a � , g�<' �, �k�,� �, k. s. � � Y 1� � � �`''��ls� � � t�C' �. ��' . r .t* ., . �..` b� � �� �.q � - B�� � � �a-a ��&* �.. `i ;¢T � d � 8 d . r �! � � � � � -: � �, y •�F a �.�.s- .., ... 'i 5' �. ,.... , *. � � k ��� � � � E /� q}�'� �",_ � � '4 k � a,"va� � !� 5-'' fi � ,44�/ � t. �� � -�..;:, ��a•C .,,�' �� l � �. � �; �,� � `� ""� �-�' �� , � j5 � � � . � . . ��� � � t' 3� �� � ���.°^ y� � � -� �/1,� � i � }��..���.�'2 � �i� � ��i�%�� B 19 9 8 r s PERSON COUNTY HEALTH DEPARTMENT � a w U � a WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # �� Owner/Contractor Location/Address Parcel # v Township 51�u ��'k Date - I — 9 S s.R.#�1�,1-l9 Subdivision Name Lot# SFD SEWAGE SYSTEM SPECIFICATIONS �rea Size of'T�nk Trenches Permits may be voided if site is altered or intended use changed. Well and Septic Layout by Comments: Date Installed by Approved by Well P i aid ❑ WELL SYSTEM SPECIFICATIONS Individual t/ Semi-Public Required Slab Public Replacement Air Vent Site Approved �[ULG��w,,L— i�� "' Required Well Log 1� Well Head Arrroved Well Tag � Grouting Approved � � - _ ��?r/ Comments: Date Installed by Approved by This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic ta�k system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l _ �.�--r��ac ����U � �� (� �� �zC`n �N--� ?� J . � � ��►•:r:;ur� c��i��v•rti� i•:IVVI.1(UNP;::tv�rni. ui,nt.rt� ir�•:i.i. t.c�c. . + _ ., Date: ;-� - _��....�1 % Ownez-: ' Location � �'� __ �o, ,� �(y��� �- . . .. � /Dirc,ctlons: �-- ,��,.., � 9 _..� --------_ SR#� �-�- l - . .---..--- � �:1�._' � visior� .N�in���:---. .... . . . Drillin� Conrraccoz�: _��,�n_ � ..-.___...___ ot ____. , ..... ..._... s--.- %I ..1/.. �� .Q �_-.�1_,:n. .�.�_,.��.� � Dist�u�cc 1'+�1::1.(. C�'(:)Nti_1'I�lJCC1�InlV from Nc�u-cst 1'c-o�,crty I_,i����.. /S - Po]lution�_d�� . �-� ���`-�-s--_. llisi:l��c� �rom Source o.f ' Total Depth: p � Ft. �'ic:lcl: , > . � �:--- C�1 M Wacer Bearing ;Lones: Dc, th -- ,�.. _- ,Stalic Water Level .� . C � 'P 1 r. �:� �Fi • � --�...... , . asulg: ,Depcli: From a' ..._. ._..� I'[. _�_._ <<� ____._._.�t. T�'PE: S[eel . � -. ._._.�`Sr_ __j'�• lliaiiicicr: b%C�- ------------_.----__. .C',:ilvrini��d S[ccl // �--Ynches ��s[CC], CjOCS OWI1C1�.1�)�)["OV�:: ���::: --r..� . . wC1s�lI'. r.� 111C --. Nc) . •� �iI1 C �. . ---_ s�.�.;(1ci ht�A Drive Shoc: Xcs No � bovc Ground:�_<�nches � Werc 1'roble���s E�,count�r�cl ir� .Sc:ttint; �lc C:isi.J�t�'� • . .Il� .,ycs" �;ive rct�s�ii: .� • Xcs`--_ o Grout: Typ�� ------------- _... __....._ _._� _____ --------.: Ncat �;�nc1/C:.'cmcnt �" ��°: A�uiular.�Spacc Wi�]�� — - — Coricrete • . . , �, Y w1[CI" ' ' -�. _ __.__711C11Cti ,.. � 171 .F�.illlitl:tl' Sp,tc�: �'�:;; • ]VIc[�lod. - -- . ._---- i.,�" . . j�w�i x:c ti � I ��----� .___. ll� . ._..._ 1'r��::::uc�:_--. ___- ►'uui-c:c] ---�L�...�. . • . , . P�1: From � ' � � , Mate ' .`�..__. _._ <<� . � d_---I'�- � � . � . I"l�IS USCCl: No. .C3at;s ,['orcl:crid Cc�llcnt . IFmi;,turc (s.zncl, �r:i�,cl, cuttin,,,, .—..�%-- Wci�;ht of.l ba lbs:-' ,. ) - ]Zacic�: _ �- to � �-1-'�— .,..,,,. ID 1'l:itcs: Ycs ti/ Nc� ---__ . • �� x �� :;lab Ycs_. ��%_ -- Nc� . .._ :. ' � � ... . _._ __ .. -- . �--.__-----_...__._.. . _ ....���l�.i l ,l .1 NC� (..�X�__ UcDt11 From �� — -----------...._... _.._._ TU : ----...•--_______ --- ----. .---..- : . . . l:c,rrnat�on llcticri [ion -s- -�'-�C--.�.L�� �`--- _ .�_ � : ----- ------- _._s�� . ..... .�iQ .L._._._._. `�- - --��..� �d L-�•--��..�._.___�_.__ ---._..._._.. .... ..._.--••-- _... � , Z HEREBY CE1ZTIr-Y T�1n�1..1.1 rL nr3c)v : ;. T�S WELL WAS CONS'1'R UC"1'Ll) f IV ACCO�ZllM�11 XON !S CORRECT AND TH% : FORT�-I B Y�T�-I � P�RSON (��UNrI�Y. [�11;n r.�i�I-r DLP �C� WITI I REGULA,'I'ZONS� S� ,. ., .. Al,, fMCN"!'. � "•:� ._ _. ....��r,�,� �, _ .Si�;ri;�lurc c�fCont�,��:tUr -__ �� -i Datc ,,.�: -:�.,..�... .. _ � .�.. _.