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Application Date: �-o� q'�c�i Tax Map:
Amount Paid: a06 • � Parcel #:
Receipt#: �} 0 a �7
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Application for Services
(Septic Svstems and Wells)
Services
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
❑ Construction Authorization
(Fee is dependent on the type of sy;
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
No Char�e
Important: If tlie information in tlze application for an Improvement Permit is incorrect, falsified, or the sile is altered, then t/ie
Improvement Permit and tlie Autl:orization to Construct sha[l become invalid.
1) Services Requested by:
Name: � �
Address: � O
Q o �
Phone # � ��
(work/cell):
2) Name and ad ress of current own (if different than applicant):
Name: O �
Address: O � ��
r
3) Property Description: Lot Size: �/ L/�'/ Subdivision:
Address and/or directions to Property: /7S ,,���1"P,�
� , , , i _ , / , I T"T _�'�f
4) Proposed Us�e a�n Type of Structure:
Residential !/ Business/Type: Other
Number of bedrooms 3 / Number of people served (seats/employees):
Basement: Yes No�(with plumbing: Yes _ No � Garbage disposal: Yes _ No _
Appro�mate size of u�lding foundation: Length Width
#:
5) 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 completed apnlication must also include:
➢ A plat/site plan of the property tlzat shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing tl:at tlie property is ready to be evaluated
�
I am submitting this application to request services from the Person County Health Department. The information
provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become
invalid.
Signature (O /Legal Representative): ; � Date: " �—�
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
` i �" I � I � � (�) � , .
T�x M�p - Pa�rcel �
� ��� � � � � - Su��bdiivision
1 � z . , , « _�,_ �*.., . � , I I 1 . . , I � I., Ph�se Sect�ion tot #
Permit Valid for�
Type of Facility:
# of Occupants �_
Proposed Wastewater Sy
Proposed Repair: ��,
# of
Improvement �e�mit
_ 1�To �zpiration
New Addition Water Supply
ooms Projected Daily Flow -�l� g.p.d.
Type:
Type:
1�' , , ��
Permit Conditions: /'�lpt Qlh Q�� S� OCACS
Owner or Legal
Authorized Statf
Date:
Date: — ''0
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure 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 Permit 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 and Rules for SewaQe Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
�nvironmental Health Specialist 4varrants that the septic tank system will continue to function sadsfactorily in the future or that
the water supply will remain potable. �
Au�horizat�on to Const�uct'�aste�water Systean (�equired %r �uilding Per�t)
* See site plan and additional attachments (__).
Proposed astewaterSystem:�,on✓en�ono.l Type� WastewaterFlow3�o g.p.d.
New � Repair Expansio � Soil LTAR: -.3 g.p.d./ ft 2
Type of Facility: pri �/Q� R Si cP, Basement _ Yes No
`�asi�water System ltequirements
Tank Size: Septic Tank: odo gai Pump iank: --ga� Grease Trap. 1
Drainfield: Total Area: /?-0o sq ft Total Length �{DO ft Ma�mnm Trench Depth _� in
p o.f.
Trench Width �_ f 1Vlinimum Soil Cover: �_ in Minimum Trench Separation: �
Distribution: v Distribution Box Serial Distribuhon �Pressure Manifold
Spec�cations:
Authorized State A€
Permit
The type of system permitted is
permit.
flwner/i.eg�l Reprasent�tive:
Date: _�
V Conventional
�
Date: Co �l�D�(
-{�r�-�s ��ao�2o `�'✓
Accepted Altemative. I accept the specifications of the
Date:
PCHD rev. 11/10/OS
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SITE 9B�TCH
Na�me a cSS _
Subdivis'
A thorized State Agent
Ta.z Map # A � `� . Par.cel # -� �
��
Section/Lot#
� �-1/^08 �
Date _
System cotrrponents re��esent a�iproximc�te�contours on1y: The contractor mx.s�tflag the system prior to
begin�sng the installati'on to i�sut�s thatpro�ergnctde is mai�tained
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