Loading...
A29 67Application Date: �!-+� �3 Amount Paid: � (�O�`� Receipt #: l ISO 91.1 �,�,,,�. Z33� � Ax ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 d) obite Home Replacement or Building Addition ❑ Well Permit (Ptew/Replacement/Repair) $300.00/$200.00/$75.00 _�'?+ ) � �Jl.d�� �l V Tax Map: ��_ . ��- � � ���� Parcel#: �_ IEy,.'xnwnn-�nnvrra�.anai,en.Il J.[�[ae,s�,.11d'la. tion for Services Services Re uested ❑ Construction Authorization Fee is de endent on the e of ❑ Permit Revision $75.00 Q Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Informati n: ,� Name: �v�C�?< C� �h'�� Address: �G�r � f�ur�'L�We 7 G� ��� �t o.[c7aQo ,;-�v C ���-? �' 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Phone (home): ��S'� - �"�✓�`f (work/cell): Sn � - 4� o-!"� CaCe g N� � Phone: � #: ❑ 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 properiy? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: ❑Residential ew Single Family Residence Maximum number of bedrooms: % 0 Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well Q'Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wetls, springs, or existing waterlines on this property? ❑ yes 0 no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the ir formation provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. ' :%G�� C . � Signature (Owner/ Legal Representative*) * Supporting documentation required. //- �f-/3 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/I 1) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ���, f I�I��. �S �� . -- �c � ���� � �v ns�aanaa�as�.��.�� �'�.a.m���x�. SITE PLAN Name 1��-� V`'�� Tax Map #�_ Parcel #(o� Subdivision Secrion/Lqt# p�P.�1cX. A_ Sr�r� 11 �8 1 Authorized State Ageat Date System components repruent appmximate contours only. The insnre thatpmpergrade is maintained. �J �w ��+� ���J�. x�u g t6e system priot to beginning the installarlon ro i%� � 4'.. ?� �s �J� P� ` �� � � ' �,� , `�� \go ���,� � � �� �C" 0 ��,S�c T��i� Q,t�v`�-� ) S� ��1" �.�w �" � � � 37� , � 80 , 3Qp Ac�il \ � 3��` �px '��J►c.� QEYT� ) � � � 1 �.�5 1 J��\ � rC�YAN7\'Cla - �so 6�0 _ c.3a �-rR� - 3�� �.Z �ow oR c,r��•�. 4�Owv,�,o ���.s�- ���.���� �,� � � ���� J:E-�s���a�-��� ��.��.�1 IL—���.Il�I� Applicant: �wi��(t-�C" W�-t�1, �lddress/Location: �19 Sc►�tsN �i arl� t� ,pT Er�� �i�.s: i3�FoS�.�. S�A�P Ci1W� 5 ��'ORS.. Improvemeni Permit Permit Valid for: Five Years � I�lon-expiring Type of Facility: M��R�+�CC Nov� New � Ad�ition ` Number of: Bedrooms �/ Occupants�/ mployees / Seats: Proposed Wastewater System: c �v a5 g. itto� ��.tv Proposed Repair: cc.Tf�O w �`�o v Taz Map: �.� Parcel:�_ Subdivision Phase/Section/Lot # C�i Water Supp;y: �x�s�t�►b i 5����J t� Projected Daily Flow: y�o gallons/day Type: 'IL C Type: �16 Permit Conditions: �a�.ww SseE. S�i-Tc,}� ;�Acf PG�O Lvi C�1�sr.�tiS � M�*�m�'t€.. Sn�_— S� ►ssUt�Ata �. Authorized State Agenc: Date: 1 ae 1 (X) Owner or Legal Representafive: ,�� C GJ.,.------- Date: �- z 9-�� _ The issuance of this permit b r the Health Department does not guarantee the issuance af other r:,quired permits. It is th� responsibility of the app(icant/property owner ±o insure that all Person County Planning and Zoning and Building Inspections requirements are met. This [mprovement Permit is subject tu revocation if the site pian, 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 t6e North Carolina `L�ws ruiil Rules fot Sewage Treatment and D�cnosal Svstems'(1SA N�AC 18A .1900). Neither Persaa Covnty nor the Environmental Health Specialist warrants tha? the septic system wi�t cantinu,, to function satisfacto::ly in the future, or that the water supp,y �riil remain potable. --__ Authori�ation to Construct Wastewater Sys#em ,i�ee site plarc and additional attachments (�. � Proposed Wastewater System: Ac,c��p w� a57o I (*)Type �_ Design Flow �1� _ gal./day New Repair _ E�;pansion � Soil LTA.�Z: 0.30 gal./day/ftz Type of Facility: M�t�P�� 4�c►�1� (,Swt^!�� Basement: � Yes 7� No ('") System Types I�Ib, Ilibg, iY, �rnd Y, reqkire periudic systsm inspections by the Person County Health Department. Wastewater Sysiem Requirements Tank Size: Septic Tank �.X�s�t*�ta gal. Drainfield: 'Total Area 9� � sq. ft. Trench `vVidth � ft. Pump Tank � gal Total Lengtl� ��G _ ft. Min.Soil Cover _� in. Grease i ra� � gal. Max. Trench Depth 3b in. NSin.T'rench Separation �_ ft. Distribution: �istrihution Box� / Serial Distribution ! Pressure Manifold _� 5pecifications• ��!�• �� �'�'�'��� • b�w 5� ��� � �� t�T�w� • p►vi�r `�,rr� ts�t��o 'Z'q tC. , Authorized State Agent: � [ssue Date: Permit Expi P-t�s�rbr ��at ��.. � ct �14�eE.e. The system permitted is: Conventional /Accepted 'i'C / Alternati��e / Innovative . I accept the conditions and specifications of this permit. (7�) Owner or Legal Representative: ,Z��-�-�.X C- L� - Date: %- .2 9-/`� Person County Environmental Health, 325 S. Morgan St, S`uite C, Roxboro, NC 27573/ph.• 336-597-1790 (rev 5/12) ���ss ���.��� �'�� �` � c� � �TT�T��Y ����m�.���.��.71 IHL��.71� AppLicant: Location: �a ��eration Perrnit Taz Map ,},�,�,�, Parcel # � � Subdivesian Phase/Sec�ion/Lot # # of Bedronms � System Type (From Table Va): �� ��1 Product (IIIg}: 6 � EZ. e"-�w � Type V& VI Expiration Date: ' a Type V& VI Renewal ate: e1 A.� This sysiem has been instaIled in campliance with applicable North Caralina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Comstruction Authorizatibn. i���c.� �4 _ Sr, m� (Authorized Agent) .�. J s��e'.. S-►Y•�.�T (Licensed Contractor} �.� -� - ���.. C�' �,� S. in/'. N1. N � Scale t�iS Pru�. ���� i zn a; i z � an i ( a�e) a a� � {Date) I�� � r�5 �,a 0 .. � � � -�, r��„� -�.. ac ti�. �IU crc`�ea,`w7.EF��i �.O i.ine Ler 1 wW� ' � ��o 3 �ov i� a' _ .i . a � �l� j � 3 -t-{���� �{-�� ���'� ra -t�� � ua� - v�c�a��. �r � � l�sG ���-n�ac� ��c. ��•�-�c -f o� �' �.���,� N�D3 � LE �a�l E. MA�� B�Gm �.t � Aei��ta #"` �-D �• t �J �. ��js1�3 ►�.. ��� �� �o,a� � �� �,.,�,,�.. T,-�, �.�,�� -���L R ��-a � i�.. ,��. --� v � a�r -n�. S ��c��a�c-�z`t ��. -�- �'� ; a�,s� , a �a��� � w t`�.. � �J�..�.o -ca ►�►1 co•�.�t. ���as � --� s� 5� �c�o ��-c�c��r� �-�� � `Dw����..c� Car��x, �a�.-�so' �� ns-�.�. t..�c.�=c� �,� wct� �51. M�a`( t�w� -�v �Cr�o C�r��.�c S`i �c� '�tc.. 3_ 4�,�,,�a� . � `D�..�c.1L 1���`� 1h� �"Fssr�- s�.� �� s�� ����a�. ��1►� �' A�b P�s � 1 s�, sr�. ��a�, �� s�ts-� 'Ex��'w�.� . �it��i�.. �t��� a�,r��t �� t5��� , �,w Sv r.l� � s 3-I�.t�R.o�h, su� �.��.� 4E. y'�'�'`'�'� `i� A,s. . 1-�- ��s -I � ���� �- � C. � ��:� . �� Z.,2���� � � ��C. �,,��.