A29 67Application Date: �!-+� �3
Amount Paid: � (�O�`�
Receipt #: l ISO 91.1
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❑ 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: ��_
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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� ���
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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.
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� 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)
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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.
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x�u g t6e system priot to beginning the installarlon ro
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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�
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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�_—
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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 (�.
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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� ��� � ��
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Authorized State Agent:
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[ssue Date:
Permit Expi
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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)
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AppLicant:
Location:
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��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.
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(Authorized Agent)
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(Licensed Contractor}
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