A29 88Application Date: `" � y -j�'
Amount Paid: .0 O
Receipt #: 1 �026 7 � _
�-�k 70 6 Q A
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/Re c t/Repair) •
$300.00/$200.0 /$75.00
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ication for Services
Services Requested
Tax Map: �Z�
Parcel#: g�
r aX `�� ,
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Construction Authorization
(Fee is dependent on the type 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: Shannon Allen �
Address: 5064 Burlington Rd.
Roxboro, NC 27574
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): 336-599-3203
(work/cell): 919-812-0087
Phone:
3) Property Description: Lot Size: 2•3 aCre�ubdivision: Lot #:
Address and/or directions to Property: gravei driveway beside Fieldstone Farms de�
approximately 1 mile from Hwy. Patro sta ion ea ing sout on ur ington .
❑ yes I�no Does the site contain any jurisdictional wetlands?
❑ yes I�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 C� no Is the site subject to approval by any other public agency?
❑ yes I� no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
nt drive
4) Proposed Use and Type of Structure:
❑Residential . 3
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
l� 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 � Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes 0 no
6) If applying for `Authorization to Construct', please indicate preferred system type(s)c
� Conventional; O Accepted ❑ Innovative ❑ Alternative ❑ Other ' ❑ Any
I cert� that the information provided above is conzplete 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*) � Dat
* Supporting documentation required.
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 (336-597-1790)
Tax Map: �a°t
Subdivision:
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Parcel: $$
WELL PERMIT
(New _ Repair i� )
Lot:
Applicant's Name: S�Lae�.�o�.� P+���
Mailing Address: SOb� �vw,,,�zva �
�OYC3Cf�A �tJC. ��15R�}
PhoneNumbers: 33b-5`1q-3�3 `t\�' x►�-a�i�l
Location of Property: SOb� A+x�.�-ro..\ R�
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years fi•om the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:� L1t�E'�,�
Permit issued by: ��:�CL A- St�ti�
�Tew Well:
EHS(Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Com�nents:
Date Sample Collected:
EHS:
Date: b �`i �`i �
Certificate of Completion
�L,iner:
EHS/Date
Depth: ��
Grout: ���g�yG
�bandonment:
Date:
Method/Materials:
License #:
License #:
Date:
td�1 Cl.c�s�ii✓•��a • -
Date Results Mailed:
Person County Environmental Health
325 5. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808
Roxboro, NC 27573 il/26/13
Aaalication Date: 1— � 6-6 �
Amount Paid: 0
Receipt #: 2
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APPLICATION FOR SERVICES
Tax Map #: �`� �
Parcel #: g U
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT. FALSIFIED,
CONSTRUCT SHALL BECOME INVALID. �
1) Permit reque ted by�c (Owner/agent/prospective owner): CY �
Home Phone�� �,l S�°! "�I -�/�� Address ` ' Q$ L� C a �
Business Phone�yS�Lf —O/(o� � .�°�
2) Name and address of current owner: "SI'1�-n I i'�_
SO i o`
..l'�o�t (ao�o �-. �75-�I�
3) Property Description: Lot size: 2• 3 Z Township: �,�o Subdivision:
Directions to the prope�t (Includi g road names an numbers):
� SO�h_ ;�— �✓� ,�� �4s'�;�
Lot #
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4) Proposed Use a d Structure Description: answer each of the following questions: � � a��
� a) Proposed , Existing , Type of Structure: �i�� Width: � Depth:
b) Number of Bedrooms: Number of occup nts o eople to be served: �
c) Basement: Yes_, No � Will there be plumbing in the basement?�
d) Garbage Disposal: Yes No '�"
5) Water Supply Type: Private (new _ or existing�, Public_, Community , Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAF(ED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE. FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid. ��� , ,, J
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Owner�`Legal Representative
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Date
PCHD, rev. 06127IO2
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