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A29 91Application Date: � ' 2i" t-{ Amount Paid: � �� oO Receipt #: i Z 6 ! ��zug� A� ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) 0 Mobile Home Replacement or Building Addition $ I 50.00 (if site visit required) 0 Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 �_�g-�� `,�,s.� I��I��T �� l��cawna-x�+�* �s��ad.mll 1HCm�.11d,�1a. tion for Services Services 0 Construction Authorization �Fee is dependent on the type of 0 Permit Revision Tax Map: !-� 2q Parcel#: �� Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Inf mation•] �, f�I_ Name: �--G(. C T�G�' (` 1 Address: �7 PS � ./Vc� � �' � 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: "hhone (home): �-3� - SR 9- 8 0 � (work/cell): 3 3 - S� 3— ' 8 Z Phone: Lot #: ❑ yes ❑ no Does the site contain any jurisdictionat wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? � yes O 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 Structu� ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: � ❑ 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 ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other 0 Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is ina cu�ate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. 1�� / Signature (Own / Legal Representative*) Date '� 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 evaluatioa. (10/I 1) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��.s� ��.�� 7��s�ra�n�r�ira�.-„-„ c��ra.��.� ��.��a Applicant: Jnh Address/Location: Permit Valid for: 've Years Type of Facility: Number of: Bedrooms Proposed Wastewater System: Proposed Repair: Permit Conditions: Authorized State Agent: (X) Owner or Legal Representative: Improvement Permit Non-expiring New Addition / Employees / Seats: Tax Map: �_ Parcel:�_ Subdivision Phase/Section/Lot # Water Daily Flow: gallons/day Type: Type: Date: Date: The issuance of this permit by the Heai� Department does not guarantee the issuance of other required permits. It is the responsibility of the applicandproperty owner to insure 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 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 a�rr! Rules %r Sewa�e Treatment and Disposal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will remain potable. _ Authorization to Construct Wastewater System See site plan and additional attachments (�. Proposed Wastewater Sy,�tem: �� S%n Re�t�-�j��) ('�)Type � Design Flow (QD gal./day New Repair �� Expansio r Soil LTAR: . 3 gal./day/ftz Type of Facility: � P� �r„�a �e5id nC� _ Basement: _ Yes _ No (*) System Types lllb, Illbg, IV, and V, require periodic system inspeciions by the Person County Health Department. Wastewater System Requirements L�aSf�n� Tank Size: Septio Tank UA9� gal. Purrip Tank�- gal. irease Trap � gal. Drainfield: Total Area � sq. ft. Total Length DO ft. Max. Trench Depth � in. p,G� Trench Width � ft. Min.Soil Cover � in. Min.Trench Separation � ft. Distribution: Distribution Box V I Serial Distribution / Pressure Manifold .� � Authorized State Issue Date: _� ZR- /� Permit Expiration Date: 5- 2S - J� The system permitted is: Conventional A epte lternati / Innovative . I accept the conditions and specifications of this permit. • r (X) Owner or Legal Representative: Date:s ��'� �% �-- Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) ��, S f ��.� �� `�= � � �� I��aa-��.Il IHI��.11�l� SITE PLAN Name C Tax Map #� Parcel #� Subdiv' n Section/Lot# � 2�-/ Au orized State Agent Date System components represent approximale contours only. The contractor must flag the systemprior to beginning the installation to insure that propergrade is maintained /� ... K Q�� "3��_ q��3 ��- - _ __ ,_-„ 9fi53�4 �� r ��-�,�:s� ��.�� r � � �� '.�4 ga�n�amaa�sra.��a��,l�. g"'��am.�'��n. Applicant: Location: System Type (From Table Va): Type V& VI Expiration Date: ��'a�1�Il �e�i111� Tax Map � Parcel # � Subdivision Phase/Section/I�ot # # of Bedrooms �3 Product (IIIg): �Z Type V& VI Renewal Date: This system has been installed in campliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, �nd all condiiions of the Improdement Permit and Construction Authorization. (Authorized Agent} � , S-�-ree l� (Licensed Contractor) Scale ��ea�2 PCHD, rev. 12/14/12 �uSF. 21� __ � � ; �� s�� . Date) �-3-1� (Date) �s� C��x�c�e� � 63-box 5'!! __ , - � � � a � A � �_ �- ro r � �. d # � � u' . � — — � — c) i Line Length I Oo 2 __ o�_. Total 300' Tax Map: � parcel #: �_ Septic Tank System Checklist (Type II-I� Notes• 5ystem Type: � Pump System Checklist Contracted Certified Operator (Type IV �ystems): . Notes: ��d h G .� � ��f 0�� U O G/�` � �\ � a . � � , The District Health Department CASWELL - CHATHAM - LCE - PERSON COUNTIES ' Water Supply. and Sewage Disposol IMPROVEMENTS PER�IT ��__ T�a� '�'� IOWner: � Location: � Contractor: ' � ��,6!�:�— Water Supplp: Private � •� Public � � v v v. /y 5ewage Disposal Facilities: No. bediooms �— Dishwasher, Disposal, ashing machine, her auto atic appliances c: �� Nitriflcation line: _, Other disposal facility: , Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years an3 shall be main- tained by owner in such a manner.as not to create a public health hazard. Septic tank and nitrification line MU5T BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DiSTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COi7- ERED ANB PUT INTO USE. .. � Date approved: — Signed Sanita 'an Well: Sewage Disposal: Counter- By. ' 9igned � (Owner or his representative) � " �'" Cerliticafe of Completion/, � Date Approved: J� L By: itarian (OVER) Location of well and sewage disposal facilities sketched on back. � 0 ► ��, y � � � D K � Y � � �. w w 0 p m � i � 0 WY N� fD a a � � d b � 0 0 w r. 0 � 0 � � 0 c N m m m 'd n � � � N �cs �. . �. � I� m L y