The URL can be used to link to this page

A30 151Y1 � . �� _ � B 01 �� . PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # � 30 Parcel # _� _ _3� Zoning Township �� , �1� Owner/Contractor � � /?-�,—��- Location/Address � q S !ofi d� �%�F- .�.� F- w�� St2��/� �' Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area � G' r Size of Tank� SFD Mobile Home ✓� Size of Pump Tank_ Business # of Bedrooms Nitrification Line �� /r.�► �Vo.,�, ,�,-� Max Depth Trenches � --, - � - � v Permits may be voided if site is � Well and Septic Layout by a+ Comments: Date Installed by ell Permit Paid ❑ Public Site Approved Well Hea rove mg Approved Comments: nded u changed. ; r Approved by � .o n lZt ✓w�- 'ECIFICATIONS Semi-Public quired Slab teplace Air Vent Required Well Well T.�� Date This report is based in part on infor�nation provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l Application Date: a�8� �b Tax Map: ;'-� 3U Amount Paid: I.`��6. U v Parcel #: �� I Receipt#: � � ,2 38� �-�I� � ��, � I�J�1�$.� �� , � 1 � � �� .gara n�t+aag�naan¢a_'�zad�..mll �I�3I�c�,.�u.IltG7Ea n Gri�1 � Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if> 600 d) (Fee is de endent on the e of sy: obile Home Replacement or Building Addition � Permit Revision $150.00 (if site visit re uired) $75.00 ❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 No Char�e ) Services Requested by: Name: ��r('� ��r a fe��,�, Address: i !\ (1 . u,rd f`n; l l� C, 2�5N � �,1e�� 33�_��3-�7 � Phone # (home): ,��(� �`j $�-�'s� -�j (work/cell): 4 f 9 - �f 77 — �(u?�/ 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: . 2�'/r,u.,�ubdivision: Lot #: Address and/or directions to Properly: 3�{�,p r rl ��n�Rc4, I-{c.tTrj �e ; � I.� Y' 4) Proposed Use and Type of Structure: Residentia) _� Business/Type: Other Number of bedrooms �/ Number of people served (seats/employees): � Basement: Yes No ✓(with plumbing: Yes No _� Garbage disposal: Yes No ✓ ater Supply: Private Well ✓ (Proposed ✓ Existing � Community Well: Public Water System: . Are there wells on the adjoining properties? No _ Yes ✓(please show location on site plan) Note: A comnleted anplication must also include: ➢ A p[at/site plan of the property that shows property dimensions and ihe size and [ocation of a[I proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. � , Signature (Owner/Legal Representative): Date • � 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ` � ; �� ) � 1 � � � ` {� : �. �' � � �� J:L.7.�.��i.�{�.ii�.�r�i.C��i�.��i.� l3. 1L�i��4�JiAL � �u��fl��aa� r'��g$Il�Ilfl�I P1/g�l��flc� ��3t�fl� ��D��flc�flIl$5 Tax Map #:�¢_ Approval ReqLested for: Parcel#: ��r ✓ 1Ylobile Home Replacement Building Addition Applicant Name: �� ` � Address: r� �Lt r(��P I'� i �< �? ,7 ^�i � ( Phone #'s: 33(0-�$�- Oc�7�� g/9-y17- y�17 Permit Located: Yes No gp Instaliation Date: /Z-ZO-95 Design flow: ? � (gpd) Current Contract with Certifie Operator on file (if required): Water �upply: Well Public or Community Wastewater system shows no visual evidence of failure on: 2- ll -/0 (date) (Applicant's signature if sits visit is not required) Comments: l�ropro�e� A��' 'o��l��aa�� °��v�� 2 // -/D Envir ental Health Specialist Datz 11/15/OS . �•�� J �� .IS.. I.S_C11� �j,� �� ]� �-� u- � �� .�.11 1HI �.�.]l � � 1 / N��e_ C�a��r�e.. �I��<�� ,e�,.�>�.i S��l�� / _ A, � orized Sta.te Agent -- �� Ta.� 1V�a.p # 3C�.Pa��e� � 1 �_�___ Sectian/Lot# _� �� (��— / ° - L Date 3'_ystesBa cdr��ioneasts r�e�rr°eser�t ap�,roari»uzte �co�ator�rs �s�: ihe con�ctor rr�s�s� f%iig the systersa pYior �� b�gznr��a� i&e isistc��on to qnsa�re tlaatiinv�ies�g�de as r�zss�tairur� %�,��__ .. i = ,- , , � 5 S�� w y� t w h euSe �Qc� MPn� ar�c�'ar.� �� ewt a �� ar� ��/ I � � P "-� �4��:;�x _ , . Application Date: �, a5-to . Amount Paid: �?,-�•,� Receipt#: n�\�,. � _ Tax Map: Parcel #: �a �I��$.� �l� c� 05 ��.�,� ' —,— c� � TC� � � `� Tr� "�ca-��i u-<ca aa �•-,•�, <c=. aa �..tn. � 1�� ac-".�a. ll�:�a Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) 0 Construction Authorization $200.00/$300.00 (if> 600 d) Fee is de endent on the e of s stem ermitted) ❑ Mobile Home Replacement or Building Addition 0 Permit Revision $150.00 (if site visit re uired) $75.00 ell Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 No Char�e 1) Services,�tequested by: , Name: ��c'� 2. w L�'SC-� �P,�'S.� Address: n ��d� c�;,�� r . `z-��yi P�e # (home): �3� �� 3 -DL�-t9 (�.lo,ld/cell)� Gl��%- �7�-y�/7� 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: 4) Proposed Use and Type of Structure: Residential �� Business/Type: Other Number of bedrooms / Number of people served (seats/employees): ?� Basement: Yes No ✓(with plumbing: Yes No � Garbage disposal: Yes No 5) Water Supply: Private Well ,� (Proposed Existing � Community Well: Public Water System: , Are there wells on the adjoining properties? No _ Lot #: Yes �� (please show location on site plan) Note: A completed application must a[so include: ➢ A platlsite plan of the property that shows property dimensions and the size and location of a[l proposed siructures. ➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. � ,� �/� Signature (Owner/Legal Representative): � 5%iv 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��. sf ��.� �� ___.: ^ �� I� .�� a � � � � � �. � �. ll .�. ll � .1� WELL PERMIT (New_Repair� Taz Map: 3b Parcel• �� f Subdivision: Lot: Applicant's Name: �/' i Mailing Address: C z�5 PhoneNumbers: �Q- S$3-�,p79 ��-y77- �f�f7� r,�orK� Location of Property: Permit Conditions: 1) See attached site plan for proposed well location. 2) All applicable State and Counry regulations governing construction and setbacks apply. 3) Permits expire S years from the date of issue. Other Conditions/Comments: � „ �Ji� ��.� � S� ��; 5 Permit issued Date: 3-3d '/d CERTIFICATE OF COMPLETION New Well Inspection: E S/Date ,�p Location: SS �� Grouting: . Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: MethodlMaterial(s): _ � Well Driller: _ _ (. Uph� License #: Pump Installer: License#: Well Approved by: Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Date: Date Results Mailed: ' Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 �`-�'� �� .1��1k�.��l�! � �� ]� �-� �- �y m,�,� �.��.11 7HC � �.]l � �I'TE 5I�'I'�� — Narne �Z�� ;� `��15�c ��►,�5 K� Ta.g Nlap # f� �c � Pas_�e1 �/�'/ Subdivision-- �ection/Lot# __ - � �._ � � _-30 _ /L' � Au.�orized Sta.te Ageflt Date sy�� a�po�� res�t �pp�.�i��o�:�o�� y: ihe con�'snctor rrasrst`. flag the systesn prior to , begar�ras�,g the installra�eon to �nsz�re tlaatpnm�ies�gmde ss re�iv�taaned _ _ � _ � �j�c� cn 1� �►�Z d �fi ��3 � �/ ��'��,,�i�(� ��ua1 u►�^ � , �� _ _ � � � � � n e �'/i �t i 5 �— A�i��►1c�� - �._ .� ._..��.....��.. j cs � �U e �--o n.... '� � �� K� C�� {' -�._ � Io; ��r ,``" �A � � , �' �� ;�.� v ,� t ' I � � �n ti, � �� ..' 1 _ � � �4 � i ( � " � fi t ,>f.} ..�� • � . � Y r...n '�'� � �.�*�.__ _,.._�.:..�„� � �_'�, "- � s � �, � � _`�--� �'`>^�` ; � �� F i ___-�_-_ , i .> a � � - � a � � f � � � �' � '�',% � , . „ - �y ,€ � : • , — , -. . . , .- � , � � �$ � . ... I �, _ � � � � . �; � � { .�: � �� R �� # } �� '� ; ��..�---� ' :t, ` s+� ., ��'T � . � / � � 1 �' - ,� � �. � _ � ?t � r �; �`,� _ �'� ��,-- �� . � � ��y�_; f -� k�� r� � � :� `�� , � � �;' �� , � � . �� f' � � , , � � �. = � - � � � g � _ � �.� ��. � 4 . sj �. � "�. �� w.1 �Y� ��' ��,.;� j G _ ' M 2" �� ?� i � � �M. �a .� �.. ,� w, . � y '�a ,� .' �" � '�'� ._� . - ' � � �m �� r,,,,,�_ � � � "h' � ,� .. �!s„ �k �� x ' m�• ��. � ��,.'^"_.,_...........-- � �-�� s. �. � _ � �Y� ,� � '� � ,,,,�,.,....� .. � . . . -. � : ` �' � �, �.� .�� ,...,+.-,-.. . " \ . ' � l ��:�+',.. _M,�,��,,.:t'�"-^-"' � S ..--,^!�----"""� � ^ , ,�:,�.:�%---•-_ �r7v•_ .„„�,,._-,....-,-;�._:^Y.,,_,�.,—,-,; \ �,°a��"^�8' _ - $iS � L"� �' ' �..� --�^",'. "'" � �� , ' `�„ ,,,,�.,.,.... "'� r �.��, ' ,..,..—.-*..,:—.., "'"`" � ,' ,,.``,...,r,.--M f _ . , /