A30 160�t/�/i �
Application Date: '2 7 i GG ��� S ������
6 .. � .f
Amount Paid: (3d •00 � � ' .�...�
Receipt #: 1 7 7 I � 1�� ';�' �����
, � ,:'ar� �TM*�aa�.m.Il I�'3[a�,m.11iElla
L1��G� i � �I oC.CC �r�o �
Aoolication for Services
Taz Map: � 3 �
Parcel#:
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5ervices Re uested
Im vern�ttt ermit (Site Evaluatioa) ❑ Construction Authorization
$200.00/ 00.00 if > 600 d ee is de endent on the e of system ermitted)
❑ Mo ' e e 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 Application: No Charge/ CA $150.00 or $300.00
1) Applicant In�f�! t'on: ,�/ _
� Name: J"oo'"�� E /"�' 6l�� � Phone (home):
Address: (work/cell): �-3 �~ d 4- ��g 7
2) Name and address of current owner (if different than applicant):
�� Name: (,C�1�0. ��OC��S �e�� � �
Address: G N�b �rl i►� t �•l `
P�ax bo�-� i� L �7 7 i-i
/3), Property Description: Lot Size: qCrv Subdiv'sion:
/ Address and/or directions to Property: o!� _�'
Phone: � 3 6-� q 9�g T 7�
#:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
� yes ❑ no Does the site contain any existing wastewater systems7
❑ 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 property?
(if `yes' is checked, please provide supporting documentation)
�'lC,�I�CS
4) Proposed Use and Type of Structure:
j �Residential ' i
New Single Family Residence Maximum number of bedrooms: �/ Occupants:
I�xpansion of Existing System If eacpansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? O yes ❑ no With plumbing fixtures? O 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 ❑ no
Please note any known ground .water resfictions or sources of contamination:
6) If pplying for `Authorization to Construct', please indicate preferred system type(s): .
'� onventional 0 Accepted ❑ Innovative C] Alternative ❑ Other ❑ Any
/ /
1 certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Legal Represer
* Supporting documentation required.
� �
D e
Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
�( Tag Map: 3b Parcel: 16 0
�.1� j `�� ���� �� Subdivision
— � � ��'� � Phase/Section/Lot #
):E�+e���-��� ����.:1 IE-���.Il�]]�
Permit Valid for: Fiv�e��Years�
Type of Facility: TT79c9h
Number of: Bedrooms � Z/ �
Proposed Wastewater System:
Proposed Repair:
Improvement Permit
✓ IVon-expiring
, New �C Addition
�cupants / Employees / Seats:
Water Supp;y: �'��
Projected Daily Flow: , gallons/day
Type: �t
Type: ���
._
• • ir : A. � . .:i � � � ! �' i �9 i. >s.<i
�
Authorized State Ageni: __ ,• ' � Date: 3 /7
(X) Owaer or Legal Repressntafive: jC. � Date: �-3 /
The issuance of this permit by the Health Department does not guarantee the issuance of otfi"er r:.quired permits. It is th:, responsibility of
the applicanUproperty owner to insure that all Person Gounty Planning and Zoning and Building Inspections requirements aze met. This
Improvement Permit is subject tu revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. T6is permit was issued in compliance with the provisions of the North Carolina `Laws
and Rules for Sewage Treatment and Dicnosal Svstems'(1SA 1�iCAC 18A .1900j. Neither Person Couaty nor the Environmental
Health S�Cecialist warrants t�at the septic system wiil continu� to function satisfacto: �iy in thc fature, or that the water s��p1y wifl
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
x
��t �l
Proposecj. Wastewater System: [�,�/'�,,�/�p,�/.ri� (*}Type �_ Desi Flow D_ gal./day
New �� Repair _ Ypansion _ Soil LTAR: � Z� gal./day/ft2
Type of Facility: _.. Basement: _ Yes ��o
(``) System Types Illh, Ilibg, Iv, crnd V, require periodic system inspections by the Person County iiealth Department.
Wastewater System Requirements
Tank Size: Septic Tank �DD O gal.
Drainfield: 'Total Area ,��tD sq. ft.
Trench Width 3 i�.
Pump Tank � gal.
Total Lengtl� Z�O ft.
Min.Soil Cover � in.
Grease i rap gal.
Max. Trench Depth � in.
Min.T�rench Separatian � ft.
Distributioa: Distribution Box K/ Serial Distribution / Pressure Manifold
Specifications: �f �� �? �� � �
Authorized State Agent:
[ssue Date: � � �
Permi� Expiration Date: _
The system permitted is: Conventional �/Acc,epted i A ternati�e / Ini�ovative . I accept the conditions
and specifications of this permit. �� d.�, r ' � ,,• r�
(X) Owner or Legal Representative: %� � `�,�ZE. �— �• ���' Date: � � � /
Person County Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
�l",)f �����1 � Name: �
����,�� Subdivison:
lE' aavirommmacxa�mIl I�emfl�a
Z
i�
System Type: �C_
Septic Tank: �DDO gallons
Pump Tank: �/�" gallons
Total Linear Feet: �
Max.Trench Depth: Z "
Site Plan
Lot:
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,. _ _ . �` �5 �
> � /o�� � �
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• �/dI' �es�--�s��
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EHS:
Date: Zt7 f 7
Tax Map: Iqc30
Parcel: � � �
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IF� � .
—�
.
Scale• � ��=5�
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Health with any questions (336) 597-1790.
,4dditional Comments: �f U��, � �� � �/yJ!(%� �'.��lG /y/uD Ll�'� dJf��
Tax Map: �3�
Subdivision:
���.sf ���.���
,---- � � ����
1E������m���,Il lE-���.Il�l�
Parcel: � � 6
WELL PERMIT
(New_ Repair_)
Applicant's Name: /i � �/�d��1�
Mailing Address:
Phone Numbers:
Location of Property:
Lot:
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 from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: Date:
ew 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 Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Certifcate of Completion
OL,iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
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