A30 40Application Date: 1 ilc� 15
Amount Paid: ��j J0
Receipt #: 1 5 I
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Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobite Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/ atT�
$300.00/$200.00�l.�
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ication for Services
Services
Tax Map: A3o
Parcel#: y�
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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: T-G ! �!'l Phone (home): - S �l'�' 'SG
Address: �,,N /� (work/cell): 3 3 6- S� ��
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2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: �� c- Subdivision:
Address and/or directions to Property: q S /
Phone:
Lot #:
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Ja ►, Q-!(e� Ko( o'►+- K7` �� �wus� o,.� �P_rof—r-,
❑ yes C� no Does the site contain any jurisdictional wetlands?
0-yes �cno 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 Ca no Is the site subject to approval by any other public agency?
❑ yes C�no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4�) �Pr posed Use and Type of Structure:
QResidential
❑ 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 Squaze footage of Building:
Maximum number of seats:
5) Water Supply: 0 New well l7�xisting Well ❑ Community Well ❑ Public Water 0 Spring
Are there any existing wells, springs, or existing waterlines on this property? �yes ❑ no
6) If applying for °Authorization to Construct', please indicate preferred system type(s):
� Conventional � Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate�if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
- �G -15
Date
* Supporting documentation required.
• 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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map: � Parcel: �
Subdivision:
WELL PERMIT
(New_ Repair ✓ )
Lot:
Applicant's Name: ��fY %�1
Mailing Address: �� �_� �n {� ��n�
���%vv7 NC ar16�7�
Phone Numbers: ,�,?� a-599 -�5'b 1 �3Ls -5g � a 1 y�-
Location of Property: w9 ��� �r� c��hr� A � tiPn �r c! � 2rc� {�v<Se Cn�
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: � � �p�.���1'S
ONew 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:
Date: � � � ls> � IS
Certificate of Completion
�iner:
EHS/Date
Depth: `i3'
Grout: �sa�J4
�-�
DAbandonment:
Date:
Method/Nlaterials:
License #:
License #:
Date:
Additional Comments: �,►JK•,J w�•�..t.r�c�so �,,L i�s�-4 u�__
Date Sample Collected:
EHS:
Person County Environmentai Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date Results Mailed:
d��li I-ZZ-4�S'
Phone:336-597-1790 Fax:336-597-7808
11/26/13