A30 48The District I�ealth Deparfinenf
Orange, Persoa, Caswell,'Chatham, Lee Counties
SEPTIC TANK PERMIT
-�,1 �-- �7 �-
,�„ �, /�,�� � at
-,� �.�,��
Name of owYier: � `� ��
Name of contractor:
Addre �s *and�iDirec� ns
Person or firm doing installation: .�.1���_��( ('� %�I `—T�}'� �? �'�"�T -'•� �
Address � T;� �i/ 1'� j C��,^st'� �'�;_ ���__- i
�
No. of persons to be served Bedrooms 1, 2,Q4.
Additional appliances to be used: Disposal, dishwasher, washing
,.�..
machine
Recommended: Septic ta � a��� I•
Nitrification line: �;� ( '� I , � � �
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspecied and
approved bp a member of the Disfrict Health Department s2aff before
any portion of the installation is covered.
Date Approved: �--,�'?i ���
By:
Signe�
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
�NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on �
adjacent property, etc. Write in measurements in order that installations may be located at later
date. -
SUGGESTED INSTALLATION (Date ) FINAL INSTAI,LATION (Date )
(Road or street) , � (F.oad or Street)
I i I I i I I I,I I I I I I I i i I I I I I I I I
, � }
�
�_
�� �
-� � d���� .
� Fo�, �1�
�'� G
Application Date: r�' '� ��� S� ������ Taa Map: '10
Amount Paid: ��, on `...�."�l. ����.�,�. Parcel#: �
Receipt #: —( �(�=�
IEuavnroaaa�ncaa�mfl IHComIl¢Iln
Application for Services
Services Re uested
❑ Improvement Pcrmit (Site E�•aluation) ❑ Constivction Autl�orization
$200.00/$300_00 (if > 600 Dpd) (Fee is de ndeut ou the n• e of s�stem ermitled)
biobile Home Replaceinent or Building Addition ❑ Permit Revision
$1�0.00 (if site �•isit required) $7�.00
❑ Wcll Permit (New/ReplacemcntBepair) ❑ Rcpair of Eaisting Septic S��stem
$300.00/$2U0.00/$7�.00 A licatiou: No Char e/ CA $1�0.00 or $300.00
L� �'
1) Applicant Information: / �-- �i
Nacne: �Q- � PirC Phone (home�� b� 7�� � 1� ��
Address: («-ork/cell):
2) Naine and address of current owner (if different than applicant):
Name: Phone:
Address:
3) Property Description: Lot Size: Subdivision:
g� res and/or directions to Property: ~
` -K oX� ��� N� .�—�S� y
Lot #:
O yes YI'no Does the site contain an�� jdrisdiciional tcetlands?
��es ❑ no Does the sile contain au�� existing ��aste�cater systems?
� yes ❑ no Is any w�aste��atcr going to be generated on the site other tl�an domestic se�cage?
�cs ❑ no Is die site subject to appro��al by any oQier public agency?
❑ ycs aho Are there any easements or right of �vays on tlus property?
(if `y�es' is checked, please pro��ide supporting documentation)
4) Proposed Use and Type of Structure:
❑Rccidcntial
8'Ne«� Suigle Fanuly Residence Makimum number of bedrooms: �/ Occupants: �_ /
❑ E�pansion of Etisting System If e�-pansion: Current number of be ooms: ��g�t�O �, ��� T
❑ Repair to Malfunctioning System Will d�ere be a basement? ❑ yes ❑ no Wiili�bing ii�tures? ❑ yes ❑ no
❑Non-Residcnti�t
T}�pe of business:
M�,umum number of employ ees:
Total Square footaDe of Building:
M:u:imum number of scats:
5) Water Supply: ❑ Ne�v ���ell Id E�istin� Well ❑ Community Well 0 Public Wat�e. ❑ Spring
Are there airy eaistuig ���ells, spiuigs, or existing �vaterlines on dus propert}-? ��es � Iio
Please note any kno�r•n ground water restrictioi�s or sources of cont:unination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Con�•entional ❑ Accepted 0 Inno�-ati�•e ❑ Alternatit-e ❑ Other ❑�'
I certify that t1�e infornzation provzded above is complete and correct. I also understanc� that if the information provided is
inacca�rate, the site is saibsequently altered, or t1�e intended a�se clzanges, all per»aits and approvals slzall be invalid.
Signatui•e (O�r-ner/ Le�al Representati�'e*)
* Supporting documentation required.
�-i-� 4�
Date
Percnits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
!) ' �� � � '
.
, \, �
� �t� � \ � I � � �
�-���..,I 1__I�-,:�I� I,
Building Additions/ Mobile Home Replacements
Tax Map #: .�%' �? Pazcel#: � Address: �rLZ �J6 �{-�tf' �'1%fN' eP77 —
Approval Requested for:
Applicant Name: _
Address:
Phon� #'s•
Permit Located:
Installation Date:
✓ Mobile Home Replacement
_ Building Addition
Yes � No
Design flow: (gpd)
Current Contract with Certified Operator on file (if required): �_
Water Supply: _� Well Public or Community
Wastewater system shows no visual evidence of failure on: ____s�`""*'�(�_ (date)
(Applicant's signature if site visit is not required)
Addition/Replacement Approved
Enviro ent 1 H h Specialist
5 f
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-59?-1790/ Fax: 336-597-7808 www.personcount, .�net
ConnectGIS Feature Report
� � — � � �i
:i�8 H�;in•dC.
�y � ,
'.� � +�' 1!(/:�P(���� d�'�r i�i� J�. ,
P i
Person County Environmen#al Health 1'age 1 of 1
325 S. Morgan S�eet
�'KII�{AAV� IR/ GI� Person
Printed May 11, 2016
See Below for Disclaimer
. ' �� M�P: ,� 3� - ��
/foT��y � • /✓o � ✓1 i,���✓�i �<°' �`�'�����.,� 0 5�o/i�
, �fi�t/i�cf� ?'/1/IG�/C o✓E-�, hf��y ,�Lt,�
• R�co�f���✓a ,�r.�u�O�,fg
2 !YV
�t� �r✓����/� �orrc '{� �
Tf� T/�I �" �J's>,��t1 �v��iG Con�is+/v�
,�O��s� .
/ ��c '� ' �
"—�-�._���-, Q, J'l,/� �
-__�.�,;
b�1'b � �
.z2 �
�! 1
��
.4�� t�
�R
� (%i.�
� 'i/
s-T-� �
�,Na ►P,,,.
� 5�p�� �
�� � �
1 � � �1 r:
'�: ` � `
�
� �
ti
-�_--_ —�'
`'-.
,
�
653�
.;
!��1 2
� � � c:,-t-s 0.1 r.�
� � `�'� +-.- . � �
+'
E
T�tal Lennth: i 5�. i Feet
9 i �.46 S�. Feet
a r.02 .:�cres
�r Sq. h.9ile�
�� 50 Feet
�TICE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who ha�
cently upgraded to the Windows 8 operating system or a new version of Internet Explorer. We were able to resolve this issue by directing users to the internet Explor
�mpatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.<om/emUS/internet-explorer/products/ie-9/features/compatibility-vie
this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnedGlS has be�
epared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system a
>tified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectG
sume no leqal responsibilitY for the information in this system. Grid is based on the NC state plane coordinate rystem, 1983 NAD.
http://gis.personcounty.i�et/Conn:.ct�iS_v6/DownloadFile.asl�x?i—_ags_map�e�e4fE78?78... �/11/�C16