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/�"J / Person Cauniv Health Deaartment .
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' � � ' APP_L lCAT10N Ft�i SEit1/ICS
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Dir+ectlons io ihe pnoo�qr � t�d nsn�ee acxintunbas�: �i c�•
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4) Pt+op�d Uw and Shw�iae Descriptbn: ainsuw� �c}t of the folioxdn9 �
� � ProPaaed'�6ddin9 �
b} Slidc Buit Q Moduiat 4�b �de 4 Dau�e Wlds 11'�
c) Mtur�her of Bed�ornx .3 • • � Nwnbet of acxx�pants ar pwple bo he setve�
e) 8asement Yes 4 No �}Fyes, � of base�rrt fldurex
n ��Yas4No�-
gj D6ner�dons af Prnpoaed S6lxxure: VlRdtt� Dopih: .
��' �Nfl TYPa Prlvate �(new � ar eod�n9 �, � 0.�Y 4 SprinA a
• � Ara any we8a cn a�oine�g p�opaKy? Y� ❑ No � Ifyes. locatlon
�� Indip�a D�irsd Sy�m TjiPe� (sY�s can bs ranioed in ortler of Y� P�'��l
� Canv�Wond 2 Ab�#i�d Comr�tlana! ,� Atbansativa �nova�tive
S Dttw' (�P�►l:
' CLFARL.Y STAI� ALL CORNEii3 AND LWES OF THE PROP�R7Y.
9TAKE THE CORNEiiS GE ALL PROP03m STR�JCTURES.
PL.FASE ATtACH SURVEY PLAT CR 31TE PUW TO TH19 APPl1CATION
! h�eby msice �n• to the Pe�son� Caunty hl�ttt Department tor a s�e avaivaibor� far thn oR-a�e sew�e dtapos�ai sSiatem %�'
tlte above-dea�bed propedy. f agt+ee Uts�t the � af this appdc.�ion ats true and re�resetrt the ma�n�an f�r� to be
Risced an 1fie properiy. I understand if itte siba ia aiEeted or the in�r►ded use ct�artges. �s pen�it shsil bacome inu�d. i tuu�taitd�
thffi as appNc�rt, 1 am �na�bie for i�g and meridn9 P�P�Y �. comers and meidng the �e aa�b� fior the
P�nnei of the Person Caunty Heatth DeQsrane� io canduct fheir avaiva�ona I�d it�t i a�n respo�ie for natliyut9 the
HeeQh Departme�rt if mY ProP�Y � �Y �$ � ��d bY � �Y � � � . .
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Applicant:
Location:
/ �
Ta�x ����� �
S�u h c1!i,vli_s�i,o n
•
Parcel #
Ph�a,s,eiSect�ion1Lo�t ??
Improvement Permit
Permit Valid for � Five Y rs _ No Ezpiration � •
Type of Facility: �$� �� � New Addihon Water Supply '��
# of Occupants � k # o B ooms Projected Daily Flow '3� g.p.d. � �
Proposed Wastewater ystem: �J � � . Type: Q
Proposed Repair: C�t� l/`, TYPe' -�_
Permit Conditions: '�Q�2 s��1'�C ��s�P�
Owner or Legal Representative i
Authorized State Agent:
Date: � ��"%1�OG
Date: '$'-v
The issuance of this permit by the Health Department in does not guarantee the issuance of other pe2mits. It is the responsibility of the
applicant/property owner to in sure 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 Permit 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 and
Rules for Sewage Treahnent and Disposal Systems' (15A NCAC 18A .1900). 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 wi71 remain
potable.
Autho.rization to Construct Wastewater System �Required for Building Permit)
* See siie plan and additional attachments (_�.
Proposed Wastewater System: LQ�i 1J�✓�i`� S�i � Type �� Wastewater Flow �.p.d.
New � Repair Expansion _ Soil LTAR: � � g.p.d./ ft 2
Type of Facility: �j � �P�, Basement Yes yCNo
Wastewater System Requirements
Size: Septic Tank: _� gal Pump Tank: gal Grease Trap: gal
field: Tota1 Area: j%��p sq ft Total Length �� ft Mazimum Trench Depth � in
�h Width � ft Minimum Soil Cover: � in Minimum Trench Separation: � ft D� L.
Specifications:
h� Distnbution Box
��,
Authorized 5tate Agent: __d���
Permit Exnira on Date:
')'L Serial Distribution
Ser,�,L r s ��
�
Pressure Manifold
�L:�
Date: � ���
The type of system permitted. is �--Conventional Innovative Altemative. I accept the specifications of
the pernait. � _ '
Owner/Legal Representative: Date: S/�'- � D a�
PCHD7/30/2002
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N�ame ` � � � � � �'� lYla # �t? Parcel # q �
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Subdivisi � Section/Lot#
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Authorized Sta.te .Agent � Date .
�� System com�ionents reprnessent a�i�broacimate �cont�ours. only. The contractor must, flag the system prior to
beginning the is�stallatwn to insure that propergmde is maintained .:
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Scale: �
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WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Taac Map 1�"�� ar el #
Applicant:
Subdivision:
Township:
Lot #
Type of Water Supply: � Individual _ Community Public
Ytequirements:
Site Approved By: �/l� � � ~ � m `�
Grouting Approved By: /�� � ` � o�
We11 Log: � h -�',-�-P
Pump Tag:
Well Tag:
Air Vent: �
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller: ���.,�,, (..��1
Well Approved by:
****See Attached Site Sketch****
Liner:
Installed by:
Depth set: _
Grouted• _
Date:
Water Sample:
,rl
Wells must be 10 feet from property lines. .
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:.
PCHD rev O1/27/04
06/09/2004 07:43 4773708
HUDSON WELL CO
PAGE 01
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own�; Q,1 ; Z� Tax Msp 3� Pairca►t #�
Lac�ion: � , r
Subdivisinn: Lot �
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'VVelt C
.Diatsace k'rom n�xrost Propaty i.iue (Minimt�d� 10 foat) / 4
Dist�wca from Septic Syatem (Mini�vaum �4 faet}
Totai �cpt�: �� ft Yi�ld: C3PM 3tatic atet L�va�: �_ $
water Seariu� 2oaos: Dc�lt Ip f} �$� g� g
c'�.in�: 6b 5
Dr.ptb: �ram �� ta ti. Di.�aae�er: �A� ia
Type: Gatvaui�od Ste�1
wq,gh� �. o!k�$ -Tiu� , 0 6 H�ight abov� c�tauad: 1� in
�hivc Shoe: '�'"Yes � No Auy ptabletns �cattatand whila aetting caaing? Yrs `�No
I�"yes" give reasan:
CraAt: .
Neat: Seu1d/Cem�at ,,,� j,� Canare� Crr�vc�lCa�ent
Ac�n'War �pacc Width ,�--,,., inchas Viiatar in Atmul� Spaae Yaa �Na
Medu�d of Groc� Pumpod Frtasut�e �_._ Poured � Dapth �_ to —�v F�
_'vs�teri�N� U�ed:
No. B� �'oitland ce�uent �_ Waight of 1,8a� � Pnuada
If m�cture (��trrel, ca�itiaBs) �- R�tia �. to �
� ID plat�a: ve No 4 a 4 slab ,�, Yae tf�io
prIIlia� Lo� Locstba 1'�r�.vinQ
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I brreby cerdfy that rho abova infarrnation i� corrcct and ti:et this wel] waY eor�structtd in accordance w7t�t regutation�
set forth by tha Pa�on Coumy He,sttb De�rtmeak
si�tt.:-� of Cvatx��tor �QJ211 U ID �# ��o Dste �� �'
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Suf�d!i�`�i�5�ion
�P�h:a�se Sectior�`Lot r
Applicar� �� _ ��- �f� . . .
Loca�on: s � /a�}.�-, � ���- � s � �
. . O-perattoii: Perrni$ . -
�-
System Type (In Accordance With Table Va): -(.-� � �
THIS SYSTEM HAS BE�N IN�TALLED � IN COMPLIAPICE WITH APPLICABLE NORTH
� CAROLINA GENERAL STATUTES, RULES .FOt� .SEWAGE �:TREATMENT ANQ �DISPOSAL,
- AND- ALL CONDITIONS OF THE IMPROVEMENT ' PEftMiT .AND CONSTRUCTION
AUTHOI�IZATION. . . . . _ . . � . � .. .. . . . - .. .
� ' �� . .... .. _ . � ..1.� q_o� . .. � . ..
Authorize S te �Age fi . - � � . . � .. � � � � � Date � - � � -
Installed By: �� : �S . .. Date: / - �= 05 � � �
..� ._. . . � � - •.... . � . _� _. ._. . _ . . � . . . .
PCHD, rev. 07/29/02
Application Date: ti"�= �
Amount Paid: `� ►�O'�C'
Receipt #: 1 j35�
C:�'t'�� : o1Q►��4
Ao�
Improvement Permit (Site Evaluation)
$200.00/$300.00 if > 600 d
Mobile Home Replacement o uilding ,
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
'`—.�. ; ; ,Jr„ �11d��'V'1 � Tax Map: �:3�
Y ������ Parcel#: �
IF1:.innwna-annnuarnz.nn�mIl �I'�Lr.ra.�d�in
tion for Services
Services Re uested
Construction Authorization
ee is de endent on the e of s stem ermitted
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Chazge/ CA $150.00 or $300.00
1) Applicant I rmati n: �
Name:
Addres .
�
2) Name and address o current owner (if 'ffgrent th n applicant):
Name: /I,,c/ `
Address:
S
3) Property Description: Lot Size: �., 3.� Subdivision:
Address and/or directions to Property:
Phone (home): 1'l�'— If 7 �%�" �lvl��
(work/cell):
Phone:���/�. '17-- 1 � � �
Lot #:
❑ yes � no Does the site contain any jurisdictional wetlands?
�yes ❑ no Does the site contain any existing wastewater systems?
❑ yes 0 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 Ja'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 Structure:
❑ esidential
New Single Family Residence Maximum number of bedrooms: Z-
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes C'fno With plumbing fixtures? ❑ yes �'no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Ma�cimum 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
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, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�ignature (Owner/ Legal Represer
* Supporting documentation required.
�� l �- �.61�
Date
Permits are valid for either 60 months or are non-espiring when accompanied by an approved piat.
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 Ivlap #: �� Parcel#: �1'} Address: Q.r�, �
' �F����lec -to �'X bb8`1
Approval Requested ior: 1Vlobile Home Replacement
�_ Building Addition
Applicant Name: �a A4s1�.�r w,�rc��
Address: �p1a. C�v-;��azJ '�ofa4
IZo�t�.'thv�Cc �tJG �`1S'13-
Phone #'s: y1q - �} �I �1-1b�3
Permii Located: x Yes No
Installaiion Bate: I- y- 05 Design flow: 3b0 (gpd)
Current Contract with Certified Operator on file (if required): t� � .
Water �upply: � Well i'ublic or Community
Wastewa#er system shows no visual evidence of failure on: 1- lb-1� (date)
(Applicant's signature if site visit is not required)
Comments: '�•f�.�.. i�� c��►rc +"�'c cNhPv�.'cF0 l�► �c►it. "r� ►ss��r�C. O�-
C. O. `"� clt' � 1`.s r1�r i'O t�Q �: P�'�x`t S�c� "�i�o
V�a,�..v.�c� '►� s,�,.�.�vG �5 �c �ri-� s�,-v�� car.o�,�S � ar �y.sr
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Environmental �iealth Sneciaiist
1
I•��-15
Date
PPYson Coun�i Env:ronm�:�tai :�eaith; 3�5 3. tiiorQan St., Suite C; RoYbaro, NC 2 i�� 3
Fhcne: :,�6-597-??9C/ ra;:: ���5-�9"-iSO� � �v�:,•��i.�,ersoncoun�tv.i,e�
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SITE PI.AN
Name �� A- 1����� Tax Map #� Parcel # 9�
Subdivision Secrion/Lot#
��wu� a. s�+;� �-ao-�s
Authorized State Agent Date
System compoaents represmr approxrmate contours only. The conuacrormustflag the sysrem pdor to begianing the installadon to
insure thatpropergradeismarntained.
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