A31 128Amount Paid: ~�vo2�� �
Receipt#: s 3 0
i ax Map: �' 3 i
Parcei #: i �
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Application for Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$ l 50.00 (if site visit required)
1.7 Well Permit (New/Replacement)
$225.00/$125.00
�ptic Systems and Wells
�ervices Requested
❑ Construction Autltorization
(Fee is dependent on the type of sy:
L Permit Revision
$75.00
❑ Repair of Existing Septic System
� No Charee
Important: If the if:forrnation in tlie applicatiott for an Improvement Pertnit is incorrecl, falsified, or the site is altered, t/:en 1he
bnprovement Permit anrl the Autl:orization ta Cvnstruct sl:all become invali�l
1) Services Requested by:
Name: E,' p r e �1r'o�'� S
Address: �� � 'R � �.�-� 5 f ,
�oXbo r� �J�, �—� �"7 3
Phoaie # (home): 3�i0-5�7 - y SR$
(work/cell): � I c�- c� S�-�-� S
2)Name and address of currenf owner (if different than applicant):
Name:
Address; - �
_ w; Id
3) Property Description: Lot Size:o� .) $�} Subdivision: �}1'q,�i' �e.IdS Lot #: �_
Address and/or directions to Properiy: e n �� ,�,.�
er� t � hem,� p r i►�� s
,., - -
4) Proposed Use a d 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 ✓
Appro�imate size of building foundation: I,engih VVidth
5) 'Water 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 application rrYust also ifzclude•
➢ A platlsite plan of the property that shows prvperty dimensio�zs and t{ze size and locatioft of all
proposed structures.
➢ A signed copy of tlze `Lot Preparation' for�a verifying that tlze property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Departmeni, The information
provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become
invalid.
Signature (Owner/Legal Representative): .f-��'=,{/1 �� I)ate: � O
11107 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applican� �
Locati6n: �
Talx Eiir ;� � �r�"'e'� i' � �
Su,'� diie��i�s�i.a�n . �.0 . ..
P�h a s�e'S cct;i a:«:�L��t �
.,:� . . .. ..� • �- �
� � Ian�Qruve�ent ��rmit � . _
�'�rffiai 'i�alid for �, �ve =I� I�'o� �iration ' `. .
Type ofFac�ity: .��r-nLQ �,;�L�, c��.�11 in� �%w�Additian_ �ater. S��piy t.��ll
# of Oc�auts ,�;� # of B�rirooms 3 Projected Daily Flow �_ g�,d. ._
Propose� Wastewater System: Type' �'�
Proposeti Re�air. .c-c�� p n�; �� Type" :�- a..
' :�ru� • � a � ► � • � ..' � I_'1
Owner or Lega1 Regresentative Sigaa�ure• Date:
Authorized siate Agen� `�, � 9 � � � Date- ��l � g I ��
The issuance of this pemut by the Healti� Depar�eat � does not guar�ea the ;��,�*+�s af other permits. It is the responsib�ity of the
��aP�Y owaer to in sure that a11 Person County Pla�ing and Zomng and Bwldmg InsPections re4ui�emen�. a=e met. Ti�is
improv�me�t P�ermit is snbject to rev�cation if the site. p1aM Plat or t�e intended vse chamges. The �mprovement'Permit is. �not
:_�•....� a$esteti 3ip a c�ange in o�avnershig:o�th��roperiy. This�pes�mitwss�issued in_eomplianca wit�t the prn�sians oithe.No�#3�ar.alina •
�:�;:;>: �Zasus�,:'aad .ttul�s far Ses++ii�'_.T.reutnc;eri�r:umd'�.�isnosal ,Svstelns __�35A. Pt+��::-18A�� :19Q0). Neither P�rsuu'��oun�.nao��he;,�;�
��^�nx�mcutal �ealt�s9 - , . . septic ta�k.sysiQm. 'ctimn'sa�fac#oa-�'i�t � .
��Yl��G1.gW�� lrLi.�,.i�'.�n.'.�0�6tliG:.' ..._......��.��� _ .,.. � ' _ . ;r:.�,_...:eV:i_�.,�.. _ - ' ' _ __ .s__ . �...'�'. �.'�,:.�'�G.c.y",mr �'�`
:i-'r4,�,y,p�'.� ^`-"'�j •�2= � �.'���1Og37.."1ttQII1 �O L`'OII3�7i[C� '�`�19't�'FV'�3' .5'�►S�'�' 1 �"`i""�"""�1•"�lIIg ��llt��� . ��.- �y .T:�
� .x,�, .. L.•�<:iJ. -
. � * See� sife Flan arid additional attachments (� j. . , . - ' . . . . ._. ��
Proposed Wastewater System: i^r��lP �1; �-�n!rnX • Type �o` Wastetivater Flow �b �-p.d.
- � . New cL ' Repair_ F.xpansion � 3oil �AYt: , �5� g.p.dJ � 2
� Type of Fac�lity: Bascment _ Yes �`No .
�aste�va#e�- Syste� �es���anes�ts�
'�at� Size: Se�ic '�am.�C:� l oc �n gai Fnmp �ank: `— ga1 G�ease Trap: � g�il
Dr�imfie$d: Tot�l �rea: ;� 13e�8-�� ft Total I.ength �� 3(��_ it � 11�aaiffi� 'Prenc� De�i�a � a�
__ - _ . �
�re�c3� ��Vidt� �_ ft il�I'�am.n� So�1 Cover: _�_, �a �u� '�ench Separalaon: 9 it
�istribnt�on: D�striiDutio� �oa � Se�ial �istn'ibution 7Pressuae 1Nia�a%ld
� :..� , «� , � � . ._ _ � � �. �•�'1��'1R�GGTi�i+ �` 1�►.TuTi_ '�i3'li �:����:
�ntlaoa�izeai S$ate A��n� ' �t�`�A� �. c �t��l— -
Pezmit Expivation �ate: S -�
The type of system permittes3 is � Conven.tional
P��
i�w�c�l�.���i ��a�sE�tave:
Date:
Acc�ted �Iteraa.tive. I acc�t +he specifis�tions of the
Daie:
pCFD rev. 1U10lOS
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I� ��na-��.��,�,��.71. 1F-3L�.�:Il�76s.
SITE PLAN
Name r� C'�Q1�5 Tax Map #%� � Parcel # IaR
S divisio� S�^� W ��e�s Secrion/Lot# �
�S� � 51 \� 1�-�8
<�uthorized State Agent Date
System componeats tepresent approadmate contorus only. The conrracto�musr tlag t6e system pdor to begianing the instnllarion to
insure zhat pmpergrade is maintaiaed
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a-� Ca���
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Tax Map 31 Parc$1 # la� Tov�rnslup:
Applicant• C'--�et�o.e �vG.ns
Subdivision: , \ ` Lot #
Location: 4 S L �' �.�.
_ -� l � �- �r
�y�� of ��te�- �aappfly: �C Individual
�ea�uire�ae��:
Site Approved By:
Grouting Approved By:
Well Log:
Pump Tag:
Well Tag:
Air Vent: �
Hose Bib:
�Casing Height•
Concrete S1ab: �
Well Dri11er:
Well Approved by:
��*��ee �ttac��d Si�e S�e$c� :�::*
Community Public
Liner:
�Installed by: _
Depth set: _
�routed:
�ate;
Wa#er �ample:
Wells must be 10 feet from property lines. �
� Wells must be 100 feet from septic systems.
Wells must be at Ieast 25 feet from any building foundation.
Other canditions:
Date:.
P�HD r�v Ol!2710a