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A31 128Amount Paid: ~�vo2�� � Receipt#: s 3 0 i ax Map: �' 3 i Parcei #: i � �.-'}� 7 �--�-�,`� � ..�" . ��I�'�.� �� �G � 1 r.. �```�_ � � �tc.r���. �r� � .��'-�!.r.:['{l. S"T. ]L: .C:D.IIT.:]tZT..�L�'! 1[']L.'Q:..LR.A1 �L. �� �i:^.•.LR.��.'lt..:�Z1. 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) � `���� ��I ���� � -� �' � � _.� � ���� � �a:n.���o-R-� nTM-+ ���:�.� I�-���:Il.� 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 � ���'?, �� �Jl.e�� �� "'- ����� ]� 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 �d ma-�-��C�r� � �i-%QC�S � ��� �- u-,s�o.\\ �s-}em a-� Ca��� , �`, r �� �;;_.� � � �- i.�-,�q\\ S�S� i..r� � . ,� �, - J ' �,�?4 �.' � � L��- G.`x�c���� �S , �+• � •, �,� �� '' � �� aues-l; a-,s �; �� �.'�'�"'�'-�':� . ;.-:� c..�-�-4ac� Cn� � . � ��,179� . ,� ,�- �t;., �,:� , :,:, s :i n�-�i QD -------� 31�d 3�0�a� G-r7�R tl3(n �',�- o� C�V. �� ►�,�, -}-rerach c�� � a� ► . ��eh�i�r� S��- � �' �� � i ' • . ���.:'�`' �.:::..�.�.:..: •. .:� . �,. • '�: ..i�� .�.: :`:�'��.� . . . . . ..� a:• .,�:. .. . ... ����� '�!�y .•' :.:.;.' -. : : :'•:�%�:.�,'•�• . . T �•� •� �.3K��T,+�7T,:'7Z,^.,4�?�.1°'^' M1�'�,.°"^:�SC�7. 349:.'�'..aSI:�:LL'�;'�?.�}t3L.11:�'�� -. 'VW��� %",��n�l7Y.fiS - �]L��� S�E A��i��E�D �L�t �41R ���, �g� �����J�' 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