A31 166Application Date: �l � � l��
Amount Paid: a� . c�
Receipt#: 6�,�,�
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Application for Services
(Sentic Svstems and Wells)
Services
� Improvement Permit (Site Evaluation)
5200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
Tax Map: A 3 I
Pazcel #: 1(0!0
❑ Construction Aut6orization
(Fee is dependent on the type of
❑ Permit Revision
❑ Repair of Ezisting Septic System
No Chaz�e
Important: If the injormatlon in the application for an Improvement Permit is incorrect, fa/sified, or the site is altered, t/ten the
Imnrovement Permil and the Authorization to Construct shall become invalid
1) Semces Requested by:
Name: 5 H i I I
Address: 15
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Phone #(home): q � 9' � 7� - g�o �0 8
(work/cell): 9 � 9- (01 '� - 5�/ I
2) Name and address of current owner (if different than appGcant):
Name: ' + {<S
Address:
► C 75
3) Property Description: Lot Size: .2. Subdivision:
Address and/or directions to Property- �� ke ,�i1dL�—
N�rdlv �fi lls v►��rkef. +nke nah-�
4) Proposed Use and Type of Structare:
Residential ✓ Business/Type: Other
Number of bedrooms �/ Number of people served (seats/employees):
Basement: Yes No ✓ (with plumbing: Yes No _�
Garbage disposal: Yes No ✓
�t #: a
'� � Water Supply:
Private Well ✓ (Proposed ✓ Existing _�
Community Well: Public Water System:
Are there on the adjoining properties? No �_ Yes (please show location on site plan)
Note: A completed application must also include:
➢ A pladsite plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated
I am submitting this application to request services from the Person County Health Department. 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): Date : - � O
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
APR-10-2008 10:34 AM James Hill Realty 919 479 8336 P.02
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Application Date: �D�o��O�
Amount Paid: 7 S. oc� --Fd� �"� S �Z �
Receipt#: ?,�.,-� "aq
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7� e�rn-a>>i �a-�n n n i�aa ��rn. Q-an.11 7 fH C a� �n. IL Z[:lla
Application for Services
(Sentic Svstems and Wells)
Services
� Improvearent Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
Tax Map: �' .3 �
Pazcel #: �(�
-���� ��
�EU151UiJ
❑ Construction Authorization
(Fee is deuendent on the type of sys
�Permit Revision
$75.00
❑ Repair of Egisting Septic System
No CharQe
Important: IJthe information in the application for an Improvement Permit is inconect, falsified, or the site is allered, then the
Imnrovement Permit and theAuthorization to Consttuct shall become invalid
1) Services Re uested by:
Name: m es I � �
Address: 1
_��►vl�Dr�f NC �75�a
Phone # (home�: ' � 'O ��J�
(work/cell): �) - - //
2)Name and address of cnrrent owner (if different than applicant):
Name: SQ,�"Yl�.
Address:
3) Property Description: Lot Size• nl. �i Subdivision: Gl.- Lot #:
Address and/or .; ections to Property: r � S
.�� �.�
4) Proposed Use and Type of Structnre:
Residential � Business/Type: Other
Number of bedrooms .3 / Number of people served (seats/employees):�
Basement: Yes No (w✓plumbing: Yes No _)
Garbage disposal: Yes No
� Water Supply-
Private Well � (Proposed Existing _)
Community Well: Public Water System:
Are there on the adjoining properties? No Yes
(please show location on site plan)
Note: A completed application must also include:
➢ A plat/site p[an of the property that shows property dimensions and the size and location oJall
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated
I am submitting this application to request services from the Person County Health Department. 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/Lega1 Representative): Date : � �'��U �
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Anplicant ��^�PS T� � �
Locat/i�an: v.- ! /�t ,'-1/ � -' R u., > 6-, �/�7 GLiu �. •� /c,t o�
/�l%O�.l C�T ���o� U^1�.-r �i't�3Vf �C"7U/'G� K�. .
�ffi�Di�V�El@Il� ��19IIIf
���# ��ad �ar� ��ve �� _ �o �Sa�on - .
Type of Faciliiy: 5 f D New � Ad.ditian �ate� �aa�s�ig �
## of Oc�upants Co # of Bedrooms Proje�ted Daiiy Flow ��O g.p.d. ���, I
Propos�3 Wastewater Syst�m: �Q /'a , i�- �-r G �-� �� �� ti �., Y l Type:
Proposeri Repair: _ � �-, _ o�� P ,� �R � _ . Type: `�
. �_ �
Permit Conditians: �P P S i�F' S�P�� �
Owner br Legal Regresentative Sagnature: Date:
Authorized State �Agent ,- �'�a5� �,rps�� Date: � 13/ 0 8
The issuancs of this peffiit by. the Health De}�aim�ent in does not guarantea the �ss��� of other pezmits. It is the responsi`bility of the �
appiicant/gropezty owner to in sure ti�at all Person Cannty Planning and Z�g and. Bu�ding Ivspe�ons. requirements are me� �his
�aprovement �'�ermit is snbjert tm revacation ii tlae siie plan, plat ar the intenderi use ci�anges. Tite Ixnproveme�t �'Qrmit is �ot
a�feste� by a r3iange in ownership af #he property. �"�i is �ermit was iss�� in ca�liancx.�vith the provisions of the North C�rolina
`Z�ws ar�d Rules �'or Sew�e Treui�nent a�d �isaosal Svstems' (15A 1�TC�C 1�A .1900). Yeither P�on �Connty n�r t�e
Envia-anmmaeatal �3eaith Spe�ialist' -�varrants t$�t the septic tank systeffi wslt can�tinne ta funciion satisiactorily in tiie fut�nre or'that
tlae wa#er supQiy will remain: potable. _ � - .
��at�or�ation �� Cmmstr�ct �as#�ater System (Re�n�esl f�� �iuidang �ea-�at�
* Ses site pdan and additional attachments (_�- .
Propo Wastewater System: � I`G � l�`f' Q CGPjO�(� � �e ��' Wastewater Flow �:�.d.
1�I'ew �� Repair Expansion . Soil LTA�t: �.3o � g.p.dJ $ Z �
Type of Fac�lity. � S� n Basement _ Yes No � � ,
*
. �a�i��at� Sg�tea� �.eqaa3r�naents �
i� siz�: Se�tac �ani�: f�ba g�i �am�'Ta�c: /�%�1'�l' gai Grease'���: �l� gal .
��aa��edc�• Tot:ai A,rea: �%82- sq � -Tota� ��g#la � �' o o '�t � l��nnan� �rencit �ep#� � � ' a�
�re�nc3a �Vidt� � � tl�g's�uasa Soii C�ves�: ' ' _ �- -- fm .. `` lytinim�nm �re�cii Separation: 9 it
�fist�aataon: �is�ii��aoxa ��� �Seri�l �3ista�i'i�ntaom Pressure oi1�i%id .
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�peci�tcations: �pP Si y-P S1tP�c � �, ---- ., -
. ;,
�ntdao�esl �tate �g�t ��
- Permit Ex�iration Date:
The t��pe of syst�.m permitte3 ?s
pe�mit.
s�w��rl��� ���res€��ive:
Date: Il /l3/a
C�nventional ��Ac��tea t�lternative. I ac��t the spe��ications of the
Date:
PC� rev. 11114/OS
:���,�� ��1L�V ��
``'� --- � � 1[71�T°IC�Y
��..z�-�..�,Y,.,,���.;� g-��ma�
siT� S�Tex .
Name -� ci^'� PS �� I I Ta$ Map # R�� P�xce1 # ��O �'
Subdivision Secrion/Lot# t o+ Q
n�. a�r�., _�''.-L�'" �l,�.c=e� I I/ I 3%v g'
Authorized State Agent � Date
Sy� �o„�o,� „��J�,r app,�.�„���a„�� �y The contractor murt, fTag 1he rystem�rior to
begiarning ihe installatson to insure that properaQrttde is mairdais+ed .
I�
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'w El.c.
t1�P Ef1
; So,
�
Must install septic system on contour.
Must not install septic system during wet conditions.
Septic system must maintain all proper setbacks.
Any questions call Environmental Health Dept.
336-597-1790
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�'V���, ���1V��' (1'aTe�v /�Repair�
'Tas iViap: � � � Parcel. � �o � C .t �
D
Subdivision: �,ot:
Applicant's Name: �R ^-� P s �' ��
ll�ailing Address: pp (� ��c � �
Ro��P�,b-,�t N � a�s7 �
�hone Numbers: � 19 - y- � / - � �, �� �l9 - C� � 4 - S$ I )
�acation of Property: � �� a IP � i �� S �� -� � U„ !�, � �d �
G � . �d . --� ).�'% a-: � i � �a�,f o'�' F3 j � U� � e-, ��� �rP
cL, Q�,
iDermit �onditions:
1) See attached site plan for proposed well location.
Z) All a�plicable State and County Negzrlations governing construction and setbacks appdy.�
3) Permiis expire S years from the date o, f issue.
Other Conditions/C'omments: SP Q S; f e S N��G� -
P�s�i# issued by: �'���'��"`'``'��� � �ate: � � ��8
C�R�'�'�C�'� �F' C�1VI�'L�+'I"�OI�T
New �ell �ns�ection:
EHS/Date
Location: '
Grouting:
Well Log:
Well Tag:
Purnp Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well �rSller:
Pump Installer:
�ell Approved by:
Date Sample Collected:
Person County Environmental Health
?2� S. Ylorgan St., Suite C
Roxboro, NC 3757�
Liner �spection:
EHS/Date
Installer:
Depth:
Grout:
W��1 Abandonment:
EHS/Date
Completed:
Method/Material(s): _
�icense #:
License#:
I)ate:
Date Results Vlailed: ' I
Phone: 336-�97-1790 Fax: 336-�97-7808
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