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A31 174A�plication Date: � � i�'+C` /'� Amount Paid: �.�� R�ceipt#: 3 l 0 � I ��`?_S.� ������ ��� - �'� _ � � �[ �' �� `�[° �� �E.: :�ea.wii.n: a:axaa..�raT.a.Rn-n.R;.en.11. 7�':Jra.�.rn..u.Q::.3�a. . Application for Services ���'�' 7�. Tax Map: � j Parcel #: 1 � � Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) C Mobile Home Replacement or Building Addition $150.00 (if site visit required) � ❑ Well Permit (New/Replacement) $225.00/$125.00 �ptic Systems and Wel Services Requested C Construction Authorization (Fee is dependent on the type of sy; ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System No Char�e �.C�'r Z Important: lJthe infor»:ation in t/ie applica[ion fvr an Improventent Permit is incorrect, falsified, or the site is altered, t/ien the Improvement Permit and the Authorization to Construct s/tall becnme invalid 1) Services Requested by: Name: ' �'[ �S Address: SYf'S �..w�/i .!l/�S � iCgxs«��, .vc �rs�Y Phone # (home): �3Cgi — 3(e �- Z$3S' (worlJcell): 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: /. �f Subdivision: /l�w�/� Lot #: z Address and/or directions.to Property: �s'7 5—� o� ��.�,.d� G��s C�Crra< iCel � 4) Proposed Use and Type of Structure: Residential �� Business/Type: Other Number of bedrooms -?� / Number of people served (seats/employees): Basement: Yes No (with plumliing: Yes No � Garbage disposal: Yes No 5) 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 plan of the property that shows property ctimensions 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 evaluatecf. I am sabmitting this application to request service� fpom 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): / �I Date : O � � � 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ') , �� . . �(} , \. � � �t� � V � I � � � «�.���. ���.�.�� � Building Additions/ Mobile Home Replacements T� Map #: - 3 � Parcel#: ( i[� Address: hes /67Z Approval Requested for: Mobile Home Replacement � Building Addition Applicant Name: • t,,� � T�ccl.�e�s� Address: ( o7Z �,�.,,,���,� G—��e C��.-�. �-o-t . �c�t P I�` llS /� � 5`i ( Phone #'s: ��--5�33�'�� �t Permit Located: Yes No Installation Date: 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: (Applicant's signature if site visit is not required) Comments: O r Addition/Replacem�nt Approved Enviro ental Health Specialist �—Iq—lc� Date (date) Persan County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net ConnectGIS Feature Report Page 1 of 1 � Person � Printed September 19, 2016 � See Below for Dlsdaimer � �: � t �s� � � K�,� �'"y � �` �. a � a ��za. � gw�., €.r€ a ; . J �� , � ��.: � � a '�., ? y. ` k � �. . .. . � F 2<@ f 4�#<3 Ye t r � . . �� > � � "a g" w. . - 5 � � , q � 41 . °� F �e� _ .. _ � ,� ^� r � � ::� � ; . ,`'��' +. ' ' � . .. . . . . � '� �°a � � � � a',: 4 3 . a E'i' ` - , ' � > � � a � � $ x �� . , . . . � . ,' � " f' .. . .. . . . . . _ . _ � +�, d .. � . . .. �, � . �. . �„ .... ... � � �. . s � . � . . . ��. .. . . .. � ., : .... . . ..� . . . . . �a � ,� � "� . .� . . . . . ... . .. . .. .. - � :.. . . . , . .. e '. _ 'a . '. ! � � �. r� F .� 7�%�,:r;� .�k � �.� � ... �� R ���.� .# � � '_� � �F���� ' � �s � � � �� ��F�'a �� �� � � ��� �� � � _�� � � � .� ' � ,_� �* � e� ���` �,�; � �'� �� �� Ia�,���� � ' ,��_ � � �� N � r , " ' � �_ f "» � � . � _ , � ` 2 a � . Z "" �,,_-� �:. _"— ���� . , � ��°�� _. �� � � ..� � � ���.: e � � , , � � �� � � � ° � ,� t � , � s. �. � � i �`4 � � �. <� � - .�"'i����" a���_ � � �� ; � t �- ,� , �Fk`` � ''� „ . , :� � ��. �' ��'�r � � � �� ; � -�� � y, "� � ��� � � � � , � � ��� -�r r � ° �.t x �� �� f � `� � � � . �. �`��' � '� �� ���,��,� � � � a � � � � � � ��� � < �� _ ,_ � � °d � � N a. �. $ : ���,MV.. ,� � �` ....�.�� . h ��� . x . ` . . . . � - ��� �a�� � � 1� 1. _ ( �" .�' \. F ���� . � ;; � �� � � � � _ �� ���; ' h�� F"�t � � � :�.., � � � � . NOTICE: Recently, we have had several users r'eport bio.� ser compatibillt, issues when trying to access our GIS websita Typically, the problem stems from users who hav� recently upgraded to the Windows 8 operatiny system or a new version of Intemet Explorer. We were able to resolve this issue by directing users to the Internet Explore Compatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.miuosoft.com/en-US/internet-expiorer/products/ie-9/features/compatibillty-vie. If this does not solve the problem feel free to contaa us at the number listed on our main page. Welcome to the Person County GIS Website. ConnedGlS has bee� prepared 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� notified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectGl'. assume no leqal resqonsibilitv for the information in this system. Grid is based on the NC siate plane coordinate system, 1983 NAD. http://gis.personcounty.net/ConnectGIS_v6/DownloadFile.ashx?i=_ags_map27a71 f3bac00... 9/19/2016 � ���� � � � lR /T���� V � .'11 .( � �� � ������ � 1��n.-�-��r�m �-++ -��aa�.�e.Il. I� �3L �an.IliEIl�. Applic�t �. � Location: -�� P�r�'IIit �alfd fOi ✓ i+aV Type of Faciliiy'���� # of Oc�ants Proposed Wastewater Sys Proposed Repair: �c� Pe�mit Conditions: Owner or Legal ] Authorized State Y� # T�x IV1a� � �rcel � Saibd�ivisian P�h�:Se,�S�ctian.Lo��t � �L1PiifY►CIIIBII� �B. • I+To �iiration ' e New Addition . irooms Proiected Daily Flow _ � _� . The issuancx of this permit $y the Healtii Depattm,snt in does not gvaranies the ic�„a„rt of applicant/property owner to in sure that all Person. Countp P3anning and Zomng and Bui7di �mprovement Permit is snbje�t to revocation if the site plan; �pTai''�'• the intend e c a�ected Iiy a ci�ange 3n ownership oi the prope�ty. This permit was is�uedin c.�c� Environmeatal Health Specialist war thewater suppiy will remain potable. � Authorization * See site plan and additional a#ac� propos�astewa#er System:. New Repair Exp� Type ofFacility: _,�iva�e, a the septic tank system w�31 Construct �astewater i� �-� _ . . � �� �ater Su���9 �e.�� g.p.d. Type: Type: Date: Date: Cf —/ 2 �T7 pertniis. If is the responsib�ity of the . rQections require�euts are met �Lhis �. 'i8e Improvement Permit Ls not �provisions of the Narth Carolin�, .� . Neither Person �Cnuaty.; mor="t}ie.` �� � �n satisfactonly 'vi the futnre�or�#li�f. for Building Yenmit) .��� Wastewater Flow ��.p.d. LTA�: • g.p.d1 ft 2 �eent _ Yes _ o ��1�13'@IIleDll$S 'Tank Size: Septic'Tank:' ldD� gal • —� Iaraisifieid: Total Area: �o�a sq fit To ength 3(Qa ft Trenc� Width 3 ft NYinma�m Soil Cover. �n in Distsibntion: v l�'ishl7bntion �oz Serial �istribntion Spe�ific�ations: �Ar rl�R� aliil� ��ta�h �m p S 0 State A.genL � Permit ExQiration ;al Gre�se T�: �—gal . - " 1V�a�mnffi Trencl► Dep#bt � in Minimntn 'j'regtC3i $@�IaiA1nOII: q °�. Pre�snre 19�Ianifold . Date: � f -/2.-D7 5 The type of system permittesi is Conventional ✓�c��ted Altcrnative. I accapt the specifications of the P�• � �e�/���i �a�aa�s��at�tflve: Date: ' PCffi� rev. 11I10I05... , .. . . . � � ��: � _ :�:�.- ... j�� .� . .. .�:: .�Y . . ., :i ' < • ' ~A��� +� -�� p` ' -.�•�+l ����y''$n'lij�L'{^ � ��.•b+v �� • •v;TST^—�yi;•'n'� w�•v..+v,� %� 1 <n ,A .• hi+{. i•.....�i�!... R."� $ �4w^^�[�.r•i!���r�(1^r�.��•��-���—,�•�� � ��'�rs�'ir„<,y...�.,,,�'�=g,�"`,`���. ��� ��.c �+- '+7L:.�3�L;1�C'� : Oi9.i1LJHJ �Y'iifLYi.iY � . ' ��t�.'1t�l�1Q� •�a••'•• i�Jf. 8Y1� �u'rr�iY ��� 17HS1G M•E41��q% S v � Taa 1l�p 31 Parcxl # 17�, T'ownship: . � Applican� he � � Subdivi�ion: Lot # _ . . I.00a�IOIL' �S7 �� d n ��%u� ovl � r e�K it.%t.. —} � f bSS q �-t� C e. /e� bh � t �('S'� �Q r✓% � � � �0 . � � � • • '�1B ��S$Cfl''��1�: V lII�.VldURl _ � �111C. .�e��rt ` Sito Approved By: �rro�ng A�paroved By: . Woll Lo� • . � T�. - -= Wall Ta� � ' Air�T� ' . Hoee Bib= • . . Ca�g Heig� Cn�rsate 31ab: . � . . �� Lil11G�. .. Well A�pmved by: ' . *'�*�ee �tt�ed S�te S�'k*�* . Lin�: � . -. 7nstallod by: . Degth set . . c�a: Da#e: ' ' • 0 watea Sampie: � Wol]s mnst be 10 feet finm p�operty lines. Wella muat be 1�0 fe�t fmm �ptic syst�ma � '�Tells muet�be at.l�st 2S f�t�from� any buiiding £ounda�an.. Dat�:. - , . Other canditians• 0 PC� rev 01127I04 , . •�1��, �� �1S.B�0J �� ' `�./ � 'v l �7 �� �lmvd]t`�7L71.7c33�O701."�.�A.L. ��p��Ilg . SITE SB�TCH � .� . Name � PkQ � Taz Map #- ��,Pa�:cel # Sub ' on . 17� . Section/Lot# . � _ 2—a . . Authorized Staxe Agent . • Date . System componessts rrepsie.rent a�C,prna�imate�contours o�ly.' The contractor mr�stflag the system�tirior to be,ginning the instal&xtion to i�sa�re that pro�iergrrtde is mai�taiued 1 � � , �M 146 �2 � � ,a� S �� a � �h Y , •3t�c� g.P� �3 b� � • 3�, ` �ccGp� r 1�� � `�� �i �D _ �2" ,ken�h � �P(ate t�" soiL co�ec o�e�r �o� 5 YS�r�1 ° .,�,v�°��� I S _. ,. Sc�� . i = �o' N�. � _ . ��o.a ,-- 0 � 3� ��. � 1q.g.8