A31 188Application Date: � �—,zoo8 Tax Map: ;�_��
Amount Paid: Parcel #: a a
Receipt#:
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Application for Services
(Sentic Svstems and Welis)
�I'Tmprovement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
0 Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
� Well Permit (New/Replacement)
$225.00/$125.00
Services Re uested
❑ Construction Authorization
(Fee is dependent on the type of sys
❑ Permit Revision
$75.00
� Repair of Existing Septic System
No Charee
Important: If the information in t/:e applicativn for mt Improvement Permit is incorrect, falsified, or the sile is alte�ed, then tl:e
Improvement Permit and the Authorization to Construct sl:a[1 becon:e invalid
1) Services Requested by:
Name: _���-� �. �J �� Phone # (home):
Address: �,(� , j�� t g73 (work/cell): �3� -�SFC - r� o y�
�I(�xr��a , ti1�C • 27'� 73
2)Name and address of current owner (if different than applicant): �Q� ��
Name: A P��E S `� � ac,V0.r�C�e
Address: { (S (-i�-� � ���
e. Ils �J - . 75�1
3) Property Description: Lot Size: �� �t,f�S Subdivision:
Address and/or directions to Property:
Lot #:
4) Proposed Use and Type of Structure:
Residentiai � Business/Type: Other
Number of bedro ms �- _/ Number of people served (seats/employees):
Basement: Yes �No _(wtth plumbing: Yes _ No � Garbage disposal: Yes _ No ✓
Approximate size of building foundation: Length Width
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 completed aunlication must also include:
➢ A plat/site plan of tlze property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifying tliat 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: r3'���"�
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applican�
Location:
. �
T�x M�p ' Paxcei # ` •
Subdivision
Ph�se Sect�ion Lot �
�ermit Valid for V �ive YE
Type ofFacility: ��J4�
Improvement �ermit
l�To Egpiration
# of Occupants �� # of Bedrooms
Proposed Wastewater System: ��'q'�"'"`
Proposed Repair: ��,���%
Pernut Conditions:
Owner or Legal Representati
Authorized State Agent/
New �Addition
ed Dailv Flow �8'D
Water Supply W 1�
g.p.d.
Type: I�-
Type:
Date:
Date: -- Z- �
The issuance of this permit by the Health Department in does not guarantee the issuance of other pemuts. It is the responsibility of the
applicant/properiy owner to in sure that all Person County Planning and Zoni.ng and Building Inspections requirements aze 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
`.�aws and Ru[es for Sewa�e Treatrnent and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
�nvironmental �ealth Specialist warrants that the septic tank system will continue to function sausfactorily in the future or that
the water supply will remain potable. •
Aut�orization �o Consi�uc�i L�asteyvater Systean (�equired for Building Pe�mit)
* See site plan and additional attachments (_�.
Propose�Jd�astewater System:Q � (-�iae•�nr �jo�n r.PZ�iG�TyPe� Wastewater Flow 8d .p.d.
New '� Repa�}�r Expansi n Soil LT ��S g.p.d./ ft 2
Type of Facility: Yr�v �Q�j� �P Basement _ Yes _ No
�Yastewat�r System �tequirements
Tank Size: Septic Tank: D00 gal Pump 'I'ank: ----gal Grease Trap:—gal
�rainfield: Total Area: J�(�O sq ft Total Length g0 ft Maximum Tranch Depth �� in
Trench Width .3 1Vlinimum Soil Cover: (,Q in Manimum Trench Separation: �� it
Distribution: ✓ Distribution Box �/ Serial Distribution Pressure Pvlanifold
5pecifications: I� _
Authorized State A�
Permit
The type of system permitted is
permit.
�3wner/i.eg�l Repr�sentative:
Date:
0
Conventional " Accepted
Date: ,le 'Z �4�
Alternative. I accept the specifications of the
Date:
PCHD rev. 11/10/OS
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SITE S�TCH
Name i� a, C;�/Q Ta.g Map # 3 �� Pa:i:cel �� g�'
Subdivis' _ � Section/Lot#
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uthorized State Agent . � Date
System cvmponent.r r�e, prese�rt u�iproximate�contours os�ly: The coniractor mustflag the systesr� prior to
beginning the instal�atian to i�sure thatpro�iergmde rs nruintained �
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Tax Map .A 3 � Parcel #�$� Township: .
Applicanf: � �
Subdivision:
Location:�
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Lot #
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�i�iDl�'�ffieHd�:
Site Approved By:
Grouting Approved By �
Well Log: �
Pump Tag: �
Wei1 Tag '
Air Vent: � �
Hoae Bib: �
Casing Heigh� �
Concrete Slab: � � ' �
Well Driller:
Well Approved by:
����Se�.A�e�aed �ite 3�e#c�a�p��
Linez:
'Installed by:
Depth set: _
Grouted:
Date;
Water Sample:
Wells musi be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be �t least 25 fe�t from any building foundation.
Other canditiens:
Date:,
�CHD rev 01!27/Q�