Loading...
A31 189Application Date: 10 O� �� , Amou�t Paid: a-vo, o p.�„- Z P .> Receipt#: ^�?� 7 � 9 ��� S� ���.� �� _._._. : - - j.-.. � � � ��(�� 7l_�sllTd]l4�QD]['71.]t7L"LQ7]ta.1LdR�� �`�� Q3�.�'.l[:��� Application for Services (Sentic Svstems and Wells) Services �Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Aome Replacement or Building Addition $I50.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Tax Map: A 3 ! Parcel #: �� ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision ❑ Repair of Existing Septic System No CharQe Important: If the information in the application jar an Improvement Permit is incorrect, facs j',ed, or the sile is a/lered, then the ImnrovementPermit and theAuthorization to Consiruct shall become invalid 1) Services Re uested by: Name: � 1 � Address: � 7 Phone # (home): � � � - � - 8� � 8 (work/cell): - - 2)Name and address of current owner (if different than applicant): Name: �SLI 1'Yl � Address: 3) Property Description: Lot Size: o� Address and/or directions,to Property: �� 4) Proposed Use and Type of Structure: Residential ✓ Business/Type: Other Number of bedrooms 3 / Number of people served (seats/employees):�- Basement: Yes No (with 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 comnleted application must also include: ➢ A plat/site 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 verifying 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): O`�• Date : Iv "�' v� 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) I � , ; � , ! �' � . � �j � �� � �� � � � �� �� � . �' ��' � r � ,� � � 7 ��� �' �� � �, �� � . � � � ��� . . , �, � � � _ , � ' .`�. 9 � s,�� � � � �t'o� -�--..-,.`. _� � �� � � � ���� . � , oc� , � � ;, , � �, , � � �d ��Q� �5�� � ; i� , � -� -�- - �i, � - , � • �. . � �► � � _ ; � : . S ay �•-� -,� a ? ' % � ;� � i � , -- � �� �' . 4 � , '�Q ��'' � ,,, , o Q , �,��. �, . .� � �. � ,.. �I /.i �� . 41 � � ��i�Jp� `�1^1 � 1✓� d � � ,��/i �a �'�n� V � � . �}.. �- a S , � � U � �- P'bd � a� ”' �.-� � . . �, � o� ���, �, �- o, i�� od . -��1 .�� � �.�,, as_' � Z/ ..� c�j �o �ot,�,.� cp� S�� �� � a� �-o�s�r,�j r(�fb� � , ' a�{ b �,,� � M 3a60,��.t�8 N ��! -,�; )r%s ,Q--� s� b� c� , ., � . I 1 ' � . � �� w . . /� 4 1.11 � _� �II 0 a 4 �a�����. ��.� ��.�� O 'C � A �' �' �'C '�. yd "' ����`��� .� � a� � o � � , iro� �o'�.�� ���.� � �:��� ����:�� � ��. ������� ,�.K���d � � ro� ���p� r. �►��.�;� �.. :,��. �o ������. � ��� ,�� � ���g tV � � � � � � �p��a ��� �. �, .n � .�n,� ��. �� � � s� �� � .� �o ��� � Cs ' �t$��d � � m.' � �� ��� ��� l� `°�• � "' �: � + o� ,� o� �. � o �� �� ��p��� n �° � � !D p � � � p �� �►��� ���`°� ���.�� R"oq � ia' ��'h ��� b f�e � e�4- . � � � �� � a � n � � � <' �' � 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 L - �S, ,- L �. , ��, � � ; i15' 3 L ` `� °' w� T'a�" f�L = �a7� ,�}�C EPTE I� �y' �/',vf Mvs� no�" encr-oaGLj �,Pan /'Pp�t�/' q/�Pa, ►oo` • � . � 0 i � , �o, y �o� ��/.l�-1' � -:' '�o�/ R Ep,�.R ' `:. •5'� E,� N . �pL q I ('6 �2�' 0 � �a � 0 = c? _ 3i,%�' w,_ . �'1,��� . �a,sg� `�,�,�� 1�.'I�I����T .. . Sc,� � E; � �� �v, , �--�� - - ����� � - IE,m..3u-m..,,,.......���.�.Il �IC��� SIT� S�TCYI' Name �-�i.�•� p S ii'i �� Tax 11�lap #{t 3 � Pascel # � g 1 Subdivisi Section/Lo��-} � �'`�'� ��� ��.�b � Authorized State �ge�t/�� " � Date sy�, �n,�oo� �p�s�r app�����u� onty. The rnntnscYor mutt. fZaS ihe'�"7e»sprior io hegimm�g tlte instisllation to ansure that j�ropergnade is maintained, , ���, i � �./ � 1LLJ 1S. �1. Ll.�' � � � ^^ �/ � ���� I���.���..����.-��.11 1� 3L��.11-�.,� ���� �'�E�I��' (1'aTevv�Re�air� 'Tas iblap: .� 6�� Parcel. �� 9 suba����on: �ot: L o� Applicant's Name: �c? M P� �} 1�' NYailing Address: p o 6o x. � 5/ /.Zov�P�-, a-� �" � N G 3- 7 S�� Phone Numbers: �f 19 - 4 7> - S c� �o� g�� -6l `f --SS' � I Location of Proper#y: iJ �+ i o -, �-�.�o �! � �} u �� �P � i%/S �,6 G C 6 `}- � � i c� /I-� � � -� � i ��..7� ; � -��a� i Permit �onditions: 1) See attached site plan for proposed well location. 2) All a�plicable State and County Negulations governing construction and setbacks apply. 3) Permits expire S years from the date of issue. Other Conditions/C'omments: -' �Sp p � i� ��"C�' � - P��ni# issued by: � ' l�ate: 1/ O� C���'�+'���T� ��+ ��lYIPI�E'�'IOl� Neev �e�l ��spection: EHS/Date Location: ' Grouting: Well Log: WeII Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Weil �riller: Ptunp Installer: �ell Approver� by: Date Sample Collected: Person County Environmental Health �25 S. Morgan St., Suite C Roxboro, NC 27573 �iner inspection: EHS/Date Installer: Depth: Grout: Well Abancioament: EHS/Date Completed: Method/Material(s): _ License #: License#: i)ate: Date Results Mailed: `" Phone: 336-�97-1790 Fax: 336-597-7308 sii�os