A31 42, APAlication Date: .� / !S� �� ��' � (� � � TaxMap:
, Amount Paid: ' –� _ `'—�... �_ � ��'�,J' � Parcel#: ��.�,
Receipt #: 5 3 I ' � . _
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:Ly..ravitror�:a�cYas �.ml 7HI va�d��
C��� F�1 '
c,o��-c� A lication'far Services
- Services Re uested
' Improvemenf Permit (Site Exaluation} ' Construction Anthorization ''
$2d0.00/$300.OQ if> 600 d Fee is de endent on the e of s stem ermitted
Mobile Home Replacement o.r Building Addition Permit Revision ;
$150.00 if site visit r uired '$75.00 '
' Well Permit'(NewlReplacementJRepair) Repair of E�sting Septic System '
'.$3QOA0/$2Q0.00/$75Ap : , Application: No Chatge/ CA $150.OQ or $300.00
1) Applicant Tnform 'on: . /
Name: f�1Cl� � ' �uGX1 � Phone (home): :
'Address: S'Oo3 W�1St°E!Z IZIDb� 'l� D (wark/cell): 9'19 ' C� /fo ' SZLS"
, ; , t�A'N� r NG Z'72 �3 '
2) Namc and address of cnrrent ner (if different than applicant):
, . Name: Phone:
-Address:
3) Property Descrtption: Lot Size: 2�� 5ubdivision. Lot #:
' Address andlor directions to Property: f�T 2'N7'P�S��CTlN✓ 0�= �.�QCXTL��.
/9Nli /Y(�fZt,�t G n'J1EG S Rl�.
❑ yes '■ no Does the site contain any jurisdictional wedands?
, ❑ yes ■ no Daes the site contain any existing wastewater systems?
0 yes '■ no Is any wastewater going to ba generxted on the site other ihan domestic sewage7 '
D yes ■ no Is the site subject to approval by any other public agency?
■ yes : � no Are there any easements or ri�ht of ways on this property? : i
(if `yes' is checked, please provide supporting documentatian} , �
4) Proposed Use and Type of Structure: ;
❑Residentiat '' : !
i New Singie Family Residence Maximum number of bedrooms: �_ �
❑ Expansion of Existing Syste�y If expansianc Current number of bedrooms: E
0 Repair to Malfunctioning'Syslem Will there be a basemeni? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ;
❑Non-Residential �
Type of business: Total Square footage of Building: '!'
Maximum number of employees: Maximum number of seats: 4
,
5) Water Supply: ■ New well �, Existing Well O Community Well O Pu6lic Water ❑ Spring �
Are there any existing,wells, springs, or existing waterlines on this praperty? ❑ yes ❑ no
6) If applying for `Autharization to Construct ; please indicate preferred system type(s):
❑ Conventional ■ Accepted D Innovative ❑ Altemative � Other 0 Any
�
7certify tl:at tke information p'rov�ded ubove is coniplete and corre'ct. l also'understand that �the informutian �rovided is ':-
inaccurate, or if the siie is subseque tly altered, or tlte intended use changes, all permits and approvals sl�all be invalid. '
/; S! l�
Signature (Owner/ Legal Representarive*j te '
' * Supporting documentation required. '
• Permits are vulid for either bQ months or arc non=expiring when accompanied by an' approved plat.
•' A completed'LotPreparation' form must accompany any application requiring a site evaluation.
' (10/11), Person County Environmenta� Health, 325 S. Morgan St., Suite C, Roxbora, NC 27573 (336-597-1790}
_
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Taz Map: � Parcel• �Z
Subdivision _
Phase/Section/Lot #
Permit Valid for: iv�
Type of Facility: l�
Number of: Bedrooms
Proposed Wastewater �
Proposed Repair: �
Permit Conditions:
Authorized State Agent:
(X) Owner or Legal RE
Improvement Permit
Years �_ Non-expiring
� Ps. New �—Addition _
/ Occunants � /„Emnlovees / Seats:
VVater Supply: (/1/'P �
Projected Daily Flow: ga[lons/day
Type: �
Type: �
�
Date: G-
Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applic�nt/pr�perty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or t6e intended use changes. The Improvement is noi affected
by a change in ownership of the property. This permit was issued in compliaace with t6e provisions of the North Carolina `Luws
ar�d Rules for �e►vaFe Treatment and Disnosa! Svstems'(15A NCAC J8A .19Up). Neither Person County aor the Environmental
Health Sp�ciatist wurrants that ihe septic system will c�ntinue to fanciion s�tisfa�torily in the future, or #hat tne water supply wi�l
remain poia5fe.
Authorization to Coostruct Wast�water System
See site plan and additional attaehments (_).
�
Proposed Wastewater System: -CGP►�*� — o�S� �/ (*)Type�� Desi Flow �� _ gal./day
Nev,r `� Repair _ Expansion ( Soil L'ff1R: .'Z gal./day/ft2
Type of Facilit-,�: �t �1`° j„QQ�. Basement: _ Yes ' I�To
(*) System 7'yp�s Illb, Illbg, IY, and v, require periodic system inspections by the Ferson County Health Department.
Wastewater System Requirements
Tank Size: Septic Tar�k � 0 4 � gal.
Drainfield: Total Area �� � sq. ft.
Trench Width 3 ft.
Pump Tank '—' gal.
'fotal Length so� ft.
iVlin.Soi( Cuver 1� in.
Grease Trap — gal.
Max_ Trench Depth �� in.
Min:Trench Separation � ft.
Distribution: Distribution Box� / Serial Distribution__ / Pressure Manifold
Specifications: _ S lOc� � l► �'!� 5
�iuthoriz..d �tate t�gent:
Issue Date: 2� Z f¢ `��p
Permit Expiration Date: 2 ZC�-2 (
7'he system permitted is: Conventional /Acczpted �/ Alternative / Innovative . I accept the cotzditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Printed February 25, 2016
See Below for Disclaimer
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'l� �r ���I��S S'�I�i( � - . ._. SITEPLAN �
Name ✓ C �� Tax Map# �` parcel# `�
�� C,�.g (l.�,Q .�( � s�� u%�i � Subd' is' Section/Lot#
7V �
— n
/ �1 ,, Authorized State Agent Date
Ci�{'� Z� �d'T�r' s D I,�s � .
System components represent approximate conlours only. The conlractor muslJlag the syslem prior to 6eginning the
insla!lation to insure thot propergrade is maintained.
Nole: An Accepted system may be used in place oja convenliona/ system witnout permit aulhorization or modification.
Tax Map: �� Parcel:
Subdivision:
���.sf ���.���
- � � ����
�nawn�r�IDaa�rncam�ra�.m.Il ��caa.��Ila
�2
WELL PERMIT
(New `� Repair_)
Applicant's Name: _�Q�V'ry /"ECc�GP,�
Mailing Address: _
Phone Numbers:
Lot:
Location of Property: ��� /�, ► ��S � � (�% ,�2Q.� y � i�►-� �S �✓Lt
�
o i v` _1( r' �
Permit Conditions:
1.) See attached site plan for proposed well location. .
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: �� �^
�Tew Weli:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Addi[ional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date: z—Zl�—�(�,
Certificate of Completion
OLiner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13