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� Pragerty Descr[�tioa: LoE Six� •�'I �a �isioa: Y1 D.�' Lat #:
Addcess aadlac �i�s tio Pmpaty:
17 yas Does tf� si� r�in any► jraisdictidQa! ar�?
� yes I?oes tl�e afGe � aay tacistiag vvasbaovaiac systcros'?
Q yes Ls auy vrastewa0� goiog to be g�ratod a� tht sim �her i�a darnastic sewag,�
❑ yes � Ia ti� siGa subjed to �uv�16Y a�' ot� P�� �Y�
L7 yas �ina Aro t�r+e any essems�ta or rig� of ways on ti�is pmpoat�t
C�''�' � �,�� �� �P� �)
iree aad T�pe of Stracinr�
o xcw �a�e Fa�►R� r�cimuna numb« cf �omx 3
C1 Bxgaaai� of E� System if a�ansiaai: +Cuira�i m�mber of bai�ooms: �-'
D Repairto Ma3functionIqg Syst�m WII! ihare ba a basera�t C7 yes �c o Witl� plmnb�ng fi�ctucss? U y�ea L7 no
� of b s: T+o�l Squara foat�e of Bue�din�:
Maxunuas� af�pioyee� Maximamn�anberofs�ta:
3y 'G[►at�o-r �cAi�3" ❑ New well �i�,Fadst� Wet! t3 Comm:uttlty Weii Ct Pablia Wa�ar ❑ Sp�ruig
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Are thare an�► existing wel�s, sp�gs, ar eacisting watalin� an ffiis pmperty? C] yos Q�
6j Ii�P�+jing for `Ast6nr�attoa �n Cott�rac#', P��ae �i�is P�fee�e� � tYP�is}:
Q Camenisooal O Accapted PJ I�avadva D Alt�ive Q Oth� Q Aay
1 cert� t3tat tfie ir�'urmation prwided above is conrplete ar�d con�at I also �rtt�r�trv�d t�iat f the lnfurmdton prrrvidQd ts
�ate, or if the sit� ts y cd� or the a�t�nuTed use chan,g�s, c�ll �lt.� arrd approva� s1�aT1 ba it�alrc�
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• {owaer� Rep�settrative ate
� Snppo:ting �io�vmeamtioa mquirod.
• permite �r8 vattd for �tt6�r b0 �out�s or are non�cxpiri�� wl�a �ocompa,�iai hy aa ePP�� P�
• A eompleted'Lot�on' %cm mnst ac�mF�W�Y �P�flcation requ�ring a eita e�aluitfon.
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Tax Map: � Parcel:��
Subdivision
Phase/Section/Lot #
Applicant: i —_
AddressJi.c:.ation:
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�mpr�avement ]Permit
Fermit Valid for; Five Y ars Non-expiring
Type of FaciIity: � e5 N�w _ Addition _ �'Vater Supply: �Q ��
Number of: Bedrooms �_ / Occupants�( / Employees / Seats: Projected Daily Flow: 3C gallons/day
Proposed Wastewater System: Type:
Proposed Repair: �� Type:�
I' - J
Permit Conditions:
Authorized State Agent: ` � 17ate:
(X) Owner ar Legal Representative: _ _ Date:
The issuance of this permit by the HeaCth D�partment cloes not guarantee ;he issuance of other required permits. It is the responsibility of
the applicanb'property owner to insure thai �11 Person County Planning and Zoning 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 is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of thQ Nerth Carolina `Laws
mrd Rules for Sewage Tieatinent and Disnosat Svstems'(15A NCAC 18A .19�0). Neither Person County no-r the Environmental
Health Speciaiist warrants that the septic system will continue to functioa satisfactority in the future, or that ±he water supply will
remain patable.
Authorization ta Construct Wastev�,�ater S�stem
,.�'ee site plan and additional attachments (�.
Proposed Waste���a�er S stem: � e�on�� (*)Type� Design Flo:�v 3�� �a?.rday
New F.epair � Expansion� Sci; L"TAR: gaf./daylftz
Type cf Facility: P�r;�,�,�-� eti� �e ncP.. Basement: _ Yes No
{*) System Types Illb, Illbg, I!! and V, requira periodic system inspections by the Person County Health DepartmeKt.
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Wast�water System Requirements
Tank Si�e: Se�tio Taiak �X� gal. Pump Tank gal. Grzase Trap --� gal. �
Drainfield: Total Area �� sq. ft. Tatal Length Zb0 ft. Max. Trench Depth � m.
Tren�h Width _� ft. Min.Soil Cover �_ in. Min.Trench Separatian � ft.
Distribution: Distribution Box / Serial Distribution / Pressure Nlanifold
Specificatians: �e�,
Authorized State �gent: C�/,,,� � � Issue Date: 5� Z-� '
—� � Fermit Expiration Date: �-ZZ-I$
The system permitted is: Conventional /Accepted "! Alternative / Innovative . I accept the conditions
and specifications c�f this permit.
(X) Owner or Legal Represeniative: Date: _
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)