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A32 12407/28/2068 11:23 3365977808 PERSON COUNTY ENVIRO. PAGE 01 Application Date: ! "�� � � �. rA�mount Paid: 0. DD �� �' ,0 � Recei,pt#: I �'� � �J��-�' .���_S f �����1�! �� I.� ` � '. -,- � � �z�-a-�-� I7L"�.�rn �.—$ �,ra aa�.a.ca nad-..a� ll. .X�-7.T.e�.m.11•�G.1Lx. Applicati�oa �o� Sernices (Septic Systems and Wells) Servicc� Reauested �aX l�flpy-+-�� Paxce� #: 12� � � 17 xmprovement Permit (Site Evalaat�ot�) L Constructioa Antho�tion , �200.U0/$300.00 if>_ 600 d Fec is d cndent on ti�e e of s stem ernutted ' Mobile Home Replace�ent or Bu�ldEng Addition ❑ Pcsmit Revlsfott �I50.00 (ifsite visitrequired) 575.00 ❑ Wel� Permit (1�iew/Replacement) ❑ Repair of Existi�g Sepbic System �225.OQ/�125.00 o a e [mportant: If th� Information vt th� arpplicatrotr for an ,Im,prove�nent Pern�it is �ncorrect, fa/sifi'�d, n� the sue i� cllered, �then th¢ �inprnv�ent Perm& and the Autl�orizction to Cnriatruct aha11 becon�e iavalid 1) Services R uested by: t� Name: . c,� c�, �la ���U�'tt �� Phone #(home): 3SG� Ci — 5 5 S� Address: �i O � (work/cell): � �i-r��^ �`��s 2)Name aad dresa of current owner (if di�i'e�ent than applicant): Name: t7YG�1 Address: 5� J` 5 f rv� 1'L " ,��„ i�c,l j,� r� 1 S � 3) Prope�rty Aescxiption: Lot Size: Address andlor dizections to Praperry: � 4) �roPosed Uqe nd �y�e p�'Strtictuce: Kesidential � BusinessfCype: Otlter Number af bedrooms 3 / Number of people served (seats/employees):� Basement: Yes No 'K(with plumbing: Yes _ No � Garbagc disposal: Xes No _ Approximate �ize of building #'ountlrabion: �eu�gth„�� Width 3� �#: 5) Water Sapply: / - / Private We31 3/(Proposed E,�isting � Community Weil: Public Wate;r Syster�l: Are there wells on the adjo�ning properCi�s? No Yes (please show lacation on site plan) Note: A comnleted anntication marst also include: ➢ A pla�!/sit¢ plan of the property �hat sl�ows property dimensions and the size nnrl location of all proposed structures. D,� signed copy of the `Lat Preparation'forrx ver�ing thai the property is ready to be evarluated I am snbmittin� this application fo xequest seRv�ices from the Persan County Health Department. The informat4on provided as a�cu�te. � ttp�derstamd that if any s' ' altered or the intended use cb�a�ges, all pex�tits sl�X becobae invalid. Sagnature (Owner/Legal Representative): Date: 7 �' � "� I I/0? Person County Environmental He�lth, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � ��� ��; ����.� �� I \y` v � y f � '�..� �� � � ��'V �� ��.-����„-., -„-n-2���.�.I1 7�-3L�.�.71�I1a :. .. _ ... � ��� 32�,�� au o G'��� � � �ngro�e�es��t_�ermit ��r�i Valid ��r ��'ive e� _ l�o ��ir�tion . �jGS�irt �i Type of Facilii.y: � New � Addition . '��ter ��}�p�y �e�� J # of Oc�upants�,� A X of Be�rooms Prajected Da}1y Flow _ 3�o g.p,d. � Prnpose3 Wastewater 8ystem: �P 31� S. v�e Type: Proposed Rc�air: � . `i'YAe" . S9 � Permit Conditions: � �P � ��.$c��' � • . : .. . � , _. • - . �, � �� - j ,.. . , - ��,���.�t�•r,r'� .. - ;� � = � . �. r �- � , - �� .�� /' �L' � . - ��I'� � Tbe issuancx of ti�is permit 17y the Healt� Department in does not guara�ez the icananr.� of other persuits. If is the resgons�ility of the aPPli�PI�P�3' o�mer m in sure that aIl Persnn. County P]a�ing and Zoning and Bui7riing In�es:tions requncements aie me#. This �apr+uvement Permat i� snb je�t t� revoa�tion if the sa� pi�a; �p15t�''�� the intenaled use ci�nges. '�e Yxm�sro�emeut Permsit is nm� a�ft'ect� 3ig► a c�a.nge in ow�ner"stdp oi the �roperty, T�s permit �as is�aaed in cmtnpli�nca �i#ia tlae provisao�s of the l�orth �Carolina, .: `L�rvs and Rul�s for Sewa�e �'re�ne� ar�d �osal �vstetns' {�.SA NCAC 1�A .1900). Neitlaer Per��n �muniy;nor°;t�ic-`�'= Environmental �ealth Speraalpst warrants th�t the s�ptic tank �ysieqn m71 cmntittaue to fun�on satisf�eiva�ifly in tflne futn�e�or:#�t�t: the-water supply wiII retnain ;sotable. � • � �ivat3aoa��a�ian to Constrnet �laste�ate� 5�►steffi (.�c�.� f�r �aa��ing Pe�itj . *. Ses site plan and additional attachmenis (_}. ' • � -- , -�}�/ Proposed Was�tewater Syst�m: � ;S�' S S� Ty1�e �ll. f� Wastewater �low ��Og.p.d. . New i� Re�air Expa�nsio _ � � .� So� ]C,��18: — g.p.3J ft 2 � Type of Fac�7ity: � � S* • - Sasemeni _ Yes _ No ��$e'QPa$er Sy's$�ffi Req1flH�'effi��� 'T� S�e: S�#ic'T�nBc:' �O�g� �p Tan�:�l�ipgai �r��s�'Trap: g�l I�rai�e�al: To� ��: � sc� � Totai Lengtl� �� ft ' I�enn� Tremc� ]D�p�a — i.� '�r�sac�a i�Vici� — � SOlfl �:DY�I': — in � �"ren� Se�sar�tiona � #i �3is#a�iiaaa�on: — �is#�ibutioaa 3��z � Serial �i�trib�a�ao�a ` �'ress�e l�old Sp�i�ations: ��Ra�a�ed Stat� Agea#: Pernut Ex�� The type of system permitte� is �_ P�- C�ee'�/i.�ega.i �8a�s�s��#ave: %� � I a�c�pt the spe�ificaiions of the ,��P. ���2 - U� PCffi� rev. 11I10/4�_ : ,• .. . . � _ ti� ���,sf I��11E����1 � co���� lEavironxaieaial $�Cea.lEh SITFs SSETCH Name 'C I v��� Tax Map #�3ZPatcel # l` 1 Subdi isi� Section/Lot# M J� Authorized State Agent Da e System rnrnponents represent approximate contours only. The rnntractor must flag the sysiem prior to be�;inninA tFe installation to insure tbat proper xrade ts malntained. � �� � \ \ \ � � � � � � � � \ \ � � �p \ � ! � \ _ —i — N �� ��_ � N42'26' 22"W —'' -- � �.e_, .�``�-- _ , �� ti ` � ` 150.05' � � \ �' � ( ` t , 5� , � . ,%' �- „ , , / � � \ ,' � . � � r' � �o� 2S � � �\ ,� �' . . �, �', o - � 3s' �j�� i � • �", \ �,' �� o N , �� � � �--\ ` . � \V� �i �, o �, \ � �P ti�o �os ,� � � � \, � ` �,' ��' �`� ��� , N � \ ��'\ ���� _ N ct- i i�i. a� o �2� `�� � , � N o ,r`t'�"� � ,�' ' � �- 01 c� o � �. ,'� ,� � N � a�e' � ` '� , �� � ` N ��~���, ` ' c�. , •' . � �C� O ti,� � P 0' /,' /,�� o� � ��Q,. �. . .' � , � ��.ti�� q� .rr� ' . �P W �.�. �C . � � o M �� � ���5 o N /t,�v�. !� •�. . �� � Z ,� �;s `� ��" � 150 00' � N41°00'00"W 'S-i1NG 50` ACCESS _ _ _____ _ _ _ �CA,�,e' l � - C4a r t �� �_'__ ___._--.---- PC.6, P.39-2 EASEMENT (PRIVATE) _ _ ____ _ _ _____ — ---_