Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
A32 160
e 0 Application Date: 7- I 9- U � � 1�Q � �'1 Tax Map: . Amount Paid: � D 0. 0 O ���� b � Parcel #: _ Receipt#: 3( � C� 3 � ��� S s� ���$� �� - � � � ���� ' _IE�.�.r:['li��'St.]C�a[:D.11T..IZ".IIT..4'.•.�.R"]\Il�d:tL.� z�-ara._-,.�..n.-�:iti,. Application for Services � (Sentic Svstems and Wells) mprovement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) C Mobile Home Replacement or Building Addition $150.00 (if site visit required) � C Well Permit (New/Replacement) $225.00/$125.00 Services Rec C ❑ ❑ �onstruction Authorization 'Fee is dependent on the type of sy: Permit Revision $75.00 . Repair of Existing Septic System No Charge �0.II +� MGG� � �-��t �c�e�i �, Important: If tlte information in the application for an Improvement Permit is incorrect, falsified, or the site is altered, tl:en t/re Improven:ent Permit and t/ie Authorization to Construct shall become invalid __ 1) Services Request d by: Name: T��� � R �t 1J' 0 .T� �� � Address: � '"�u �vKiN J L� � /� �{�: r:l� /� . �'I s // �° �! c• .2 7.r5�� Phone #(home): �� 3 6 y�� yo 6 (work/cell): _ �3 6 .��3 — %� J`�a 2)Name and address of current owner (if different than applicant): Name: �� h'1 !�' Address: 3) Property Description: Lot Size:.Z .7 d Subdivision: Address and/or directions.to Property: S'�S R w��N.� LU�P u�'�� Go�'Nx� v� /t%R w�iN.J' Lo o ,¢�v0 QA�.1' L� /+ • 4) Proposed Use and ype of Structure: Residential Business/Type: Other Number of bedrooms � / Number of people served (seats/employees): Basement: Yes No _� (with plumbing: Yes No _� Garbage disposal: Yes No �� Lot #: /�i � // .f 5) 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 completed annlication must also include: ➢ A plat/site plan of the property that shows property dimensions and tlte size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing 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): Date : 7 a � 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ' ���� ���; ����� ��� ` � y �^ � �-�l�l �� �����-,�„ �-,--� �e��.,�.11 IC-3L��.]1.�I�. ��x Ma� ` ' arc�l .; S Uiq.G{:1 V I S,i a:n �h�s�e Sectian:Lat ':' ���a# �Ta�id �o� �C �ve �� Type �of Faciliiy: # of Occupants � # of Ba Praposed Wastewatez System: _ Proposed Repair. _ _ �tnv�� �provesnent ��r.mit _ �du �giiraiaon Vew,� Addition �ate� 5��p�y 1�e I I Pi�je�ted Daily Flow 3�> �.p.d. ---- _ ,,.--..---u. _ __ ;� _ Permit�Conditions: -�Il�� �..� Si-IP .f�.Yl � Tyge: a- � Type' ; .T�c� ' - -.� _' � � � " • Y � - • - �.1� Y. 11 � ' !J� . � 1 - �,��__� P .1 ' ' ' _ / i � �' • Y, ' � :i� .t�l � ��� / ! , • ' The issuancs of this pe�it by. the Health Department in does not guarantee the ;��,�*+sa of other peffiits. It is t.�e responsi`biliiy of the � aPP��P�Y owner m ia sure tha# all Person Catmiy Planning and Zamng and Bn�id'mg I�spec�ons requiieme� are meL TLhis Improvement Permit is snbject t� revacation if the site pIsa, plat or the intended use changes. The improvemeat �armit is not affec#e� bp a c3�ge in ow�nership flf the propes�iy. TLis permit w�s issned in cumpliance.�vith the provisions of the North C�Iina `Zaws and Rules for Sewas�e ?`reutment and 1)irsnosal Svstems' {15A NCAC 18A .1900). Neither Person �onnty nor the �naironueeatal Heait� Specialist' w�rranis Wat the septic tank system w�l cmntinue ta fnncfion. sati9iactoril� ia the futnre or'that the water supplp wi11 remain: potable. - --- . A�thorizati�n to Construct Wastewater Sysiem (][2e�resl fo� �nalding Pers�aait) � * Ses site plan and additional attachments (✓�. . Praposed Wastewater System: C�d'l�� �'ti� � z1..V � 'TYPe�T -'GZ- �7astewater Flow �CD C7 -g:p.d. . New .� Repair_ Exp on _ . . Soil LTA.R: �� g.p.d! $ 2 � Type of Fac�ity: �'��9�ha ��Qm i � �i`}� ((.t� Basement _ Yes - No � � , �aste�a#e� Sys�e�a R�n�ements � �ank Size: Sec�tic Tank: /� ga1 Pump �an�C: -� gal �Grease Trap: � gai �rai��eid: 'Tota.i Ar�: I(o Q U 9q i� -�otad I,ength °�(�(� �t � 11�$�mum Tr�nci► IDept�t �� ffi Tre�cii RVidth � ft t��'iin�u� Soi1 Cover. _� in N�miam Trenc9i Se}�aration: � ft �iste��ntao�: Distribu�ion �oa � Serial �istni�ut�on spe�cations: ]Pressase Manifold �ry� Autiaorizesi St�te A.g�nt Date: . Pern�it Expiration Date: - The type of systern per�tte3 is � Carnventionai Acc�te3 Alternative. I ac:.rpt the spe�ifications of the P�� _ / i�w��r1�.,�1 �8��rese�tativve: �� Date: ��ld/ U� � PG'� rev.11110/05 , a� =, , � � a\�°�S � _ -� —_�V �'4�m o "�..� 4 N �r � C�b�� �Li�S' #�. l� '�.� -�U� � 2656' 05 �I E � � Sv0 � � � 09y"�" ��„ � _-��, o i I i � '� � � �" _�"z.. .� �, � L� . _ ` 1 `'� 1 S � �., ��a ,, r�,,� ,,, ��-,�.�� � W�� ���,, � �-��� � , � 6 ll��-�� 1_" Q�' � S� �' �"1� 1\b U�-p�u��W � I �Iv � C) P � � yfid�� �.�-,ua,.�v,,`a1 -- i �'o rv au�� -n� ��,��h �1 6c1, � �� �9� � nL�-� ��,� . =?I� .- � ---�- ��,� �, �� � � � � ����L ; � , � d � ��� ' � 6 c;� ` � �� • e:C' .. ,... . � • _ " `� � ��, � �.� 1 �,,,G.�� ``� � :��.�, t p �,,,�.• gy U'vo�0 � �, 0c':: � �� � , 3 �=n �° � _ , � I • 0� :,L,� � _ 1 �, n y � � o ` .•a�0. 6� o �� 1/ . �� � ` �� � z .,��k�,� Q , � � � 4 �O ����/� � �j� 1 1 r S\%` % n i e:r + �t� o 6J� / �/ c); � :. cD ��, � ��� ���� 1 � F6�. � ' \ �t� P� ` .�'' \ �..1 ' C> 1 �/�, �� � � t�t I � � • � �� � .. �� �, " 'l � U6 � -7 -� . - '�� ..--- �� G� o� L"' 01,5 F � �� � o �' , �..:-� A�,.,�' �" .:�" =jJ��`•: ` �' f' y �f �„ •-� . •�� , � �'� � - �� ,� , � I ' .�� ' �`�'' 94�' c�. � �� �"�a- �.+� ����'` '� �P 1 0 ..✓"� y 1J/ 3\5� i ` - �' o�d �., , --� �i� --�......__ .�---'" �! g�0��,���{� s� -- ` %G, � �i v �, "f y 4 a q Qr -�i••\ -' ,( �, y C� , L u � �.1• - ,..... J B �`y:��� J t� y�� r .J .._,-._ .... .__,__"'�l +�� . � ' � pamarme� sr aper.9sadasdleqs amsur cv Qoum�sarays �mumo°oq ot:oud �ais.fs aqs �e,6isrrru�w�essuo� or� :f�rro smwuo� aaerunicmdde �aasardai siaauoduro� rmv�s.fg a�eQ �ua�y a��S pazaoc�nF 1 #loZ�uon�as UOTSTA � O � � # �,���c� � # d�y1I x�,I, aureN tr �,I S 'u����'mg� 'Q'���.aa�uxar¢a�sa��� A,�1�.�]11 � � - ; :^ � �� ���� �� ��� ' � Y � '-�1 ) � `� S�I�f �P ,� ° .'i ta � � �,� � : � � I� 1 � � ���..� �����, �_��� . � �. ��� � ����� 2e . �,. � 1�'' ������ � ��_�.��3'�*^-' ""-"r^'' �3"��.�l. ���1L.iL� � � ° P ° -✓ . A�piicarrt o J . � " ' Lflcatic� ' ----� --�> " r . , . � � � . �� � Y°���. � • �� . . . . . � � . S�s#�m T�rp� (9n t�c�nrd�r: l�!'t� Ta�l� Va�: � • ,_ . . .. � , . . '1'1-315 �Y� .� ��[ II�9�'i.41.1�3 � IF►� Ct»Pq.l�C� Vi�li�! .r�?�4.���N..E �IOE�i�-t �� � ��,RO�:.i.�. t� a�:� Si':A;'�[iTE�, Rt3�S F�� ��A�� ?R�4T��'�°T �dl� ��S�AL.; � . . .Al�it� �;�. � . c��1i���8s � t�F �� T�E iA��'���.�(�l3 P�l� �1�� �a����"i�Ucila�i � � �I.l"i'�Q �J�.. � .� . . : : . � • . . � . . . • . .. - ' ' J2,r�%�Q� -- . --- _ • ntri�d St� �4��r�tt � ' � D� � . lt��l�ri H�: � ( .���� e„ �� � ' D�: . �77'�7 � ' . • . : • � .� . � , �. .. �, . .. ' . � � . -�.� - So � . � • �r�v�. - . I� u5 � �--Z; �� �, � . � � , � . . . �° � . �3_— �� _ • � �. � - - - � �. . � ��;-t' . L 4 -1 I 5' � . ' �r . / �=� : . . . ..�d a 5 . t3,� .� '�� 2�f � r • • � . . ��.� .c�s ', � g �Z,r, �/ 3.5'�� �00 . . �,,�a �.s .� r. q , .. . 1 � . � � cj� , -n �4 5 ,� �oa . _ - � � 3� . ' - 1.. • ' . •T. . 0 +. � . , ' . ,,�; , ' , • . 12/28/2607 10:01 3365977868 PEF250f�1 CpUN7Y ENUIRO PAGE 02 .+A�l�I1C�'C'lOri .DAt�: �:o�$�� Amar.�x�t Paid: Recei�t#: � ���� �� ���� �� -`� � �► �T �'"]C' `.'�"' Jf'� ��-.� n a� KD 1Yf+�'d ZAi'..r, Svn1.�C}•!!W .IL .I� �w�. �L.li.�d� 1{�n, Applicatia►n Far ��rvic�as Se ic S� sC�rr� �tnd Welly Serviees Re ncsted f� �mprQvernent �ermit (site ��vatuatian) p Con�truction Aatt�ari� �Z00.00/$30D_04 ►i- 600 (Fee is de andent on tha l�eh➢la �Iome Replaccmnnt or Bailding Additioe U Perntit'F�ur��sEon $1�-59-88'fif site vis�t reauiredl i 2✓�c.. [� �;.r _ �7a nn TaX �1�17: � � � P�roel #: _�,�_ [7 'VV��I Perm'rt (Nerw/Replsreament) U Repair o�'Existing Santle 5ystem $?2S.Q0/S12S.Q0 rio Char�e rmportant: IJ'r/re r"r�ar�,�uuf� in the apptication for an Xr�rprovr.r�,¢rrt,pe�rrrt,�' ac incorrec�, fals(Jted, or �fie stte is aXfered, then the ,inrprovemeru Permit rrnd t}�e Au�,/ior�zatinn lo Construcl sh�ll hecn,rl�e lr�v�rldd 1) $ervices Re 4uesi� by: . N�,rr►�: OrJ �r�•.�. S ,Phone #(hvtrie�: � 3(� � o� d� B- (� �- f.3 Address: �0 5 G-r�,��a �- !�o LyaJ~��'� (work/cell): r _.• � N � �:.� a i 2) N�me uud address of c�r�rrent ur�v�er (if differe�ut th�n r�riplicant)� ��e• a r�� /�Gf.t SS a A.ddress' L p �g cJli .',�/ � 1� �o � �-1 Ik r.�'�/S rVC ��( �) �'�'4p�y ���Cription: Lot Siza: �C� Subdivi�ion; T,ot #: P,dtireyb a�ydlp� ixections (� I�ro� y: 1 .'„ g �p � p�:',,, � y;�,� � , � � � �.�J J.��' ,�~_ 4) Propo`ed Use anr� i"ype oi�ttu�tutre: Residential ✓ Businc,ssl'Typ�: �p���. • Number aFbacirooms -� _/ Number o�'p�op.l� sarv�od (s�atsl�mploy�os):.-- .2 Bss�ttt,entc Yea � No �(vrith plurnbirrg: 'Yes _,_, No „_,,,) Garb�ge disposal: Yes No �L� Appxoximate si�� af h�tt�drng fou�tions L,ongt��, WAdtli .�'.�,,,,�� � �4'stter Supply: Private We�! �/�'+rapoy�] Existing ^) Community'V"►�'ell: Pubtic Water System; Are there rveils ap tita �djais�ung properties? N� _.✓Yp:� (pl�ase ahaw location on sita plalt) 1'Virte: A com l�ied . l�catior� must QCso include: �� plat+rsile ptart o,}'the prc►�erty tha� s�Zaws prapsrty dime����'dv��r urirX t�ie size anJ loculior� a„)f'adl ,ptoposed stru�ur�� A A SYg1i�l� C�7��r �F�f1e `Lot,Pre,paratior�'form v�rifyin$ that the�prnperty is r��rd'y to be evur�te�r� I apa su6m�tting thia ttpp�ic.�►i�otR ta rcaprx�t �e�n+ices irom tM�e �'erson County �ealth T9�pAxtmeat. 'X'ha iaforrnatian provided i� s�ccurate. x rynd�t��d thst if any sitc i� alterec't or �th� rrit��nd�ed �ase chm��nges, alk pct�n�� �l�ull b�;comp invaX�ci. Sig�tatry�e (Owner/�'.,���,1 i2epresentative - 17at'�. / ��� �!/�� � ��47 F�c2'sOn Coui�ry F.nvjronmental Healih, 325 S. Mor�an St., Suite C, Raxboro, NC 37573 (336-597-1790) � � � � � � c� �� � � y,� � �,�•. � �.,� � � �J �. V � � ..�:�s3�.�37'77.3L"aCDnn.3L31CA.a�7CIl.'1�.�:J1 1L 1Lc��.11tE� �ualding Acdditions/ 1Vdobile �ome Replacements Tax Ma.p #:� Approval Requested for: Parcel#: ���% Mobile Home Replacement —� Building Addition � Applicant Name: u Address: " ��/ �� r �'I s C ��y Phone #'s: :�?! o 'c1�4� - Zoo"�-/� (fi � k�� H�mes Permit Located: .� Yes No Installation Date: ► Design flow: �� (gpd) Current Contract with Certified Operator on file (if required): N�f�" Water Supply: �f Well Public or Community Wastewater system shows no.visual evidence of failure on: �a-J�� 1�7 (date) (Applicant's signature if site visit is not required) Comments: = .� ��. _,' � ��� Addition/12eplacement Approved c.� /� Environmental Health Specialist 11/15/OS �a/��lb� Date