A32 222�c���e�i �
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Application Datc: � � � ��, '�
Amount Paid: � 00. d �� • ~-" ,,.-.r �
Receipt #: � `1� I q� ~ � � ��� '�
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�' � 3 � �3 Application far Services
T Services Requested
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> b00 �nd)
❑ Mobile Home Replacement or Buitding Addition
$ I SO.QO (if site visit required)
O Well Permit (New/Replacement/Repair)
Tag Map: �3 �
Parcel#: �Z
O Construction Authorization
(Fee is degendent on the type of system �
❑ I'ermit Revision
$75.00
❑ Repair of Existiug Septic System
Anolicarion: No Charee/ CA $ I50.00 or
1) Applicant Infor atio : ' " '
Name: � �i�'L-
Address: O J� .
' C.- � 727
2) Name and address of current o ier (if different than applicant):
Name:
Address:
�
� g� -yiv =fo-�7
Phone (home):
(work/cell): �� — �3 2 — / `-� (
Phone:
��i� . A3Z �..zZ
0.G��'S �
3} Property Description: Lot Size: �4 6 3 Subdivision: Lot #: �,� �(
Address andl,Qr directions to Property: L o-f-� f �r �'�-f-�- �N tE'�`�' �
2 2- r-� � tQ,,s O'� Oti.. U-t S,S n O Y
❑ yes no Does the site contain any jurisdicrional wetlands7
❑ yes o Does the site contain any existing wastewater systems?
O yes no Is any wastewater going to be generated on the site other than domestic sewage? ,
CI yes no Is the site subject to approval by any other public agency?
❑ yes � no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
OResidential �
New Single �'amily Residence Maximum number of bedrooms: � / Occupants:
[� Expansion of Exisring System If expansion: Current number of bedrooms:
� Repair to Malfunctioning System Will there be a basement? ❑ yes �no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
T; pe of business-
Maximum number of emptoyees:
Total Sc�uare f�otage of Building:
Maximum number of seats:
� Water Supply: �I New well ❑ Existing Well Cl Community Well ❑ Public Wat� ❑ Spring
Are there any existing wetls, springs, or existing waterlines on this property? ❑ yes o
Please note any knawn ground �c�ater restrictions ar saurces of contanunation:
6) If applying for `Authorization ta Construct', please indicate preferred system type(s):
1�1 Conventional ❑ Accepted ❑ Tnnovative ❑ Altemative ❑ Other ❑ Any
1 cert� that informa ' rovided above is conrplete and correct, I also understand that if the information provided is
irtaccura , i ubsequ ntly altered, or the intended use changes, all permits and approvals shall be invalid
� u 9
Sign e( wner/ Legal Representative*) at
Supporting documcntation rcquucd. �
• Pcrmits are valid for either 60 months or are non-eapiring when accompanied by an apgroved plat.
• A completed �Lot Preparation' form must accompany uny application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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)C�e��a���� ����.11 IE���a.Il�I�
iax Map: 3'Z P cel: �ZZ
Subdivisi�n � �
Phase/Section/Lot # / 3
Applicant: �Ji PLiQ.rt � �Q� �Qr
� aa..e�..R ,,,,.,�. ., _ . n ., , n _ �
Permit Valid for: Five Years �
Type of Facility: 3 ��°� �S•
Number of: Bedrooms � / Occu�
Proposed Wastewate System: u�
Proposed Repair:
Improvement Permit
Non-expiring
New �Addition _
�Emolovees / Seats:
Water Supply: �� �
Projected Daiiy Flow: 3 o gallons/day
Type: c�'4
Type: �
Permit Conditions: �p�2 5��f2 St�-e ��. -
Authorized State Agent: � f Date: 1" b� �"
(X) Owner or Legal Rep esentative: Date: –
The issuance of this permit,by the Health Uepartment does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all 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 Improvemeat is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina Laws
anrl Rules for Sewage Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Pleither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to functioa satisfactorily in the future, or that the water supply wil!
remain otable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: l 0� ti�� �i o� �k / (*)Typ�Design Flow 3�� gal./day
New `� Repair _ Expansion _ Soil LTAR: o gal./day/ft
Tyre of Facility: ✓�J'� � Basement: _ Yes �„ No
(*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person Counry Health Departfnent.
Wastewater System Requirements
Tank Siz�: Sep�ic Tank L�� 0 gal. -' Pump Tank � gal. Grease i rap gal.
Drainfield: Total Area ( 2-d v sq. ft. Total Length ��� ft. Max. Trench Depth Z� in.
Trench Width � ft. Min.Soil Cover � in. Min.Trench Separation �, ft.
DistribuHon: Distribution Box� / Serial Distribution �/ Pressure Manifold
Specifications: � ho � cr' SP� a� i S �• k�—� �' �'o K f�S�°t �� 2 4�� ��'� `'LS� i�e
Authorized State Agent: i7� ��✓ Issue Date: ( �– b`�'
Permit Expiration Date: – � ''Z.2
Tl�e system permitted is: Conventional �/A cept d Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date: %� 7�7
�.'
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-179�9 (rev 5/12)
Site Plar.
���+( / jTjj�����T Name: %�1 i �%► Q�� �`G�' K�Q.✓ Address:
�� ������ Subdivison:���5 �fl� Lot:�
EHS:
IEaavasmanann�aa�mIl l[��mIl�bn ^ -- -
Tax Map: 2-
Parcel: ZZZ
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