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A32 232��, s� ��.� �� -`, C� � ��T�'� )E�e��..-,Y,. ��.Il IL-��.Il�I� Applicant: C Z Address/Location: NurJle Tax Map: 32 Parcel: 23z Subdivision i.t/A Phase/Section/Lot # Improvement Permit Permit Valid for: Five Years � Non-expiring Type of Facility: ; New �Addition _ Water Supply: yfP (( Number of: Bedroom 2/ Oc upants / Employees / Seats: Projected Daily Flow: zuo gallons/day Proposed Wastewater System: 25y, q tr1�;ON s,�ty„ Type: � Proposed Repair: �ct,�� —�� Type: � �" Permit Conditions: f��i�ri'e.n nj( sc�ar.ICS The issuance of this permit by the Health Department do se not guarantee tt�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 are 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 the Plorth Carolina °Laws mrd Rules for Sewaee Treatment and Disnosal S'vstems'(15A NCAC 18A .1900). Neither Person County aor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water snpply wiii remain potable. Authorization to Coostruct Wastewater ystem See site plan and additional attachments (___). Proposed Wastewater System: ��S�Js ��,c};o� Sv,k�.� (*)Type � Design Flow 240 gal./day New � Repair _ Expansio _ Soil LTAR: . Z gal./day/ft2 Type of Facility: �;�[e �„u:(��i„o — Z, p� Basement: _ Yes _ No J S- (*) Syste�n Types IIIb, lldvg, Iv, and V, require�eriodic system inspections by the Person Counry Hea[th Department. Wastewater System Requirements Tank Size: Septic Tank �_ gal. Drainfield: Total Area `1 ZD sq. ft. Pump Tank ----gal. Total Length ��0 ft. Grease Trap—gal. MI�-Trench Depth 3Z in. �" T`'� ��Q`%� Trench Width 3 ft. Min.Soil Cover� in. Min.Trench Separation � ft. �•e. Distribution: Distribution Box �/ Serial Distribution / Pressure Manifold Specifications:•J�Q; a;,, Q1� st#d,c�.�� • �r� �r►s+all 'or. n.QeF;.,e ,vv,,,.,�n�-�t� Authoriz�d State Agent: ' [ssue Date: 3—ZG-18' Permit Expiration Date: 3-zl�—z� e system permitted is: Conventional cepted / Alt ative / Innovative . accept the conditions n pecifications of this permit. �n r� (X) wner or Legal Representative: Dat . ! , Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) ��, s� ��.� �� -`, C� � ��T�'� )E�e��..-,Y,. ��.Il IL-��.Il�I� Applicant: C Z Address/Location: NurJle Tax Map: 32 Parcel: 23z Subdivision i.t/A Phase/Section/Lot # Improvement Permit Permit Valid for: Five Years � Non-expiring Type of Facility: ; New �Addition _ Water Supply: yfP (( Number of: Bedroom 2/ Oc upants / Employees / Seats: Projected Daily Flow: zuo gallons/day Proposed Wastewater System: 25y, q tr1�;ON s,�ty„ Type: � Proposed Repair: �ct,�� —�� Type: � �" Permit Conditions: f��i�ri'e.n nj( sc�ar.ICS The issuance of this permit by the Health Department do se not guarantee tt�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 are 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 the Plorth Carolina °Laws mrd Rules for Sewaee Treatment and Disnosal S'vstems'(15A NCAC 18A .1900). Neither Person County aor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water snpply wiii remain potable. Authorization to Coostruct Wastewater ystem See site plan and additional attachments (___). Proposed Wastewater System: ��S�Js ��,c};o� Sv,k�.� (*)Type � Design Flow 240 gal./day New � Repair _ Expansio _ Soil LTAR: . Z gal./day/ft2 Type of Facility: �;�[e �„u:(��i„o — Z, p� Basement: _ Yes _ No J S- (*) Syste�n Types IIIb, lldvg, Iv, and V, require�eriodic system inspections by the Person Counry Hea[th Department. Wastewater System Requirements Tank Size: Septic Tank �_ gal. Drainfield: Total Area `1 ZD sq. ft. Pump Tank ----gal. Total Length ��0 ft. Grease Trap—gal. MI�-Trench Depth 3Z in. �" T`'� ��Q`%� Trench Width 3 ft. Min.Soil Cover� in. Min.Trench Separation � ft. �•e. Distribution: Distribution Box �/ Serial Distribution / Pressure Manifold Specifications:•J�Q; a;,, Q1� st#d,c�.�� • �r� �r►s+all 'or. n.QeF;.,e ,vv,,,.,�n�-�t� Authoriz�d State Agent: ' [ssue Date: 3—ZG-18' Permit Expiration Date: 3-zl�—z� e system permitted is: Conventional cepted / Alt ative / Innovative . accept the conditions n pecifications of this permit. �n r� (X) wner or Legal Representative: Dat . ! , Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) Tax Map: A 3z � Slt@ Plan Parcel: 232 �� jj"})j�j� ��T Name: �a e„�Ztie,,� Address: "Ilow. fu v+,�� . ��, , f 1I'11�110. l� Subdivison. /d �ot:�- EHS• •�_ �� • lE��sm�ffi��mIl IFIIemIl� Date: �-27-i g �C �re—inSf'allcd�+ov� rnc.e{iv� ��A1�� l�lin I �c.�,a{� I�,-N� 3Z,�� 0.,�c � tMf.� � �rr ��b6X � 3 �in�CS � gdr System Type: � .1'��`" Septic Tank: � gallons PumpTank: —gallons Total Linear Feet: 2i(o - Max.Trench Depth: ��" in. � u� �Z�� Q�Q y�,� �a*M &��'� �, � Scale: ,.(�_ Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation. 2) Contact Person County Environmental Health with any questions (336) 597-1790. Additional Comments: � ��,�� llil��l'�� ?��a ��.11 II-��.I1�]h� SITE PLAN Name � � ��i,�, Tax Map #/t�J2 Parcel # (...32 Subdi 'sion Section/Lot# 1�/� — �-1 —i0 uthorized State Agent Date System comnonents represent approximats conteurs o:�ly. The contra.:tar rnust./lag the syslem �rior io beginning the insta[lation to insure that propergrade is maintained _� , ,/\ I ��c� � � �ddc��lOVICI\ SO�I C6VQY OV�r $i��',Y�l l �� C�,� ��5�� ---�-�`D ��Pd � lo er�(o�-�e� — 230' J�c�`� d � � � ,� Tax Map: A 3z � Slt@ Plan Parcel: 232 �� jj"})j�j� ��T Name: �a e„�Ztie,,� Address: "Ilow. fu v+,�� . ��, , f 1I'11�110. l� Subdivison. /d �ot:�- EHS• •�_ �� • lE��sm�ffi��mIl IFIIemIl� Date: �-27-i g �C �re—inSf'allcd�+ov� rnc.e{iv� ��A1�� l�lin I �c.�,a{� I�,-N� 3Z,�� 0.,�c � tMf.� � �rr ��b6X � 3 �in�CS � gdr System Type: � .1'��`" Septic Tank: � gallons PumpTank: —gallons Total Linear Feet: 2i(o - Max.Trench Depth: ��" in. � u� �Z�� Q�Q y�,� �a*M &��'� �, � Scale: ,.(�_ Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation. 2) Contact Person County Environmental Health with any questions (336) 597-1790. Additional Comments: ��`: j�f �1.1.L/�� V� � � �� LL IE �.�,� � �,� �,� ��.Il lE3C � a Il � WELL P (New_ Repair_) Tax Map: �2 Parcel: _ j� Subdivision: /�l% Lot: � Applicant's Name: � Q �4 Q ' �D � Mailing Address: Phone Numbers: - 3-- �Yan H( na i Sy0 ��'A- 258g` - - � Location of Property: JUJ,w, � �. —�' � 7 � Permit Conditions: 1.J 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.� Issuarce of a Fermit ddes fiot arantee a potable wat suppiy Other Conditions/Coarments: l�i�1 �n a �( .S �XS Permit issued by; (�Tew Well: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Installer: Approved by: Additional Comments: Date Sample Collected: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C n�..L..... nl!"1'!c`!] Date: S-/7-/!� Certificate of Completion Di,iner: EHS/Date Depth: Grout: �Abandonment: Date: Method/Materials: License #: License #: Date: Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 , , ,�. ,.., �a^�j/ � �C � �� j:a�Esatioa�s*e: 3 '�L �j,2a�L� Amount Paid: �.DO., " Receipt #: 1 �j 3d2t� 4 �'r`s�►<� A mprovement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) 0 Mobile Home Replacement or Building Addition ❑ Well Permit (New/Repiacem $30Q.00/$200.00/�75.00 1) Applicant Inf r ation: Name: l Address: 2) Name and addr s of curi Name: Address: � N Q � z� � C�- '� 4��s ��a��-�tu u,�c�1 f�e►.M,-�- �1;� p� � !n-I (� � �� S Sw��F s�' �e • �� : ��'� � ;�� a�: � 3 � — ~•►••)% � � ��,��. Parcel#: �s� IE��s�mm � ��¢�.Il IE��mIl� Services for Services 0 Construction Aut6orization (Fee is dependent on the type of � Permit Revision ❑ Repair of ExisHng Septic System Application: No Charge/ CA $ I50.00 or $300.00 Phone (home): (work/cell): ^� � � owner (if different thaa applicant): ��_��` `! Q�f r�/11 q � .� . Phone: � 4�U 3) Property Description: Lot Size: �i �� C Address and/or,rdirectiqnst4Property: u yes ❑ yes ❑ yes ❑ yes ❑ yes #: no Docs the site con"tain any jfirisdictional wetlands? no Does the site contain any existing wastewater systems? no Is any wastewater going to be generated on the site other than domestic sewage? no Is the site subject to approval by any other public agency? no Are there any easements or right of ways on this property? (if `yes' is checked, please pmvide supporting documentation) 4) Proposed Use and Type of Structure: : esideatial � �New Single Fam:lfResidence Maximum number ofbedrooms: -� I Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no �Noa-Residential Type of business: Maximum number of employees: Tota! Squaze footage of Building: Maximum number of seats: 5) Water Supply: �New well ❑ Existing Well ❑ Community Well O Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes C�no Please note any known ground water restrictions or sources of contamination: �,6) If applying for `Authorization to Construct', please indicate preferred system type(s): L�Conventional ❑ Accepted ❑ Innovative 0 Alternative ❑ Other � Any I certify that the information provided above is inaccurate, t e site is s quently altet-ed or Signat e ner Legal Represe i '� Supporting documentation required. and correct. I also understand that if the information provided is �d use changes, all permits and approvals shall be invalid. . � �L �� Date Permits are valid for either 60 months or are non-ezpiriug when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any applicatiou requiring a site evaluation. (10/IS) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N�27573 (336-�97-1790) , ��•��{�� , � � ' . '.�._ �� r� /l�..r'• t � =:''!; �;y.�i4� 74ZB WACHOVIABAN;NATAXUNI` i �� t •" t. ��e / ��yy� �y � � :��,,��^ ` �,, f.� � , ei� � }�.-<. �j �,.' ' � ,�,�' � �Ma+� .A ,� . . . . '� � �# � ` � " - '�� ` ,`'��s 1� �=t,' i. . . ' . . , , ; ' . _ -F. �... , , . � ..,, ,� �, , ,._ _ �g� . . _ . { . . ,. .. r � r. �4..- , ,� .+✓": `, P `: � � b ; � . . • • . �'. �• h; , � �? .. _ .,. �.., o ..� . � :' '� ..S ,. . � `� }��'� � . 1 f ' �'�� ` � { , y t`�t �� 4 �� . � '� � IELD JOSHUA D � . � 222b� . • �, . , ` a� :sy , . . AQ.� � ' 'l 6,.� + 9� ' S `.� ; �" � . q. ��. . . . ' . , � . , !�A„ .. �v"' " . .,:•V +1� . . � � • .� � yf n� ' � .. t . � �„ ; 8' . � f"; • . �, � . , �.� , ' � . . . ' �. �.� �� . �i� �� ,•.� �` � AUSTIN THOMAS M 8 VIRGIN4 I�A Bu 22249,.,� �; �� . � -,r'; �', �. ' �e� �h '4 >'� .� e . �� .� � . �u, i�`.n � � , F .+ • . . � . .. 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'�- � MONK VIRGINIACAROLYN F 18915 �•+ },y � � � �� - " � ' � � - u, �_ � '�. . . . . � �;`i""��kw� ��w.�F��y��p � � -'� � � ' ' ; � �'� � . . �w�4 .yy�%�� a� �� . �' � I ` . �:: . �. ^j� � � � .1.; �./ ;� ,� .�'r ``ip� � � � _ � . _ t�- -,� _ _...�- � .;,.!'.. �,, � ,i:�i° .s.:~�R��,`k,.s,�,t . ,. , ... '�: � '�''� . .-t�.- . - �`�� ,irs y.s.' 'i � ,..r � � ��. .. . . � - � -.�� x & . ._�� ,�.�. � s . ` � ` _ , � I 1 ..� � '' x � .` �. ✓� / ` � ' eI 4 � . . , ,' � T _' �,a ' �,R� ' _ _ � � e,�/� .t - b '�Y �s �.�� . _... , n'+.'`8��. -... '•*�J. . �* . "3�, �� .w, ,�",' � r ' � ` i h �� : ,,. ,. � � ' � 1 �� . ' � ��,,� y.��T, , .. . �'� � f ��,� � �. E;fi` .. t A s�'x"` �,,, •` "9��.`1 , " '��" �'�,"�`'\ r� � ,�.. .� �� , '*-�' � �-�` . �' 'S• +• � . ' � ^S �� ,y � '� " .y;s r . a a,�eo, jp�x' �'+� �• • ��`�? ' 'i ,; jn� ",�'�` �"" �, . � . a� �0 } � ' e .,� ,r. �! � _ 4 ,� , .�.��,� ,t � +� {:' � f ,,� �*:;� "� '� •, A : ��;,;.. .t ��.,�, _ ` ;. � , `� ��.. . t � � f � � ; , � e,`� "0 �,t� t� s �K'!'�►�� ,* , ��;; ' � �, � ! � ' ��,* �' , < < � �, �J Y t ''• - � '� � - . � ` �'��?�� .�� : .l � O� i�:- r >$ a . ': • -1t' , • ' � �` . �; r� �' DUCKER JOHN E & JULIA ELLEN A - ` � � ` 16213 � �- -� ' � �� ' \� � i Y L��ef � `i�t � _ �� q" �j�i _ y�Q�� •' • ,,„/� , t;# -� � P �,��,•�,,.,R�,_ �,i , . '°` _ ...�..�,,.;' � ' � � �: G� ��` l S�tr.�, r � .��il � � ,r .;� �y%' .t,�YF'* __, , � � - J � � . � , +�,� _ ' i.. � � , � , t�; � ,� �� , �..- ,a�: � �'�" :�r-.a�+��,- • � ��'�`� �� ;� A,(: t � � � ,'�' � r � 1� • � � � -� �w� • � .: ��e, +� �.�. -. �+.' � ,•� � j �t�', �,{ 24284 -,�' � 2�111l,r :.�� s• � .' � � "��'�� x. v : �'..��A�M� � '�.�.. �:. � .p�� - � � � �t� � � BENEKE BRUCE 8 CANDVCE T f . - i;,�� r .,t �' " �'' . - � , � .1 �:iL�t�� ` � t �%� . ` :�" I + . / �kI'.. ; F.. :+�',�~i)'.�......wa�� g` � ",�,. '''�'� ' ` ..,• ' ` . � i►�� ' , � �i,�� . a � . . .-.�R'�0lv�l�.�jy,' ,i �w pw. � w ; • .K� "%�f�c � , . '�. � �� .. � �� , '^��' � .�� ; MOIZE ZEB & MOISE JAMES TRUSTE 71 OO ks ��. .� oY�' � . MOIZE ZEB & MOISE JAMES TRUSTE � �4y � {:' . - �i � . _: . �t • t�., _ � • � - � `w � !�� ,v 7100 �, • � ,,.;..� , �$�,..,', • � � � , '�; _ . � � "i.F,� � k7'�.7!.��,��'. �t . i4 , .��d : �rr�.,+a � I J � ��,�� llil��l'�� ?��a ��.11 II-��.I1�]h� SITE PLAN Name � � ��i,�, Tax Map #/t�J2 Parcel # (...32 Subdi 'sion Section/Lot# 1�/� — �-1 —i0 uthorized State Agent Date System comnonents represent approximats conteurs o:�ly. The contra.:tar rnust./lag the syslem �rior io beginning the insta[lation to insure that propergrade is maintained _� , ,/\ I ��c� � � �ddc��lOVICI\ SO�I C6VQY OV�r $i��',Y�l l �� C�,� ��5�� ---�-�`D ��Pd � lo er�(o�-�e� — 230' J�c�`� d � � � ,� ��, s� ��.� �� -`, C� � ��T�'� )E�e��..-,Y,. ��.Il IL-��.Il�I� Applicant: C Z Address/Location: NurJle Tax Map: 32 Parcel: 23z Subdivision i.t/A Phase/Section/Lot # Improvement Permit Permit Valid for: Five Years � Non-expiring Type of Facility: ; New �Addition _ Water Supply: yfP (( Number of: Bedroom 2/ Oc upants / Employees / Seats: Projected Daily Flow: zuo gallons/day Proposed Wastewater System: 25y, q tr1�;ON s,�ty„ Type: � Proposed Repair: �ct,�� —�� Type: � �" Permit Conditions: f��i�ri'e.n nj( sc�ar.ICS The issuance of this permit by the Health Department do se not guarantee tt�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 are 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 the Plorth Carolina °Laws mrd Rules for Sewaee Treatment and Disnosal S'vstems'(15A NCAC 18A .1900). Neither Person County aor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water snpply wiii remain potable. Authorization to Coostruct Wastewater ystem See site plan and additional attachments (___). Proposed Wastewater System: ��S�Js ��,c};o� Sv,k�.� (*)Type � Design Flow 240 gal./day New � Repair _ Expansio _ Soil LTAR: . Z gal./day/ft2 Type of Facility: �;�[e �„u:(��i„o — Z, p� Basement: _ Yes _ No J S- (*) Syste�n Types IIIb, lldvg, Iv, and V, require�eriodic system inspections by the Person Counry Hea[th Department. Wastewater System Requirements Tank Size: Septic Tank �_ gal. Drainfield: Total Area `1 ZD sq. ft. Pump Tank ----gal. Total Length ��0 ft. Grease Trap—gal. MI�-Trench Depth 3Z in. �" T`'� ��Q`%� Trench Width 3 ft. Min.Soil Cover� in. Min.Trench Separation � ft. �•e. Distribution: Distribution Box �/ Serial Distribution / Pressure Manifold Specifications:•J�Q; a;,, Q1� st#d,c�.�� • �r� �r►s+all 'or. n.QeF;.,e ,vv,,,.,�n�-�t� Authoriz�d State Agent: ' [ssue Date: 3—ZG-18' Permit Expiration Date: 3-zl�—z� e system permitted is: Conventional cepted / Alt ative / Innovative . accept the conditions n pecifications of this permit. �n r� (X) wner or Legal Representative: Dat . ! , Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) Tax Map: A 3z � Slt@ Plan Parcel: 232 �� jj"})j�j� ��T Name: �a e„�Ztie,,� Address: "Ilow. fu v+,�� . ��, , f 1I'11�110. l� Subdivison. /d �ot:�- EHS• •�_ �� • lE��sm�ffi��mIl IFIIemIl� Date: �-27-i g �C �re—inSf'allcd�+ov� rnc.e{iv� ��A1�� l�lin I �c.�,a{� I�,-N� 3Z,�� 0.,�c � tMf.� � �rr ��b6X � 3 �in�CS � gdr System Type: � .1'��`" Septic Tank: � gallons PumpTank: —gallons Total Linear Feet: 2i(o - Max.Trench Depth: ��" in. � u� �Z�� Q�Q y�,� �a*M &��'� �, � Scale: ,.(�_ Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation. 2) Contact Person County Environmental Health with any questions (336) 597-1790. Additional Comments: ��`: j�f �1.1.L/�� V� � � �� LL IE �.�,� � �,� �,� ��.Il lE3C � a Il � WELL P (New_ Repair_) Tax Map: �2 Parcel: _ j� Subdivision: /�l% Lot: � Applicant's Name: � Q �4 Q ' �D � Mailing Address: Phone Numbers: - 3-- �Yan H( na i Sy0 ��'A- 258g` - - � Location of Property: JUJ,w, � �. —�' � 7 � Permit Conditions: 1.J 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.� Issuarce of a Fermit ddes fiot arantee a potable wat suppiy Other Conditions/Coarments: l�i�1 �n a �( .S �XS Permit issued by; (�Tew Well: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Installer: Approved by: Additional Comments: Date Sample Collected: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C n�..L..... nl!"1'!c`!] Date: S-/7-/!� Certificate of Completion Di,iner: EHS/Date Depth: Grout: �Abandonment: Date: Method/Materials: License #: License #: Date: Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 , , ,�. ,.., �a^�j/ � �C � �� j:a�Esatioa�s*e: 3 '�L �j,2a�L� Amount Paid: �.DO., " Receipt #: 1 �j 3d2t� 4 �'r`s�►<� A mprovement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) 0 Mobile Home Replacement or Building Addition ❑ Well Permit (New/Repiacem $30Q.00/$200.00/�75.00 1) Applicant Inf r ation: Name: l Address: 2) Name and addr s of curi Name: Address: � N Q � z� � C�- '� 4��s ��a��-�tu u,�c�1 f�e►.M,-�- �1;� p� � !n-I (� � �� S Sw��F s�' �e • �� : ��'� � ;�� a�: � 3 � — ~•►••)% � � ��,��. Parcel#: �s� IE��s�mm � ��¢�.Il IE��mIl� Services for Services 0 Construction Aut6orization (Fee is dependent on the type of � Permit Revision ❑ Repair of ExisHng Septic System Application: No Charge/ CA $ I50.00 or $300.00 Phone (home): (work/cell): ^� � � owner (if different thaa applicant): ��_��` `! Q�f r�/11 q � .� . Phone: � 4�U 3) Property Description: Lot Size: �i �� C Address and/or,rdirectiqnst4Property: u yes ❑ yes ❑ yes ❑ yes ❑ yes #: no Docs the site con"tain any jfirisdictional wetlands? no Does the site contain any existing wastewater systems? no Is any wastewater going to be generated on the site other than domestic sewage? no Is the site subject to approval by any other public agency? no Are there any easements or right of ways on this property? (if `yes' is checked, please pmvide supporting documentation) 4) Proposed Use and Type of Structure: : esideatial � �New Single Fam:lfResidence Maximum number ofbedrooms: -� I Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no �Noa-Residential Type of business: Maximum number of employees: Tota! Squaze footage of Building: Maximum number of seats: 5) Water Supply: �New well ❑ Existing Well ❑ Community Well O Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes C�no Please note any known ground water restrictions or sources of contamination: �,6) If applying for `Authorization to Construct', please indicate preferred system type(s): L�Conventional ❑ Accepted ❑ Innovative 0 Alternative ❑ Other � Any I certify that the information provided above is inaccurate, t e site is s quently altet-ed or Signat e ner Legal Represe i '� Supporting documentation required. and correct. I also understand that if the information provided is �d use changes, all permits and approvals shall be invalid. . � �L �� Date Permits are valid for either 60 months or are non-ezpiriug when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any applicatiou requiring a site evaluation. (10/IS) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N�27573 (336-�97-1790) , ��•��{�� , � � ' . '.�._ �� r� /l�..r'• t � =:''!; �;y.�i4� 74ZB WACHOVIABAN;NATAXUNI` i �� t •" t. ��e / ��yy� �y � � :��,,��^ ` �,, f.� � , ei� � }�.-<. �j �,.' ' � ,�,�' � �Ma+� .A ,� . . . . '� � �# � ` � " - '�� ` ,`'��s 1� �=t,' i. . . ' . . , , ; ' . _ -F. �... , , . � ..,, ,� �, , ,._ _ �g� . . _ . { . . ,. .. r � r. �4..- , ,� .+✓": `, P `: � � b ; � . . • • . �'. �• h; , � �? .. _ .,. �.., o ..� . � :' '� ..S ,. . � `� }��'� � . 1 f ' �'�� ` � { , y t`�t �� 4 �� . � '� � IELD JOSHUA D � . � 222b� . • �, . , ` a� :sy , . . AQ.� � ' 'l 6,.� + 9� ' S `.� ; �" � . q. ��. . . . ' . , � . , !�A„ .. �v"' " . .,:•V +1� . . � � • .� � yf n� ' � .. t . � �„ ; 8' . � f"; • . �, � . , �.� , ' � . . . ' �. �.� �� . �i� �� ,•.� �` � AUSTIN THOMAS M 8 VIRGIN4 I�A Bu 22249,.,� �; �� . � -,r'; �', �. ' �e� �h '4 >'� .� e . �� .� � . �u, i�`.n � � , F .+ • . . � . .. ' �,,� ,> � 't . 4�"P .s i t y � e j�� ,^�� ' '�. ,L • s . � ., �1�� , . • . . , .. ` ��' � y _ i . 1 �\ � k .�.I ` M1L_' . � �:.i�a �Za1' ��i��?'��`:��'� _ "�I" - _�:� , '..t y�, �� } �..�..r � .�:. - � K'. _ . - e j . . .. � . ~��'.'+1�4 •i . . �� .Y,� �4 . . '. +,. 4s,'°j `_ f :` '_.--._._.__._._,,, . `s �. _ ' ' s' "< =3�!'' �, � �� . S' �r - . �._._.... � � �� .1� . � ' �`� �' C '' � '� . . � ` � . ,` _ �.� ' ¢" �` - . � . x � �� .� � `� ,J � # y�. �, � � .` i ' ��.',��.., �Z" . . � �-.aY+.`. . � I - *' .. A .y�i`` . . . ,. r�..� .* � , r�' �. � ^ .- . �� x '�. �VJ " _� � ' rY% . MONKVIRGIVIArAROLYNF � � t� `7 `� ' 1 � �� / � 7104 � � r�.- :�',' � � � � �'�, '�` + ' ,�. � 4�� *'"k ' � ��,;' : � . _- : _ L'� � >'� /�� .� ":,C•! _ �. t �. .� L.��Cg ---�" Px�r �''' vrotc ,',� �� . • _.� -.., i ` �:.�� ., � .� �7 v� � �� t �4 A S. '�- � MONK VIRGINIACAROLYN F 18915 �•+ },y � � � �� - " � ' � � - u, �_ � '�. . . . . � �;`i""��kw� ��w.�F��y��p � � -'� � � ' ' ; � �'� � . . �w�4 .yy�%�� a� �� . �' � I ` . �:: . �. ^j� � � � .1.; �./ ;� ,� .�'r ``ip� � � � _ � . _ t�- -,� _ _...�- � .;,.!'.. �,, � ,i:�i° .s.:~�R��,`k,.s,�,t . ,. , ... '�: � '�''� . .-t�.- . - �`�� ,irs y.s.' 'i � ,..r � � ��. .. . . � - � -.�� x & . ._�� ,�.�. � s . ` � ` _ , � I 1 ..� � '' x � .` �. ✓� / ` � ' eI 4 � . . , ,' � T _' �,a ' �,R� ' _ _ � � e,�/� .t - b '�Y �s �.�� . _... , n'+.'`8��. -... '•*�J. . �* . "3�, �� .w, ,�",' � r ' � ` i h �� : ,,. ,. � � ' � 1 �� . ' � ��,,� y.��T, , .. . �'� � f ��,� � �. E;fi` .. t A s�'x"` �,,, •` "9��.`1 , " '��" �'�,"�`'\ r� � ,�.. .� �� , '*-�' � �-�` . �' 'S• +• � . ' � ^S �� ,y � '� " .y;s r . a a,�eo, jp�x' �'+� �• • ��`�? ' 'i ,; jn� ",�'�` �"" �, . � . a� �0 } � ' e .,� ,r. �! � _ 4 ,� , .�.��,� ,t � +� {:' � f ,,� �*:;� "� '� •, A : ��;,;.. .t ��.,�, _ ` ;. � , `� ��.. . t � � f � � ; , � e,`� "0 �,t� t� s �K'!'�►�� ,* , ��;; ' � �, � ! � ' ��,* �' , < < � �, �J Y t ''• - � '� � - . � ` �'��?�� .�� : .l � O� i�:- r >$ a . ': • -1t' , • ' � �` . �; r� �' DUCKER JOHN E & JULIA ELLEN A - ` � � ` 16213 � �- -� ' � �� ' \� � i Y L��ef � `i�t � _ �� q" �j�i _ y�Q�� •' • ,,„/� , t;# -� � P �,��,•�,,.,R�,_ �,i , . '°` _ ...�..�,,.;' � ' � � �: G� ��` l S�tr.�, r � .��il � � ,r .;� �y%' .t,�YF'* __, , � � - J � � . � , +�,� _ ' i.. � � , � , t�; � ,� �� , �..- ,a�: � �'�" :�r-.a�+��,- • � ��'�`� �� ;� A,(: t � � � ,'�' � r � 1� • � � � -� �w� • � .: ��e, +� �.�. -. �+.' � ,•� � j �t�', �,{ 24284 -,�' � 2�111l,r :.�� s• � .' � � "��'�� x. v : �'..��A�M� � '�.�.. �:. � .p�� - � � � �t� � � BENEKE BRUCE 8 CANDVCE T f . - i;,�� r .,t �' " �'' . - � , � .1 �:iL�t�� ` � t �%� . ` :�" I + . / �kI'.. ; F.. :+�',�~i)'.�......wa�� g` � ",�,. '''�'� ' ` ..,• ' ` . � i►�� ' , � �i,�� . a � . . .-.�R'�0lv�l�.�jy,' ,i �w pw. � w ; • .K� "%�f�c � , . '�. � �� .. � �� , '^��' � .�� ; MOIZE ZEB & MOISE JAMES TRUSTE 71 OO ks ��. .� oY�' � . MOIZE ZEB & MOISE JAMES TRUSTE � �4y � {:' . - �i � . _: . �t • t�., _ � • � - � `w � !�� ,v 7100 �, • � ,,.;..� , �$�,..,', • � � � , '�; _ . � � "i.F,� � k7'�.7!.��,��'. �t . i4 , .��d : �rr�.,+a � I J � ��,�� llil��l'�� ?��a ��.11 II-��.I1�]h� SITE PLAN Name � � ��i,�, Tax Map #/t�J2 Parcel # (...32 Subdi 'sion Section/Lot# 1�/� — �-1 —i0 uthorized State Agent Date System comnonents represent approximats conteurs o:�ly. The contra.:tar rnust./lag the syslem �rior io beginning the insta[lation to insure that propergrade is maintained _� , ,/\ I ��c� � � �ddc��lOVICI\ SO�I C6VQY OV�r $i��',Y�l l �� C�,� ��5�� ---�-�`D ��Pd � lo er�(o�-�e� — 230' J�c�`� d � � � ,� �� (� �� Tax Map: 3Z Parcel: 732 `—�,� � � , � Subdivision � (� � � � � � Phase/Section/Lot # 7:E�e��-��.��,m.��.Il IE� � �►.Il �1� Permit Valid for: Five Years Type ofFacility: �rm Dui� Number of: Bedrooms / � Proposed Wastewater Syste : Proposed Repair: ��1��, Improvement Permit Non-expiring New �Addition _ � / Employees �/ Seats: ` Water Supply: __li�%Q%� Projected Daily Flow: ZSD gallons/day Type: Type: T Permit Conditions: _�/ g��h q.(( Sg�S ----- � — Authorized State Agent: Date: .�' /(Q— / (� (X) Owner or Legal Repres ntative: Date: The issuance of this permit by the Health Departmef�t�oes not guarant�'�the issuance of other required permits. It is the responsibility of the applicandproperty owner to insure that all Person County Plannin�'and Zoning and Building Inspections requirements are 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 ia ownership of the property. This permit was issued in compliance with the provisions of the North Carolina °Laws and Rules for SewaQe Treatment and Disoosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmentai Health Specialist warrants that the septic system will cantinue to function satisfactorily in the future, or that the water sapply will remain potable. � Authorization to Construct Wastewater,S�ystem See site plan arid additional a#achments (�. �tG e� o;�te5) Propose astewater System:� G�� ' (*)Type.� Design Flow Z�� gal.lday New � Repair Ex ansioti Soil LTAR�l Z gal./day/ft= Type of �acility: '' Basement: _ Yes o (*) System Types Illb, Illbg, IV, and V, require psriodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank 0 O gal. Pump Tank --�"— gal. irease Trap -----gal. Drainfield: Total Arza l�� sq. ft. Total Length 23o ft. Max. Trench Depth � in. Trench Width c3 ft. Min.Soil Cover �e in. Min.Trench Separation � ft. Distribution: Distrihution Box �/ / Serial Distribution / Pressure Manifold Specifications: rviiiiu nn��ia�ivii La�c. y -�G-%/ The system permitted is: Conventional / epted v Altern tive / Innovative . I accept the conditions and specifications of this permit. .� (X) Owner or Legal Representative: _is� Date: � j Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) �� (� �� Tax Map: 3Z Parcel: 732 `—�,� � � , � Subdivision � (� � � � � � Phase/Section/Lot # 7:E�e��-��.��,m.��.Il IE� � �►.Il �1� Permit Valid for: Five Years Type ofFacility: �rm Dui� Number of: Bedrooms / � Proposed Wastewater Syste : Proposed Repair: ��1��, Improvement Permit Non-expiring New �Addition _ � / Employees �/ Seats: ` Water Supply: __li�%Q%� Projected Daily Flow: ZSD gallons/day Type: Type: T Permit Conditions: _�/ g��h q.(( Sg�S ----- � — Authorized State Agent: Date: .�' /(Q— / (� (X) Owner or Legal Repres ntative: Date: The issuance of this permit by the Health Departmef�t�oes not guarant�'�the issuance of other required permits. It is the responsibility of the applicandproperty owner to insure that all Person County Plannin�'and Zoning and Building Inspections requirements are 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 ia ownership of the property. This permit was issued in compliance with the provisions of the North Carolina °Laws and Rules for SewaQe Treatment and Disoosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmentai Health Specialist warrants that the septic system will cantinue to function satisfactorily in the future, or that the water sapply will remain potable. � Authorization to Construct Wastewater,S�ystem See site plan arid additional a#achments (�. �tG e� o;�te5) Propose astewater System:� G�� ' (*)Type.� Design Flow Z�� gal.lday New � Repair Ex ansioti Soil LTAR�l Z gal./day/ft= Type of �acility: '' Basement: _ Yes o (*) System Types Illb, Illbg, IV, and V, require psriodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank 0 O gal. Pump Tank --�"— gal. irease Trap -----gal. Drainfield: Total Arza l�� sq. ft. Total Length 23o ft. Max. Trench Depth � in. Trench Width c3 ft. Min.Soil Cover �e in. Min.Trench Separation � ft. Distribution: Distrihution Box �/ / Serial Distribution / Pressure Manifold Specifications: rviiiiu nn��ia�ivii La�c. y -�G-%/ The system permitted is: Conventional / epted v Altern tive / Innovative . I accept the conditions and specifications of this permit. .� (X) Owner or Legal Representative: _is� Date: � j Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) �, �,Lu Application Date: o�s �� ' �5'�� S� ��T Amount Paid: � ,� ,. . b V �_ � Receipt #: s3 � � �� .If�." uavv.II-�..r,.x,,,osaa:,�.Il ]HCai�.11�,lh� � Improve Perrait (Site Evaluation) $200;00 300.00 if> 600 d) ❑ 1�7 ' e Repfacement or Building Addition $150.00 (ifsite visit required) `dVzll Permit (l�ew/Replscement/Repair) $300.00/$20G.00/$75.00 �licatioa for Services Services Reauested �truction Authorization is dependent on the tvne of Tax Map: � 3 a� Parcel#: � �j[ hoWc a►ppl+er� �or Fa�r�t 'L O #�' ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Appli�ation: No Charge/ CA $150.00 or $300.00 �) Applicant Info mation: Name: Address: L 2) Name and add e s of curr n owner (if differ nt than applicant): Name: t Address: Z 3) Property Description: Lot Size: �_ Add,ress ar�aj,jor dire�t�on� to P�top�rlv: __ Phone (home): (work/cell): �%U•.� -- ( Phone: �/j � 7� {� Z �� #: Q yes [�;no Does the sife contain any jurisdictional wetlands? ❑ yes (k�. no Does the site contain any existing wastewater systems? ❑ yes no Is any wastewater going to be generated on the site other thar. damestic sewa�e? ❑ 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 properiy? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Ty�pe of Structure: , ❑Residential ❑ New Single Family Kesidence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: O Repau• to Malfunctioning System Will there be a basement? ❑ y�s ❑ nu �'ith plumbing fixtures? ❑ yes ❑ no M � �A1on-Residential /�,� Fur��d Type of business: y►'� Total Squaze footage of Building: �y-U V Maximum number of employees: 2S Maximum numUer of seats: �b M AX � µu N# E��p�° Y �� S 5) Water Supply: �New well ❑ Existing Well ❑ Community Well ❑ Pt�blic Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? � yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): �1 Conventional ❑ Accepted ❑ Innovative ❑ Alternarive ❑ Ot�'�er ❑ Any J� I certify that the infof•mation provided above is compdete and correct. I also understand that if the information provided is inaccut-ate,��%� �' site is sub�quent� altered, or the intended use changes, all permits and approvals shall be inti�alid. Si�(ature (Owner/ Le�YR�presentative*) * Supporting documentation required. Permits are valid for either 60 months or are nou-expiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Mor�an St.. Suite C. R�xhnrn N('. �757� fZZ�_�o�_� �om Application Date: . 1 �"�� • Tax Map: AYmount,�aid• 00 vO Parcel #: Receipt#: � � 3 ,� .�-�%�1� �1`'�� .. �� = �� IG aa-.v �► y.ca �a +*-+*-+� <c= �ia � ra 71 IC-�r �,e.-- w.. Il tGl�-n Application for Services (Septic Systems and Wells) e��t �-,e� � o�.� � �M� � �� .� �o� � Y �� Services Re uested Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if> 600 d) (Fee is de endent on the e of s stem ermitted) ❑ Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired) $75.00 ❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 No Char�e � 1) Services Requested by: Name: o Address: ' ('e / / Z)Name and address of current owner (if different than applicant): Name: -�F �t� Ik i� o k Address: � a C' �2�573 Phone # �Wo eu �a �C7 (� (a3 �, r3�Property Description: Lot Size: 7��Subdivision: Address and/or directionjs'to P,/r�operty (''��eSs �- �-v l_�inw�� Q �6'kK It'i� .�Inn Sin7n1 �i L�k1�C %h) Proposed Use and Type of Structure: l Residential _� Business/Type: Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No � Garbage disposal: Yes _ No �_ � �� Water Supply: Private Well � (Proposed� Existing _� Community Well: Public Water System: . Are there wells on the adjoining properties? No _ Lot #: ,.—. ,__: Se� vka 6r Yes� (please show ,location on site plan) Note: A completed application must also include: ➢ A plat/site plan of tlae property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying t/tat t/ie property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that '►f the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. �1, � f� „ Signature (Owner/Legal Representative): Date • � 02 pd' 10/08 Person County Environmental Health, 325 S. Nlorgan St., Suite C, RoYboro, NC 27573 (336-597-1790)