A32 50�' '�l� q�� `
Application Date: �, Q � ��� S� ���� �� Tax Map: � 3�
Amount Paid: 1. S�� . r,. ,� •� Parcel#i �
Receipt #: �� � �_ � � ����
� 1��rnwnn-�anitTca�znd�o..11 IE�I�,�.ILi.�n.
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g� a Application for Services
Services Reauested
❑ Improvement Permit (Site Evaluation)
$200.00/�300.00 (if> 600 gpd)
CJ lYlobile Home Replacement or Building Addition
$ I 50.00 (if site visit required)
C Weil Permit (:�1ew/Replacement/Repairj
$300.00/$200.00/$75.00
� Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.OU
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
Applicant Information: \
Name: w C,�,. �� C� C 2 � �c� U S Q�
Address: I ��� p ,t�o� c�
��o�t� o ro �i C- 2 7� �7 3
2) Name and address of current owner (if different than applicant):
Name: 1�i � l�ac� \�jrc�c�i5 �Q v—
Address: _� 7� 3 �.�.��,r�, � e � 1)� 3–,_
j�- ��oro �} C 27� 7�
1
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property: �, � �
Phone (home): 3 � ,� 9 � – ?� (� C,
(work/cell):
Phone:
Lot #:
❑ yes � no Does the site contain any jurisdictional wetlands?
B'yes ❑ no Does the site contain any existing wastewater systems?
❑ yes �no Is any wastewater going to be generated on the site other thar domestic sewage?
❑ yes �o Is the site subject to approval by any other public agency?
C] yes �o Are there any easements or right of ways an this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and T'ype of Structure: .
❑Residential
❑ New Single Family Residence Maximum number of bedrooms: Z
❑ Expansion of E:cisting System If expansion: Current number of bedrooms:
0'Repau• to Malfunctioning System Will there be a basement? ❑ yzs Ja'no VUith plutnbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Squaze footage of Building:
Maximum numUer of seats:
5) Water Supply: ❑ New well [�Existing �Vell ❑ Community Well ❑ Public Water ❑ Spring
_ Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
�� If a 1 in for `Authorization ta Construct', lease indicate referred s stem e s:
�) PP Y g P P Y tYP �)
C7 Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
1 cert�� that the infoi•mation provided above is complete and c:orrect. I ulso understand that if the information provided is
inaccurate, or f th�e is subsequen� altered, or the intended use chcrnges, all permits and approvals shall be ini�alid.
/z ���. l�
Date
* Supporting documentation required.
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved �lat.
• A completed `Loi Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
�� ( Tax Map: � Pa cel: SD
�� � � � t ) f ���� �� Subdivision ,4
� - �� � � � �' � � Phase/Section/Lot #
IC�e�.�a-��.�.-�.-n ����.Il ]I��.�.Il�I�
Permit Valid for: Five Years
Type of Facility:���
Number of: Bedrooms 7�
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Authorized State Agent:
(X) Owner or Legal RE
Improvement Permit
Non-expiring
New Addition
/ Employees / Seats:
Water Supply:
Projected D�i
gallons/day
Type:
Type:
The issuance of this permit by the Health Department 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 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 Nort6 Carolina `Laws
nnd Rules for Sewaee Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water sapply svill
remain pota6le.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater S tem: A-C� ' 2S � d Yi (*)TYPe� Design'Flow 2�{0 gal./day
New Repair �Expansion D Soil LTAR. . 25 gal./day/ft2
Type of �acility: a' ' pj It Basement: _ Yes _ No
(*) System Types Illb, Illhg, IV, and V, require�zriodic system inspections by the Person County Health Department.
Wastewater System Requirements
�x� st� �q
Tank Size: Septic Tank ?-J gal. Pump Tank gal. irease Trap gal.
Drainfield: Total Arza 2� sq. ft. Total Length � ft. � Max. Trench Depth J2„ in.
�- �t
Trench Width �: ft. Min.Soil Cover�:��C in. Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution ✓/ Pressure Manifold
Authoriz�d State Agent:
�
Issue Date: �—� `��
Permit Expiration Date:
The system permitted is: Conventional /Accepted v/ Alternative / Innovative
and specifications of this permit.
(X) Owner or Legal Representative:
�f-<<(-Z(
. I accept the conditions
Date: %�f A�'� �
�
Person County Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC27573/ph: 336-597-1790 (rev 5/12)
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S1TE PLAN '
. Name ( 5�1 Tax Map# �{ � 2 Pazcel# .Sd
Subdivision Section/Lot# �!
i �� _� .
thorized State Agent Date
Sysfem components represent approximate contours only. The contractor muslJlag the system prior to beginning the
ins�allation to tnsure that prapergrade ts maintained
Note: An Accepted system may be used in place oja convenrional system withoul permit authorization cr modifica�ion.
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