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A32 65The District Health Department f Orange, Person, Caswell, Chatham, Lee Counties .., s Water Supply and Sewage Disposal IMPROVEMENTS PE��+i3T� o.� t �ate • � " � Owner: / Q �� Location: � � �"e� � � p, Contractor: � � �!i � � ...� - � ` �� Water Supply: Private i� Public Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal, ,y;;��_ '��}�+�,, other automat' appliances / � Size of tank: � Nitrification linec ,�.�v ��- Other disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. 5eptic tank should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTEB AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT STAFF BEF'ORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. t � Date approved: '� F � "�� Signe wAn • �' Sanita an • Sewage posal: I Counter- By. � �� Y signed -�- (Owner or his representative) Cerlificate of Compleiion ` Date Approved: �.1 e` � By: ni rian (OVER) Location of well and sewage disposal facilities sketched on �back. NOTE: Make sketch of installation showing lot size . and shape, location of house, septic tanks, privies, water . supplies, etc. Note special problems exis�ing on lot.,Write in measurements in order that installations may be located at later date.. Note location of water supplies on'adjacent lots. (1� �2� . , Application Date: � �`�'� Amount Paid: 1� C.. Receipt #: Improvement Permit (Site Evaluation) $200.00/$300.00 (if > 600 gpd) Mobile Home Replacement or Building Addition $150.00 (if site visit required) 3�.t�c,� Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 �� f �J.L�11��(�� Tax Map: �2 � � Parcel#: � . �� 7� sawu u-cana �aa: ua �m Il IH� r.rn�4.lia Services for Services Construction Authorization (Fee is dependent on the type of Permit Revision Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: "7�e o! So`o », e f% Address: 3� r`3 (,o � 1 .� %Z�( _/,/✓,��1.� 1� �( l� �/ � 2? f y/ 2) Name and addres�of current owner (if different than applicant): Name: i �� dJ'�n �✓ ra. I�( -� � s Address: 3 l 5 � p ��'e R� �/�Ydl.� M� 1l C�J c 2-� S�r i Phone (home): 3�6 ' 3 �`-�' 3 � �7 (work/cell): S� <-1- 2 y 2 I Phone: 3�� "3 �D - ��5�� 3) Property Description: Lot Size: Subdivision: Lot #: Address and/or directions to Property: �� / S(,v �� l F�� Qrl /_/�r (�(P �� 115 �J C 2� S y i ❑ yes �� Does the site contain any jurisdictional wetlands? ❑ yes 8'no Does the site contain any existing wastewater systems? ❑ yes F3-ri Is any wastewater going to be generated on the site other than domestic sewage? O yes H-no Is the site subject to approval by any other public agency? ❑ yes B 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: C�esidential ew Single Family Residence Maximum number of bedrooms: � ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes E�o With plumbing fixtures? ❑Non-Residential Type of business: � Maximum number of employees: _ Total Square footage of Building: Maximum number of seats: ,2� x�'t: � c��l�`� 0 yes 0'no 5) Water Supply: ❑ New well �isting Well ❑ Community Well ❑ Public Water � Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If applying for �Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. �.�/ �,��,v-, 2- `-( - l S Signature (Owner/ Legal Representative*) * Supporting documentation required. Date Permits are valid for either 60 months or are non-egpiring 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. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) /) ' �� ' , � \. . �� t> � � \ � 1 � � ' �_,��..�I 1--I�-..,i� I� Building Additions/ Mobile Home Replacements �}Ivir� �"�ja��-C►"S Tax Map #: A.32 Parcel#:�_ Address: I 1^(o I��, f�� c 215 1 Approval Requested for: ✓ Mobile Home Replacement Building Addition . Applicant Name: J�d ��o m a n Address: 8 e � . ,, C 2 Phone #'s: 3 3Co- 3��{- ��—i �a 5a� 2�121 Permit Located: � Yes No Installation Date: �- �►o- � 7 Design flow: 3(�D (gpd) Current Contract wi#h Certified Operator on file (if required): Water Supply: � Well Public or Cammwuty Wastewater system shows no visual evidence of failure on: Z- 5-15 (date) (Applicant's signature if site visit is not required) Addition/Replacement Approv�d Env} onmental Health Specialist 2- ��/5 Date � Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 TL...�... ��c cn� � �c�n� �.,.,. Z�� cn7.7Stllft unznu r�arcnn�rnintv nPt ��.sf ��.�� _: � � �� I��n�-��.��,ll 1�3I��.Il�]� SITE PLAN Name �vi �� n ��f �S Tax Map # �132 Parcel #�� Subdivisi n � Section/Lot# - 2- �- / � ut orized State Agent Date System components represent approximale contours only. The contractor must flag the systemprior to beginning the installation to insure that propergrade is maintained e t��"'.�- i�,�;,'., �. � � � . �' �� ,s .r ConnectGIS Feature Report �s.a�� i ��+J 4YE& k!35i13JG 6a"25 �'' �� ,r�'` �� y(i�� .. � � . �. . . ; `s, � 4 � 1�� .� _ ,�, �++ �"��—' �� ' ' � � _ Page 1 of 1 Person Printed February O5, 2015 See Below for Disclaimer �r ,',� 6$53 s�' �'a � � � � i ��,,,��_ . �r � � ft ...��'-�,,.,�`'M`.. � ��..�' '.,.,.�,.,��,�_�,�.»— i � %� ft ��---- �� :i,ry `1t� 's,_ .�f �� • ti� � •.} � �� 7536 � �' E , � _ � • 1 : 60 Feet ;�� J017CE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who hav ecently upgraded to the Windows 8 operating system or a new version of Internet Explorer. We were able to resolve this issue by directing users to the Internet ExplorE :ompatibitity View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US�nternet-explorer/productsre-9/features/compatibility-vie f this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGIS has bee �repared for the inventory of real properry found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system ai �otified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnedG'. issume no leaal responsibility for the information in this system. Grid is based on the NC state plane coordinate system, 1983 NAD. http://gis.personcounty.net/ConnectGIS v6/DownloadFile.ashx?i=_ags_map6ec1c5611161... 2/5/2015