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A lication Date: 0� � q ` Tax Map: 32 PP �,'�� �� l. � ������ Amount Paid: OO �� �— • ,^ � � ���� Parcel#: Receipt #: g2�_ � )��'!.uT.v �in-aa�rn�ran.a:�rnQ..tn.�ll 7E"�ja-:n.�t(:]i-n � Improvement Permit (Site Evaluation) $200.00/$300.00 (if > 600 gpd) Mobile Home Replacement or Building Addition $150.00 (if site visit required) Well Perm $300. r) ilication for Services Services Re uested Construction Authorization (Fee is de endent on the ty e of s stem ermitted) Permit Revision $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant.In ormation: �/� Name: � � r' / V � � Address: S" �( � Y' . �l �t h /.� : lls %�(', .� 7�i 2) Name and address of current owner (if different than appl�cant): Name: Address: 3) Property Description: Lot Size: -.Address and/or directions to Property: Phone (home): � � — � (work/cell): '� �w {,�,� a�a �' j —�3ie`'Z3 �et� � y� Phone: Lot #: -- — � e L � C7 yes no Does the site contain any jurisdictional wetlands? � yes L7 no Does the site contain any existing wastewater systems? p yes �1 no Is any wastewater going to be generated on the site other than domestic sewage? q yes O no Is the site subject to approval by any other public agency? p 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: �Residential � New Single �Family Maximum number of bedrooms: ❑ Expansion of Existing System . en number of bedrooms: ❑ Repair to Malfunc '' ystem Will there be a basement. VI C7Non �a Type of business: Maximum nu employees: Maximum nurnber 1(�30 plumbing fixtures? ❑ yes ❑ no of Building: 5) Water Supply: ❑ New well 11G �xisting Well ❑ Community Well O Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no Please note any known ground water restrictions or sources of contamination: ' 6) If app ying or Authorization to ❑ Conventional ❑ �cep�ed—"fl i ve � Alternative ❑ Other type(s): Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Legal Representative*) * Supporting documentation required. Date • Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/I 1) Person Count.y Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) . . ��.�...T . . �='��. ������ ���� �� �_�,, � � ��� 11 . 1E����� � ��.�.Il IHL��.Il-� Annlican� N'11�� ��u�,..� ,. �.:;• T?r�x �r1;:� �� � ':�,� r ;_,I � �' _ �, S�ui�ellivi���ic�n F�In�r:��;.,-.��5ec-i�i:�n��l..ah � v °` �� � 2` . ��p�o�t�ent Permit ' � ��� �ermit �alid for Five Yeara. NQ Ezpirat�on � � Type of Facilitg: ' � � New Addition R��ter Supply � # of Occupants �,� # of Bedrooms 3� �� Pmjected Daily Flow �c� g.p.d. • Propoaed Waetewater 3yatem: � . Type: Proposed Repair: ��uc,...�-��� � � � 1`YPe' . . . , r_ . ' Peimit Conditipns' Qwnes ar Legal Represe Autharized State Agent: D�• �� - �y 'Tho issuanco nf thia peimit by the Hesith Do�rtment�n does nnt guaranteo the iseu$nce of other peunits. It is t�e responsibility of the applicantfpmPertY o�ner to in auro that all Person Couniy P'lanning and� Zoning and Bw'lding Inapections requirements are me� 7fhIs Improvement Pes�nit is subjeet to revocatton ii the �ite plsn, plat ar the intended use changes. The Ymprovemnant Permit is not affected by a'change �t ownership of the propertg. TLis perniit was issu�d La compliance with the provisions of the North Carolin� `Laws and ,�p for �'e�� �•atrieent and I)��osal S`vstems' (15A NCAC.I8A .1900). Neitf►er Person �o�nty nor the Enviro�mental Healtli Specialist warrants that tlle aeptic tank ayatem will confiuue to fnnct[un satisiactoritX in the futura or that the water supply will remain PutaLle- � . . �Antho�izatiun io Constract Wa�tewater� S�ste�ii (�ntred for Bu�t� �ermit) . * See site plan and udditional c�ttachments (✓ j• rro�$ea w�t�wat� sy��: �r�c.�. i�.r� Type �.�. Wastewat.�r Flow 3c� �. g.p.d. New air ansion . So� ��TA� , ao g-P.d.! $ 2 ReP �-- E�p — Type of Eacility:. ���Basement �Yes x No . Vi�ast�water Syat�em Requirements ��. - .�x,s� . . ��� ,Tanlc Size: Septic T�nk: I�va gal ,. Pamp �ank: � g�l' _ Drainfield: Total Area: sq ft Total Length 3 5v ft Mazimum'I`�ench I?epth 1 a-1 �l in ']�rench Width �_ ft Minimum Soil Cover: �' in ,Minimum Trench Sepazation: 9 ft Distrlbution: X Distrtb�tion Box Seri�l Diatri �o�n � 1h �Pressure Manifold Spec�cations: �;ac Cs-r1s�.Q �- ��r � � ;�., S+�.Q.1ok�v-� � �'t= r�+ c.s r�c�• os .�SS�io1.� � A�tho�� st�t� ��t: � ` D�:11 r a3—� C� Pem�it Expiration Date. r • The type of system permitted is the permit. � � O�vvues/g.ega� Be�resentative: � '✓ Innova�ive Alternative. I accept the specifications of .. Date: PCHD7/30/2002 .���,�J ��+ti. V.�� � � ��1' ��O �7��^,� �� ���b4`�irn �r-'r�n:�1t3'�dD.J1 1l JL�0��c1[�, J� 1.Y�. .7'�'i.1' �d3. Name Al'1r�� �w.a Ta.g lYlap # 3Z Pa.�cel # 6 6 Subdivision ��� ��'-�;s � �Z � Section/Lot# � � �i-aa-��� Autho ' ed S te Agent � Date . � System comj�onents represent a�i�ir�oximate�contours only. 7'he conlractor snustflag the systerri�irior to � beginning the installation to insure thatproj�ergr,ade is maintained 1-` Q•'c-�>>-�-.�..,�.r� �^-�--�-�-� .� �Q �� �-�'►L � se.� �- �,� -c�r+r.R.c>-- sZ�c:sa,•.�\,--.x — C.,E, �c.:-. �i-o n�xa l ;n,i 0 �lacsz c35Z�' k 3' �n�c.3•ue ��-� o.� l��- � a- � y�� �� . �� �� � �. �" `O ►�v�a� jta,tiQ � e-� �J,' � - c� � -rLps�; I "'� e�w, Q v � . I I-�� � �^'� i � �� �� I I ��� 1 l �,, � �u ''` �� < < -� � ` �� � __ _ _ Scale: ��- � Sc�� � I'GH�, =ev. 09/12/01 _��� �� ���� �� ` v � � � ���� � �n.vra.a-� �mrn�� ��.11 I�� � �.1�.�1�n. ax Map � Parcel # _ � Su�bcllivision Ph�se Se�ct+ioniLot # # of Bed�rooms Applicant: P1 �. 1v� ��,a Location: � s`� g � .b (� �-: �f��o- G.�,e C.� � -� � 'P�,e-� r� --� � �v. f�c.. � � ,s '�cm. 2� _ �i t� s co s '1}�,.�.. � 'r-zr+-•-- 1P� . � —� . . � �. . �` ,. `.�� � , . ` •: • ; i. System Type (In Accordance With Table Va): �� THIS SYSTEM FlAS BEEN INSTALLED !N COMPLIANCE WITH APPLICABLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CO(VDITIONS OF ' THE IMPROVEMENT PERMIT AND C�iVSTRUCTiON AUTHORIZATION. � � � � � � � - � o-�oS - � Authonzed State nt Date Installed By: �'�-�,a ��,,,,;s Date: s- �a-oS � 12c.�p �rrv, ��. Z � , �� � . � i� � ` I � � . y O �- 9 t , .iro a. � � _� �s ` 1 -� � .,s�+ - l� J �'"�"OI.SZ / 3� r --� , � N N� I— � � � r � �� ____-_---� �1P,�.�� 52� �iC_ Q,x is� . (�4..,� .�¢,q ..4 �i'1 �cr ��-,s� 1L . PCHD, rev. 07/29/Q4 y 9 �E�TiG TAiVK iNS����"i�l� C�BECKilST (�ype (I - IV� Tax Map # A3a Parce! # c� �3 Sys�em Type (Table Va) Owner/Appiicant {a i r�..� r�-��,,�, Subdivision Address/Location 5�s 2�� �,,,.,, s�� Sec/Phase Lot # State ID/date Capacity gal. Tee and Filter Baffle Sealant Riser (if applicable) Tank Outlet Seal Permanent Marker Pumu Tank � /Sealant Riser Water Ti ht Pump Check Valve/Gate Vaive � Ant�-si on o e Fioats/Switches Alarm visable and audible Electrical Com onents � Rate m A roved Pum Model Block Under Pum Pum Removal Ro e/Chain . ��Distribution. System � Serial Distribution � ressure ani o Low Pressure Pi e A r. Pi e Material and Grade ValvEs � Trenct� �dth � ft. ,� �� Trench De th _ in. � T,rench Length � t� ft. � 3ti �� Trench Grade � Tcench Spacing Rock Depth and Quali Dams/S#epdowns etc. Pressure Laterais ✓ a Pi e. Sleeve � Tum-u s/Protectors Required� Setbacks From Wells �-►o--� From Property lines � Stn�ctures/6asei�nents v Surface Waters Public VVater Suppl Vertical Cuts (>2 ft. Water Lines Vehicle Traffic Easements/Righf of V� Othet` Easements Recorded e e perator oi Tri-Partate Aqreemen Comments � pchd rev. 3/13/01 ConnectGIS Feature Report � �. - ��..✓ i '� � �'�w,,. ! '�r� � � tv�B H��-STt:rJG � Page 1 of 1 Person Printed October 21, 2015 See Beiow for Disclaimer /� c,.. f ! _ `- � r�-`%/J �='-'. ^� / '�� 1 : 60 Feet �' �.�„�_��� a..�— �� _a;z� �TICE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who F cently 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 Expl �mpatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US�nternet-explorer/products/ie-9/features/compatibiliry-� 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 b epared for the inventory of real property found within Person County, and is compiied from recorded deeds, plats, and other public records. Users of GIS system �tified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, Connec sume no leaal resqonsibiliN 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_map3 de7a99946... 10/21 /2015 ���.sf ���.��� �--�- � � ���� IE ��,� � �,� �,� ��.Il IE33L � � fl �]� WELL PERNIIT (New� Repair_ J Tax Map: �2 Parcel: �( � Subdivision: � /F} Lot: � Applicant's Name: �) (�tr{-�,,rrer,.� Mailing Address: 5�Qc����( ,� t �ar�„� Rd , �4 Nrd t,�_ M, ��r�—�.�,J� 2�s�r � PhoneNumbers: q�a -`?32-qkt( 11�1 -43�- R�Cvs ce(t) q t°t- l� 3�- 23K'1 CTa 's c�11) Location of Property: �,,,� (t /U � I� 5�.�'} C� e� Wa l.n uf Gra/t Cl, � Permit CoadiNons: 1.) 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.) Issuance of a permit does not guarantee a potabde water supply Other Conditions/Comments: �q ; n-fza;„ a� 1�ef�hne�ls Perarit issued by: ��-,,," � (�ew 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: Additiohal Comments: Date Sample Collected: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C o..,,ti...., nir ��c�a Date: Certificate of Completion DI.iner: EHS/Date Depth: Grout: DAbandonmeut: Date: Method/Materials: License #: License #: Date: Date Results Mailed: Phone:336-597-1790 fax:336-597-7808 „ �,� �„ ���4sf ���.��� —= � � ���� �° �a�ns����nn��n��.Il ���ran..���n SITE PLAN Name 0 Tax Map #�2.Parc 1#�,Q� Subdi�' n Section/Lot# N C l0-2�-�� Au orized State Agent Date System components represeni approximate contours only. The contractor must,/lag the systemprior to beginning the insta[lation to insure ihat propergrade is maintained _ _. _ __ - _ __ _ V�(e��_ ecm�� � - Nta�n-�-a�� a (� S�K�cKS , f' �' , .��' ._a_ .,� � � _ � ��•'"%`� ~�Hx � i�tF � ^� i � . r�, • • 1 : 60 Feet � S --