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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
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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)
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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
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Name Al'1r�� �w.a Ta.g lYlap # 3Z Pa.�cel # 6 6
Subdivision ��� ��'-�;s � �Z � Section/Lot#
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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
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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� --�
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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 �
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PCHD, rev. 07/29/Q4
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�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
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Page 1 of 1
Person
Printed October 21, 2015
See Beiow for Disclaimer
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�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
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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
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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
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