A32 85•� � red ��- cJl i d�u o�- � e-i- eJha�r�,�
Application Date: 2�—� 5 p� pp� �� Sf ������ Tax Map:
Amount Paid: � �� o • �.`.'� • �r Parcel#:
Receipt #: . 55 � A ���1 ~ � � ����
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Impr t Permit (Site Evaluation)
200.00 300.00 (if > 600 gpd)
Mobile ome Replacement or Building Addition
$ I50.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
tion for Services
Services
Construction Authorization
(Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: J�, ,,;, LJ {M d r-f; < _
Address: 1`7 �'s l 17) c�f l�i,r 1, c, .�.� i2d
�ox�i�,�) _ �7 7�
2) Name and address of current owner (if different than applicant):
Name: �
Address: p, p. // �'i 9 7�' S� /�� �/�e i f,��
f;�L,-a/� ii��//s �'�G ��75�1
Phone (home): N�
(work/cell): 3'�G, - �83- 9 7�6�
Phone: ��6' ��`i�"�.5�3
3) Property Description: Lot Size:o� H«f Subdivision: Lot #:
Address and/or directions to Property: ����-�,��'f Gf' ��� �.-�L��vG, ��
/7 G�- �IY /!'/% /�� �i�
❑ yes ��" Does the site contain any jurisdictional wetlands?
❑ yes [��'�no Does the site contain any existing wastewater systems?
O yes Ly'no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes CJ-� Is the site subject to approval by any other public agency?
❑ yes C,� o 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:
❑�R�esi� ntial �
e�iQ w 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 io With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: C�'New well ❑ Existing 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):
O 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.
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Sig'nature (Owner/ Legal Representative*)
* Supporting documentation required.
Date
• Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved ptat.
• 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)
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Applicant: ev,
Address/Location:
Tax Map: 32 Parcel: $�
Subdivision l�
Phase/Section/Lot #
Improvement Permit
Permit Valid for: Five Years � Non-expiring
Type of Facility: �r �vcr��, �e,S;�J .�c . New �Addition _ Water Supply: 1�e [ (
Number of: Bedrooms 3/ Occupants i,a / Employees / Seats: Projected Daily Flow: 3(Fo gall s/day
Proposed Wastewater System• �,GC� c� 25% p ucf-;oh Svskn� ) Type:
Proposed Repair: —P �—� Type:
Permit Conditions: � Ps�t�S,,�; t�F�n.�- ;,,P,� 1�•ial�r�e� �i�s rb�H�� �u(es �
ai i� � —
Authorized State Agent• Date: 3-3-/S
(X) Owner or Legal Repr eatative: ....�- �— Date: _� d3'%�
The issuance of this permit by the Health Department does not guazantee 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 North Carolina �Laws
a�trl Rules for SewaFe Treatment and Disnosal 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 supply will
remain potable.
Authorization to Coastruct Wastewater System
See site plan and additional attachments (�.
Propose Wastewater System: � �(,,pn�� r� ,��;n t/S n� �(*)1`ype �_ Design Flow �I � gal./day
New � Repair _ Expans o 7 Soil LTAR: .�Z'T gal./day/ftZ
Type of Facility: — Basement: _ Yes No
(*) System Types Illb, Iling, IV, and V, requlre periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank COD gal. Pump Tank '—�' gal. irease Trap --'gal.
Drainfield: Total Arza �RD sq. ft. Total Length 3�0 ft. Max. Trench Depth rg in.
Trench Width .S' ft. Min.Soil Cover �S in. Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution�/ Pressure Manifold
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Authorized State Agent:
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Tl�e system permitted is: Conventional /Accepted ✓ / Alternative / Innovative . I accept the conditions
and specifications of this permit. ;� g d��/�
(X) Owner or Legal Representative: ..---- � _ Date:
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
Issue Date: %-/�(-�S
Permit Expiration Date: q-/y_ 2p
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SITE PLAN
Name QVI 1 VlerYi �
Subdiv'sion f�
A thorized State Agent
Tax Map #� pazcel # g.s
Section/Lot#_�S
q'-�N-l.�
�ate
System components represent approximate contours on[y. The contractor must,Jlag the systemprior to beginning the
insta[lation to insure tl:at proper grade is maintained 1
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' 330' R ���.
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Application Date: � 1 �1 �
Amount Paid:
Receipt #:
���'?, ) f ���� ��. V Tax Map: � 3�
�- � � ���� Parcel#: �—
I��cawnn-�ar�,ae�.d�..� I��e,�.l�L.�.�a
Application for Services
Services Re uested
0 Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 if> 600 d) (Fee is de endent on the pe of system permitted)
C] Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uired $75.OU
�`Neli Permit (N�w/Re�,lacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Chargc/ CA $150.00 or $300.00
1) Applicant Information:
Name: �� � u lU�o 1�h� S Phone (home):
Address: � 8�-1� � b1 u�d1e � i t1 s 12 (worWcell): — q� R Z
2) Name and address of current owner (if different than applicant):
Name: Phone:
Address:
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes � no Does the site contain any existing wastewater systcros?
0 yes ❑ no Is any wastewater going to be generated on the site other thar domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public ageney?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure: .
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repau• to Nlalfunctioning System Will there be a basement? ❑ yzs ❑ no i�'ith plumbing fixtures?
❑Nan-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
�4x��
M e�-Q� l31d � -
C G�.1-a � � �„$,a P )
❑ yes O no
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Weli ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no
6) If applying for `Authorization ta Construct', please indicate preferred system type(s):
C7 Conventional ❑ Accepted ❑ Innovative � Altemative ❑ Ot,�er ❑ Any
I C2YLl�� that the infos•mation provided above is complete and correct. I ulso understancl that if the information provided is
inaccurate,� if the '�s subsequently altered, or the intended use changes, all permits and approvals shall be im�alid.
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
�+/� /�C�
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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applicant
Location:
Tax Map �2 Parcel # ��
Subdivision
Phase/Section/Lot
# of Bedrooms '�
Operation Permit
System Type (From Table Va): � Product (IIIg): EZ
Type V& VI Expiration Date: � fA _ Type V& VI Renewal Date: �_
_�
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization. ,�
Authorized Agent)
C. CD[���.
(Licensed Contracto:)
Scale
PCHD, rev. 2/14/12
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3- 22-�[n
(Date)
3-22-I(e
(Dste)
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Building Additions/ Mobile I�ome Replacements
Tax Map #: A32 Parcel#: g� Address: �6 �ig ��� ��i���S �
. ,� ,�,,'1 s � �s�{ I
Approval Requested for: Mobile Home Replacement
�Building Addition .
Applicant Name: � � v i ►� � � �^r � � _ -
Address: g ��,•�,j; l(S � _ _ __
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Phone #'s: ��63 -Q �Q?
Permit Located: � Yes No
Installation Date: ,-2�-I� Design flow: 31e� (gpd)
Current Contract wi+.h Certified Operator on file (if required):
Water Supply: ✓ Well Public or Community
Wastewater system shows no visual evidence of failure on: �� l(e - (date)
(Applicant's signature if site visit is not required)
Comments:
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�1�h�1� � . . ,. .. ,. ......
t�ddition/Repiacemen� Approv�d
Envi onmental Heal Specialist
Li-��I-1�
Date �
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
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�i �ra�a�r�aa�rncao�tad.m.� ���'���in
WELL PERNIIT
(New�Repair_)
Tax Map: ,�_2 Parcel: gs Lot: �
Subdivision: .
Applicant's Name: !��ti � M o r r� s
Mailing
Address: ih4�I OI�I. I�ur���- �d
Rek4���o NC 27� 7 �
Phone Numbers: ?? � - �z' 9752 —
Location of Property:
�
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and Counry regu1anons governing construction and setbacks aPplY•
3.) Permits expire S years from the date of issue.
¢.) Issuance of a permit does not guar'antee a potable water supply
Other Conditions/Comments: �
i
Permit issued by:
Certificate of Completion
�1ew Weu:
F�HS/Date
Location: 1� 5 2���4
Grouting:
Well Log:
Well Tag:
Pump Tag: 3 -�2'��
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller: -� '
Pump Installer: �
�ipproved by: ��'�
Additional Com�nents:
Date Sample Collected:
EHS:
Date: �' —1 y—/�
DI.iner:
EHS/Date
Depth:
Grout:
[�Abandonment:
Date:
Method/Materials:
License #: 37
License #: �—
Date: 3 - 2�—
Date Results Mailed: ______
Perso� County Environmental Health , Phone: 336-597-1790 Fax: 336-597-7808
325 S. Morgan St.,Suite C
11/26/13
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