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The Distr��ct. Health Department ,
Orange, Person, Caswell, Cha3ham, Lee Counties
Water ,Supply� ar�d Sewage Disposal
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Owner: � � ��'�- t � ��,�, ����
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Location: ; ��� � / - , !
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- `_ l�1l,��fJ'aIls �.r!�s
Contractor: ^�-��"
Wa2er Supply: Private
(_ _. -;'."" Public
i" ,
Sewa e Dis osal Facilities: No. bedrooms J--' 1)ishwasher, Disposal,
ashing ac�ri�rfe, other automat'c appliances ,�` � �' i
Size of tank: � � �_. ��� Nitrification line: `�� t� �,
�� .^j �"• _ . . : ,• � / ,
— v
Other disposal facility: —
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Above recommendations based on information received and observed
soil condition. Septic tank and nitrification line MU5T BE INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PAR.TMENT STAFF before any portion of the installation is covered
and put into use.
Date approved:��
,, s: r �
Well:
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Sewag��3ispa3al•_
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Byp� ..��..p . .> - ,�/�I/._._�
Countersigned
ERTIFI
(OVER)
F
ealth� Department
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 existing on lot. Write in measurements in order that installations may be located
at later date.
, � � � � ��.� -- ---
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Application Date: �� aa i 6
Amount Paid: 1 �D � �
Receipt #: ! 77d y�
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 if> 600 d
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Weil Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
�—.�?,� J 11 ��� �L.t�l V
- .. _ �. � ����
JE��s�v���.��.Il ]H[��ll;�
tion for Services
Services
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
, . $75.00
Taz Map: A 3 3
Parcel#: 3 �
� �erN, 4-p
b r� �+ N o� i aca��l
pair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
�`1) Applicant I forma�tion: /�
Name: � J�la e. w�� 1(
Address: E Su S
�2�o�r'a 1JC ,�27343 �
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: �� Subdivision:
Address and/or directions to Property:
Phone (home): 33 � `" ��l `'$'i���
(work/ce11): 3 � � � � � ` � 2—
Phone:
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wetlands? /L s �
❑ yes ❑ no Does the site contain any existing wastewater systems? ��'�L'Kt � y`�� '� �(
� yes O no Is any wastewater going to be generated on the site other than domestic sewage? /i �_/ J
❑ yes ❑ no Is the site subject to approval by any other public agency? �� ��C t?�`Z;
❑ es ❑ no Are there an easements or ri t of wa s on this ro e� ' t'
Y Y � Y P P rh' • ���� /,�
(if `yes' is checked, please provide supporting documentation) ��" 0-�L ►
4) Proposed Use and Type of Structure: �� x�G
❑Residential '
❑ New Single Family Residence Maximum number of bedrooms: 3 / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Squaze footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well �Exisring Well ❑ Community Wetl ❑ 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 applying for `Authorization to Construct', please indicate preferred system type(s):
� Conventional ❑ Accepted ❑ Innovative � Alternative ❑ Other � ❑ Any
1 certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the sit is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
jZ 2 2a b l G
Si a ure (Owner/ Legal Representative*) Date
* Supporting documentation required.
• Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any applicatian requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Building Additions/ Mobile Home Replacements
Tax Map #:– ���, Parcel#:�(� Address:
Approval Requested for:
Applicant Name:
Address:
Phon� #'
Mobile Home Replacement
l� Building Addition ^- � x �b
Permit Located: � Yes No
Installation Date: - � �
Design flow: ��b (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: � (date)
(Applicant's signature if site visit is not required)
Addition/Replacement Approved
.� .� _
Enviromm �ta He Specialist
t�a/i �
Date
Person County Environmental Health, 325 S. Margan St., Suita C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcount, .�net
��2T1�L �I�T� ��'� L��/N,�'� `}�'
�\�� ! ��v �� �� Taz Map: ��'?,� Parcel:��
_ . � ` � ) � � Subdivision
- � � ����' Phase/Section/Lot#.
ICs �-� � � ������.11 IF-3I � �.11�I�
Applicant: _�
Address/Location:
------------ ------ _---------_____. -- j�E-I ►•��Act�TI�N
ImprQve�entPerrnit CbniF. ���►���-
Permit Valid for: Five Year ✓ Non-expirin�
Type of Facility: ~ New Addition ZC VVater Supply: V�%�'Ll�
Number of Bedrooms Occupants / Employees / Seats: Projected Daily Flow:.� gallons/day
Proposed Wastewater System: ���d-� -c� Type: �
Proposed Repair: Type:
Permit Conditions:
�
Authorized State Agent: _
(X) Owncr or Legal Rep
Date:
Date:
The issuan�e of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applic�ndproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Yermit is subject to revocation if the site plan, plat or the intended use changes. 1`he 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 `Luws
and Rules for Sewage Treatment and Disnosal Svstems'(15A NCAC l8A .19U0). Neither Person County nor the Environmental
Health Specialist wArrants that �he septic system will c�ntinue to fanciioB satisfactorily in the future, or ihat t�e water supply will
remair potable.
Authorization to Construct Wast�water �ystem
See site plun anJ ua'aitior�al attuchments �_).
�
Proposed Wastewater System: l'L �p-�''7� —��� W(*)Type T 1 Design Flow _�_ gal./day
New Repair _ xpansion � Soi( LTf1R: �. � gal./day/ft2
Type of Facilit�,�: — Bssernent: � Yes _�to
IY. and V.
Tank Size: Szptic Tar►k b O gal.
Urainfield: Total Area �/b sq, ft.
Trench Width � ft.
v the Ferson County Health
Wastervater System Requir�msnt�
Pump Tank gal.
Total Length 1 O_ ft.
iV1in.Soi1 Cuver in.
Distrib�ti�n: stributio�� Box X/ Serial Distt•ib�tio;�
�_ . _
Specifications:
Grease Trap gal.
Max. Trench Depth � in
���U�%i� %1'�
?I�� oF /i✓�i�i`ZG•
, � �D�
Min.Trench Separation �_ ft. ���'�i �� •
/ Pre�sure Manif�l�
�,
Aiithorizzd St4te r.gent:
The system permitted is: Conventionat /Acezpted X/ Alternativz / Innovative . I accept the conditions
and specifcatior.s of this permit. ��
{X) Owner or Legal Representaiiv • Date: ����i-�.
Person C'ounry Environmental Health, 325 S: Morgan St, Suite C, koxtioro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Applicant:
Location:
Oueration Pern�it
�
Tax Map �� Parcel # �
Subdivision
Phase/Section/Lot #
# of Bedrooms �
,
System Type (From Table Va): Product (IIIg): //������
Type V& VI Expiration Date: 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. ��t'i�
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Contractor)
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Scale --�--
PCFiD, rev. 12/14/12
Tax Map: ���� Pa;:,el #: �_
Septic Tank System Checklist (Type II-I� System Type: _��
Notes•
Pump System Checklist . .
Pum Tank InitiaUDate
State ID & Date:
Ca acity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back Iug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Mani%ld
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
ConnectGIS Feature Report �� Page 1 of 1
Person County Environm..n.al Health .�,y� ��,�
� ��� � � �� � �, 325 S. Morgan Street ,��3'3<0
�f Person
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NOTICE RecenUy, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who hav
�recently upgraded to the Windows 8 operating system or a new version of Intemet Explorer. We were able to resoive this issue by directing users to the Intemet Explore
Compatibility vew tool. This link is to Microsoft's "How To" for the tool: httpJ/windows.microsoRcom/en-USlntemet-exp�oredproductsle-9/features/compatibility-vie
if this does not solve the probiem feei free to contad us at the number listed on our main page. Welcome to the Person Counry GS Website. ConnectG15 has bee
�repared for the inventory of real property found within Person County, and is compiied from recorded deeds, plau, and other public records. Users of GLS system ar
otified that the aforementioned public information sources should be consulted for verification of the information in this system Person County, Mobile 311, ConnectG
ssume no leqal responsibility for the information in this s stem. Grid is based on the NC state lane coordinate stem, 1983 NAD.
http://oldgis.personcounty.net/ConnectGIS v6/DownloadFile.ashx?i= ags_mapc7d2d4359e... 1/6/2017