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Person County Health Department �
Sewa e System improvements Permit
,
Date: !. is Permit Vo d After 5 Years �
Owner: , �= �� ��,t� �' %� �' ! � SR# .��
Subdivision Narrie: �o�� �d%'?�- C�QW--lC � Lo[ # � �
Lot Size: Type of Dwelling: . �
Water Supply: Private: Public: Community: �
Bedrooms: Garbage Disposal �
Basement f • Basement Fixtures
INFORMATION CERTI��D B� �
$�1��: � ��� f � � oaner or representative
REPAIR: f � � -� VALUATION. ,�', ��' i% � �C
� _ �v��i—�—r�-r � —
�.��--- T"--��- �
Size of Septic Tank: 1A� �!�- ' gallons Size of $ump Tank:
Nitrificauon Line: � l � ��?/ .:, ,
,.
Depth of Stone: 12 inches "� ' J j ,'��-
Max Depth of Trenches: �`� � �'� � � -=— � � �
Altemative System: Conv. Pump LPP Pump Q
Remarks:
-------------------------
Date Well Approved: Well should be 100 f� from any sewer system
BY Sanitarian
Date $eyvag�stem pproved: � �- 23�9 1
By 7J ' Sanitarian
CERTIFICATE OF COMPLETION
Contractor.
_�
Sewage System location, installadon, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained �
by owner in such manner as not to creaze a public health hazard. Septic tank and'd
nittif'ication line must be inspected and approved by a member of the Person Counry �
Health Deparvnent before any portion of the installation is covered and put into use. If
the site plans or intended use change this pernut is subject to revocation.
(G.S.130 A-335F)
I.ocation of sewage disposal sewage system sketched on back.
(OV ER)
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. Note location of water supplies on adjacent lots.
: �1)
(2)
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�-: The District Health Department �
Orange, Pesson, Caswell, Chatham, Lee Coun2ies
Water Supply and Sewage Disposal „F
IMPROVEMENTS PERM.IT No ��
!� �Date .tt _ 7-� - �
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Owner: '1`��' S � `� `� . L '`,�_� av�pS;;� ;�
Location: � � �
F
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Contractor: ~ �` � t-` '
Water Supply: Private Public "
- - . .. ;
Sewage Disposal Faciliiiesd No. bedrooms .�L� Dishwasher, Disposal,
washing machine, other au�matic appliances ' � !
�,; : Size of tank: —���e1b� ' Nitrification line: .
7�
. Other disposal facility: �
. a=
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 INSPECTED AND AP-
'. PROVED BY A MEMBER OF THE DISTRICT �L H DEPARTMENT
STAFF BEFORE ANY PORTION OF THE. IN TION IS COV /
ERED AND PUT INTO USE. %/
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, � Date approved: ; Sign{k �
Weil:
. l�
' Sewage Disposal: _ Counte -
sign
BY: � n
�
or his pf�sentative) ;
_ � , -.
Certificate of Gomptl tion
.Lj" , .�� g .�r l �� !a�
- Date Approved. Y•
, anitarian
` (OVER) � :
7:
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
su�plies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Not � location of water supplies on adjacent lots.
, /� 1 1
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Building Additions/ Mobile gIome Replacements
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Tax Map #:— ���-�'� Parcel#:�_ Address:
Approval Requested for: K Mobile Home Replacement
Building Addition .
Applicant Name: ��"��+�� ���� � ���1�
Address: I�'4 �-���.;,����
Phone #'s: 9/�-.� �o - Dt��v
Permit Located: ✓ Yes No
Installarion Date: 14�1 Design flow: 2 0(gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: ✓ Well Public or Cammunity
Wastewater system shows no visual evidence of failure on: �v � � � (date)
(Applicant's signature if site visit is not required)
/1/a�T� : ���G T�1-�tliL /j �-°w G�2 �Q—t—' �c^rr� 4��..�
�t,4�ST � ��;,�vD -
Addition/Replacement Approv�d
Environmen al eal pecialist
�o%f/i �
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcounty.net
' � ' Appli�ation Date: ! ! � r Tax Map: ���'��"' �
AmountPaid: ��•`-��- ������ Parcel#: �y�
—1-��1��� ,
Receipt #: � � � ����
�E".,�ra�na-�cnanmra�.aa.4;an..11 )E-�I��s.11�l�n.
n
0 Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)__
Mobile Home Replacement or Building Addition
$150.00 (if site visit reGuired)
❑ V�'ell 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)
0 Permit Revision
$75.00
� Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: � �--
Address: L �'t ���5 C'�+�-_ ��.
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):
(work/cell): ji�% - S? o — �c,�+��
�Q�.lp�� d.a�,�d�
U
Phone:
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ 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
Ne� w Single Family Residence Maximum number of bedrooms: �
❑ Expansion of Existing System If expansion: Cunent 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 Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well xisting Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
G) 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 �the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
� a��-y � �-� �- I 3
Signature (Owner/ Legal �preser
�` 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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Person County Flealth Departmen� �
S��nra�e System Improvement� Permit
Date:.�r�`This Percait Vo.id Afier 5 Years � �� �_. f� ,..� �
Owner: ' _ G= ,���=� r� � �`� ,1.� ., .z �% � ' SR# � � ''o
�
.. _..• s ' �
Location/Directi0�: . .==�— � ..! �� _f _
Subdivision Narrie: •` � T�.rl� �'kr�- ��°' S,� ^�"^ Lot # /
Lot Size: Type of Dwelling: .__
Water Supply: Frivate: Public: Community: �
Bedrooms: Gazbage Disposal
Basement 1 • _ Basemenl Fixtwes
INFORMATION CE�.�'I�iED BY .yfi
`` � � "� owner or representauve
Sanitariaii: �% .�;,t✓�.',�.�?i. ". ,�
REPAIR:: - `� � t RE�'VALUATION. j-'" '*' _ . ,_ !�':.���__
` �-" �. �' ��'�_� ��
,,,..!— �' — — — —t ,_�--- — —
Size of Septic Tanl:: r�-� 1<`�, � gallons Size of�F'ump Tank:
Nitrification Line: '" �;�`r�-�-� , ,� -7i , , � �: ,
Depth of Stone: 12 inches� '�� ��T�-��—����-�"
Max Depth of Trenches: � �j`'��� � ��—
Altemative System: Conv. Pump _ _ LPP Pump i
Remazks: — —
Date Well Approved: VVell should be lU0 ft from any sew�r system j
BY Sanitarian !
Date age S, Xstem pproved: �3� �3�9 �— -- +
BY ���1 ^'�-�- Sanitarian '
CERTIF[CATE OF COMPLF.TION I
Contractor. __ _ _ ___
-----------------------�--- �
Sewage System location, installation, and protection must meet state and Iocal '�
regulations. Septic tanlc should be pumped out every 3 to 5 years and shall be maincained �
by owner in such manner as not to creaze a public health hazard. Septic tank andb
nitrification line must be inspected and appraved by a member uf the Person Counry �
Health Deparmient before any portion of the u�stallation is covered and put into use. If
the site plans or intended use change this pemiit is subju.t to zevocarion.
(G.S. 130 A-335F) �
Location of sewage disposa; sewa�e systcro sketched on back.
(OVER)
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NOTE: Make sketch of installation showia� lot size and shape, location of house, septic tanks, privies, water
supp:ies, eic. Note special probl�ms existing on lot. Write in mea�ure�nents in order that installations may be locatcii
at later date: Note location of water supplies on adjacent lots.
(1) (2}
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
���ni�cctGlS Feature Kcport
Page 1 of 1
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