A35 29AUG-10-2011 10:21AM FR0�4-
�►.rp�ao� aa:e: 8 I� � 1
�moan� P�tia:
12eseipc �: 1 � 3
'�, �- I ►�
� �tabik Home Rephcemts�t or
S150.00 (if site visit � uin
� R'eD Permit ' lacemec
S30U.�0 Z00.00 �.00
1) Applicaot Information:
\ame:
Address: � lA�
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�dias addition
T-T3T P.001/001 F-203
...��� � j 1� !L� �ey�l� � s ax Map: /k � �
`�'''�� ���3�T'�'� ran��: �
�..i,�.o�. �..,��i �FII�.a.��
�tication for Services
Services R nested
Coastractioa ,�ntb�rizapoa
ee is d deat on t6e e of
� permii Revision
G Repair of Ezifiag Septic 5ystem
Applieation No ChargeJ CA SlS0.Q0 or 5300.00
Phone (home): �� "���" ���
(wotklcefl): �a�
Z) Naate and add df cnrr�n t enroh �(� differeot t6an applicant): ���
\ame: �� 1�0�'�' �"` �. �' ` � I � ; Phone_
Address: I � � ,� � i _,
3) Property pescripdou: Lot Si�: ���'�ral�5ubdiv'tsion: . Lot #: -B /� .�-
A d and/or directio to�rope : � �', .r, ` .( �, ' aat � � Uh .+'� �.��N�'_ l .�-�% ���`�� ��,�
a ✓�J' D.�,PiNI ' r��x11 '' � l9 , � , 1� �r� n ,� • ed � . a r7-t� �f�.
❑ ao Does the site contain jwisdictional wetlands? I�!� �,�¢Q���+�.��,���rn�r- �J+�� a�n �
yes ❑ ny� Does the site contuin any existing wastcwaie[ syscems? "TM"� n e ��.,� fy��-
p ycs �o Is any wastewater going co be generated on chr site other chan damestic sewa e? l'�1+�' -�i.r rl D- � �/�
ite sub'ect to a rovaJ b an other public agrney? s �J �'�,! ��� �-t� �r'� Y�'���
s G}� o Is che s Y Y U� ��� �
❑ ye G�}� 1 PP ,� ��4 ,�� �
� yrs [3 no Are chcre any easemenn o� righc of ways oa �his propercy? �i l���e�. �(�a�
(if'yes' is checkcd, please provide suppoRing documcntation) �� �
4j Praposed Use and Type otStrncture: ���Ci,����� ���,'u'-�'1 ����' ���J� ��������' �� 3 �
pResidenti9l
p�lew 5iagle Eamily Raideace Mauimum numbcr �f bedrooms: a- t Occup ts: �_
D Ezpansion of Existing Systcm !f expansion: Currcnt nutnber of bcdr�s: __� (un
�Rcpair to Malfunccinning System Will thetc be a bnsement? ❑ ycs no With pl bing fixnlrts? ❑ yes ❑ no
❑!�on-Residen i
T��pe ofbusit►ess: __ _
�Sa�cimum number oCtmployeas:
TacaI Squnre foota�e of Buiiding:
Maximum number of seats: _
5) Water Supply�: C7 vew well��xisdng Well O Communiry Wel1 D Pu lic Water � 5pring
Att there any cxi��ing wells, springs, ot existing watcrlines on this properry? I�yes Q no
Plca�e note any known gound watcr resttictions or sourcts of contaminalion: ,/►tUlti .
6} If appi�•ing for'Author'��acion to Goastrucc'. please indicate preferred system type(s):
❑ Canventional � Asccpiad ❑ lnnov�live Q Altcmative O�thcr _ ❑ Any
I cGr�iJy tha� �he injormadan prnvided above rs completP crnd correct. ! also underycand that if rhe injormatlon provided is
ir+ucc•urate. th i�z is sub.��quently alrerrd, ot the intc•Rd2d use r.�l:unxrs, al! permirs and approva/s shall 6 im !id
_. � `.� - - .- � I� 1 `�'
5„nat re (O���n�rl Legai Reprasent tiv�•) ate
�' tiup rtinb dOcurn2clfati�n requlCZd.
• Permic. are valiQ for eitber 6U montbs or are aon-expirin� when aecompanied by an approved plat� ,
. .a completed •Lo� Preparaliun' form mast areompany any ap��licat;on requiring a site evaluation. ,
_ .. __ . _t _..`J
� � u �� i P�rso►t Count� En�•ironmc;ntal Healch, 32� S. Morgan Sl., �uite C, Roxboro, NC 27573 (336-597-1790)
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August 15, 2017
TaxParcelPublishing
Person County
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1:564
0 0.00475 0.0095 0.019 mi
I—+-�--T�����'�--r'
0 0.0075 0.015 0.03 km
Esri, Inc., Person Canty GIS
For Reference Ony -Always referto the original sou�e.
Person County is rat respmsble for the use, misuse, or m'sinterpretatlon ot this iMormacion
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Y'r �'�-�-
System Type:
Septic Tank: gallons
Pump Tank: gallons
Total Lin r Feet:
Max.T ench Depth: "
v f �2�— � ���G � rJ� �—,��—
Site Plan
Name: LtE�rIt1� G'�t..4U;-z�nl Address: �E
Subdivison: Lot:
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EHS:
Date:
Tax Map: ���
Parcel: �9
.i .
Scale: / _
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Health with any questions (336) 597-1790.
Additional Comments: �ill5�!/fC� G1%� ilil/Ls�I �� �/1//�'j%• �¢�i/�il�i�JV� �✓/i!�
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IE��,�,��,�.m,���.Il 7�33C��.➢. �lEn.
WELL PERMIT
(New� Repair_)
Tax Map: ���j Parcel: �
Subdivision:
Applicant's Name: /�/yr/'�/f_ ��✓1,r.���1%
Mailing Address:
Phone Numbers:
Lot:
Location of Property: f • ► ���/�w �/' -
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regula#orrs governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not arantee a potable water sup !
Other Conditions/Comments: /.�c,/ �ill�rrtl/�� �,1� � �'!� _ !�i l✓'
Permit issued by: Date: �
QNew 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:
Additional Comments:
Date Sample Coilected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Certifcate of Completion
OLiner:
• EHS/Date
Depth:
Grout:
(�Abandonment:
Date:
Method/Nlaterials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336•597-7808
11/26/13