A40 28Application Date: 3 I 3� 7
Amount Paid: �d6. D�
Receipt #: 1 �{ 3 �� �
C/�� � � b Au
ermit (Site Evaluation)
00.00 (if> 600 end)
or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
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T�anwnn•amaa.mraae�n4:m� ��a�s.11.�.�in
tion for Services
Services Re uested
Construction Authorization
(Fee is denendent on the tvpe of
Tax Map: /`t 4 �
Parcel#: �
�A11 �ay
��,� � � �� s
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant I formation:
Name: ��L� l� L/� �L��/G ���1����
Address: � �
L
2) Name and address of curren owner (if different than applicant):
Name: ��a tiA
Address:
��
3) Property Description: Lot Size: 3�'+ Subdivision:
Address and/or directions to Property: �. � a�
Phone (home):91g- ��-(0.�� �
(work/cell):
S �.p-}}-
Phone: 3 3 6-S'�17-085' c�
Lot #:
❑ yes ❑ no Does the site contain any jurisdicti 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 agency7
❑ yes � Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
Ca.� 1 �
4) Proposed Use and Type of Structure:
OResidential ,.
� New Single Family Residence Maximum number of bedrooms: �_/ 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
ONon-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: C-3'�Vew well ❑ Existing Well ❑ Community Well ❑ 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 a�plying for `Authorization to Construct', please indicate preferred system type(s):
�onventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other � Any
�
i�e-s���
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequentl�qltered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Lega1"I�epreser
* Supporting documentation required.
��� �s�� %
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.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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7 E�e �rn�n. �r- � �caa.-na � �rn.��.Il IL-� � �.Il �7�n
Tax Map: A�0 Parcel:�
Subdivision Nl�
Phase/Section/Lot #
Applicant: Qt,�Qcco� ('_re�s�,�..�
Address/Location:
Fc�- R��er C',I..�r�J�g,,�. ---? ��..��,,sa�. acToss �a►.� #t 2�ye
Improvement Permit
Permit Valid for: Five Years � Non-expiring
Type of Facility: New �%—Addition _ Water Supply: _�(e l �
Number of: Bedrooms 2/ Oc upants�/ Employees / Seats: ' Projected Daily Flow: 2�{0 gallons/day
Proposed Wastewater System: ZS% Re�l� oH , Type: �Q
Proposed Repair: _�cce�o�c�( Type: g�
J
Permit Conditions: �la-F' R;ver bJakrsi�e,� P�raaev�,f
Authorized State Agent:
(X) Owner or Legal RE
Date: y-/�-( 7
Date:
The issuance of this permit by the Health Department cioes not guarantee 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 aze met. This
lmprovement 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�:d Rules for Sewaee T�eatment and Disnosal Svsfems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that t6e water sapply zvill
remain potable.
Authorization to Coostruct Wastewater System
See site plan and additional attachments (�✓�
Proposed tewater System: �� �� Q���{,�,k, �,S{�> (*)Type � Design Flow Z�0 gal./day
New Repair _ Expansio _ T Soil LTAR: . 3 gal./day/ft�
Type of Facility: S��P Y,,,; j� Dw�[li�e —.2 �i(L Basement: _ es _No
(*) System Types Illb, IIIBg, IV, and V, require pPriodic system inspections by the Person Counry Health Department.
Wastewater System Requirements
Tank Size: Septic Ta��k o0 gal.
Drainfield: Total Area (o oc� sq. ft.
Trench Width 3 ft.
Pump Tank —gal.
Toial Length � ft.
Min.Soil Cover �_ in
^vrease Trap ---gaL
Max. Trench Depth � in.
Min.Trench Separation � ft.
Distribution: Distribution Box ✓/ Serial Distribution ✓/ Pressure Manifold
Specifications: � -
.. . �. -
Authoriz�d State Agent:
Issue Date: �{-/9-('7
Permit Expiration Date: �(-[9- ZZ
The system permitted is: Conver�tional /Accepted �/ Alternative / Innovative . I accept the conditions
and specifications of this permit. �
(X) Owner or Legal Representative: ��� Date: �� - I� �`�j
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
Site Plan
���+(� ������T Name: ��b�cca CfcnS�n�.r Address:�c,
� 1� Subdivison: lJ�pr Lot:�
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System Type: �a� ��P�
Septic Tank:1• a� gallons
Pump Tank: gallons
Total Linear Feet: 200�
Max.Trench Depth: �"
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Tax Map: _Ay0
Parcel: 2$
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Date: y-1q-(7
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Scale: ���= Zoa'
Vote: 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.
4dditional Comments: