Loading...
A40 366Application Date: 6 g (i� • . ���� �`�,S (` ������ Amount Paid: ,206. O(J �Q• � Receipt #: 1 7 � � % [�� - � �' � ���� � ).�.an.w�isacD�ra�rn.n.a:;�ra.tL�m.11 JHja:..m.�sL�in �� � �� � Auplication for Services Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Home Replacement or 8uilding Addition $150.00 (if site visit required) W�II Permit �New.�Replacement/Repair) $3 00.00/$200.00/$75.00 Services Re uested Construction Authorization (Fee is dependent on the tvpe of Tax Map: �i'� Parcel#: 3 G � Permit Revision $75.00 Repair of Existiag SeptEc System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: / Name: /��/.,��°lj �j %70 rv�� lt 5 Phone (home): ,�36 �c�d �f — � �6 � Address: ' ' / (worlc/cell): D ��� �� � ����y. - � �o 2) Name and address of current owner (if different than app[icant): Name: Phone: Address: 3) Property Description: Lot Size: �� Subdivision: Q � Lot #: �p Address and/o: directions to Property: v - �' � �"� ��1 /,�i 1�.� i��/r 1+°/��� �'�i�n r r�� �.�,�,� �p �7 o n�')o.�c� �n�l a f eo/ c�Ps¢G ❑ yes no Does the site contain any jurisdictional wetlands? ' 0 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? 0 yes C� no Are there any easements or right of ways on this property? � (if `yes' is checked, please provide supporting documentation) 4) Yroposed iJse and Type of Structure: ❑Residential e�gle 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 �I 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: Ca'fVew well � Existing Well ❑ Community Well ❑ Fublic 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 ❑ Altemative ❑ Other ❑ Any I certify that the ifzformation provided above is complete and correct. I also understard tl�at if the information provided is inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Legal Representative*) * Supporting documentation required. � ! r � Permits are valid for either 60 months or are non-expiring when accompanied by an approved ptat. A completed `Lot Preparation' form must accompany any appiication requiring a site evaluation. (1�/15) Person Count.y Environmental riealth, 325 S. Nlorgati St., Suite C, Roxooro, Iv'C 27573 (336-597-1790) �����s� ���.��� �, � � ���� ILe �-Ya � � ������.I1 I�3I � �.11�1�a Applicant: ��� Address/Location: _��r�_L�S•_- Permit Valid for: Fiv Type of Facility: Number of: Bedroom Proposed Wastewat r Proposed Repair: �( Permit Conditions: �_1..� s� ' Ccc ( � C__���`� c ------ Improveanent Per�it e Y s � Non-expiring ✓j� 8 New � Addition _ s y / Occ,�pan� /„Employees / Seats: S stem: �;�p, �{�(� � `� .Sk'-e Tag Map: I�'f" � Parcel• 3��p Subdivision�-�,Y�� •� Phase/Section/Lot # VVater Supply: ��� � Projected Daily Flow: �U gaIlons/day Type: � Type: � Authcrized State Agent: ,t�-f�,?'r''� L' .�-lYl''"el Date: (P �( (X) Owner or Legal Rep sentative: � j�, vvti�� � r��— Date:�j The issuan�e of this permit by the Healt�h Departc�ient does not g�azantee the issuance of other required permits. It is the responsibility of the applica�ndproperiy owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Percriit is subject to revocation if the site plan, plat or the intended use changes. The Improvemeni is noi affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carotina `Luws nnd Rules fo� Sewa�E Treatment and Drsnnsa! Svstems'(15A 1VCAC l8A .Y9U(1). Neither Person County nor the Environmental Heaith SpEcialist �varrants that :he septic system will c�ntinue to fanciion sat;sfactorily in t6e future, or ihat t�e water supply wiii remair potabf2. . Authorization to Coostruct Wast�:�vater System See site plan and additional attachntetits � ). � Propos` �d Wastewater System: i, (��/l��C — oZS ��V (*)Type:.� Design Flow �� _ gal./day New i. Repair _ Expansion _ Soil LTE��� gal./�aylftZ Type of Facilit-,�: �✓�I� ►QPS • Basement: _ Yes � I�'o (*) System Types III6, Illbg, IY, and v; �equire periodic system inspections by th_e Person County Heallh Department. Wastewater System Requirements Tank Size: Szptic Tar�k (%�� gal. Drainfield: Total Area jZd � sq. ft. Trench Width 3 ft. Pump Tank � gal 'fotal Length �� ft. Miti.Soil Cover �° in. Grease Trap ' gal.Z$, Max. Trench Depth � in. Min:Trench Separation � ft. Distribution: Distribution Box� / Serial Distribution �/ Pressure Manifold ____ Specifications:�—%Io1C c1�r �P�:°�� r5 d•K. --�� 1�`h�7C i�s���—�u_4i 1�t�� ��''��S ,�uthoriz�d State Agent: �� M � �lvv'2� Issue Date: (� ` � 7' «p Permit Expiration Date: % � ('�C �Z ( T'he system permitted is: Conventional /Acczpted �/ Alternative / Innovative . I accept the co�iditions and specifieations of this permit. (X) Ovvner or Legal Representative: � Gtwv►" l,• vcv Date: �% j �(((a Person Counry Environmental Health, 32� S. Morgan St, Suite C, Roxboro, NC27S73/ph: 336-597-1790 (rev 5/ 12) _ __ ���,5 � ���.�� � � c� � �J1�T ]Eaa�flsoaax�amam.v�-mIl' ]E"3C�e.a7l�lla SITE PJ AlY �O ,�� j vt S Tax Map# � Pazcel#�___— Name� '� Section/Lot# Subd' �s Q' � f "/��- Date Authorized ate Agent — System cornponents represent apprnximate ccntours only. The contractur must flag the system prior to 6eginning fhe installa�ion to insure that propergrade is maintained. Note: An Accepted syslem mny be used ir. pince oja conven�ional sys�em without permit authorization or modificution. ��` �� � � 1 5 l�� �. '� vo � a� ��" l�'�2 � � Z�'' � K c� o�,/�� � a W r� � �� �`^�.`� ��`- ���- � � � �y� �� � �� •�` � �«L�,6 .LLS +J � 4 , ��'��,�.�. • �,� "� ��, �o�� ��� -.� ti �a, . �sa a (,r� �,� � ���-�.��a,��... :.� �,.� c.,�, y � � ��� �� ����� , �°� �� ��s s Si�p,r,,, q�- (,L.9L��- � �-ri�-- ! , � . �� �,� . ...b:..:._.. ._._ _��' � �.o �o P1� r �' �� �! . 3��9��6fi�Z8� � � • �'^I �� 6� `0� �9s � � .,.,� . 99 �-� ���.sf ������ �_ � � ���� I��.�n���,.,,-„ ���.�,Il IL���.Il.�I� Applicant: Location: System Type (From Table Va): Type V& VI Expiration Date: nI ��i���tl��i ���'iyli� Tax Map y � Parcel #� Subdivision Cr � Phase/Section/Lot # -1(v # of Bedrooms �( 0 0 Product (IIIg): �r� Type V& VI Renewal Date: !� This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sev��age 'Treatment a�ad I)ispasal, a�d all conditians of th� I�tprovement Perm:t and Con�truction �Lutharization. (Authorized Agent) �I�� �-2Wt� (Licensed Contractor) Scale � PCHD, rev. 12;14/12 q-R-ll� (Date) 9- � J � (Date) J Tax Map: �� Parcel #: 3fQ[¢ Septic Tank System Checklist (Type II-I� System Type: �_ Notes• Pump System Checklist Contracted Certified Operator (Type IV Systems): Notes; ���.sf �I��.��� . ������ IE��au-���m���.Il IE-3L�mfl�l� WE�L PERMIT (New Repair_) Tax Map: � Parcel: 3� Subdivision: n Lot: �_ Applicant's Name: ��..0�,,� �,�j(w �� ►2 �_ Mailing Address: ' Phone Numbers: Location of Property: s jJ) �� �� �� -� ��{- �►.� �Ot►�CQ L.h • Per`nit CoKditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and County regulations governing construction and setbacks apply. 3.) Permits expire S years from the date of issue. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: Permit issued by: 7�.1 � Certificate of Completio� �Tew WeU: 1 Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: EHS/Date Q�� 314 q -2-t-1 � Date: �P�f'T-L� �- OL,iner: EHS/Date Depth: Grout: DAbandonment: Date: _ Method/Materials: Well Driller: �,� Yn�? License #: Pump Installer: � \ License #: Approved by Date: c3—�({ Additional Comments: Date Sample Collected: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C Roxboro, NC 27573 Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 11/26/13 £[�Z'iJel� •G!Ima�'ld3u w�sa!Q—�os'g 1�t1 P"� �!^TM33�s�Q eu!IarJ R�1V t•M`J �iO3 '�110� �R� annomtr �l IIo?��3�!Q'9£I �� �� � rb� �t�y .�� �t,. w �mnu� �r� � �►md� n� �t 4 H1H 3� �P Q£ u�sp�� uuo; s�43 ;o .idm auo .7!in4ns os� '?eoqs (s��'PRE �� �sa�10 P�4>>31l Y�� IIP!1l '�£T o'i uuo.� �A Bv�P+xis o3 uomPP� �{ sl e1 �. �t �9. eg p7rtA� .w ayL a�tu�m pZ�19 �`Z 9i91�69LZ �N `4�lRI `�°�'S1 `x'S t!�1� �f9T =A3AI0 S17�M A7ddf1S iYB�.Yt4Y.tI03 'msa�wa.pJ,ao� nun�arcq p�os�rapn j�'61�eeD �=MJo no!�a ('�'9� P�!P •�14e� •du+c* a�+s »3 �oito3?iA�#�0'� � �/ `.P.oAj�w nog�n�qsno�.lt�M'Zi It?"► 3o uona(drnm 3o s,(eP 0£ +�!�ix� puo� snP }o � 8�Qns � b�oqe et,� m ssaiPDB'tR a1 �3 �A 9tnpuas.o3 �1?PPR u1 �1Pt1A aog a.ol J4 '9D2 �'�3 v :�a�aump alo�t?��8 'll LT4t-¢b9Li��i `4�1�1 `�a°�'�!'�S i!'�t'N LT91 ymn �o�ssa�o�d aogcm�a,�ai `•Sl�snap7sy:io uoxwQ �mhwl�°3.�A44 �m�D Il� 3� �!�ldwoo;o srSeP 0£ �4#,T^� �013" �!4i I!@9�S �7P ItV ��3 'eYl SAIOI.r.�11;IS[�'IV�.7] Wgf iS •�ess�o�u;��iSed teu4n?PPB'�A8 � � �.I �s7-�P �O�°? il?m �o sI.�P � iP� �°9?PP� �'PTeo�d o� �1 snA 3a �9 �B qsn �w no,X �1.�'P IP�i�o9?RPs.to m�n.P.�3�'£Z , »reo �aic �ip.vi poplAaK1 r�s4�tF�u �1°'fdos a� P►� �?'n'P7°�S�±�t»MQro'J Ii�dl.00ZO' at0 �V:7K i3/ � 0070"3Z03Y�At YSJ+p?� '�eooa u! P�° (arae5l rax lr�1NK �Y► my/ ��° d4a»Y! 'nuaf sFFB�+l+�$n' �9 :� �`J IPaA Po4�3�� � ��� -�Z J" � r �_� - . �oa�.� -zz _ <, �Z� � � C�8/ �S� �. � -ti -a��aS v sb -s � i'''j'.S ( � n{� �r �%�$' �v . -Er( � -,� � Z -� ? . lY��°7/ °1��o�A-A �s Z -�y �i �+„ anr B+gsw qnnqn s11�!?�%°M�fl ���) �,2 :�a�a;o da� xoNA lasai ra�a,� a9qS 'Ol G�OJ�ZP�.00Z�£-?Id�n1 ��FTl +*l�PIl�7s71 sD'�?l�>Y°Y���` ��7) • �� j ;»t}tnsputf�Ri�991�?P11p�.I�Q.L"6 ztt,�jwo f�wqrrs imv Jmuf'so�m4+�►� �s?Y/ Y�!"�d7N0 ��Xkhu mcerLae �o uo.n�(u.r vld'A� JO.� / :Pa}�nalsnmsQae�JolaqmnH:-g � ��rl�Pf°fi�O?yyt uo lo umnas apemua� 7ZO /aprx+.qod�u �%�' a'/+ ri?nld�irs7+� �tluumf�+!'io'talqa'n' Il�"i,ie»or9rr+n Af'ftadau u+7 t1'AI! � �o a�p .ryps��itgslirsns.o?�redua�4lsi'L . dnaodmayp .�o ��mnsmaa� :fs)lt�n+?�B.(an}si.9. � 2 �' /cj " $L• � �L �`r/S ' `,�£ c�� �u���rps r�� :y�u3?p Itwmp �ospuo»s�dpim�sai�ap n� aP�!�o'I Dne opn�9s'I'9S U1IdJ'�t1�'4!�Pl l�d �01� `� 5� � �'�:�}�a � �!z� •�a'�vav ��ua - � �� t� � cn�!�r.) ��r.n� �u�ot�np8a � _, , rn d :nege�u'I II�M'sS � #QI.IPe41�J z/— �a»idmoJ(s)iNrts.�at4'7 't) �l �.t �! w, wo� r va��v��auvs:-f � �t � �� �y'..72 �) CJ � 7) 7! � -� �r �►s aa�rma ot - ;: ";<Ar�3a w 7! �J v� 'il "�3 _ ,--_. r._ . . � , � 2 C��� -� u /�2�Z z �� �� » tLF/ .t�' ,, � „ oz < -� �� � ----- - =A1N0 x111��°I �O� 3 tZii pR� II1el�) p�PO❑ (uw� �ml�'J/��i7)1�4��JD ��].D ��'7 Paml�) �=JD ln��'J�P��SD �ao�oU�i����o a�e+na�Q»7en�t�uo�SO �.i,�3!nbVO »NRfi �iP?!I?S❑ {anox� pus a�$ a.;!nb�+D uo!7erPaun21+�3�+P�rJO ��{�ZI �3!flbVO lPM•C�ddng iP�4s) �f�S p7Eh1 iEA°�P��IO IE!�nmIDo'J/le�"P�ID (o fdors) ,(�ddng �e1�A lei1�� ��lddnS �!l�'J/$�7eaI� Ie�ti3�JD -�!ia�p��wD �rn!�io :(asn iP�+ �P�) �II IPM'£ (�a �xxrq�o� 4roJs �Grom'J ��� struuaJ uor»�uuvav 11� �19�tJ� lln �t!7 n� :p ?�w�ad numwqsuwJ irn� Z �meN dned�uo, ��u� �6u�11!�O IIaM a��awe� nqtunN uonay,n+�� �an�A�'J IPA13N ~� G 2. �H ��� n�nn `�' �� _ � `�' '�� :noUtuuo�ul �oa�Wuu� IPM'l s�p", ��dn� �o a�ms,o; P� �9 � "O°! T:41 a�o��x uol.�ni�.suo� ���