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A40 377Application Date: ! � y Amount Paid: ► �6 , 00 Receipt #: 844�7`� � �� A ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (1�1ew/Replacement/Repair) $300.00/$200.00/$75.00 '��i,. )� �1l.�� A. V Tax Map: � 4' � ��.��,�� Parcel#: � 7 7 ��m�aa-��,.��..n iHr��..n�.�.�. Services for Services 0 Construction Authorization (Fee is dependent on the type of ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information• Name: S�.ndYa ►4�br► �hf Address: I 1� HP �� le,�r � �� r�xbor-o ��_ �75'1� 2) Name and address of current owner (if different than applicant): Name: � Address: Phone (home): �3 3(, - 3� 2-1 � c, 2 (work/cell): Phone: 3) Property Description: Lot Size: 1�crc Subdivision: �Iqt� R��e.rTw� Lot #: Address and/ordirections to Property: �I� HQ�nsle�� r��.l�crrz� Y�r _ 2�5�� ❑ yes � no Does the site contain any jurisdictional wetlands? ❑ yes Q no Does the site contain any existing wastewater systems? ❑ yes j� 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 0 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 ❑ New Single Family Residence Maximum number of bedrooms: ❑ 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 0 no Non-Residentia! ype of business: Maximum number of employees: � � � Total Square footage of Building: 2�{ � 3� �� Maximum number of seats: �v—� i— �( GL��rP✓t f' 5) Water Supply.: ❑ New well � Existing Wel! ❑ Community Well ❑ Public Water ❑ Spring a Are there any existing wells, springs, or existing waterlines on this property? � yes ❑ no s I � 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Legal Representative*) * Supporting documentation required. y-o2-l�l 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) � Apulication Date: 9 a h' �-� Tax Map #: J�} �%i Amount Paid: G, Recaipt #: �— Parcel #: 37T_ � � � ��5� �� b - --_ �� -a��,.-.�,. ��a ��.a�� APPLICATION FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED. CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. �� 1) Permit requested by: (Owner� prospective owner): iw�•Q f�'1C1. s 6 a�wOo � Home Phone: Zs�-i�1 � le4N� Address: I c.� 5 . r S�r Business Phone: a�s-�l9�- M�..�lr�aDu . NC ��53� . � 2) Name and address of current owner: 5a,�^n�►.0 F-�%�S �ss J��,��L � �:�l� i2c� • ��o , nrc. 175�� 3) Property Description: Lot size: <<. Township: �y�oro Subdivision: Q�kr►d;� Kl�., � Lot #,�Z Directions to the property (Including road names a/n�d numb'eIrs): ll.. _a1. M: 11� N�.li, L., lIC � D/�+ �-f(�tt %� i w�e Sf�L1ii e uiSibi✓ nu �u <� 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed ✓, Existing _, Type of Structure: 'D/ I,J Width:�� Depth: L�' b) Number of Bedrooms: �_ Number of occupants or people to be served: �,_ c) Basement: Yes_, No ✓ Will there be plumbing in the basement? d) Garbage Disposal: Yes _, No _ 5) Water Supply Type: Private �(new �or existing�, Public_, Community_, Spring _ Are any wells on adjoining property? Yes_ No ✓ If yes, please indicate approximate location on the site plan. 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. -; ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAf(ED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. or Legal Representative �-��-o� Date PCHD, rev. 06/27/02 ��.�� .� �� "� � � �� I��aa-��.�•-�. ��.��.Il IL–��.Il�I� Applicanl Location: T�x M�� P�,rc�el # S�uibdivi�sion %� �. s �- - Pha�s�e Sect;ion'Lot # • Improvement Peranit Permit Valid for �Five Years No Expiration � Type of Facility: S'.;�„� �,.,,', /.��,��_ New r�Addition ed �� Water Supply __�� # of Occupants �# of B rooms � / Projected Daily Flow �� g.p.d. Proposed Wastewater System: N ,,� ,��,�,/ � _ Proposed Repair: Permit Conditions: Type: � � Type: , �, Owner or Legal Representative Signature: � Date: l�.ZG Q3 Authorized State Agent: � �.�.�I�..S' . Date: �_ - a„� The issuance of this pennit by the Health Department in does not guarantee the issuance of other pemiits. It is the responsibiliry of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspecrions requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit 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 and Ru[es �or Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmentai Health Specialist warrants that the septic tank system will continue to funcrion satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewatea� System �Required for Building Permit) * See site plan and additional attachments (� Proposed Wastewater System: �✓�'� � a� New ✓ Repair Ex ansion _ Type of Facility: 3� �,� � ' '' � �� ,. �y � ��-- Type ,� Wastewater Flow 6b g.p.d. Soil LTAR: .. 3 g.p.d./ ft 2 Basement Yes f�o Wastewater System Requirements Tank Size: Septic Tank: � gal Pump Tank: �' gal Grease Trap: -- gal Drainfield: Total Area: %a�'%D sq ft Total Length L vc ft Maximum Trench Depth �� in Trench Width 3� ft Minimum Soil Cover: Co in Minimum Trench Separation: _� ft Distribution: r/ Distribution Box Seria1 Distribution Pressure Manifold � 5pecifications: Authorized 5tate Agent: / Permit Expiration Date: Date: �9, — G f � The type of system permitted is �Conventional Innovative Alternative. I accept the specifications of the permit. Owner e al Representative: ,�, , — Date: % 2(r- 63 PCHD 1 / 17/2003 F ; �� I�I� � ' �� . `--= � �--�- .� � �� ]G �� a-� ��.a��.�.]l. IHL ��.Il�7��. STTE PLAN Name sa��is� �� Tas;�iap # ��Parcel # 37 � Subdivision ' � Secrion/Lot# �'7 �-/a-� � Authorized State Agent Date System componeats represeat appmarimam coarours oaly. T3e coatractor musrtlag rlre sysrem prior to beginning the iastallatran ro iasurr that propergrade is maiataiaed s�.� �i (r�:)�a z� ' C�' n � /�.�s �a�°�� s��: 1 "=so' S82'49'3fi"E 2 " �j � �� rcfm, r�. o�/�z/oi � ConnectGIS Feature Report Page 1 of 1 �� Person Printed April 03, 2014 ,+,��, ��T�,��, See Below for Disclaimer ' S173 �2�.5 �t: =�� 9 ft ��' 2.?�.1 f} � � : r`� " ' � � _ � k(S . � �� ., �: �'�� s � � 2�arr � T � z��s� � `�7 , � ?�� o ` �� ' ^ , ' �,'`� . � r 0� - �,�.\ �.� � �� ``�°`�`°�.. �: ��s ; �� `�-. * � �� aas � `" , � � 331:7f} - c,� � � � c: � � � �� 25088, N� : z��t '� � � �. � � � m r,�� _r . �� . . � �� . � . , .. .. . � ��:2 �� '_ _ . � �� . � . .. . . � �� -�.� . � : �7{�� F6�t. ' � • � . � .. � �. � . . NOTICE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typiwlly, 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 resolve this issue by directing users to the Internet Explore ompatibility Vew tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US�nternet-explorer/products/ie-9/features/compatibility-viev f this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGlS has beei prepared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GLS system ar� notified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectGI: ssume no leqal responsibility for the information in this system. Grid is based on the NC state plane coordinate rystem, 1983 NAD. http://gis.personcounty.net/ConnectGIS v6/DownloadFile.ash�c?i=_ags_mapbb39ba311ad2... 4/3/2014 � �� ?��i :: :� 1l�1�.�.1.. � �.1��. V �.�:.,;.. :: _: C�;��`� ��.�. ��.�¢� Building Additions/ Mo6ile Home Replacements T� Map #:�� Parcel#: �� Address: 2� . � o�_�lP, Zi5 � Approval Requested for: Applicar Address: Phone #' Mobile Home Replacement —� Building Addition ( �y�� ca�Por�� Permit Located: �Yes Installation Date: 0 — 63 � Design flow: �(�U (gpd) Current Contract with Certified Operator on file (if required): Water Supply: v Well Public or Community Wastewater system skows no visual evidence of failure on: �� 3�/�{ (date) (Applicant's signature if site visit is not required) Addition/Replacement Approved � Envir ental Health Specialist � � /T 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 ��.sf ��.�� —= � � �� 1��a-�� .11 I�-3I��,.Il�11� SITE PLAN Name ✓1 Tax Map #� Parcel #37� Subdivision • � Section/Lot# �—L�� Au� orized State Agent �/ Date ' System components represent approximate contours only. The contractor must,/lag the system prior to beginning the insta[lation to insure that propergrade is maintained �� 1, 1 ,.� � `-^ - "ti- � � �� I��-�.�� .Il. I�3L��.]L� Appiicant Loca#ion:_ � � � x ��l:�,p � � . .�;r�c �l '. __ 1 � � ' Suqci�ivi:s�iQn �,^ �,�_ , . , � h�se�S�c�ia►��, Lot � � � . ��'��i0� � �i' � �t � � � '. . � � � � Sy$tem Type (in Ac�ordance With'Tabte Va): a THIS� SYST�3VI HAS • BE�N I1dST.ALLE�] �M C�APt lA►NC1E. ��UITH APPLtC�►BLE NOia'� C�►ROLIMA GEiNERAL STATUTES, •E�t1LES ��E� SE�YAS�E "FRE�TAfl�i�T �D i�iSPOS�, . �ND ALI. COf�1D[Tl�t�� ..OF THE tNIPR�!l�9�E9dT� 6'lE�1T A�D. -CO[dS'F�UCT6�6�1 � ��+,UTHORl7� OI�!-. � � � • � . . . ..�.. ..' . � .: . � . .�,�,-�,� . : _, _ . � - � I�- l�� . � �. � �. • . .AuthoRzed State Agent � - • . ' � � . .' _ .• ' ' Date . � -�� dwa�� V�'Cl��t�. 'Date:- ��.J �'`.�'.'a� . - lns�alied 8�: • , � - . � � �,� -��- . -� � �� , �; � �`�-�--`� 5fi� �� . . _......._ . _.. _...._._...._.. . . . \ ,... . n I . � �$ 3�� << � ta�; - � � �,�` l��s � � rc��, �U. o7,2�f�2 ��'"�G �� i��`�� i��' �#'�p� �1 a i� _ � T�.: N1aQ ��_ �arced �� 5 i r -. �ystem Typ� (T ie 1ia j Own�rlAQplicant SLsbdivision ��n Addr�..ss/Las�is�n � S�f�ase � # 6 St2#e iDldate � 5�� Capaci�y. �� . g�i i Tee and Fli�r Bafffe S�alarrt Riser (if aQplicabie) �-, � Trencf� Wid#h � - Trenctl. D�pth _ � � � � � � Tr�nch Length �-ls� � ?rench Grade � � � Tren�h Spac�n c' � --� Ro�c Deptft and Qu � Tank Ou�e�:�Seal . � Dams/Stepdowns �et�. —� . Pemzaner�t iVlar#�+er � � - � � � � � Pre�sure La�rals . . -- . • � P�ra� Y�nk . . .� Hoie �Spacing � :..�. . . . � tate at� � . � o e iz� � � _.., . . . . Gapacity. ' . . � .9a1. . . : Pipe Steeve . ' � '� . � . . = Vtilat�rptvof ISea�ar� : � . _ � � . Tum-ups/Proieciors • � �� ' . . _ . � Riser . ' • . " . Re�it� S�ac�: . . . . � Wai�r Tighfi . Fr+om 1Neils : " ✓' F�uae�p — Frarn Property lines • � �t��ck Vai�a�lGate Va�v�e : � � �• : Sttvctu2s/Baseme� . � . . .: . . �fr��Qhon o e � - � . • . � ... es rainage ays _ :. _ �. . � �loatslSwitci��s -. . . � . ... . .� . _ . . _ . - �SurFace•�laters �� Alarrn� visak�ie and audibie Pubiic Water Sup �ies Eiectrical Campanert�s � Vert�cal Cuts F>2 ft. Rat� g m � Wat�r i.ines � � . ,4 �roved Ps.tm Mode� . Vehicie Traffic �(oc��lnder Pum .�ldjacent-Systems 4'uanp Removal Rop�/G9�ain.. �asementslRlgh� oi Ways - ' �Dtsi�nlbtrta�n �� ' �er � Seriai Distribution ' E,�semea� Recordesi . ' ressure an' i �� pe r ontract � � Low Pressure Pip� � Tri-Par�aie Agt�em�nfi ��r. Pi�e �Ulate�a! and. Grade • �� : .::, : - , � �� u p�;t� rev. 3l'i3lQ1 � ��,�� .� �� 1 � � � �� Y. � �a�'��i�i��7t9.�'31'�.�. a.�.iLll..�� 4��f�.�L�� `Yi +1.JLiJ �SJ� 1 1'I.�SE SE� A�'AC�E� I'Lt�N ��I� WEI�. SI'�'E �Y��J'I' TaX Map #: /T �' � Parc� # 3� 'g'ownsiiip ��a � �'v�e� e A�pplicanr. Subdivasion: /.�+iz i^;'r�s� e�rt�� Se�tican: I.ot: �s% I.ocation• � 'I'�pe of Water Sia��lv: �ndividual Community Public Rec�uire�ents• Site Approved by (��t ��.3 Grouting Appzove p Well Log Well T � ✓ Air Vent � � � � Hose Bib Concrete Slab Well I) Well Approve�. �p: 1��$e: 1 I-a�- 03 �See Attacfliesi Site Sketcla� Wells must be 10 feet from property lines. ' Wells must be 100 feet from septic systems. Welis must be at least 25 feet from anp building foundation. Other conditi �/ . �y �i�x d PC�ID, rev. 09/07/Ol �� S � ��.� �� ao � �o� _ . � � � r�--�' � � � � � � " " 'lJ . �u sn �7fC /,�C// �r-r_, . � na v n �r^ �rn -n�n�rn'n. c� �n t�.a�.Il �'� �.tn.Il tE �n l�tl� L�MA�I'�I %� '� �?, �� Grout Log Owner: !C, ko.,� �s Tax Map Ayv Parcel # 377 Location: � Subdivision: t�a, li'�r��c, �' /�%a�rS Lot # �_ Well Construction Distance From nearest Property Line (Minimum 10 feet) Distance from Septic System (Minimum 60 feet) Total Depth: ��_ ft Yield: �SO GPM Static Water Level: ,Z� ft Water Bearing Zones: Depth 1��1 ft L�ft ft ft Casing: . Depth: From �_ to �� ft. Diameter: �o� in Type: Galvanized Steel Weight: Th�c� f �� Height above Ground: / �/ in Drive Shoe: �Yes No Any problems encountered w�iile setting casing? _Yes _�,CNo If "yes" give reason: Grout: Neat: SandlCement _� Concrete Gravel/Cement Annular Space Width inches Water in Annular Space Yes No Method of Grout: Pumped. Pressure Poured _� Depth to Materials Used: No. Bags Portland cement �� Weight of 1 Bag � Pour�ds . If mixture (sand, gravel, cuttings) — Ratio to ID plates: �Yes _ No 4 x 4 slab ✓`Yes _ No Drilling Log Location Drawing Ft. From To Formation vc��i�th • ,�D G z s� � 'v��." � �ar� l �� G ��, Is , ��`' a n Ra��° I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth by the Person County Health Depa e. : Signature of Contractor ID #�2 � Date __ �i�-13 D� PCHD rev 09/30/02