A40 383Application Date: q 2g ��
Amount Paid: o?DO �
Receipt #: �Z,
(Ic�at�% �
�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 (New/Replacement/Repair)
$300.00/$200.00/$75.00
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�:,,.•' � � � ��,�,.� Parcel#: Sy� 3 _
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Services
for Services
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
0 Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Info mation:
Name: ` w �r/ /1 S
Address: '� " i
�r Xhora�,�7S�'�' `'
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home):3,�,� �` y' ���� �
(work/cell):
Phone:
3) Property Description: Lot Size: �_ Subdivision: � i'G�g� U�l,� Lot #:
Address and/or directions to Property: %/'zi,�tai DT�lzd /.� i, r; D�J liv F�
� yes v C�'no Does the'site contain �H►y jurisdicti6nal weflands�
❑ yes �o Does the site contain any existing wastewater systems?
❑ yes Ltino Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes f"f� �o Is the site subject to approval by any other public agency?
❑ yes L� J 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 '
ew 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 basement2 ❑ yes � no With plumbing fixtures? ❑ yes � no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Squaze footage of Building:
Maximum number of seats:
5) Water Supply: M New well ❑ Existing Well ❑ Community Well � Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes C� 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 ❑ Alternative ❑ Other � Any
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I certify that the information provided above is complete and correct. 1 also understand that 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.
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ate
Permits are valid for either 60 months or are non-egpiring 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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Applicant: �q�(
Address/Location:
Tax Map: A� p Parcel: 383
Subdivision DelC.; ee. c���_
Phase/Section/Lot # 43
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/ Improvement Permit
Permit Valid for: Five Years ✓ Non-expiring
Type of Facility: New �Addition _ Water Supply: L✓el �
Number of Bedroom __L�__ / Occ ants� Employees / Seats: Projected Daily Flow:�1 � gallons/day
Proposed Wastewater System: (� e,►�e�{a'eNa 1 Type: �
Proposed Repair: �_�y�Vih��lnh I Type: �.�q
Permit Conditions:
. .�ca}G�-4� _
Authorized State Ag�
(X) Owner or Legal
Date: �O -l4 �llr
Date:
The issuance of this permit by the Health Department cloes 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
Improvement 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�:rl Rules for SewaQe Treatment and Drsnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environnnental
Health Specialist warrants that the septic system will cantinue to function satisfactorily in the future, or that the water sapply will
remain potable.
Authorization to Construct Wastewater,�ystem
See site plan and additional attachments (�.
Proposed astewater System: �,ohv� �oha � (*)Type �g_ Design Flow g� gal./day
New � Repair _ Expansion _ Soil LTAR: , gal./day/ft2
Type of Facility:����,�;(� 7,,,,,��(�tAQ. . l/ /�Q Basement: _ Yes _No
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(*) System Types IIIb, Illhg, IV, and V, require periodic system inspections by the Person Counry Health Department.
Wastewater System Requirements
Tank Size: Septic Tank 1•T D pp gal. Pump Tank �-gal. ^vrease Trap gal.
Drainfield: Total Area ��.Dn sq. ft. Total Length �� ft. Max. Trench Depth � in.
o.C.
Trench Width 3 ft. Min.Soil� r�_ in. Min.Trench Separation q ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold
Specifications:
Authorized State
Issue Date: � _�Q /�
Permit Expiration Date: /0 -/9-Z 1
The system permitted is: Conventional Y/Accepted / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph.• 336-597-1790 (rev 5/12)
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SITE PLAN " � . ..
Name J�polnr� �t�ei ;ns TaxMap# Parcel#_3$3
Subdivision Sacti�n/Lo:# _ _43
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Authorized State Agent I3ate
.
System components represent approximate contours only. The contractor rriusl flag the system prior to beginning 1he
installalion to insure that proper grade is muintained . .
Note: An Accepted systent may be used fn place of a convenliona! svstem withoul permit authorization or mvd f calio.n.
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WELL PERMIT
(New�Repair_) _ _ __ __
Tax Map: � Parcel: 3g�
Subdivision: OaKr;a�Acr-es Lot: �
Applicant's Name: �� h �Q�,�(;,�5
Mailing Address: �
exboro 1UG 275'7�;
PhoneNumbers: �3s�-3 y ZS42
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 no guarantee q potabl�e water supply
OtherConditions/Comments: in��n All �o.�aG�S
Permit issued by:
Tew Wetl:
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 Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Rnvl�nrn N(' �7S7i
Date: /0�/9 fG
,
Certificate of Completion
DI.iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 fax:336-597-7808
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