A40 46AApplication Date: �- j 2-/v Tax Map:
Amount Paid: Parcel #: .
Receipt#:
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Application for Services (Septic Systems and Wells)
Services Re uested
0 Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if > 600 d) Fee is de endent on the e of s stem ermitted)
❑ Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) L�'Repair of Existing Septic System
$300.00/$200.00/$75.00 No Char�e
1) Services Requeste�y:
Name: � ` Phone # (home :
Address: I� (work/cell):�� '� �'l d -,�/ g �
� ar,P_..��,.� l�� G - �/
r ���.�.c�%`-' ..
2)Name and address of current owner (if different than applicant): ���� _._.
Name: �rrt�_ /��
Address:
3) Property Description: Lot Size: %� c Subdivision: Lot #:
Address and/or directions to Properly:
4) Proposed Use and Type of Structure:
Residential v Business/Type: Other
Number of bedrooms 2 / Number of people served (seats/employees):�—
Basement: Yes L/ No (with plumbing: Yes !'i� No _�
Garbage disposal: Yes No
5) Water Supply:
Private Well �Proposed Existing �
Community Well: Public Water System:
Are there wells on the adjoining properties? No /Yes (please show location on site plan)
Note: A comnleted application must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed struclures.
➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid.
Signature (Owner/Legal Representative): �,����w�- -�i Date :� � � � `'� �
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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T�x Ma� 9 • P�rcel # . •
Su�bd�ivision
Fh�se Sect�ion Lot �
Improvement Permit
Permit Valid for _ Five Years _ No Expiration
New Addition _ Water Supply
Projected Daily Flow g.p.d.
Type of Facility:
# of Occupants # of Bedrooms
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Owner or Legal Representative Signature:
Authorized State Agent:
Type:
Type:
Date:
Date:
The issuance of this permit by the Health Department in does not guarantee the issuance of other pemuts. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections 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 Rules for SewaQe Treatment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmental Health 5pecialist warrants that the septic tank system will continue to function satisfactorily in the future or that
the water supply will remain potable.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�.
Proposed Wastewater System: �C�a��� /AI/ ��,m d Type�� Wastewater Flow ��.p.d.
New Repair ✓ Expansion _ Soil LTAR:J , g.p.d./ ft 2
Type of Facility: �;J�1�2 Qe�i��n��.�. Basement Yes _No
Wastewater System Requirements
Tank Size: Septic Tank: d��fi�al Pump Tank: 600 gal Grease Trap: gal
Drainfield: Total Area: �Q� sq ft Total Length DD ft Maximum Trench Depth �� in
o-C-
Trench Width �� ft Minimum Soil Cover: � in Mini um Trench Separation: � ft
Distribution: Distribution Box Serial Distribution V Pressure Manifold
Sp
Authorized State A�
Permit
The type of system permitted is
permit.
Owner/Legal Representative:
�
Date: �'/2 /G
Date: '
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Conventional Accepted lternative. I accept the specifcations of the
Date:
PCHD rev. 11/10/OS
ConnectGIS Feature Report
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Page 1 of 1
Person
Printed September 18, 2013
See Below for Disclaimer
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IOTICE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who hav
�cently upgraded to the Windows 8 operating system or a new version of Internet Explorer. We were able to resolve this issue by directing users to the Intemet Explore
ompatibility vew tool. 7his link is to Microsoft's "How To" for the tool: httpJ/windows.microsoft.com/en-USlntemet-explorer/products�e-9/features/compatibility-vie�
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 bee
�repared for the inventory of real properry found within Person County, and is compiled from recorded deeds, plau, and other public records. Users of GIS system ar
�otified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectGI
ssume no leaal resaonsibility 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.ashx?i= ags_map71837e99198... 9/18/2013