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A40 56Application Date: ���'d `� �, p G � Ca.S� Tax Map: �` Amount Paid: 02 � 0. OG � v � � 0 rl �.� � Parcel #: Receipt#: ,� � z � [ �� ����� � ������ - � � � ������ � L�: �z n-a- n u- av �za �c�cn <c�: �v �l. ,�n. ll 1r �L <e-�.:.a 1l ti: �ia. �X�S���'C� Application for Serviees (Septic Systems and Wells) ���,�,5�— Services Re uested Improvement Permit (Site Evaluation) U Construction Authorization $200.00/$300.00 (if> 600 d) (Fee is de endent on the e of system ermitted) CJ Alobile Home Replacement or Building Addition ❑ Permit Revision $] 50.00 (if site visit re uired) $75.00 ❑ Well Permit (New/Replacement/Repair) 0 Repair of Existing Septic System $300.00/$200.00/$75.00 No Char�e 1) Services Re ueste y: Name: �-� Address: 0 � Phone #(home): c�J d S lM1 6/.�� (work/cell): 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: � Address and/or directions to Property: �2/rnjA,/ �S�ts �. n , ..l i .. �i . , � . ri -, .� 9a do�vn road. +v old I o" ho�s�. " � 4) Proposed Use a}� d Type o�Structure: Residential // Business/Type: Othei Number of bedrooms / Number of people serve�(seats/employees): Basement: Yes No (with plumbing: Yes �� No � Garbage disposal: Yes No ✓ � 5) Water Supply: / Private Well (Proposed Existing s/ ) Community Well: Public Water System: Are there wells on the adjoining properties? No Yes Lot #: (please show location on site plan) 1Vote: A cornp[eted application musf also include: ➢ A plat/sile plan of tlie property that shows property dirnensions and the size and location of a[I proposed structures. ➢ A signed copy of tlze `Lot Preparation' form verif}�ing that tlze property is ready to be evaluated. I am submitting this application to request sen�ices 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): �,���a-.-y'-�.�,e pe�-� Date : � — ) �/ -- a cJ' 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ' J . I �� I ����� �� �,� ��� i �` ' s � ,, -�^ � � ���� �JtII.'�^a�<�7L-n �rrr-n c�a:Z.�.�.� 1L 1L�a8l.�L� Applicant: �� µo ��� e o C� - lo-v► i G �Sd�R,�PS Q �'r'��o a � � � �prawe�ea�� �ermit ��r�it �alid ��r %� �'ive �eaa� I�io �iar�on Type of Facility: .pxi �:� 3 gR CA 6� � New �Additian . ��te� S��p�y �_ # of Oc�upants ��, of Be ooms Projecte3 Daily Flow _ 3rov g.p.d. Proposed Wastewa System: � � � � � � Type: Proposed Repair: • Type: � Pezmit Conditions: Ownea or Legal Represe Autiiorized State Ageat: Date: Date: The issu�cr of this pe�rit by the Health Depaztment in does not guarautee ti�e ;��,�s� of other permits. If is the r�spons�ility of the applicant/property owner to in sure that aIi Peison Couuty Plaaning and Zo�g and Bu�iding Inspe�tions requnremeats aze met '�his �provement �'ermit is snbj�t #o revoeatian if tlxe si� pd�n;�pl��'o'r ti�e inteud� use c�nges. '�e Y�gsro�e�eut �ern�ait is �a�t a�f'eet� iiy a c3�ange in odvner'ship of the propertp. T�s permit �sas issued in c�mplianca witdi ttee provisaons of the Notth �aroDin�_ . `L�ws a�ad RuPes for Sewage ?'re�tment and 19isposal Svsterns' (�5A NCAC 13A .1900). I�Teithes� Pea-son �munfy: nor°;t3a�.` ' Envirmnmeatal �ealth Specialist �v�-rants that the septic �ank systeyn w�31 caniinue to fnn�on satisfact�a�ily in tdae futnre'or:#gtat. the-wai�r supply wiIl remain potable. � �� � � ' �,uattnoa��ation to Const�ct �astevvater Syst�t (i�cgn��esi for �aiadding Pe�at� � • *. SeE site plan and additional attachments (_)- � � �� � � . -. ��ea w�� sy��: r� ' � G w�e�� �o� 36o a d .�` ,�d� �- � C'�+a►�hl,.- Ty� f —�•p• • New % R�air F.Rpansion � _� Sa�l LTAIB: . 30 g.p.d1 ft 2 Type of Facility: 3%��� 1PP. S. � � Basement _ Yes X No ��te�a�er �p����n �eq����n� T� Size: Septac'T�n.k:'� gafl �p Tank: gal +Grease'.�r�p: gai I�rsinf e�si: Ta#a� ��: � sc� ft To#al Lengt9� �o f� '��na Treaac$a D�pt9a � a�a �r.enc�a �id#h 3� 14�i�mmnan Soi� �over: �_ in 'YYenc3b Sepaa-�ona �_ at Dis�abu�son: %� �iistrii�u#ion �o� k Seriai �istribn�on �'re�s�re I��old . State Agen+t: �dtxsTr-� (� Date: Per�it Ext�ira.tion Date: o � The type of systern perimite� is Conven�ionai � Ac��tea Alternaiive. 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' . . : � ' , . ►3�fof ��� . � � .� � : - .{ • m -.� _ . - .. . . - � � :. _. . � .� : -�. �� . . � - � . . � �°�, . . . - . ; : =: . . . . . .= t =`� � .. .- � : . - : _ - . _ ,. -- � . -� - � _ .. �: .�'`� . � - .� �.. ��-� � �.i ( � _ ,- _' . ' , � ' _ ... , �•� - � . _ . • • ';;. _. . . - . . .. r:•. � - . '., , . . . , ' . ' � .;. _ _ . - . - . �: � � . . �: - � : : �. _ � "� � � _ .; ! ,�� �� + ��.r ,S � ''�.< � .l• '4�'�� �� - �� W� . . � , �.�. • _ s� .�� .. ��� ��:� w . . . � � . . . _ �;� �, � - . .. . . �,,�: S �.�, �c , ,.�-� _. : . - � ,: - , .; �. ,� : �� � _. -. � . � � � - SSUE;c.j �/t�� s�' �-e ✓�'�-a�k� ��en� r�..� l� : - � - �t - � ._ SC�e.: � `�= C�� � ���. � II�I�I�� �� - ������ �aa�aa-�,.,, �-�-�. m��.n � �.B�a.Il��a STTE PLAN Name � Qf`r`'r Taa Map #�1'arcel #� Sub vi ' 4 S Section/Lot# O Authorized State Agent ate Sysrcm campaaents trptrsmt appmvatate rnamurs only. The contracror must Bag the sysrem pdor m beb�aning tbe insrra111arioa ro lasurc �atpmpergrade is msmrliaerl. ���� �� ���� �� �r�. o b 1 � �/ � � �-. V � � � ��-�a- � �s�rn. � �.. ��.11 I�� � �.IL �I�n ax M�p i � � ��rc i � Subdivision •• = ' � - Fhase Section: ot # • # of Bedrooms Applicant: ` � G����rK. �C�ICrP,r' . Location: � _ . � e � ���� �� � 't �Z ��Ow . System Type (In Accordance Wiih Tai�ie Va):c �"— THI� SYS?�llll h3AS �EEN IIVST�,LL�D li� COMPLIAfVC� WtiH APPLlCAB E:iVORTH CAROLI�A GE�IER�►L STATUTES, Rt1LES �OR SEWAGE TREATMEfJT AND DISPOSAL, AND � ALL CONDITIONS OF � T}-!E IMPROVEIVIE�lT PER1VlIT AND CONSTRUCTION AllTHOFZ[ Tl N. � � . . ,�, � . Y� -� l� � o - . Authorized State Agent ��d , Date lnstalled By:_,,�) ` S�� Date: � � �d a � � � . P'" � . � � . _ . (�� . . � �_<< ; � �—�g�'q j�1—S 1 �'' . s�rr� 3��' . << . g'01 1 `� \y � � `� � < <, ,z� � . � �� �3 � �' � �r�� . ����� S� 1 �rS'I ,"} �.Qo�f' � �� . � y �3 , � ��',�.�,� p`L,. � � Dd �,� 6e G4M ,� < <��5 _ � �� ,� . �� � PCHD, rev. 07/29/01 r; � �/� ��3��1C �'a4i�lK �NSP��T3Oh� ��'iE�i��.l�vii �lype �@ � I� Tax Map # Y'� �� Parce! #�_ Sys�em Type (Tabie Va) Owr�er/Appiicant � Subdivision Address/Location SeclPhase Lot # � State �lD/date �-e < Capacity j,T�-� Tee and Filier - Baffie Sealant Riser (ifi applicable) T-'ank Out(efi Sesl Permanent Marker Pum� T�nk � � - Ca acit al. � Wate roof ISealant � Riser Water Ti ht � ���� Checic Valve/Gate Valve � Antt-si an o e Floats/Switches �41arm visa�le and audible Electrical Com onents � Rate m .. A roved Pum iViode! Blocic Under Pum � Pum Removal Ro e/Chain . 'DIS$B'7�9�1�10l7. �\f5$�dil � Serial Disiribution � Pressure fVlan o Low Pressure Pi e A r. Pi e I�iaterial and Grad� . ,-.- -_- . e Trencti G�ade � Trench Spacin� F— ft' in. d'� ft. -- ock De th and Quaii +� Dams/Ste down� etc. �. Pressure Laterals � -� Hole Spacing - o e �ze PiQe. Siesve � Setba�k� From Wells � From Property lines StructuresBasements �tc es / rama e a� � Surface Waters Public Water Su iies Verticai Cuts >2 ft. Water Lines . Vehicle Traffic � Easements/Right of V� ��'1�6' Easements Recorded Co�amen� 0 . 0 �� � pchd rev. 3l13/0�1 ���.s.�- ���.��� �� - � � � ���� ).�-9�s:a�n.�acv�rns_nn.�.mi.��..� �.���s.�l��n. WELL PERMIT (New � Repair� Tax Map: Parcel: ��P Subdivision: � Lot: �� Applicant's Name: Mailing Address: _ Phone Numbers: Location of Property/• A,-E- 1 P?r•.� �vccY ► i'.I + ' • ' ,r� Permit Conditions: 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. Other Conditions/Comments: Permit issued by: �+ �<\�tiY�.� Date•� j0 3 a � CERTIFICATE OF COMPLETION New Well Inspection: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Cancrete Slab: Wel� Driller: Pump Installer: Well Approved by: Date Sample Collected: Liner Inspection: EHS/Date Installer: Depth: " Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ License #: License#: Date: Date Results Mailed: Person County Environmental Health 325 S. Morgan St., Suite C Phone: 336-597-1790 Fax: 336-597-7808 Roxboro, NC 27573 � 8/1/08