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A40 76
�� � � �-.r� ne�u��strtcr� neai�rn��u�epa,� � ���,', ���', 2 i.;:�., �:.Or,ange Pe �. ..�Caaai,ell. Cha3ham. Lee...! ��, : y ci +.+ ' , t ' . � s:` . .. .. ,. � � � : � : Water Supply and ewoge !', .. • .. f,. . :. . . . .._ :�_. _ :.... IMPROVEMENTS�PER�T._ .�o�"-� n , , � ����,�_ .. __ f �; - �-- l�.�� . . . : ._. "� � . � . OWri@T: ���y` . , 4.� �Cq -: Loca�n ,.` , _ " � '' „�""'�. . .� � ,r ,: ,. _ • `�� ,�t,b,b -. '\ �� � Contractor �- ;""-y . ,• TA �'E� ..��� ..'. . r'.,.. . . . � 1Nater Supply: Priva .i:� �. ��� F ¢"t: �_} .. . ��y_`._ , .R, ,,.�,.�+'y=i . • • `p � ,f '.�-'�. : . ��� ' ... . •.. • . ..... yi.�.. ..!'.':-:.f.•.g'�"'..�Y_� � �_ �_ .�� a,�� ..� - s. 1Silwca�u� v+r.'3r r••��•-s Searage Dis saL-Fac�lities: No rooms —:;�-- „�,a,,.o aslung achin - sutomatic ap liances ` �,,�,.......• i'� 4vt �-: � , .; � ,i�t�fiflcaLioa line. �� ��� �'� � _ : � . ` Size of tank: _ ,.: , _ :. ,<,_ .....:., ,.., ....., _ ,_.. Other disposal=-facility: : ° Water supply and' sewage disposal 'facilities �lo.cation, installation and protection must meet state and--local regulations. •.. , _.. _.,__ ._ . ...._.. . Septic tank�should be gumpedr.out every 3 to 5�years,a�d s1ia11-be mam.= �' tia.ined by ownei in such a manner as not'to create a�' pubi�cc health .hazai'd. ' Septic tank� arid '7irtrificat'ion` line'�1VIUST'""BE'"'I�NSEECTEI3'; ANI3' AP- ' PR,pVF� BY A MEMBER OF THE DISTRICT I�EAL'TH DEPAR.TMENT � S'pAFF BEFORE- ADT�Y�� PORTION OF-THE:-INSTALLATION IS- CQV- � ERED ANI3 PUT INTO USE. ;- ; : ', ., ... _. ; Date approved.��� „� ; .. : '". . _ . ' . .. . . Well•;� ...... •.._ Sewa Disposal; _ _� _. ��: �..a�-- - � ,.. r.. � . ; , - . . _ _ . . .. ... �: _._.. _ : ,. ._... _ .Certificate of Completion �, . .. . Y � � . � �.. ..... . :. .. r .. . ... -. . .' �_' . Date Approved r B3' _ _. _ � ._.---_. , --, _ _- nitanan • - __- .... � � �`� . . 1 : , . 1 - - . �, . . . ���1 . . . . . ..'� .. .. ...._..�Q-Y'L' ,... .._.. .. � Location of well. and sewage disposal facilities sketched on back. Y � � � .3 U 0 v � p .; a � � a Y � � .v, � y y . � N � .r�i N y � N +"i .C�+ '� W O o � o �' � � a�i ? � � c, u .c°c � N N �"' � � f �• � �' � � � � 3 `° �� �. .s ° '� o � o � 3 � � � yti � y .� N i�+ °' d Q VJ 1+ (� ' ^; 3 r. y � 0 � � O � w � j' � V U N .n a ° u N ,'�,' +' O N°z �z . �y � Q% � N F . H � a R. '� z ' �� �` ` :.� ; � r,. I; .� �� �. �� � `J �;�� ��, � � , � � .� �� � �� � � fj !+e � `��-�'� �� " �� �l ��' �; �- ?�',��.zs�-�����������.�.�i..�.?l {I~�.�����.il�::� �a�a�d��a� ��s���m��/ IY�a�b��� �-I�a�n� ���fl����a��n�5 Ta�� Iv1ap #:�D�. Parc�l#: 67� Address: G, 1l S�� � a �G � Approval Requested far: Mobile Home Replacement ✓Building Addition Applicant Name: %����"l L %�G�1 �/ Address: ��� Phone �#'s: 3 - � � Permit Located: ✓ Yes r10 Installation Bate: /o �- Design flow: �O (gpd) Current Contract with Certified Ope:ator on file (if required): _�✓� , Water Supply: ✓ �Vell Public or Community Wastewater system shows no visual evidence ef failure on: ' 3— �i —// (date) l (Applicant's signature if site visit is not required) �� ���� �tr�������1�3�pfl����ra�eaat ��p���r�e�l Enviro enta �i th Speciaiist / Date Pe:son Co�n�i Environmentai :,eaith; 3�5 �. ti:orQan St., Suite C; RoYboro, N� 27� � 3 Fhcne: ��5-�97-??9C/ra;:: ����-�9"-i�0� � tv�:�,,�i.�,ersoncountv.l,e: 69°43'18'E 18.18 Z,00 AC. �Pp�`"t� , ?�� X ��' O N 4 8� 38 G+-�' . � , 026 �43"I✓ Person Cour�ty Environmzntal Health 325 S. Morgan Sfreet Suite C Roxboro, NC 27573 �� SAMMI9993W00 N46 p166Y . H� H�LT PIN# T,M. A40-15 RECN 5722 D.B, 74-613 S 69, 4 p� 3�18'f �/ • WELL Zr. CARPORT GREENH��SE PR�POSED 12' ADDITI�N 258,46 N 88°28'08'W � "_ ��' WALLACE & ADDIE BRADSHER PIN# 9993-00-34-7782 T.M. A40-75 nrf A1 �?�1Fi Application Date: Amount Paid: Receipt#: _ Tax Map: Parcel #• ���.s�- �I�I�' .� ��T - - _ � �����-� IL--��na�-nvc-�csa'a�►�*-� .�+�n.�.zn.l1 IF3I.c�aa.l1 �7�n Application for Services (Septic Systems and Wells) '� 1) Services Requested by: � Name: �11ya. �,�,,� [. � I�� �` E� yt c.� Address: S 7� S htc,sQ i � n.�.'Lr s j�,.I, �[�X�nl4�, C. �7S�L! Phone # (home): 33 � 3 6 � � � �' (worklcelt): ✓ 2)Name and address of current owner (if different than applicant): Name: S� � � Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: 4) Proposed Use and Type of Structure: Residential Business/Type: �'i��p�•l4 � 20 `x Z o� Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No _) Garbage disposal: Yes No 5) Water Supply: Private Well (Proposed Existing _) Community Well: P.ublic Water System: Are there wells on the adjoining properties? No Yes Lot #: (please show location on site plan) Note: A comnleted apnlication must also include: ➢ A plat/site plan of the property that shows property dimehsions and the size and location of a[[ proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing 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 iatended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): � Date :3-'�—/t 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � � v iv. • � ' � . � .� � .� ��� ` ,. 7' , . , �y . �. . ��_ �' �. � . �.. ._ � " —_ �. _ � . � — _ � �ZS�05r �i'�J✓I /�''!� � �( l��t��. �.�����', � ; EP,NEc7 G 4 M�4� W'RS DRr'.lh'A� F.!Y SUPcRi?Sf�1�.', ` OR THi � PRD�Ef BOLNVpARf=S h'v^7 D�h wn� r ROt,d rrJ� THl;T �Ht RL,fIG CALCJLAT�D IS ? OR i,REF: �ic. Tr;. FAAc Vdl;$ i�pcGr,; A :COr2DA/v"'c kti:' i 47-3C AS AM�N� 4,"TNESS AfY pR1C- SIGNFTUR" R�G,', h'UM6�P, AND S=f �1ST Da:' D-= JAP 2D0&. L"`_=k .1 �. PR0�5SIONAL �� H=n�c,�' C=?Ti� GS. 47-3G (F}� P:,RCEL OR P,;R $TK�� G� i:,�l�l �� J �_�-- t�r^C?==.5$(0(Jn"L ' n�o� 'a' �U9SURFAQ- AN� EN�7�'0.VM% WER£ HO7 £XAMJN:D OF �On 7H:5 SURVFY �AL.: BUILDINCS. $Uni[1RFACf lM�ROV&.�ET175 TO n+£ S7TE AR_ tf0' NfC[c H�RfLW N:; S7kTMc'NT IS � nt� Erv^TErrC� c� uroc�nc�� iVrll.^.Y. Af�`" A���? THc .. " NJT� c. TH= LO�FT,O:v O' UN^cRi,RG a� Sr�ISr: aF,= EaSF�. a� t' ANC' ORAtS'h'�_ FR���7�2 7C io�� nor; n- un�c��ouu� STRJ�TUQEC Alqt� VAav cROa SHOVSf: MfRFCx':. Ah',',' FDDI,'i�; 'JTi�i7]E; M.4Y �X1Sr C'�V:Tf AP?R.xRlAT: UT(LIT`' �^,QV.nA. IN=.�4AI::TiJi�: R�GA�?�;Hi� £ii%- h'OT= .. AL: D/STAf:��S AP,� HOr'.:ZO', R7JG AP,_f ?`- C��iDfNAiT ' nr • vTM;` SU?l�` VA' RQ^!: Yt• S�AR?' ANC 15 BP.S<< M' ' f.A'%On^MAP,Jf.. TNcf�_` MA" [: DCCUMEn"S p� R�CORt� h*+�. �n-c-C• T�•� FROa£F*e v � r_ 'e' ' �E� " AS 'C��'�A_ � �.+�_ c,�; �i :c p.�rc h'� -`pCc iY_ Fv�_0�4�h'G C<S�L;M1'T�. THOS� Y,,^EL` C+JR/N;� Ri;.G .8U't1�'N.'� _'794�✓L. 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' . �.. . � � ^�' � � ' � �. � � ' + , �7 � � 5205 A � � � �� :,: � � � � � � � �a � � ���� �� � : � �� � , � ,� � � � �" J �x �E �: � ; . � � ., 1:60 feet ������ ������ ��� iti[ [ ��s �I r r -- .. � � . r . . r - ^� � y' � �rc r�' tt : �; �^� rs. ��_.�r. _ . .,-,ac: _ _ � r � . _: rr�c:-t atc rr� r ��. . : 7 l]t �. ;'1 3 t .— l;.. r� a .'-#a sY�- �.? r � r 5: f f' r i F r:��.� SY! lr� r' S:�:" --,. �..._. cr r , ,-..�: http://gis.personcounty.net/connectgis/Map/PrintWindow.aspx?Map=http://gis.personcount... 3/7/2011 ConnectGIS Page 1 of 1 RECN: 6324 DEEDBOOK: 163 TERRY DARRELL P 8 NAME: TERESA S CITY: COUNTY NAME2: Parcels TAXMAP: A40 76 DEEDPAGE: 286 HURDLE MILLS RD SITUSADDR: 5745 SALEDATE: 0/0/1980 BILLINGADD: 5745 HURDLE MILLS RD ZIP: 27574 BLDGVALUE: 137495 LANDVALUE: 21000 SALEVALUE: 0 TOWNSHIPS: FLAT RIVER OTHERBLDG: 47528 SUBNO: -999 ACRE: 2.00 PAC: 4 FTR CODE: PARCEL 1:378 feet l � C `��rt,fT`f ,. r �.�� ������f� ���s�n � � ,'*" � � ''�.� ,,,;�, �:.'� � { . ,,� � � � 1 �,. �:.; ' ^�- ;z Y i T., 6 � �� �� %� ! '. t. ' _+� •t 5 lt�� ��,. �'{ .. � r � . ,,l�� � 4� �.�� ~� �._ �'\ �'���„ .,^- � �/� \� _ �`��Q���� �J�� 9993-00-34- PIN: 4796.000 PLAT: ROUTE: FR 117 021 FLAG: CITY_STATE: ROXBORO NC CURRENTVAL: 206023 AC OR LOT: A DESCR: 2 ACRES f� HOUSE CALCACRE: 1.82552 ��u��� ��� 7YI�� � t�� �.�a �t- r r � �_ �r r s - � �r � � �EI ] �. ��1'J f "13C 7 f . r � : rr r : l5te ' 3 '�' :' f,• rti_ ��. ti- � -f'. s F_^.:zr � r�: ;cr�r �. r. ' F r =. . !Ye ia! r :_-. .. ,. �. a .r - . n��.. http://gis.personcounty.net/connectgis/Map/PrintWindow.aspx?Map=http://gis.personcount... 3/7/2011