A40 77Application Date: %'3 i'% 3�� `�� ��" ������T Tax Map: !��
Amount Paid: '� , (� � ..,... ." �:,,1- � � ���� Parcel#: �_
Receipt #: I 7/3 S'7 . 7,�7 p
1F�,�ma ll.II�GDffi_7CIl'Sati3T.�.tL.Il J� llCi R.11�171.
ication for Services
Services Requested
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if > 600 d) (Fee is de endent on the e of system ermitted)
❑ Mobile Home Replacement or Building Addition ❑ Permit Revision
$I50.00 (if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Itepair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Applicant In�mation:
Name: 1(GJrS L�.m er� � Phone (home): �3�' S�3 O �/2 j
Address: (work/cel l):
2) Name and address of urrent owner (if different than applicant):
Name: /%('iS L ( ( � /�1 � �� i/� Phone: �i % 3 �
Address: �(>L �" �ur�leS .f�'�1� 11 S IZe�,
5�7-3 0�
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
� yes � 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 ❑ 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:
0 Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? O yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
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.
%---3/ �C3
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)
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1L.:S.Il11�b7��'�'n'�'n'T �Ga.'��ffi.�1. �A��ffi..11'��
VV]EI,i, I'ERMIT (New 12epair�
�az Map: ��.Q_ Parcel• � �
Subdivision:
Applic3nt's Name: P� �`� � i� l o � c�',�
Mailing Address: y 22 5 {� ur� ��e N� �( � S �,� .
� nx�or'n . �1 C� 2�5-1 �
Phone Numbers: SR � - 0�2�
Lot:
Location of Property:
ZS �cr��r�/ i � � d
Permit �onditions:
1) Se� attached site plan for proposed well locaticn.
2) All applicable State and County regulations governing construction anc�setbacks apply.�
3) Permits expire S years from the date of issue. �
Other Conditions/Comments: L r h� r S�is�� II �,-��o,� �
�
i .
P�rmit issued by: , �ate: 7- 3 J-�3
C]ERT�'ICAT"� O�' C+�IdT�.'�E�O�T �
I�ew Well Inspectio�:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
L�ner Ins�ection:
EH /Date
IIlSt311@T: r t ZSi�s
Depth: l S `
Grout: ��z-! 3
Well Abandonment:
EHSIDate
Completed:
i�lethod/Material(s): _
License #:
License#:
I)ate:
Date Results Mailed: r
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
A lication Date � � �✓
Amount Paid: G— -03
Rec�ipt #•
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�Eaavaxc-�aa�-�--�- osa.�all. 7E-3L�.m.I1.�7La
APPLICATION FOR SERVICES
Tax Nlap #: � / �
Parcei �: �
G�a,�e
EV�^�'.
IF THE INFORMATION 1N THE APPLICATION FOR AN IMPROVEMENT PERMtT iS INCORRECT. FALSIFIED,
CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PEi2MIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME 111�VALID. . . �
1) Permit requeste b:(Owner/ ent/prospective owne ). �j �
Home Phone: — Address: � � ( �S
Business Phone: —
2) Name and address of.current owner: ����� �'" `� J
���,�D����
�I_ . �"I
Township: Subdivision:l�c at # �
3) Property Description: Lot size:
Directions tO;h�e prope (Inclu
L �ap��
4) Proposed Usq apd Structure Description: answer ach of the follovy' questions: � '
a) Proposed V, Existing , Type of StructureG� c � Width:�� Depth:�_�
b) Number of Bedrooms: Number of occupant� people�to be served: � e��j _-�ro u'�
c) Basement: Yes , No Will there be plumbing in the basement?
d) Garbage Disposal: Yes No _ F� la�r i�
5 Water Su 1 T e: Private new or existin ; Public Community , Spring _ bO'�` � b�M
) PP Y .YP � — 9-1/ 10
. Are any wells on adjoining property? Yes_ No _ if yes, please indicate approximate focation on the
site plan. _ . .
6) Does your property contain previously identified jurisdictionat wetlands? Yes_ No_
PLEASE NOTE THE FOLLOWING:
➢ A PLA►T OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢� PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. '
➢ THE PROPOSED LOCATI�N OF ALL STRUCTURES MUST BE STAF�D OR FLAGGED.
➢ THE SITE Ml]ST BE READILY ACCESSIBLE FOR AW EVALUATION BY THE HEALTI-! DEPARTMEAIT
STAFF. �
I hereby make application to the Person County Health Deparfinent for a site ev.aluation for the on-site sewage disposal
system for.the above-described property. 1 agree that the contents�of this application are true and represent the ma;.imum
faciiifies to be piaced on the property. 1 understand if the site is altered or the intended use changes, tt�e permit shall
becar�invalid. _ � �,�'
�
�7
or L gal Representative
lY
ate
PCND, rev. 06I27/02
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`,: ._. .. �_, ., . .,_.�, ._ .. , , _ � �: �: - __ � � , .
T� � #� gaz� # ��7
Existing Sewage Spstem lte�ort F�r. Mob�1e ]E�ome c�m
S �
. • Additton Type: � �5��1� �0�'
Y�eqnester: ►° � �c � Home Phonc# �`� 6�
22 S' rt�� ���� Busmess # �6�— �o
o �vo �'7 S'�l � �
��2 Qs ��lou� .
Onriganuat 7Pemnit Locatesi: � �ater Snpply:�� '��� � S�
Scptic System DP��ed For. �esidenrial Bnsiness Othes
# Bedrooms � # Employees O�
Syste� Type: Vil�� d�� 'I'an3k Size: ? Nitrification I.inne: � .
� t• .
• I.)ate InstaIled: � Cettified Operator �tequired: � �
(3n site wastewates dis�posat system shaws no �isual sigsis of ffialfunction on� -`�g`a 3,
�'eamission is ted to: � � `� `5 `�� . `,2�f �3�'
� �
Comments• .
�e� �r'�-e �S���i�'1 i [�.� �'� l.� � UU'�� � P'h �
ealth S ecialast ��5��� I?ate• L'-'�� �
�nvir�nmental � p .
: ���� )� ���� `ly�
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IE�va3-�� � �s,��.11 IE�Z��.Il�
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Ta$ Ma.p #�Parcel # 7 7
Section/Lot#�
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Date . �
System comjiones�r repr�esent cr�iproximate�contours only. The contractor must, flag the systesrzprior tv
beginning the isrstaAation to i�ssrsre that pm�iergrade is s�ntained
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