A40 82a
�
�
The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES '
� ,� �
Water Supply and Sewage Disposal
IMPROVEMENTS PER T N .
Date —
Owner:
Location:
r
���� /ct,�,�,
Contractor: `
Water Supplp: Private � blic
�.-f r, _
Sewage Dis osal Facilities: No. bedrooms �� Dishwasher, Disposal,
s ing machine, ther automatic appliances T L
Size of tank: ���t! itrification line: / D p�-
_� � -Q IA f'� i , .�Q �� ����
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an� shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED ANB PUT INTO USE.
Date approved:
Well:
Sewage Disposal:
By:
t
Signed
San' arian
Counter-
signed
(Owner or his representative)
Certificate of Completion
� �
Date Approved: — By: �
itarian
(OVE
Location of weli and sewage disposal facilities sketched on back.
NOTE: Make sketch of inst llat on showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note sp�cial pr le s existing on lot. Write in measurements in order that installations may be located
at later date. Note 1 cation f ater supplies om adjacent lots.
�.
(1) (Z)
,.� �P.e� � � b. -1 � ` �,
�
Application Oate• �' 3 I -G �
amountPaid: � 66.UU �� .
RecEiQt#: �!.'� .2 z . . �
IF
Tax Map:#k �"' D
�arcEi'#� � ��
� �.�� �� . I�I�IE�� ��T
� �-����
� ._,...,_���,,....,..,,.o�:�.� �.��n�.
� .
� APPUCATION FOI� SERV�IC�S
SHALL BECOME INVALlD.
1) Permit requ�sted b�: (Ownerlagentlprospective owner): i�/��k L ��d �7��` _�l
Home Phone: S�' D R/ i Address: / kRA� �7 '��� L :v/�
Business Phone: S4 7 l� �_� � o X �d it/. �. .� �� 3
2) Name and address of current owner: 7'r1 ��/-�/�1:� 1 j�0 Q 6�L`'
`
3) Property Description: Lot size: 5�� 3 Tawnship: -� o�Subdivision: Lot#:
Direcctions to th� property (Induding road names and numbers): �
0. 0 V� _G. �'-�
4)
5)
6)
Proposed Use ap�Structure Description: answer eact� of the fol�owi g questions: �
a) Proposed �, Existin9 � TYPe of Strudure: .�t � c � Width: � D Depth: ��) �)
b) Number of Bedrooms: Num be� o f ocxupan t s or pe le t o b e se e d� ;
c) Basement Yes _, No _ Wili there be piumbing in the basement? __ ! i'"
_... _
d) Garbage DispasaL• Yes _, No _ �
Water Suppty Type: Private _(new _ or existing �, Pubiic_, Community _, Spring _
Are any wells on adjoining property? Yes _ No _ If yes, please indicatse approwmate locatton on the site ptan.
Does the property cantain previousty identifled jurlsdicttonal wetlands? Yes _ No r/
PlEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR StTE Pf.AN MUST BE SUBMITTED 1NITH THIS APPLlCAT10N.
➢ PROPERTI( LINES AND CORNERS MUST BE CLEARLY MARI�D.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAEfED OR Fl.AGGED. �
➢ THE SITE MUST BE READILY ACCESSIBLE FaR AN EVALUATION BY THE HEALTH DEPARTAAF-3NT STAFF.
l• hereby make appl'ication to the Person County Health Department far. a site evaluation for the on-site sewage disposal
system for the above-described property. 1 agree that the contents of this appl'�cation are true and represent the maximum
faal"�tes to be placed on the property. I understand if the siie is aitered or the intended use changes, the permii shall
become invalid. .._, � �
,�e�:��:��/ ,�%r�/ �'"��, � ` 3 U `
Owner or Legal Representative � Date .
PCtiD, tev.10l17/0�
�1��' .�� ���� �����
`__�-_� � • • —� � � � � � �
���aa- � ��-r ����.IL �E-� � �►.Il �1�
Tax Map #� Pazcel # ��
Exisring Sewage System Report For. obile Home Replacement �
- Addition Type: o� ��3d 5 ��
Requester. 1 �� V "l. ��'�
�t � �e ��`��S •
���,10� Jl�� a7� z�
SQ�� �.� R'�� �v�- -
Home Phone# �RQ "��l`�
Business # ��?"���
Original Pemut Located: � Water Supply: UV ��'
Septic Sqstem Designed For: �Residential Business Other
# Bedrooms � # Employees Other
System Type: ��U �+�1�� � Tank Size: �� Nitrification Line: � �� '' "' �� �
Date Installed: ��� ��^ �d Certified Operator Required: JU �
On-site wastewater disposal system shows no visual signs of malfunction on `�Z �bz
n _1 � /�s � ,.,_ C �
Pemussion is granted
Comments•
Environmental Health Speciatist dV'e� Date: � ����
�
31,00
Recor�bination Survey For
� .1�7aore
2
c hcx
eZ
G
� er Tw ,,Person Co,,N,C,
Flat R�� p ��=50'
May,2002 Scale 1
50 25 0
50 100 150
SCALE IN FEET
est B,Wood,Jr, PLS-z648
Ern N,�, 27573
252 N,Lar�ar St,,Roxboro,
Michaet G,& Susan A,
Moore
D,B, 211-246
S SD°21'S4"E
419, 00
Ref�Un-recorded Plat
Dated,�ct„1983 by
E.B, Wood,Jr, PLS-2648
3,47 acres
4,39 ACRES
Total
Ref�D,B. 152-662
& D,B, 300-781
0,92 acres
312, 26
N >4�32�43"i,/
M�chael G,& Susan A,
Moore
D,B, 273-295
-�
�
9-=11 17,3
2
N 80°Zl'S4'W
Lot 3
Colon�al Esta�tes Subd�v.
Sec,l,Blk, A
0
Michael C
M�
D,B,
��
�ot 4
Colonlat Estates S
Sec,l,Blk. A
NDTE�N❑ FIELD W�R APPING�R 9 02AS
OF THIS DATE OF M
„.. _.. �pplication Date:1�1�
Amount Paid: /.�D
Receipt#: Z�Zyy 9 _
Tax Map: �' �{ � ' � �
Parcel #:
�� r� ���--�`�+� � ���� ��\�
� - � � T�7� �� 1� �
ZC u: an -a- i� u- �ca �zi �i�a <c� �ra �i:.,�n 11 _IC' �L <c-+.; n.71 ti: �a
Application for Serviees (Septic Systems and Wells)
Services Re uested
❑ Improvement Permit (Site Evaluation) 0 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
$150.00 (if site visit re uired) $75.00
O We11 Permit (NewlReplacement/Repair) ❑ Repair of Existing Septic System
$300.00,'$200.00/$75.00 No CharQe
�ervices�} uest d by:
Name: T crn �� I'h a v!'-�
Address: S} � b j.Jvi d i�1 i I�s n�
' o�- b a r� it/ L �-'1 � 1 y
Phone # (home):
(work/cell): _
2)Name and address of current o�i�ner (if different than applicant):
Name: nliG�a�� "�'10or�
Address: �( ur' 1'vl i��S �
� oa' �d ,�t�C— �-7 � �y
u f}C,l'�5
3) Froperty Description: Lot Size: -_�1• 3 Subdivision: ,iV�� Lot #:
Address and/or directions to Prooertv: y Lll � )-� Urr�� rh � i I S ��/ `
4) Proposed Use and Type of Structure:
Residential ✓ Business/Type: Other X
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: Public Water System:
Are there wells on the adjoining properties? No Yes (please show ]ocation on site plan)
Note: A completed application must also include:
➢. A platlsite plan of tlze property that shows property dimensions and tlze size and location of all
proposed structures.
➢ A signed copy of tlte `Lot Preparation' form verifying that the property is ready to be evalua[ed.
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): PI'�'1 Date : � i' ��” d q
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
��� j }. �
' �� � ' � � �
�. � a , � � �.
; �-,� �-; ,� �� l�.�l��`�
� ��:�-�.��{� �.:�:�.f��.�..�.:ii ��--�C�::�.I1�.:��
�
�un����a�� ��a�gta��a�/ I`✓g���flce ���ae ��������nc��n��
Tax Map #:�_ Parcel�#: �_
Approval ReqLested for: 1Vlobile Home Replacement
�Building Addition
Applicant Name: 1 vt j �, / v 1 oc,�
Address: ,.
��l�y �,� ox(�r� IJC 2757�
Phone #'s: �q -� - 3 2� -�
Pemut Locate�: v Yes No
InstallationDate: 5-►2-$� Designflo�,v: �(,�D (gpd)
Current Contract with Ceriified Operator on file (if required):
Water �upply: V Well Public or Community
Wastewater system shows no visual evidence of failure on: �(- �(� -p� (date)
(Applicant's signature if sit� visit is not required)
Comments: /�/i �,:,-�ai,� /D ��1-e�v� C�l� Dar�S � S'�o�i� c�;f` ����,�
A��n�no�/��}��a������n� ��a�a���e�
,
_ 1��� _��
Enviro ental Health Specialist Date
11/15/OS
. �� 1�, �� �J1.l1 �� ��
1
' � � ����
1� �� u- � ��..� �.�.11 IHC � �.]t �
Nanne_ I�ll�e.����� l l�r�a�;�
Subdieis' n
_
�
Autho�ized Sta.t� Ag�flt
���� �1�����
Tag Map #.�.�_ I'a:��e1 ��''
�ection/Lot# _
_ ��-�1; -r�>
Date
S,ystes� cbrninorie��s re�resent u�ipr,aximcri'e�corstorsr.c �sly: The co��trector rrsrrst, f8a� the systern�irior ��
beginras�ag tfie instadlr��ion i`o �nsa�re that pr�nlberg�tde ss rrures�tained
-
� %
��� �;; �,, �'a ����� I b ��� �;�v� �t b I ��:s �,�-i"� a`� :;� � c, s� s`�� a✓l
� F Y