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Applicant: Sg�
Address/Location:
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Tax Map: � Parcel:�_
Subdivision �K.�d�,�_
Phase/Section/Lot # qQ
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Improvement Permit ; �
Permit Valid for: Five Years ✓ Non-expiring
Type of Facility: � ' �New �/Addition Water Supply: �,�(Q(�
Number of: Bedroo �/ O cupants / Employees / Seats: Projected Daily Flow: ugo gallons/day
Proposed Wastewater System: ��{� (?S% R��d;ok Svskw.� Type:
Proposed Repair: _/�cce.,lt.� Type: �
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Permit Conditions: �KFtak Q►v�r 1�(akrsl,t� �ao�.+�
Authorized State Agent:
(X) Owner or Legal Re
Date: S-1-1-7
Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements aze met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement 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
a�:rl Rules for Sewage Treatment and Disaosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmentai
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water sapply zvill
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�/ .
Proposed Wastewater System: cc�nlyd ( S�le e� �aN Su�Jcw.� (*)Type �A - Design Flow �! gal./day
New � Repair _ Expansi Soil LTAR: ��� . 3 gal./day/ft2
Type of Facility: Basement: _ Yes _ No
(*) System Types IIIb, Illbg, IY, and V, reguire pPriodic system inspections by the Person Counry Health Department.
Wastewater System Requirements
Tank Size: Septic Tank _ 00 gal.
Drainfield: Total Arza /Z:Ob sq. ft.
Trench Width 3 ft.
Purr�p Tank -- gal. ^vrease Trap — - gal.
Total Length ���od ft. Max. Trench Depth _� in.
p.G.
Min.Soil Cover �_ in. Min.Trench Separation �_ ft.
Distribution: Distribution Box �Serial Distribution ✓/ Pressure Manifold
Au:horized State Agent: ' Issue Date: 8�r-�-1
Permit Expiration Date: g-1- 22
The system permitte� is: Conventional /Ac epted ✓�lternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date: �� l�"' l g
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Tax Map: A�lo
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System Type: � i�c�
Septic Tank: doo gallons
Pump Tank: - " gallons
Total Linear Feet: �L C�
Max.Trench Depth: �D _"
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EHS:
Date: Fi���'��
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Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Health with any questions (336) 597-1790.
Ac+ditienal Camments; --- — .
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App�ic»t�Qs Da��• 7 I� Od ��?��� ll Jle���J'��V`�
Amount Paid: G O, 0 ��• ������r
Receipt #: 1 g� t�1 S d-' J Il
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� ��j�� Aoolication for Services
�Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
0 Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
Tax Map: � "N
Parcel#: 3�Y
Services Re uested
❑ Construction Authorization
Fee is de endent on the e of s stem ermitted
0 Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Chazge/ CA $150.00 or $300.00
1) Applicant Info ation: Q � �
Name: �����
Address: � SS' � .m
�
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): 33 � 3 �y �-5-6 v
(work/cell): � 3 6 ,59�' z. � a 9
Phone:
3) Property Description: Lot Size: �}-� Subdivision: � � Lot #: �/
Address and/or directions to Property:
❑ 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: � / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ 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 e isting wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If a plying for �Authorization to Construct', please indicate preferred system type(s):
onventional ❑ Accepted �[nnovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccu�`e, the site is subsequ�ntly altered, or the intended use changes, all permits and approvals shall be invalid.
�
Signatur�wner/ Legal Representative*)
* Supporting documentation required.
'7_ �� — (�
Date
Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any apptication requiring a site e�aluation.
(]0/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC�27573 (336-597-1790)