A41 18� s_����
A lication Date:
Amount Paid• _ ���� �
Receipt #:
Person Countv Health Department
Environmental Heaith Section
APPLICATION FOR SERVICES
Tax Ma #:
Parcel #: % ��
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CHANGED OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID
1) Permit requested b:(Owner/a ent/prospective owner): '�/ '�.� �
Home Phone: �3 Address: �
Business Phone: .,t , ,„ � e / - G_ �S y/
2) Name and address of current owner: ,� ��,
s
� ' S�
3) Property DesCrlption: Lot size: Township: %`> 1�- �i ✓e ✓
Directions to the property (Indudir�g road names and,numbers): �
,//s ,�,�
4) Proposed Use and Stru� re Description: answer each of the following questions:
a) Proposed 0, Existing
b) SBck Built �, Modular �, Single Wde� Double Wide ❑
c) Number of Bedrooms: � d) Number of occupants or people to be served: ,�
e) Basement: Yes 0, No�lf yes, # of basement fixtures:
� Garbage Disposal: Yes 0, No,�;.
g) Dimensions of Proposed Structure: Width: � Depth: �
5) Water Supply Type: Private�,(new ❑ or existing �, Public �, Community �, Spring �
Are any wells on adjoining property? Yes ❑ No 0 If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
�,Conventional _Modified Conventional _ Altemative _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
I hereby make application to the Person County Health Department for a site evafuation for the on-site sewage disposal system for
the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be
placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand
that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the
Heal Department if m property contains ny wetlands as designated by the Army Corps of Engineers.
. �
�- a 2�-OlJ
Owner or Legal Representative Date
PCHD, tev. 10l12/99
Yerson County Health Oepartment
Existing Sewage System Report For: �obile Home Keplacement
Addition '
Etequestee: /�/ .- �l�IClL��t������1�'!�S Home Phone# 336'�6 =2?�3
��'/ /ict /�2i�vli'�� �7"� Businessn S`' �
�Lfi�� ��' �•�! S �� �%5� j'Pax Map� 1f� l�
� ,. % i0 /_ � �� .D7/l, /� /i�� _
Location/Uirections:
�BLX/C /`��///<:A1.
e
Original Permit Located ��= ,
Septic System Uesigned �'or:
ftesidential v 13usiness Other (specify}
� Bedrooms � # Employees ` Other
llate �nstalled �i�vl� Water sugply 2 4h S�'���---
Type ot System (,.2�/r%///
Kitrification Line G'(�t� �/��" 4�.5��`'VC�__ _ �`�
Tank Size ������'
Certified Operator ftequired � �
On site was�ewater disposal system showes na visually apparent
malfunction on ��`����
� � r /
Yermission is grante to: 1�� c� ,S �
t -
,e
According to the at�ached site plan.
Comments:
Env.ironmental Health ��G. � , /�--�► ��%�
DATE
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Application Date: / I ►5 Io . Tax Map: ��i �
Amount Paid: I aS � Parcel #: 1�_
Receipt#: �v3�5c�,
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Application for Services
(Sentic Svstems and Wells)
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit ( acement)
$225.00 125.00
Services Re uested
❑ Construction Authorization
(Fee is de endent on the e of s s
❑ Permit Revision
$75.00
❑ Repair of Ezisting Septic System
No CharQe
� �
Important: If the information in the application for an Improvement Permit is incorrect, falsified, or the site is altered, then the
Imnrovement Permit and the Authorization to Construct shal[ become invalid.
Services Requested by:
Name: ?c: /1l<
Address: �
ll�Q� lvl J/lS , l�! G, 2 i����
Phone # (home): ,��36 �36 �' �'763
(work/cell): S a y,., �
2)Name and address of current owner (if different than applicant):
Name:
Address• > Gn �
3) Property Description: Lot Size: ��-�ubdivisipn: Lot #:
Address and/or directions to Prop '" C' z� �
/ G ✓� _
4) Proposed Use-and Type of Structure: �
Residential �_ Business/Type: Other
Number of bedrooms �_ / Number of people served (seats/employees):
Basement: Yes _ No �, (with plumbing: Yes _ No� Garbage disposal: Yes _ No 0�
Approximate size of building foundation: Length__���idth ��
�ter Suppl : -
Private Well � (Proposed Existing _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes �(please show location on site plan)
Note: A comuleted apnlication must also include:
➢ A plailsite pla�z of the properry tliat shows properry dimensions and the size and location of all
proposed structures.
➢ A signed copy of tlze `Lot Preparation' form verifying tl:at the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. The information
provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become
invalid.
� r
Signature (Owner/Legal Representative): te:
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map y I Parcel #�$_ Township:
Applicant: ►.�.�M�r, i�Q l� i I l�ctms
Subdivision: Lot #
Location: I�i,rc�le t��\1�� . f�c� ����'�� .M i i I Rd -� 1�-I- �n �—
�yp� of W�i�r 5��p�y: � Individual _ Community Public
Rea��aire�ents:
Site Approved By: M
Grouting Approved By: 1 0�
Well Log: j�7'
Pump Tag: �
Well Tag: �
Air �1'ent: � �
Hose Bib: �
Casing Fieight: �
Concrete S1ab: � �
Well Driller• iav�.s o�
Well Approved by:
��**�ee �4i��c�aeci �ite Sketch*��*
Liner:
�Installed by:
Depth set: _
Grouted:
�ate:
Watea� Sample:
�Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems. �
Wells must be at least 25 feet from any buiiding foundation.
Other canditions:
Date: ,
PC�ID rev Ol!27/0�
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IE��s��.�..a��.]L IE-3L�.�Il�77�
SITE PLAN
Name �%'(�LQ�I �I.� \�,1i�YY�S Tax Map #�� � Pazcel #�
S,� �vision Section/Lot#
�c 1��7
Authorized State Agent Date
System cvmpoaeats represeat appraxrmare conmurs oaly. The contracmrmusrtlag tlte systempaar to begianiag theinstavation m
insrrre that pmpergrade is mainrriaed
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353� C�-�es �,�� (�
Scale: ��OrJY
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PCHD, rev. 09/12/Ol
�.�..,`�� s:.s �I�.�.���
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IE:.a-zr►�ia�v�rs.:a��+�aE.��l IF'3Im �a.71��a
t�� ���. �� �o :: � �./ .
Cc�rir��.rn,, IV-.,i���• �►! / L .
C1,�t�� O��P�'� -1 � /
,p.��., Q� Well Log
Lacat�a ���.� I•c� �(, � td �( Tax Map � Parcel # g
�li�!(�1 V1113UTa: �—� �
LOL � "'
Welt Ca�rtrnctio�
Distance Fr�m �eanst Property Liar (Minimum 10 feet) _( U�y..._.
�i1St821CC f1011l �Cpt3C Sj19tCn1 �illllm'l�m 60 fCCt� -----r�--
Total Depth: o'? 05 ft Yield: � �'M Static ater I,�vel: �3 �{
Water Htasing Zones: Dapth ` � 3 �Ca.'C�#i � � �} —
C�aaia$: Ce3
Depth: Froru �_�w to ft. Diameter: �2`% in
Typc: GaJvanized Stecl
Waght: .��'Ibickness: ,�, L Height r�bove Cround• __ �.�____ in
DTive Shoe: _ r/`Yes N� Any problems �c►c:ountercci while �ettiug casing? �Yes �%To
��'"yes" give r�san•
Groat:
IVr�t: SandJC�snent Cancrate CnaveUCemtat
Annular Spaca Width ,�_ uzc�es Water ia AAnular Space r Y�s No
'.Vitthcx�i oi�roui: Pumpe�i ____. Pressuse _ Poured Depth to r
'_b�ktcrials Uxed:
Nc�. Bagx Partland cement Weight af 1 Beg �_ Poundss
if mixtwe �s�nd, grav�l, cutting�} — Ratio to
ID plaus: � Yea ____ No 4 x 4 slab � Y�s � No
Dr1113n� Lag Lacition Draw�%�
F�
I hereby cenir'y th�t the a�+ove informAtion ia eorrect and that this weil wa..a canstructed in accorciance writh regulations
sct farth by *.hc P4-rson County Heaith Degartmr�t.
Sigaature nf lbntruc4or�,j�C/r_,���C� II; � 07�� Dste f�—c5�._,_
Pcxv n� oiii �.�e: