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A41 47An�lication Date: � �6-� 7 Amount Pald: �o� Receipt #: l7�_ Tax Man #t: Parcei �!: ��' �����?y �� ����� �� o� ---,-- � � ��l V �� �- �T�^ aa�n.a-���a�-�- ms:a�ml1 1���m71�7�a APPLICATION FOR SERVICES .: ->:.. ,. ;:: ,:ServicesRequesteci'.. � , ,..: _:. : ,:. : :. _:, _ ,.. .. improvements Permit (Recorded Lot) -$200.00 ❑ Well Permd (New/Repiacement) $2 I Improvements Pertnit- $150.00 0 Construciion Authorizatlon for Septic (Mobile Hame ReplacemenUAddition) $150.00!$200.00 I RepairlReplace ExisUng System Permit � ❑ Pertnit Revision Fee -$75.00 IF THE IIVFORMATION IN THE APPLICATION FaR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFlED CHAFVGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CO(VSTRUCT SHALL BECOME INVALID. . 1) Permit requested by:(Owner/agent/prospective ownerj: /rMo�y �'7-;.� � (7-�' f��'an1 Home Phone: 336--s<<Q-s��s Address: __ �55 � t�l Ho/tew 1�J:. Business Phone: 336- 5�'f7- oz'otl� k'oxbo�� NG. 2��7� 2) Name and address of current owner. __ /��ra�i� -� /� .� 1�; i� (T�'I )c`uw� ��ss c�-�«�i �-�oi��n-.. ,�:oxbnr . Nc a.�,�#-- �j �l' 1F � v I' ��d-� ���Nv� �^'G 3) Properly Description: Lot size: 33. l�c Township: T�Mbp�laf=Z Subdivision: Lot # a�S% � Directions to the property (Including road�jn�am�fes and numbers : So� � � _ I,� ��%� STrQU Y�PS�G((/ ITGf N� �� ri/w�" 't`l�l r�4%Q' � ur �;� �i ,n e a L� � p�. e.. �S o., �e �'�jNt- Ca r��ks) pCIfS SikYr:f� c�d:tes' �1�se c'�Kl ,1� ►'ooc�waF 0,,� y-�re r�5tif-. 4) proposed Use and Structure Description: answer e�aach of the foliowing questio�: a) Proposed � Existing , Type of Structure:��x� �ir��k � wc�z.( hcus.z Width: Depth: b) Number of Bedrooms: _� Number of occ pants or people to be served: c) Basement: Yes ✓, No Will the�e be plumbing in the basement? 1� d) �arbage Disposal: Yes No ✓ 5) Water Supply Type: Private ✓(new ✓ or existing�, Public . Community� , Spring _ Are any wells on adjoining property? Yes_ No _ If yes, piease indicate approximate location on the �site plan. � 6) Does your property contain previously identified jurisdictional wetlands? Yes,_ No ✓ PLEASE PIOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. . ➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED.. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE S,ITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEAIT STAFF: � I hereby make appiication to the Person County Heaith Department for a site evaluation 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 placed on the property. I► erstand if the site is altered or the intended use changes, the permit shall becom ' v id.. G� �� ' � � 07 Owner or Legal Representative Date PCHD, rev. 06l27/02 ' ��,� � � � ���.��� �� ' � � y � y � 1 /''a� -� r�-p w _� ' ``/ �' �� Ji � �����„-„ n-„-, «��.�,,71 I����.IL¢11�. T�x Map '� �rc�e{ : Su;bd!i�ri s,i�aia Fh�s�e Sect+ian�Lot'' . ��zmi�t �Ja�id �ox� ��ve �� Type of Facility: h # of Oc�upants � ,r �uc # of Be� Proposed Wastewater System: _ Proposed Repaar: (' €��,►�r� Iaaprovement �'ermit PTo �piration Permit �Conditions: �',-j\l Z,�� 8��te ��c�.r� Uwner or Legal Regresentative Signatur Authorized State �Agen�k ���?c��n x o New �OAdc�itian �ate� Sn�pplp � Proje�ted Daiiy Flow 4� g.p.d. � Type: J a � Type: �� Date: The ieenancg of ttris pe�tit by. the Health DepartmBIlt ia does IIot guazazltes tlle issua�8 of othel pe�. It is the responsibiliiy of the � aFPli��P�Y owner to in siue tha# all Person Couaty Pla�ing and ZaIIing and Bu�d�g Inspectians requ;ircments are meL This Improvement Permit is snbjert to revocation if the site plan, plat or the inteuded use citanges. The Improvemeirt $ermit is not affecterl by a ciiange in ownership af the properiy. This permit was issned in compliance.with the prnvisions of the North Carolina `Laws and �iules for Sewa�e Tretttment and l)isnosal Svstems' (15A NC�,C 18A .1900). Neither Person �onnty nor t�e Enviranffieatal geaith Specialist� warrants th,at thg septic tank system w�7I continue tn function satisfactonlp in tiie future or'that the water supply wi11 remain�potable. � . . " . A�thorization to Consirnct Wastewater SysEem (I2eqnirerl for Bn�ding Permuit) * See site plan and additional attachments (��• . Proposed Wastewater Sysfem: C1�lyeY��i �v� � Type � Wastewater Flow�$�:p.d. New Lc , Repair FxQansion . Soil LTA.R: a oZ.7S g.p.dJ $ 2 � Type of Fac�ity: �{ �{� �_'� IIi.e � ��, c� we1�,r1� Basement _ Yes _No - - , �Vasteevater Systemn Requirements � 'Tank Size: Se�tic'Tank: � gal Pnmp Tank: �;,,, �,al %rease TraPs -' gal �rain�eld: 'Total Area: t�7�i5 sq ft -Total Length 1�� ft � lYla�mum Trench Depth %� in Tremc�i tiVidt�t �,"� ft M'inimum Soi1 Cover. �D �� in lYTinimmm Trench Sepazation: / �t �istribnfson: �istribu#ion �o� � Sesiai Distribntion Speci£cations: Anthorized State A.g�nt �, i Permit Ex�iration Pressure Manifold Date: -� The type of system permitted is � Cunventionai Acc�gte3 Alternative. I acc�t the spe�ifications of the P�� . r �' i�w�nerli.�gal �aprese:utative: �� �G ` Date: � 02% 0 � . PCID� rev.11I10lOS ���`?� )� ���� �� . v'- �: � ���'� I��a.�na-os• T-�-�•.��a��.Il ]HC�.m.]t�l6n. SITE PLAN Name�l M� i II iQM Tax Map # N� Parcel #� S div�ston Section/Lor# �d �� c� a� �-� Authorized State Agent Date � Sysrem compaaents represent appmadmate rnotouts only. T3e contractormustflag the system prior m beginning the fnstabarlon tv msure thatpmpergrade is marntaiaed. .� � Ma�h-�a�n at1 �backs � . '� � ��.�.� � 1►-��z�� �� on e�,-bur �+ `�u N�� � r1�1Q1\ s���m ;� we.-4 c���-honS � (�r� C��ins c-�; � Mee-�; ►-� Mon�oa�rt�� � -� � �ues-� io-,S C�-ae�- Env. � -�- ��t � ��t�i� ���� . . . . . . . . . . �1r� ��a�a � �a, �k �� C�-�-1�►�e . ��,n -�-r� c�p� � . �nv- . r SC�Ie - I': � � ``.`��.':.` � ": ' ::..:.....: :... ... . . .. . ... .. : .. .. ` "::':::':•�•:.:'. :..y.:'• ��. .:�'1L:'LJ ��;L/'•���' •Y .`�^'�y�... 4.. �,.{l:.':.�r:�..��.�.� -. .,� .:...,... ...•:•+ .. ... r .;• :•:.,:: • �.. . . , . r . . •....:..: .....::,..:. ..,.: . .,... ; . L�` . . .. ..:it..:�;t'••;:C�:::i>::'^Y> ::Yt';;••, . . ;., : ;; :, � : . ;.,. �.: .; ::. . . ... .......:... . . :-... . .,.., .�.�. � . ... 7��`�� ,,, ... � 3L.IL;'�9,:33i]r!¢9';�,; GC�7J.Zl:�.v�1%�•;'�:a�'�II-.1L'r"U�1�: �: ... .. � . . ��-n�•�t•�y^n�> ��L P]EIt1V�['�' PLEASE SEE A'�'�r��,�+ D P� F4ilt �+ LL SI� LA.YO�T'�' Tax Map �� Parcel # � Township: Applicant• �� (�,',\\�C�m Subdivision: Lot # � � Location: ��,1 � -�- CR5 �`�+ nl,. . �r�, -�- CR� �,� �'rn;,-,�k i �.,,.I,o�l�. 4�� � � Type of 3�a#er 5upply: � individual �.tequirements: Site Approved By: /�l I Grouting Approved By: � Well Lag: Pump Tag: T �.J / o Well Tag: � Air Vent: � HQae Bib: Casing Height: Concrete Sla.b: - � !�� Co�nmunity Public Liner. 'Installed by: _ Depth set: _ Grouted: Date: Wate� Sample: Well Driller• � v O�S o r�. Well Approved by: � �� Date: ****See Attached Site Sketch**** Wells must be 10 feet from property lines. . Wells must be 100 feet from septic systezns. Wells must be at least 25 feet from any building foundation. Other canditions: J v�d 3��� PC�ID rev 01/27/0� -�,`�� �:� IPI�.I�.��� •�r„� � s ► + . ' � ���7��� I�.a�.. �.�-o aa.sa�.d �.� 11 IE�3t 4..+� fl�� U, , r�. ., ! D I� � �. c;�t�t)l -�t,; i...,tt• � � � . D:�' D��!'� -t ch�m�r: � Wel� Log � m C� ,-�� �n I,acation: 5 o I S�.- � � N ,� h,. Ra��+,�,-` ��// ""-- ---'�'i-yi - �i3TYClI�+ �\�� Q:� � Subdivieiur.: I.OL�_ ?ax Map � Pa�el # .��. r�mbx.rl�kP 2�. m on� S`I� Luw� P.o �"�- r d v c� 2U � c.�S�- ��S-� Distanct Fn�m nearsst Prc� �%cl! Courtt�ection Pext}' I-iae (Mimimum ! 0 feetj _ I O bistanae fzom �ep4c System (Mu�imum 60 fee�) (,�� ��`�"" Tot�I Lkpth: 4 5� fi Yicld: � t3PM Static Water I.CveI: ________ ft Wacer Hearing Zorres: Dcpth �{{ ac�� �} ft � � 11 go Ci�t� Law� �.D C'��: � 3 I�tp�h: Frarn --�— ,l_____ to �� I3iameter: lp ► Type: G�lvaniz�d Sieel �" � � �'aght: � Ul $ Tbickness: � I� Hcight �bovc Cmound: _ I�_ ia T1�ive Shoe: _� Y�s � No Any proble�ms r,nc;ouaierrc� whilc settiug'casing? �Yes �io l �' "yts►' give re�.4an: Gro�t: - .�ir.�t: SsitdlCanent Concrete GrnvcUCemcnt Annuiar Spacc Width � inc��s Water ia Annular Spact Yes No .'trirthai of Gtvui: Pum�sai ��� Pr�ssiu�e Pourr�,d Depth to � Fk '.►�dxtrri�tls Uaed: � ?V�. $ags Portlaud cement Weight of 1 Bag ._.._� Pound� It m.�.xture (s�nd, gravel, cuttings} — Ratia to ID plaus: ____ Yes ____ No 4� 4 slab ,� Ye� ____ No D�� �+$ L6cadon Dr�wiug t�ereby certii'y th� th� aisove informarinn is eorrect aud that this well was canstruct� in accorclance xzth regulati s�r forth by •he P�rson Couuty Heaith Degartmea� Si��ture nf Cuntractor _____ ��(� IL � a o�� Dste �_(�o - C) - PCHD rev lll/1 + ���,� �� ` � ' �-�.� ` � � --�`-�''�° �� � � ��T' � �s T��.—�.�-�-r-, ,----, ��.�.1 ���.�.�.�. � n ... ?,aplicani: 7`�a '�� A �{ 1 ?�UC�� _' �- � J�'Ul a o c�i�� /11I/1 ���I���o���� w Z �o� o� � ao � . .������� �� �� � . S1st�m Ty�e (In Accordance Wiih Ta�ie Va): �� i'HtS S�S ;'�cs'�1 i-��,5 ��:.� i�4�T�LL�7 It� GO[��Ll�4�l�� V�I i 3� �F��1�A�S...� . R�ORTH �'�1ROLl�A GEs1{��L ST�, s ilTES, �U�.�� F�R S��ilACE T��tiTMEi�? ��iD DlSAOSAL, .a,i�D •.�LL COIi{�["iiC3NS C�� � Tl-3E �IVi�R01����T PE�,�IIT .�n{D G�NSTRUCTIOi� �illi'�iO�si�TiO . . . • � � �o -Zq-og' � Au rize� State Ag�nt Daie 1 nstalle�. B�r �, Date: � I e- 2q f pg � ' . �,_ � ��� � � � � ' c� ' O ��.:.c--�--"�-� • . �l ` . ,1 I ►,�z "� ��q . . . � ' .� � �► � 2� ► . 'li . _ � • . ., �I�' l , � u'/2 0 _ -A I b .1rD �� ��� �, � l i'r�C n e�a r�(,Y �!-d yv�Qasure "�a n �Li :U. I Gt/. CJ ( r�.G���,,i1 r , � ��y�� ���� �������"��� �����,��5 a � ���� ]9 a 1� , : a� 1Vi�i� ��� ��rca! � Sys��:� Type (Tabl� Va) a O���er;A�pljc�nt ' �a S�bdivisior� ,�ddresslLoc�fion 5��; Phas� Lnfi � . �����.'��tn� ��i���9�'��� �o��ar�����a� �n� in��a �m� State �ID/da�e - Z -- JS I�'Z�Q � renct� UVid� � 3 %. ✓ s �o- Z9 - Capaci � 5- n a aal. � � T.res�c#� De �h in: Tee and Fi1i�r - � � T.rer�c�t Lsr� �. � �afffie � Tres�cti Ga�ade � �✓ � Sea(�nt Tre�ct� S �cin � � Ris�r (ifi applicable) � � Roc� De and Qua�` �'an�C Outiet Sea! Daensl�t� dOa�� �#c. Perr�nane� il�a�er Pressure Late�ls � � � . ��s�e� iank � � H�I� S��cing � . S$ate D/da#e � o e i�' Ca�ac' al. � Pi �. S1�ve Wa#e roof /Sealant � Tu�n-u slP.rote�#ors � Rise� ��ui��' S�tb��� 1lVater Ti ht � Frorn� �llielts � � � �'�m� �rom Prape�ty iines � �S - Cl�eck ValvelGate 4��Ive Struciuresl�ase�ne�is � � . �/ �� Anti-si on o e � etc, es ! ratna e V1(.2 s Fiaa�slSwitches � • � �Sur�ac9 Waters .Alarm visa�le and audibie Public V1�a#sr �a�p lies • E3ecirica! Com onen�is • `�I.e�ficai Cuis >2 i�. � Rate m .. tiJVater Lines , �. � A �-or�e� Pum i�hode� 81ocR Ur�d�e� Pum � Puerz�o R�moval �Ro e/C�ai . �•D'as�Bbu�aon: S�#ea� � Se�ial Disin�bution Press�are il�annad Ln�nr PressUre Pi e Appr. Pi � A:�ate�iai ar�d G� , .-�- -- .. ■ 1 � O��r s Re�arded �c:�d �i. �I'��IC�! PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS � r- � � Name of Owner or Tenant ��`' � �' � � � � � � Address � n � � �-' � �'� `` � C�''�`f County � e �5 !�"'i 1 , � Collected By � � �--�� -� �%��s Date Collected � � �' �'�"� �`;� � Time Collected l � Source: m�ell O Spring ❑ Other � � ; �, Locatio : ❑ House Tap ❑Well Tap [��ther �+.��i ` � � :,;;�j'� �•,r� j�;� � f`� / � � Charge pCharge �**���****�������:�**�����*�*�*�*��������****�**����,������********�*�*�����**** *��*:��*�*���������*��*��������*��*�����*�*��**������**���***��****�**��**�***� Total Coliform FecaVE. Coli Present ❑ f1 Results Reported By �� %L ,�^- bactreport Absent G.,� I F-F�t- �PS ���s I�- I a 3���