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A23 105
�,,r,e,rrc� wct:i�aee rerson County Heatth Departrr�ent � Sewage System lmprovemenis Permit Date; 1�' E- � Tfiis permit Void After S.Years Permit # � � �Dwner: � Vr�i v� a' ` SR# _ / ��..,_ `�i L.acadon/Directions: � Subdivision Name: r� y,; r.1 � Lot # • I.ot Size: `� • -:� +' ' "" Type of Dwelling: � ' � � Water Supply: Private: Public: Community: $edioom� � Be DisPo� Basement Basement Fiu �ii es • iNFORMATIOLJ C�TlF�D BY '' �l- G' �,E/ • Sanitarian: �is �-�.F`� .•'%!` _ � � „� �-' %� �Q�r � �a,sazi.�e ��: x�v�.vATTorr: _ _,� _ � � ; -r Size of SeptiC Tank: ons Size of Pump Tanlc ' i� ,. --,. L+�itrification Line: _ r.> � J � X 3 �• � i�epth of Stone: 12 i�hes Max Depth of Trenches: Alfemalive Sy3fCm: Conv. Piuop ts',=' LPP Pump � itemarks: Date Well Approved Well should be ]00 ft� from any sewer system BY Sanirarian Date S g S te Ap�mov • --� 2-- y Z BY_����� Sanitacian C�R CATE OF COMPLETTON � Contra�ctor. _ �,^�• 1•Q,u,;s � .__._._.--------------------�.__. � 5ewage System iocation. installarion, and protection must meet atate and locai � regulacions. Sepdc tank shovld be pumped out every 3 tn 5 years and ahall be maintained by owner in such manner as nos tn create a pub[ic heal�h hezard. 5eptic tank and ni�ifi�ation line must be inspected and approved by a member of the Person County Health Depar�ment before a�ny portion of the installation is covered and put inco use. If the site p1�s or � use change this permit is subject to revocaaon (G,S.130 A-335F7 Location of sewage disposai sewage system skeu:hed on back, —: i, l�i i� r .i ,l.� ` � lr? \QVG�1} r` . /' � t� � t . .s , l 1 � 1 � C � � � a � � Application Date: � -�� -}_( Tax Map: /4 �3 Amount Paid: Pazcel #: �D S'— Receipt#: _ ����, � ���� �� _ _ -�- � � ���� � 1 �. �ra-a n �t aa a a �*-TM�+ .c� �ca �,m. v. � � .e3.sa, ll tiG7�a � /� l� ��'� � Applieation for Services (Septic Systems and Wells) -�p �`'��� Services Re uested ❑ 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 $150.00 if site visit re uired $75.00 ❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 �'�) .Services R iested Name: 11 G� f L� il�C� (/� Address: Phone # (home): � — `L 2 c� (work/cell): 2) Name and address of curr t owner (if different than applicant): Name: -� � Address: , 3) Property Description: Lot Size: Subdivision: � Lot #: Address and/or directions to Property: 4) Proposed Use and Type of Structure: ii� /� � � Residential Business/Type: Ot�--' �o�v� /�C�t �� Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No _, Garbage disposal: Yes No f,5) rWater Supply: 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 comvleted apnlication must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of a[l proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am submitting this application to reyuest services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is su6sequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): Date : � 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) r � ��� � � � � �: ♦ J� .��Q'' ' i � �.�-..� 6 � � �1✓ � �1f � 1S � J:L.L:.-l.1L."�.�'']i]I"{� �Y'1..R�7:.�C�?i7i.t�.�'t.� 11. �icG"':c..�i.��.� � �unn��n�a� ��a�a��a��! Pvg���flce ���a� ��������n��n�� Tax Map #:�`L� Parcel#: D Approval Requested for: lYlobile Home Replacement Applicant Name: Address: Phone #'s: C • i• • �� •� � � i�' .[' ♦,_ � � -��� � Permit Located: �' Yes No Instailation Date: — Z Z Design flow: � l00 (gpd} Current Contract with Certified Operator on file (if required): Water Supply: V Well Public or Community Wastewater system shows no visual evidence of failure on: Z' 22—�� (date) (Applicant's signaiure if sit� visit is not required) Com.ments: ���n�o�������e���� ���a����� �� \ z —zy i/ Envir nmental Health Specialist Date 1 ? /15/OS . `� 1�,./� �1.��+� ��1/ V � . � ,/� p�y ' ^~ �/' \J ��Y� l� � JJ..r/JCn'V�71���1rn I�NT ��3i�.��.JL �L JL���� 5I'I'E S�TC�-I Name N� ���1�, �_�� e S Tag Ma.p #�� .Pa:tcel # l �j Subdi �' n c� K Section/Lot# 1� " 2 _ Z,�_/f Authorized Sta.te Agent Date System componen�ts represent approximate�contours only. The contractor »aust, flag the system�irior to beginning the installation to ins�sre that propergnade is maitsta%ned `� � Q� (oy�� ^— �C` �a�' u� (ti��' ��� � I j; K�v �-i�� �'zv�c��r��� I r n� w;ll ��. enou�{l� � �% J �� ��,a� � ,�; �� � ,� -('� s . � _ � ,� . � �� � � ,� : �,.: o � � �, � h�� ,�� ��, �s � � �'.:,� � � � � s ,� �'�`gg +i. '�i+- � 5 �, � � 3 �k�'z` . _ p �. z y g', �� �•-�y�.' . ` �. � , � � ': `.. � = ' � ' II "` ` . OD < � � . . , • � �, � t � . fi'^ . � � � ��i _ �� � � � ,_�- ���: � �� �_, � �¢ � . �� � � �� � . �� �� = � =��� � � ; � ��. 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