A23 128_ _.. c.����
, Applicr,tlonDate: � ���`/'
Ainouut Pa[d: 0�0. c1� �
Receipt #: _
Periuit (Site EvaluaUon)
�300.00 (if> 600 gpd)
Replaament or Bntldin!
f site visit reaiwedl
���5� I���$��I� ���axM�,�: �-3
...... ,,..� ��u��� Parcel#:
�'',i�via•asr�aaaa•a�tu'� iLII�.�slila
�lication for Services
Services Re uested
Consh�utIou Autho�izallon
ee is d endent on the e of s stem ermitted
Pe�wit Re��ision
S75.00
RepatrotEzlstWg Septic S��stew _ j � '
AppGcation>No Cl�arge%CA $150.06 or 5300.00 . �'' € ' � r -
1) Applicant Informution:
Nawe: �17,J, /CQ� � ��J�(� Phouc (hoiue):
Address: '3lop w��Q�cG.{� (wvrk/ccll): C�� '� n�,^(s4,! �
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2) Name and address f cutl•en[ owuer (if ditfereut than applicant): �
Name: Phone:
Address:
3} PropeiY,y Desciiptiou: Lot Sicc: I � OQ) Subdivision: \{E(�1"�hL G Lot #: � 3
Address and/ur d'ucctiuns to Pcoperty: (L.�
❑ yes �o Dces the site contain any jurisdictional wetlands7
[7 yes ❑ no Does the site contain auy e.�cistni¢ w�astewater systeuu?
O yes Cl'fio Is any wastewater going to be generated on the site ofher Oian domestic sew•age?
� yes �'fio Is the site subject to apyro��al by any other public agency? ,
❑ yes a'fio Me tlxre any easemarts or right of �eays on this properiy?
(if `yes' is checked, plense procide suppodin¢ documentatinn)
4) Proposed Use and Type• of 5tructm•e: � '' ,
6dlFesidentiat � %� �j•,�nut � was 3�?C
Q'New Single Fa�vily Residence ;btaximum nwnber of bec4•ooins: �� �
❑ Expmsion of Existing System If expmuion: Cim�ent number of bcdroonis:
❑ Repa'u to Malfimctioning System Will there be a basement7 ❑ yes ❑ no With plumbing fixturesT O yes ❑ no
ONou-RpsldenNnl
Type of business: Total Squaze footage of Building:
Mvcimum nwriber of employees: Maximum mm�ber of seats:
5) Water Snpply: �'1Gew well ❑ Existing Well ❑ Conunwiity Well ❑ Public Water � Spring
Are d�ere any existin¢ u•ells, springs, or existing u�aterluies on tlus property? ❑ yes Q�no
6) If applying for `AutLo►izaUou tu CousirucN, pleAse ladicate p►•eferred systrtn type(s):
Q Convmtional ❑ Accepted ❑ Innocatice O Altematir•e ❑ Other O Any
I cernfy thar r �rff+ fation rovi�l a ove is comp/ete n�rd correet. l also understand r/iat rf tlie inforrnntion proride�/ is
inaccurnte, o' th e is sa r� altered, or the uuen�ied use c/innges, atl penuits nnd a�prot��/s sha/1 be inralyd.
" �' �d' �L�
Signature (Owncr/ Legal Represtntative*) Date
* Supporting clociunentation required.
• Permits are valld fm• eltLer 60 muuths ur are uuu-expiriug when accompanied by au appruved plat.
• A completed `LotPreparadon' Iorm mast accumpauy an�� applicaUon reqidilag n slte evaluatiou.
(IU/11) Person Couuty Environmental Healtli, 325 S. Morgui St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Ta$ lYlap #�Pascel # r o�'g
Seciion/Lot# 13
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Date .
System compo�ents re�iresent upproximate�contours onl,y. T31e contractor must, flag the systemprior to
beginnrng the isxstallatzon to insure that pmpergrade is maintained
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Person County Health Department
Sewage System Improvements Permit
Date:��=�=fld- �s Permit Vo�d .;fte :;iYears C� v�d of
LocatiO it � � ���f� $R# ��
ii/� eCLiOnS: _ ,,, i, 1_/� Ll..
Subdivision Name: �v �I,ot#�_
Lot Sizc: � Typ of Dwelling: '
Water Supply: Private: Public: Community:
Bedrooms: 3 Gazbage Disposal
Basement Basement Fixtures _ •
INFORMA C BY
Sallltcll'lail: ' oancr or representative
�P�� REEVALUATION: �
Size of Septic Tank: —�� gallons Size of Pum T c: ��
Nitrification Line: / �
Depth of Stone: 12 inches " °
Max Depth of Trenches:
Altemative System: C� v. Pump LPP Pum
Remarks: __ `I✓�,r,,, n �1„ „ o .J� ' � _
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Date Well Approved: Well should be 100 f� from any sewer system
BY $1I11�I1SI1
Date Sewage System Approved:
BY Sanitarian .. '
ERTIFICATE C�F COMPLETION
�
Contractor. < , ,nn L o js
_._—_._—__—_—___--___.— •-:
Sewage System location, installation, and protection must meet state and local i4
regulations. Septic tanic should be pumped out every 3 to 5 yeazs and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and'b
nitrification line must be inspected and approved by a member of the Person Counry �
Heatth pepartment before any portion of the installation is covered and put into use. If
the site plans or intended use change this permit is subject to revocation.
(G.S. 130 A-335F)
Location of sewage disposal sewage system sketched on back. •
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