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A23 196�La�.°� re���,� �/ Application Date: � � � � -� � p d 8, � ^� � �e�ue�'� Tax Map Ar.t`�unt Paid: 0. Od 3 7 S' � �_� s�� Parcel #: Receipt#: �U �{ OSS I� 4 �"� Z 4 Z-' �� ��� ��� I�'I��..� �� � � - � � � ���� v'I � 7��v�x-.�„�-,..�.r.���.�71 7E-3L�.�1i.�� Application for Services (Sentic Svstems and Wellsl Services �'Improvement Permit (Site Evaluation) � $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) G Well Permit (New/Replacement) $225.00/$125.00 ❑ Construction Authorization (Fee is dependent on the type of sys � Permit Revision $75.00 ❑ Repair of Existing Septic 5ystem No Char�e ,1y a 3 � I v ��� v ��" � � �- Important: If the information in tlie application for an Improvement Permit is incorrect, falsified, or the site is aliered, then tl:e Imprvvement Permit and the Authorization to Canstruct shall become invalid _ ,/d� Services Requested by� Name: �FS� � �; c� ��0► V �S Address: ���j' � p,q �� � �(7 � �� r�� r� t'�',�,�,`�' ��3 ( 5�)�� .��T9.`� Phone # home : (work/cell): 33( � - . 5� � ^ .`� �i � 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: ���ubdivision: Address and/or directions to Property: •� Y� Lot #: a v�s �, p �s�9 C��ues 4) Proposed IJse and Type of Structure: Residential B iness/Type: � �i�-- Other Number of bedrooms �L,, -_/ Number of people served (seats/employees): Basement: Yes No _(wrth plumbing: Yes _ No � Garbage disposal: Yes _ No _ Approximate size of building foundation: Length� Width �_ � Water Suppty: � Private Well �Proposed Existing _) Community Well: Public Water System: Are there welIs on the adjoining properties? No Yes (please show location on site plan) ldote: A completed apnlication must also inc[ude: ➢ A plat/site plan of the property thai shows property dimensions and the size and location of all proposed structures. �➢ A signed copy of the `Lot Preparation' form verifying that the property is reail,y�to be evaluatec� I am submitting this application to request services from the Person County Health Department. TI provided is accurate. I understand that if any site is altered or the intended use changes, all permits invalid. Signature (Owner/Legal Representative): " 1 Date: (� ` � � " � 11/07 Person County Environmental Healzh, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) L IJ � �-�.�� `� ; l ���.�..� �� Y L 1 , � � � -��- T �w � � �-�1.�I �� ' ' ��.1Z' �� �L�, „-,;--, <C� �v�.E1.� �"' 1L � �. �.�11�L T�x Map � '�.rc I" � S�u, � dii ui s�i o�n ' h.�s �- � ect�ion: L� t ; �YfffljBia�effiE�:11� �8Y&ffiit - ���t `��ad �or ✓�ve �e�s �To ��pn�inon Type of Facility: � •�cM, __ ___ New '� Addition _ i�late� �aap�ly �_ # of Ocaupants of Bedrooms 3� Projected Daily FIo1v 3�o g.p.d. Proposed Wastewater System: ��1Jt�J-co �JMe- � Type: _'►T'4, Proposed Repair: �,��� I�IT ��L M r.� __? T�i�: Permit�Conditions: �ll —�o�.�,sf —�i 4_-�-��I r��o� ��.,..�.sv s�e_f 'S47— L74D Owner or Legal Representa�ive Authorized State �Agen�t: c Date: The issuance of tbis pe�it by the I3ealth Depaztment in does not guarantes the issuance of other permits. It is the responsibility of the � applicant/praperty owner to in sure that all Person County Plauning and Zoraing and. Building Inspections requirements are me� T'his . �prove�u�nt ��r�at i5 subject to re�ocadion if t4ne sii� plan, piat or �e int�aled u� claaaages. Tine Iuflpa�m�e�a��t lP�ii is not affecte� by � ei�ange in mwnessl�ap of ttne propertp. This per�it was i�sneal in cn�pliancE v�ith tflie provfl$io�s of the Nort� C�lina `Laws rend Rules far Sewa�e T'rer��asaeru� aaed l�is»ms�zd �'vstems' (15s� PdCA� 1�A .19�0). 1�Teithes� Px�so� �maanty mor the Enr�ira�aaental �ealth Speeialist�warrasais ti�a�. t9�e septi� t�nk systex�t �1 c�ntinue ta f�ction sati�iac��a ily in tixe fia�uxe or'th�t th� wate� sup�lp wii! remain:potai�le. - -_...: . . Authorization �o Co�traact W�stewate� Sys�e� (R�qa�r� for ��is�g Pe�) * Ses site plan and ada'ztioraal attachments (_). . Proposed Was�tevvater Syst�m �nl✓f.r/�to�/2� � Ty�e�_ Wastevsratex• Flow�g:p.d. New ✓ Repair ansio� _ ���� LT�a •� g.p.dJ ft 2 � Type of Fac�ity: � � Basement _ Yes _�l�o � , �1as���v��i�� ���t�ffi I�.�a������s '�� Sfiz�: 5e�tac '�� I e oo g� ]�}� 'T�c: — g� G��e '��rap: gal �r�a�el¢i: Tot� �ea: / ZoO gq � � Total i,engt�t o�, it � l�i�� ��ench IDe�t3a 3� " ffi Tre�ac3a'aVadth 3�t 1��'ina'ffi� So� Coaer. �i� in I�Yi�ais��'I'rencHa Se��tia�n: ��i �istriiautaon: Y �i§�ibaa�,ion �e� Se�ial ��tribnti�n Press�re Nl�ifofld Sp�ci�cati�ns: S t—n�� c! �o ' -�uthorized S�te A.g��� Date: Perinit Expiration Date: o � The type of system permitted is �Conventionai Acc�pterl Altexnative. I accept tlie spe�ificatians of the persnit. . , ����/��b� ���res����ave: '' Date: � .'� ' Q � ' pC� rev. 11/10/OS ���.5� ���.���T `-�= � � � ���� 1 °�n��n�am�ns.�nc�n�n.��.�. .�'3���.��J�n. WELL PERMIT (New_Repair� Tax Map: � 0 3 Parcel: Subdivision: Lot: Applicant's Name: ��,� f�,P�.h/� Mailing Address: D f� � , _����-� �1 /G 2 ?3 �3 Phone Numbers: S�- 37 93 �_, - � Location of Property: , at.J f1Dll.l D�/ �lD�r Permit Conditions: 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply. 3) Permits expire � years from the date of issue. Other Conditions/Comments: Permit issued by: 0,1�/�/,/i Date: �G�a � CERTIFICATE OF COMPLETION New Well Inspection: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller• Pump Installer: Well Approved by: Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): License #: License#: Date: Date Results Mailed: Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 :���,�� ���.��� ������ �m��o� � ��¢.m.Il 7E����4�. $�� ���E�. r 3 qr Name �JI,�SS l��,L A�/ ���j Taz Map #�� Pa=cel # I 1 Y Subdivision 8ection/Lot# ��lo �b�_ Autho ' ed S Ageat ' T� sy� ��� �� �,����� �y. � ��. �r.f�g � ��� � beg�,�ing rhe �sta�on to rnsur� that psoperg„ade u masnrarnea 4' +� .`'„' n 0 ►?o" � 'O� - -- � � I \• — - � �^ ` ' � µ ; _-�`�.t\ - __� _-___..._-- W �`' \�` . �QppiO �J'tia � � `, �, y�pJS� � _ � � � � � .----��--- - : � .... � ���� 4 �,�'`r�s � + f ���4 �� �C ��! �S ���� �J��e2� ��s� n Y��J �� � > / /�/• ( ' � T 4 y�oovE,� I�.-- �� t <��f✓ 1 r zt� r� �..� ��.�v' /O � M� � t� � ID ' Mir1 �� ��� � �. � a 5��� �� � # � � � �- �� � � �• � O 3 ��oo� _ ��O �Z _ s�c�o �.�.1. �T. .3 �-rr�t = 5 !-�.✓f.� G'' �''� • 30" 'n:��`� ��r'aM' . . r�- ir�sr�t..��oa Cb�t-�e��c.� �����2� ��-T-�. �G►�'[� 5�7- 4? gb �'��, ,', �.� ���� �� � � � ���� IC, �m�-�� ��� � �a ��-�-� � ��a �.�.11 IC� «.a,. ]1 �.Il-� Applicant: Location: T�x M�p � P�rcel � Subdivision / Ph�se Section�Lot # # of Bedrooms �����'�� �'� �� �,.. ; System Type (In Accordance With Table Va): T�4 THIS SYSTEM HAS BEEN INSTALLED IN COMPLIAIVCE WITH APPLIC,4BLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTIORI AUTHORIZATION. //�z� � Au ori ed tate Agent Date Installed By: %� �f�>rs Date: /���%r�� �- �s �� '� - 1 OOD �-r6 3� 77; q-r�2 �i�� � >" G/it�f.�i � �v � �"r� - � L,t/.f=i: /i�� � /.s��-r�'�2 ���uy�rs �;, �,���,yrf��i°� ��� 1��,�'��o.� �"/�i✓,v �o2�aG � ,,���G�ro�✓. ��ScvSyf� .M�Ja��I�✓GE y' �Lc/%L' T2�✓� ,�6r�� - PCHD, rev. 07/29/04 0 aS�._ i 1�i 1r�/VY'A fl➢`5w�`��'Lr��� i.r����l3..1� 1��9� Ij - i� Tax MaQ #����L Parc2! # � Systern Type (Tab1e Va) . Own�r/A�piicant s �h Subdivision AddresslLocation — Se�fPf�ase Lot # � � St�te IQ/date 3 CaQa ' 66� . Tee and Fiter Baffle � ' Sealarrt Riser if ap iicable Tank Outiet: Seai Permanerrt Marker - � � Pta�e� Tank �� IRiser ���z �Trencf� Width � Trencfi Length � Trenci� Grade Trenci� S acing . Rodc Depth and Quafi - Dams/Ste downs etc. Pressure Laterals � Hole Spacing o e �ze .. . . . ft. �� z in. • . �ft. ya�. P4pe Sleeve . � - - � /Sealarrt Tum-ups}Protectors �Reqta.i�d Seibacics � � Frnm Wetls �. � . Pum�- � From Propert� lines � a �bec� Valve/Gate Valve . -- - .StrvctureslBasemerrts.::� � �.� . � - - � . �-sip on o e . . � r�c es rainage ays. _ . . . . .� F�OatslSwiiches � : . � � . � . . . � : . _ . Surface` Waters . _ . - . � - - � � �� � .. � Alarm visable and audible Public Water Su p(ies � E3ectrical Camponerrts Vertical Cuts {>2 ft . . Rate pm Water Lines ' ,� Ap roved Pum Model Vehicle Tr�affic . Biocic Under Pum Ad' cerrt�Systems � � �� Pum Removal Ro elChain Easements/Rigtrt of 1N/ays . DHstcibution Sysi��e � O�er. Serial Distribution ' Eas�ments Recorded . . ressure an' o e erator ntract Lflw Pressure Pipe • Tri-Partate Agreemerrt Appr. Pipe Material and Grade � �_ Valves . . . � . - � a �G C�rili�lent5� � � pci-irf rev. 3113I01