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-'
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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
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v ��"
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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)
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' ' ��.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
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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
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Applicant:
Location:
T�x M�p � P�rcel �
Subdivision /
Ph�se Section�Lot #
# of Bedrooms
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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.
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Au ori ed tate Agent Date
Installed By: %� �f�>rs Date: /���%r��
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T2�✓� ,�6r�� -
PCHD, rev. 07/29/04
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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� �
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pci-irf rev. 3113I01