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A23 197
Application Date: � - � �' � �' Amount Paid: oZ �0 . b� Receipt#: .5 �k,�� �' � # �..,�--�� s �� I�II�IE�..� ��7 q 37 � "-�=�='�'� cC � �[C�'� �C �Y �C��a-n.wn.a-.cq:ic-n.n:�za:.c�na.tL-.cn-P. �.��I..r_-.cn.��:.v.a. � � � � Eva� S a�� Application for Services ��OC). (Seutic Svstems and Wells) Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Home Replacement or Building Addition $150.00 (if site visit required) Well Permit (New/Replacement) $225.00/$125.00 T� Map: Parcel #: Services Re uested Construction Authorization (Fee is dependent on the type of ,� � ru N t �` �'�I� wTorv �'o -3�9� �fS� - 7333 Permit Revision $75.00 Repair of Existiag Septic System No Char�Te Important: If tlie information in the application for an Improvement Permit is incorrect, falsified, o� the site is altered, then t/ie Imnrovement Permit and tfie Authorization to Construct s/iall become invalid. 1) Services 13egues,ted�y: �r Name: � �f�i'� ��,bS� Address: c� ,-� a Phone # (home): 336 ' ��y%' � �7� (work/cell): 3 • / oZ 3 3� 2)Name and address of cur�nt owner (if different than applicant): Name: r-o � f 4S� �-- �"` �er' Address: �r'So� � 3) Property Description: Lot Size:��% ���ubdivision: _ Address and/or directions to Property: �,� �„ V/► �,�_�. h� Lot#�rG� �� 4) Proposed Use ap d Type of Structure: Residential 1/ Business/Type: Other Number of bedrooms �/ Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No �� Garbage disposal: Yes No t� 5) Water Supply': � Private Well I/ (Proposed Existing _) Community Well: Public Water System: Are there on the adjoining properties? No ✓ Yes (please show location on site plan) Note: A completed anplication must also include: ➢ A pladsite plan of the property that shows property dimensions and the size and location of all 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 request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representative): �� `�c� Date : � � lU � 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � ��,� `� i �����.� �� �� �� �}�yd-i� �� i ' ���I � � ���� ��.��o„-�, -m„-„ ���.�1 I�-+��.�,.�,�. ��� �3 �a� �97 �0 01 0 �Tu1'�j{%�� G���c�i � � !S ADulican� /�b �OS�2 � T-� -- . .. � ��t °��l'ad �or D� �'3ae ��s Type of Fac�i-ty: __�_,�3� # of Oc�ants�t� # o e: PrQposed Wastewaier System: ,� PTOUOSEtl �ali: � ` P�II371� C�IId111�II5: o�� � L�g�t R�S� Autliarize3 State Ageat �prawe�e�a� ��i� �o �a��on s . �ew � Additi�n � ��t�� ���a��y 2l( �oams Projec#e��ailyFlow 3loc� g-p•d- y >�-� �✓/-� �_ �i�k S � .- �� • .:- ���e Daie: �Dat�: o � The issuanca o� tiris pe�it liy �e Healt3i Deparuaeut im does not �e� the ;��,ar�� of other persrrifs. Tf is t�e responsinil� of the aPPli�in�P�Y owner m in sure tiaat aIl Peisnn. Cou� Pia�ing an3 Zoaiag and Bn�ing InsQections requnrer�enis a=e me� ��aas �p�v�s��t �er�at i� saa�sj�t t� �evo�a.tion 9f t3�e sa� p�am; ��t�'�� t�ae iaate�de� �e c�g�.s. i�a� ����es�e�i P�t � a��� a�e�9� �y � ci�asags iaa ov�aa�s"siangs o� �9a� pr��ert3►s T�s pesr�i# �as is�ed � c�o�li��� �i�a th� pravis��u� of th� �Tor-f� �C���, .: `i�►vs �eal �?rales far Sesv�.�e �'re�aetat rurzr� tD�so�ul ,s�vsfesns' (15�i l�TC�� fl�rS .19�0). 1�Teith� ��S ���#y�: IIpa�':t$r,�.` '= �aavaa��eat� �ealt9i Spers�a�t �r�rants t��t tffie se�tic taa�k sy� � c�n�nse to f��tion s�fa�iaa�fly iai tRne fiat�e �r�#��� #��-wa�r suppl� wa'dl ��sin �aot�hie. . . � :��a����i�n t� ��nst�aact'�ast�v��� 5�st�a (�.�-s�a�� ��� �aaa�ld�g ���t� � *. Ses szte plan c�d additional attac}�men�s (_�. � � � . . �. ��5� w�� s�: � A i� ���e—��1 Ty'p�� 4�v��.� �m�36o�.�.a. New � Re}�air Expansion � � � 3+�� ��.�►..�.8: � l 2 g-�.si.! ft 2 Type of Fac�ity: g� � Baseffient �C Yes _ No . � y10vt�� ✓�tA�e � ��.����wa��� Sp�$� �e����a��� ' � . .. '� �' : �e 's '��:' � � T� �DO ��� �� : �— � � . � ..� �a � �_ � P . . . ���d: �m� ��: �4 o s€� � '�o�ai �e�egt� lS�� ' ' �n'��n�a 33e�� _�_ a� � ' ���cia �d#h '— � Sfla� ��ave�: �?� ������ �eBa�a �e�a�ao� 2 #i ���a�on: ��abaa�ao� �o� Ser�l��ra�aart��n X�es�� l�old� G�✓Q4L��C GlM' "1 . �n��e�tiomm�: ,�S�I �� � R �GY !u4'%u,���� a S G{$�''� � 4 DP rv✓ � : � . . . �` _ �, _ _ . _ �..�.. _ _ �. � n ., . i , n n�7`-C "' �' .:ita , ,: - ' :�*a� i : ;�� t I.� yi ! . - The �,�� oi syste� p�;tea � Convea�onai p�mii. ��-�' ��a.i �z�aa�ps���.�'a��: �i�c,�'v� ,s � � c:.�tea Date; �1t�aiive. I ac�,��t the �er,incaiions oi th;. �aie: PC.� rej�. iI/161��_ � .. �. : ����� �� ���� �� �. � � -�^ � � � � � Jl I���a� � �.a-� ���.�.11 .IL�L � �.Il �1�. W�I�L PERIVIT� (�1ew�,Repair� Tax 1VIap: ! �23 Parcel• � � 7 Subdivision: ►-Uf Q�Pr . Lot: l� Applicant's Name: g� �DS'P —�.. 1l�Iailing Address: Phone Numbers: ocation oi ,r.,�n ;,.csr �t Permit Condations: • 1) See attached site plan for proposed well location. , 2) All applicable State and County regulations governing construction and setbacks apply. 3) Permits expire 5 years fi�om the date of issue. Other Conditions/Comments: Permit issued bv: ,�l� �^ ,_ �✓'e✓� Date: ����o �' C�IaT�FICA�� OI+' COMPLETIOl�T 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 32� S. Morgan St., Suite C Roxboro, NC 37573 I,iner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ License #: License#: Date: Date Results Mailed: Phone: 33b-597-1790 Fax: 336-597-7308 8/1/08 _.._ . � _._ _ . . ' f: ,/ � ,� � r x � , \ / . � � , � � /•� � � �i� �- t 1 I-;��. ����.����������� .�i [ t�,:,l f� CLEARWATER S/D PERMIT CONDITIONS Information for the Installer: nsuring a healthy environment 1. System shall be installed per approved engineered plans. 2. Contractor must be certified by the drip and pretreatment manufacturer in order to 3. 4. 5. 6. 7. 8. 9. 10 install system. Contractor shall have a set of approved engineer's plans on the job site througlioL�t installation. Pre-installation meeting mandatory (Design engineer and drip/pretreatn:ent inanufacturer rep. must be present). Contractor must re-flag drip lines on contour after clearing and have layout approved by health dept. When clearing drainfield area disturb soil as little as possible. No site work should be done under wet conditions. Contractor, design engineer, drip and pretreatment manufacturer rep., and certified operator must be present at system start-up. Before operation permit can be released a registered professional en�ii�eer ar certified designer and drip/pretreatment manufacturer rep. must certify in writing that the system was installed in accordance with tlie approved plans and specifications. All tanlcs must be accessible from grade. phone 336.597.1790 fax 336.597.7808 325 South Moraan Street, Suite C, Roxboro, NC 27573 't ..,,, . �''a �:.'� ...-. " � `-�� .. �....-�"'... . �{� a, . � � ��� 1l �]L�L�IlII'�7m]Y7Y11Q�SCb�.�.11 Jl J1Q��1.11�� CLEARWATER S/D PERMIT CONDITIONS Information for the owner: nsuring a healthy environment 1. Before the operation permit can be released a copy of the signed certified operatar (ORC)contract must be given to the health dept. (a contract for operation �;i;d maintenance with an American Certified ORC shall remain in effect for as long �:: the system is to remain in use.) The ORC must be laoth a Grade II licensed wastewater treatment facility operator and a licensed subsurface operator. 2. Grass must be established over the drainfield area and cut when needeci. Caution must be used concerning volume of water entering system and what is put down the drain(ex. Grease, personal hygiene products, cigarette butts) phone 336.597.1790 fax 336.597.7808 325 South Morgan Street, Suite C, Roxboro, NC 27573 `' �aT 15 �=' _ sEpr[c � �RqtNF[�ED u= E�45ExqEIVi �a 14 o�S ':�. �� � . ;� C'JRVE c, - � C- 3 C - -# :- 5 \ �, � .� v � i;� / � J � 1^� ,1 1:x , � � S` 1 — : G ,7. � vVAS '_:Vr �R r' •� . � �4 P�_,`! � � _ a��41E�dT . � ,� �,� , ����z 6AsEna�nrT ;'� � _. _. �=., � ,����w� y. ,. . � . �� � � . -� .7 I _ Y \ ����ra. 28°20�a9�� �0°41�41�' �v,�o����� 09'29'So`� 1G°23 4,° cq,�8;��„ �t-r "� ;r�,f � �/� i f� �J�� j L ;�ADiUS ARC T,iti ��QRD BR:i C�-IORD 325.00 408.i7 208.�5 N2�'y1;�9�N jC�.J� 8=5.�C 'O.QO 5.00 i�40°2�'0�°4Y 10.'JO �25.00 °?6.'� 48.22 N45'58��,��tY 9b.0Y 5%5 . 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