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A23 200� �� Application Date: .� �5 " C'� �.3 Tax Map: Amount Paid::�'�' ttiC� �C)�� ��.� �� �, Parcel #: _ Receipt#: •5 3.3'�-`� G� ..5 .�-�5 �?�� I� i�'���� �o�ti � c:k� � � 3 7 �i ���_ S � ���� �� ' ����4 ���9 ' ' � � ���� ���.��a-.m�n�.��¢.m.n ��.�.a�n.-�. C � �-'�t�� Application for Services (Sentic Svstems and Wells) Services 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 Construction Authorization (Fee is dependent on the type of sy: Permit Revision $75.00 Repair of Ezisting Septic System No Char�e Important: If the information in the application for an Improvernent Permit is incorrect, falsified, or the site is altered, then the Imnrovement Permit and theAutl:orization to Construct shall become invalid. 1) Services ues ed b,�;� ` Name: �� ��v�P -�+�, Address: ` ; P "� ' � �-- v� t .�-c. � �-�, �. �a� Phone # (hom�:�`'�'�' ��%r �� �'� f ✓o c/cell): .,�.� - w ��.�� �� � -� 7� 5 y� �`'� 2)Name aprdL�•address of current wner (if different than applicant): Name: s.s'��°�r��s �t�' S'�3�� Address: 3) Property Description: Lot Size: J���`S�bdivis� Address and�or directions to Property: t"'��,,�`, �,4 ;`r�, � �6��. 3r 4) Proposed Use and Type of Structure: Residential �� Bu�iness/Type: . Other Number of bedrooms � / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No _� Garbage disposal: Yes No � Water Supply: Private Well �(Proposed E�cisting _) Community Well: Public Water Syste�} : Are there on the adjoining properties7 No ,�/ , Yes (please show location on site plan) Note: A completed application must also include: ➢ A platlsite plan of the property tl:at shows propeYty dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing tlzat the property is ready to be evaluatec� I am submitting this application .to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. .� j , V,� Signature (Owner/Legal Representative): ��` �� �`"��� � Date c =' �� � � � 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � ���� ���i ����� �� i 'y � 1 d � //�q �`T � \�. � � �� �J � �� V � �'.`1 ' " .s�.s:i� �o -,�, �,-�-, «�.�.a � �"� � �.�z�.i t1�Iican� �c�� �-5�— . T ,.,...a.:..�.. . • . . ��r�$ °iT�lid ��r � �39e �' Type ofFaciliiy: 1�3� # of Oc�ants ►�+ a �( (A � of Proposed Waste�vater Syst.em Proposed Re�air: � ��9YiD�P.39�3d� �..3�11$ �c��a3 I�c�� 2�0 0 0 � �l$ar1�4.� ����`,�C�9i � � 3 '��#�� ������ �!/f(( g.p.d. Type: �R __ 'I�1p�: �q �wner or Le�a1 Repres�.ti e i � Da#�e: Anthorized Stat�e Age� � �� ✓v'P� • ' Date: � S D The issvanca of this pe�it liy ti�e Health Depaztmezrt in does not � the issuanc� of other per�nifs. �f is the r�spons�ili#�j of tlle aPPli��P�Y owner to in sure that aIl Persaa Ca� Piazmiag and. Zoning and Bu�ing Inspe�tions reqt�.'ements aYe me#. � �pr���n�at �er�aat i� saa�s,g� t� re�oa��non 9f �e sa�e p3�; ���'�� tia� intesade� �ase ��ng�,s. �� �svveme�t ��t i� ��$ asse�� 3i� a c�ge in o�aer"s�aip o� tiae pro�aer#3►. T3aa� p�s�tit vaas issuaed i� ea��sli�ca �+i�a t�t� �ara�isso� of taie l�or-t� �Carm�a, .: `��s asa� Rsades far ..�esva_�e �'re�dane�at �rzd ]9is�smsal �vstesras' {�.SA. I+TC�� i� .19�0). l�eit.�a�s �i'r�a ��rimmfy�: no��'t�.` ': �nv�nanent� �i�Ith Spess�st v�ars�ani� ttaat t�ae s��tic � sy� �! c�mti�n�e t� fnm�o� s��f��is�s�aip in 1�Ene faai€�e�oe��#�t. t�h�-w��r suppi� wsII rauaaia �tabie. � • � � ��noa��isa�a � ���strm�t ���aate� Sgs�snt ��-�a�s� ��� �aaa�a� �'��t� � T. Ses site plapa c�d addi#ional attac}�men�s (_}. � � . . . F'rog�seri Wastewater Systezn: ri �Yi Q�i�+n�� U/ �V.'L-11��y'P�,� aste�vater �1�� 36�g.p.d. . ti IVew �.. Re�air F�ansion � � � Sa�� ���: ' � g.}�.d.! $ 2 . Type of Fac�ity: � �PS •• � Base�aent iC Yes _ No �' � pr-�2�,0� ,^� oc� � — QG O � . . . . _ _ - .. � �7����.���' �'���������� � �D d� (� y-�'� r� . �-aHK . . . a,. . . . . '�� ��: 5��c '��:' b� �p T� r� g�d � g� � . ���¢�. T��fl ��: '�l� s� � '�o�i Lemgt�a `��:� � ' ' � �� ���a I3e��a �P � " � . ��.�a�n �ci#9a r' � Soi� �ov��: �_ in ���aa�on: �i�i�aa�non �o� ceri�i ��i�n�aon �srn���ti�a�:�ts��l. QK� /LrQ,k/�t;v� a s o% �r» A�% 1.r�P C C.DCI 1� QCGtI �c.+2 �� � S ��� ���: �� Permii E�iration Date: � The tyne oi systeaa pe:�;t�a is Conven�onai Ac:.�te3 Pe�it• ��l�' eb� ���a�s�����e: -�,.cvtd J a�i V� �ys�-eM �----- - • r--- �,���,�� '�����a �e��ao� 2 � x �r�� ��o���t�'"au��� � un' f- � � �,����, . _ . - . I / � / A A�� - . • . . Date: Altsrnazive. I a�:,s�t �e �e�catians oi the JB.tL; p� rev. l?I14i��_ � �� � .. : � ������- ���.���� �= �--� ������ �� �����,ma-���.��.Il IHI��.11�7�. ���� ���18��� (1`1e�v��epair� �a� lY�ap: �Z� �aree�: Z � �ubdiyision: {QY� .� I.,ot: A��licant's 1�Tanne: �o.� /��5�- I�✓Iailiang �`sddress: i'l�one i'��a�bers: �ro � --'= L <-eAn-w�a. � h an.� Permit Conddtions: 1) See attached site plan for proposed well location. Z) All �pplicable State and County �egulations governing construction and setbacks apply. 3) Permits expire S years frofn the date of issue. (�dher �onriition�/�onarnents: Perflni� is�ued ��: � '� �'irv��' I��te: T�O-� ��I����C�"�'� O�+' C�1V���'I'��l�T l��e�v i�leli �nspectioa�: EHS/Date Location: GroutinD: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: d�Ve�l i��nller: Pump Installer: `�iTell ��p��ved by: L�ate Sample Collected: Person County Environmental Health 32� S. Nlorgan St., Suite C Roxboro, NC 27�73 �iner ��aspe�tion: EHS/Date Installer: Depth: Grout: '�e91 Ab�nc�oa�anent: EHS/Date Completed: Method/'Vlaterial(s): �nce��e #: License#: I3a#e: Date Results Ivlailed: Phone: 336-�97-1790 Fax: 336-597-7803 siiios . ,.. ; '"``��'`� �. ra �n ,_:u:..�,,, ` ,': , , .. - �- Y ' -. _�°` � � ���� ��n.�n��n����n��.� ���.�tC�n 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 inanufacturer in order io install system. 3. Contractor shall have a set of approved engineer's plans on the job site throughou� installation. 4. Pre-installation meeting mandatory (Design engineer and drip/pretreahnent manufacturer rep. must be present). 5. Contractor must re-flag drip lines on contour after clearing and have layout approved by health dept. 6.. When clearing drainiield azea disturb soil as little as possible. 7. No site worlc should be done under wet conditions. 8. Contractor, design engineer, drip and pretreatment manufacturer rep., and certified operator must be present at system start-Lip. 9. Before operation permit can be released a registered profession�l engiueer or certified designer and drip/pretreatinent manufacturer rep. must certify 111 Wlltlll�' that the system was installed in accordance with the approved plans and specifications. 10. All tanlcs must be accessible from grade. phone 336.597.1790 fax 336.597.7808 325 South Morgan Street, Suite C, Roxboro, NC 27573 j, w.,�:,._ .' $. � s _ ,7 ..:. � � �� 1L � ��n�a��n�a��na��.� ���,���n 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 certifed operator (ORC)contract must be given to the health dept. (a contract for operation aild maintenance with an Amer.ican Certified ORC shall remain in effect for as long �s the system is to remain in use.) The ORC must be both a Grade II licensed wastewater treatment facility operator and a licensed subsurface operator. 2. Grass inust be established over the drainfield area and cut wheii needed. 3. 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 \ . /'% /,�' G�� � -�>-'�� ,%�w �' I �1 t7. ) , � � . 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'7. 8. 9. 10 CLEARWATER S/D PERMIT CONDITIONS Information for the Installer: nsuring a healthy environment System shall be installed per approved engineered plans. Contractor must be certified by the drip and pretreatment manufacturer in order io install system. Contractor shall have a set of approved engineer's plans on the job site througl�out installation. Pre-installation meeting mandatory (Design engineer and drip/pretreatment manufacturer 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 profession�l en�ineer or certified designer and drip/pretreatinent manufacturer rep. must certify in writing that the system was installed in accordance with the approved plans and specifications. All tanlcs must be accessible from grade. phone 336.597.1790 fax 336.597.7808 325 South Morgan Street, Suite C, Roxboro, NC 27573 } �hhc�. ..��'�� {� ° �. i -z�.,,� u.. - � � � ���� �t ,�Im�Il�"�IIYY�Il�Il.�IYa�<�l.11 Jl J1cC���l.�1�� CLEARWATER S/D PERMIT CONDITIONS Information for the owner: nsuring a healthy environment 1. Before the operation permit can be released a copy of tlie signed certified operator (ORC)contract must be given to the health dept. (a contract for operation �ii;d maintenance with an Ame�ican Certified ORC shall remain in effect for as long �:: the system is to remain in use.) The ORC must be both a Grade II licensed wastewater treatment facility operator and a licensed subsurface operator. 2. Grass inust be established over the drainfield area and cut when needeci. 3. 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