A23 219� z/"� � �%n� ��/� �1 � . � �r.t�
Application Date: �i �" � 3
Amount Paid: �D 0 .0
Receipt #: S' 3�} 6 7 7
�#-�- �F 0 6 �
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
L� Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Q Well Permit (New/Replacement/ltepair)
$3 00.00/$200.00/$75.00
`��+5� ��q ���� Tax Map:
� � ���� Parcel#i
�" . uno* n a-� ana.x�. ao snQ:an.Il IHL c� �, ��,��a
Services
for Services
❑ Construction Authorization
Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: , �2�
Name: � � Y' � 1J � c>... �O ��1 � Phone (home):
Address: .� 5 U �Ul�, M� � (work/cell);,�
2) Name and address of current owne (if different than
Name: So./v.e S �d i ucQe.X �? �
Address:
Phone:
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C�` � AA�o e�'
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C
3) Property Description: Lot Size: �� Subdivision: _Lot #:��
Address and/or directions to Property: JUl _ ��' 1�,�� �(��, � J.� ( t—) 0.��ei
�aX �� lQ3
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other thau domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this properiy?
(if `yes' is checked, please provi�e supporting documentatien)
4) Proposed Use and Type of Structure:
esidential 3
New Single P'amily Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of edrooms: � �
❑ Repair to Malfunctioning System Will there be a basement? es ❑ no With plumbing fixtures? C5'yes ❑ no
ONon-Residential
Type of business:
Maximum number of emptoyees:
Total Square footage of Building:
Maximum number of seats:
5) Wat�r Supply: �New well � Existing Well ❑ Community ��Vell ❑ Public V6'ater � Spring
r'1re there any e;cisting wells, springs, or existing ��aterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indic�te preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
1 cer•tifv tha the inf'orniation pr•ovided above is co�r:plete and cor�•ect. I also urrderstand thut f the information provided is
inaccurat�ir if the site �subsey�t ntly altered, or the intendecl r.rse changes, all perm.its and approi�als shali be invalic�
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
� o2-I 3
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-17901
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Applicant: IR�►v�s__ � V1K�61�\�{1 ��t�j�X�'�
Address/Location: jhCc�EES M��.`, P�Aa �a �.�.1 AFi�R...
Improvement Permit
Permit Valid for: Five Years � Non-expiring
Type of Facility: S�,Jt� �w� ij�tO�y�. New � Addition
Number of: Bedrooms �/ Occupants� E loyees / Seats:
Proposed Wastewater System: t,c- t,v a5 `Ja ,�c��
P�oposed Repair: cxa w �l \
Tax Map: �?� Parcel: ,-� ��'1
Subdivision
Phase/Section/Lot #
�
Water Supply: �.w� ��LL
Projected Daily Flow: �(,oO gallons/day
Type: �_
Type: �_
Permit Conditions: ��a�M�-�. Sc� �p�stU�S3qacE �,,,•�E�,�, C�a�t,�a(, p'���,����p p1�� ' p�l c�►.iY
-� - . — .. . . _. - � - - -•
Authorized State Agent: pf�„�..�, Q, '��, Date:
(X) Owner or Legal Representative: Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws
and Rules for Sewage Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: Qe,c��p w� �`la 1��e�o� (*)Type i� !'o Design Flow 3b0 gal./day
New �, Repair _ Expansion _ Soil LTAR: 0.3� gal./day/ft2
Type of Facility: 3- S�p�M S,at,�. Ffan���t !}c� Basement: Yes No
(*) System Types Illb, Illbg, IV, and V, require periodic system inspections by ihe Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank l4vG gal.
Drainfield: Total Area QOO sq. ft.
Trench Width �_ ft.
Pump Tank �' gal.
Total Length 3 �O ft.
Min.Soil Cover � in.
Grease Trap '' gal.
Max. Trench Depth 1$ in.
Min.Trench Separation � ft.
Distribution: Distribution Box� / Serial Distribution X/ Pressure Manifold
Specifications: i>-
Authorized State Agent:
��
�S a
Issue Date:
Permit Exp
The system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Name �A�1S � V'�t,b�l�►�tF1 �i1�UfxYE(�,
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Date
System compoQe�ts �r��t appmx�in�te ccurtaursr odv. The coatracmrmust llag the s,ystra� priot to be
insure rkstP�P�g�de is marntarrled. ra
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WELL PERMIT (New�Repair�
Tax Map: Aa� Parcel: �(�j
Subdivision:
Applicant's Name: ��vts � V��-E���A �a►a��Q-
Mailing Address: q5S� Mc��,S c���. Roap
s�a� , �,c. �n 343
Phone Numbers:
Lot:
LocationofProperty: N1c6NEE5 t��� �owD '��� Ll—� �F�-'iL
�o x -#� 91 g3
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 S years from the date of issue.
Other Conditions/Comments: K�s'.p wc�. �ao �t �F�c� �u- ��'�
C'�,�eoa E�ts
Permit issued by: ��,.,�, Q� ,p,� Date: 1� � 1�.. � i3
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:
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
License #:
License#:
Date:
Date Results Mailed:
Person County Environmental Health
325 S. Morgan St., Suite C' Phone: 336-597-1790 Fax: 336-597-7808
Roxboro, NC 27573
8/1/08