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A23 37.,, e �=�!�?'�i ' :� J Sr. . � r. _.�r/j'1�°° ._. � , ).. "_ ; a i'r ��° . � Th� Di�trict H�alth D�partment CASWELL - CHATHAM - LEE -.PERSBN COUNTIES Water Supply and Sewage Disposal � IMPROVEMENTS PERMI No. . atp ,� � Owner: � � Lacation: � :_ , �._, � Contractor: Water Supplgs Private Public 1 / - � I . , �7"'� a /`�. /r� �T '— _ n . . %LT7.. Sewage Disposal Facili3ieas"No. washing machine, other suton Size of tank: �/> >� } r� i r';fiii � appliances Nitriflcation line:: _ � i 3��- T��re.�--_��,11ooI -� --------- �� , Other disp f cility: _ "`' � ✓'��' � � ' �`� "� • { /��/e .S -- ... __ � .. . ,�. t � .�� " n�� `'�y��'�; , Water �u ply and' �ewage osal facilit es �lo io inst llation 'ailti- � . protection musY meet state and local regulations. Septic tank should be pumped out every 3 to 5 years, and shall be main- I tained by�owner in�such a manner as not to create a public'health iiazard. • i ROVEII BY A MEMBER OF THE DISTAICT HEALTH D PAR.TMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND. PUT INTO USE. � �r `% (� 1 ` _, f � �, ,'; 'r�1 _'�.! Date approved: Signe ��"�'i f �� ` . anitarien ' Well: �: -� Sewage Disposal•– - Counter- f . By' si�e `- (Owaer or his representative) CestiScate:.of.. Complelion � Date Approvedr-_... .. �.2.Q –� . . By, nitarian . _.. .. .. __ .. . .. . : . _. . ��R� .... Location of well "and sewage disposal facilities sketched on back. m m � Application Date: '� Amount Paid: Receipt #: q 3 y 3/ Cred�� C a1�� `+�-�� ' ��'�1'1 V Tax Map: � SJ Parcel#: _-��3� ~ � � �� 3E�.sawna-acvnaaaaz:�radruIl JH[��.11dlln for Services Services Re uested Improvement Permit (Site Evaluation) Construction Authorization $200.00/$300.00 if> 600 ee is de endent on the e of s stem ermitted �l�Iobile Home Replacement o uilding Addition Permit Revision $150.00 if site visit re uired $75.00 Well Permit (New/Replacement/Repair) Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 7� 1) Applicant In ormation: Name: �p�� ..� � h ,. _-:,. �' Phone (home): ��,—,Z� 3 3G7� Address: ��5' 7',�y.�//_c�,��/ yr/ (work/cell): 336�' 2�03— 3U7� Z) Name and address of current owner (if different than applicant): Name: Phone: Address: 3) Property Description: Lot Size: Subdivision: ��, ��Lot #: � Address andlor directions to Pro e —�' P �Y� ❑ 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 than domestic sewage? O 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 property? (if `yes' is checked, please provide supporting documentation) 3°x sz'' ` �� 4) Proposed Use and Type of Structure: ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: _�� Expansion of Existing System If expansion: Current numbey�f bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? Cdyes � no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: � New well � Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If applying for °Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if�e site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Legal Representative*) * Supporting documentation required. � � Date Permits are valid for either 60 months or are non-ezpiring 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 (336-597-1790) �� . � . � l �.� �� `L� �� 1��-7��.� 1�-�c�:�. � Building Additions/ Mobile Home Replacements Tax Map #: � j Parcel#: �J7 Address: Approval Requested for: Mobile Home Replacem ent �t Building Addition ��i�� St�o� .4.r�t p t,�v�.E �� -�� s�� Applicant Name: �,�,�, �� Address: � 7 �� ^r'��c_z� ��ot� ��_ �L�.la�� L Phone #'s: ��' �� ,r ��_ Permit Located: ✓ Yes No Installation Date: ?A / � Design flow: 2� (gpd) Current Contract with Certified Operator on file (if required): � Water Supply: ✓ Well Public or Community � '��M �r�.k�,�w�fl� Wastewater system shows no visual evidence of failure on: �/�Q %T � 5 (date) (Applicant's signature if site visit is not required) Comments: r"/✓jl�I!7'/1/� ��lllQ� ��►7*1�S�GJ�i7i7i�"�+ � i ,� z_ r> �� u.e � A i �r ii� r.r ��i L� +' ' / i . . , . � Addition/Replacement Approved Environmental ea Specialist l �� Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcounty.net ConnectGIS Feature Report �I �a 7 ��w��GIS LYE� � :'•51l�lw 1551 � , Person County Ernrironme�al Health $t11�8 Ci �ro. NC 27573 "' -✓I I+FrStL I ��t�iS �.:w��-.±-',.� �� :�. i�� i�, CI MA.TE �,QG,JL`CLOI� 132't i5� � \ ,. �� :� �� =:� Sys r�..� � �� -; � T ,� � � ��_,• �� 'a ��M//�1 �� . i � � � = �'�� XKT�''� �� ,. ��►.a� vJ�fl E ,, , ? 'j�."�i ti� Page 1 of 1 ?Z9�� ' Person inted July 29, 2015 See Below for Disclaimer �Parcels . ❑ �' Pragre5s �,reas (1] �� 1�-� Progress �,reas �2j ' �2263 G1 Parcel Address Pair�;� � €��rcel Lire Gimer�sior.s �akes � � Roads � _ Ci:� oy Roxboro Q �� ltviur��ar,E A�ric�l:ural Cistric�s � � l�Z � T�� 'l, �I ��L r�'D • � /�t23 — �� ' � �� : EO Feet pl ._, ; JOTICE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who F ecently upgraded to the Windows 8 operating system or a new version of Internet Explorer. We were able to resolve this issue by directing users to the Intemet Expl� :ompatibility View tool. This Iink is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US/internet-explorer/products/ie-9/features/compatibility-� F this does not solve the problem feel free to contact us at the number iisted on our main page. Welcome to the Person County GIS Website. ConnectGIS has b �repared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other pubiic records. Users of GIS system iotified that the aforementioned public information sources should be consulted tor verification of the information in this system. Person County, Mobile 311, Connec �ssume no leqal responsibility for the intormation in this system. Grid is based on the NC state plane coordinate system, 1983 NAD. http://gis.personcounty.net/ConnectGIS v6/DownloadFile.aslix?i=_ags_mapd5419677c98... 7/29/2015 _ �