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�� i. The D�strict Health aepartrtie�t
� ;- � CASWELL - CHATHAM - LEE - PERSON COUNTIES
-! f '� Water�Sup;p.lyMand-Sewage Disposol
J �i�f%�D __.IMPROVEMENTS. PERMIT _No =_
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f `� � � ;` �, ��� �/� � �,, fi .- � -�' .
. o Ownerc _� �
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11'J� ..
Contractor: �_
Public
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IJ
Sewage Disposal Faafli3ies: No. bedrooms � Dishwasher;;�Disposal�
washing machine, other a toma c appliances -
Size oi tank: �� . �� " � Nitriflcation line: ' � "�'
� � _
i Other disposal faciIity'; : _. _ .. .. _,....:.__ _ _,.•-. � --
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and-shall be main-
tained by owner in such a manner as not to create a public heaith hazard.
Septic tank and nitrification line MU$T. BE .INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION :OF `THE INSTALLATION IS COV-
ERED AND PUT INTO USE. '
Date approved: Signe -
t.
We1L• '
Sewage Disposal: Counter-
By• aigne .
( er or i' epresentative)
d
y
,� Cesli6cale o� Coaipletioa �
Date Approved: - ( �a �� 4 � gy
Sanitarian
(OVEB)
Location of well and sewage disposal facilities sketched:::on :back.
,
� ��� `� � � � �.—.,����, f � ������ � ax M� s A � 3
iication Uat�; __,��� � .� `
A,nYauntPatd: t o • ,..., . �.%���r�� Iarcol#� ,� ' 3 '
Receipt #: 7d3N �! �3; �t-��.�.��1t�.
—�-�--- usv a� a�.cs ar.�arn, cs an e�,� 11�,�
C�-��'f C°`w� ,
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_. . . Servicea R uca�tec� �:,�.� .A,
� ^C3 �mproveaue�st Yermit (Sit� Evaluatlon) CI Ca�i�tr+�Ctlan +�t�tlto�I�arklon :
,$20�.�0/�300.00 if � 600 Cea ia d� endont gn th,�! a oP a rtom `�rrniitacl ;
,, ��iobile Home Replacement or Buildin� Addttion Cl Psrmlt �+�vla���
$15Q.04 if site visit re uire $75.Q0
G�'vVeil Permit (New/ReplacementlRepair) CI Ra��lr 4f �xblMup� Soptl+e i�y����l1 ,�,
lia�t��n: Tta� �har �I �,�'� t �4,�0 �r ��{�.��
�30Q.00!$200.OPi$75.00 �Pl� � ,�„„�
1} A.pplicant Inifoxnaation: r"'�� �� S � � � '� �� �� � �
: Nam�; : G-�-{S i��'}.t� .,� .. �'hon� (h�m�):
: A�idress: ` 't� C ' G.'T', (wa�lacll�i
y�� t� , i i,Y` 2. 'i •�ac�
'�� I�i:���4 ;�n� addresa of c�rrent owner (ifdif�'erent than a�p�ir„�pt):
;�zrne: Ph�rc�3;
�3dress:
3� �r���a-tjr De�cript�on: I..at: Size; Subdiviaic�n; GAt #: �,�„�, .
� r� dd�ess andlor �lirections �o Prop�rt�, "�C� � 5� s .�„<, _��- �,�:-r �
.�.�i'���'�ORJ4° ���� ' � �.- � ,.k...�'.
� yes r,o Dae,�, th� siw ,^,Vt�t��.n �zy juriM: ac�iort�t watlands7 ��,
�"'yes � no Doas t��; si�: c�tttaiu,~� �sy e�istSn� v���t�wa�rt �ysta�•s'? ,'
� ye� c1�'�o Is any ��r�st�watcr �ving t� be �net�ted anr th� �it� �.,tlt�t` t�a dantastic �e�+a�a�
C� yes �3"'nQ Is tho site subject to sapproval by. any oth�r pabli� ugancy7
�,e5 � Are there any casemgnks' �r rlght of ways'on this pro�erty� ��, �,»it�` .
(if `yes'; is ohecked, gte�s� providc support.�g dacument�tion)
.�� �t��i�c���u `�,�� and T�p� of Structure� � �
r���.�i c��a� ' , ' �'
'"` ��a'ec�r �iagle Family Resideacc MaxunutTi numb�r afb$dt'oott��: _,,,_,,,�„�,,,, -
f.� �:cpansi�n cf Existiug 5ystem If cxpaasin�: Cur�r►t n�maar �F�����'��r��; M:
��pafr to .�1aEf�nctio�ai�g Syst�m _ Wi11 tb�r� ba a b�s��acz�t'�y� t� z�� V'Vith plumt�i��, �u�tur�ie��yo� � nc�
� o�-�es�Wartia .. Ta�t�l �qa�r�"�`�aata�o o�t�ut�din�t �
� ��'��c�'b�ssine�s� �� � � �
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��irr�um��aumbEz��ofomgl�yees, �� � M�x�t��t#m �t�rsiboc p�'�nat�; �
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1��� �rn.�vn�a.� Zr.n.Yrnncc: �c�n.tL�n.�. 1F"� �::,.rn.�l. i��:n.
November 18, 2014
Christopher Jones
5008 Prancer Court
Wake Forest, NC 27587-8800
RE: Site Evaluation Application Dated 9/16/2014
Dear Mr. Jones:
The Person County Environmental Health Department has a policy that states any
application, which has not been acted upon for 3 months becomes void, and any fees paid
are then forfeited. Our records indicate that an application was filed on 9/16/2014 for a
mobile home replacement permit at 1313 Terrell School Rd. Our Department conducted
a site re-evaluation on 9/19/2014. We have not yet received a surveyed plat showing the
lot with proposed house location along with the septic system drainfield area. If action is
not taken by December 19, 2014, the application will become void and all fees forfeited.
If you have any questions concerning this process, please contact Derrick Smith of the
Person County Environmental Health Department at 336-597-1790.
Sincerely,
a�! � :.��
Derrick A. Smith, LSS, REHSI
Environmental Health Specialist
Person County Health Department
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
Application Date: � 30 ��
Amount Paid: 0 .
Receipt #: �j 3�
e�� ��-Q 3
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 e�dl
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/ReplacementlRepair)
$300.00/$200.00/$75.00
��, j,)� ��q ���1 V Tax Map:�
� � ���� Parcel#:
� sav n�- o an uaa � aa �tu.Il 1E-� � a�.lL �l�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 Info� !ati n: ��
� Name: ,1��. ��P � �, ffi '�t� �L �
Address: L ;
� �i Ll �� � �'tl %
2) Name and address of current owner (if different than applicant):
Name: _���r:f f ��,-,, ' .Jo» �s
Address: � �
�/� /�t f�i� f[/ o77S ��
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property: l3/,�
Phone (home):
(work/cell): �,��?- �/�D- �iv7�
Phone: `�l < - c��D � .����
Lot #:
❑ yes C9'no Does the site contain any jurisdictional wetlands?
Q�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?
❑ yes 0��� Is the site subject to approval by any other public agency?
❑ yes 0' n o Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) roposed Use and Type of Structure:
�esidential
ew Single Family Residence Maximum number of bedrooms: �_
❑ Expansion of Existing System If expansion: Current number of bedrooms: _� ��
❑ Repair to Malfunctioning System Will there be a basement? G3�yes ❑ no With plumbing fixtures? ❑ yes lKno
❑Non-Residential
Type of business:
Ma�cimum number of employees:
Total Square footage of Building:
MaYimum number of seats:
5) Water Supply: ❑ New well ��sting Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If �pplying for `Authorization to Construct', please indicate preferred system type(s):
(g Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the,site is su�sequently altered, or the intended use changes, all permits and approvals shall be irtvalid.
Representative*)
�` Supporting documentation required.
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 (336-597-1790)
4
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THIS IS NOT A SURVEY
carorna
CORNER
PROPOSED SITE PLAN
2/23/15
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TANK
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Builder—Tony Hirst LLC
1292 U.S. HWY 1 BYPASS S.
KITTRELL, N.C. 27544
PH: 252-430-7722
FAX:252-430-6377
m... e� ar. aa.cr a e�w.�-ro�y �x uc
ona �annot w ooplW « nyreao.a .�mwe
�AtGn psmMMon kam Bu1da—Tmy MFtt LLC
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LOT 10
iHE JOFW C. TFRRElI FARY
aucr �oc�nori uao �ws oF
HOME TO BE DE7ERYINW
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Chris and Tamie Jones
cuiaw� Pow� � ua�r Person County, NC
HYCO LAKE
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Tax Ivlap #: a3 Parcel#: 3� Address: 13�3
Approval Requested for: � Mobile Home Replacement
Building Addition
Applicant Name: C�►�s `S'c�s �-tv�1( 1��C�.s-r
Address: �qa u.5. Nw.� � A�'t�ss s.
K�-v... , +.1c.� �,hs�1�
Phone #'s: �5a- ►��o � ��aa. � 9►q-x�o s��3 Lc�s �-o�,s1
Permii Located: %� Yes No
Installation Bate: g��3-$3
Design flow: 3bo (gpd)
Current CQntract with Certified Operator on file (if required): �'
Water �upply: 7�. Well Public or Community
Wastewater system shows no visual evidence of failure on: �3, 31 � 15' (date)
(Applicant's signature if site visit is not required)
Comments: • A4�.ov�., -so '�� �,x,�sn�. 3�i1+��,� --«�w-v.._ wi
�A t�W 3�'l1�oy�,�r--. S`�4-�� cy.'�� A.S S�o�, v� S� ��wi. � t�o
s�ts�r. Ucbcta.'�� 'Rca��Rcx) : �c.o,.r.ti.� �1s��. �^ow ��v �,x��S ►eJ.
�1e�w �asc� ;=r�a� G��� w�v�. ��s� A, v�"�a•� -ra l�l.�.-fOv�
5$-Y4a�,�, �to 'r�t� wc�:� 'A� ct���. rkrr -sv �w�� S� 5-s�-� w��
St�-,�v ��6 F�c,��.-.r� s�� •
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Environmental Health Speciaiist
y-t�- r�
Date
Person CoL�nri Environme:�tai �Tcalth; 3?5 S. yioraan St., Suite C; RoYboro, rJC 27� � 3
Fhcne: ��b-�97-??9C/ ra::: ���5-�9�-i�0� � �v�:.���.�ersoncoun�tv.i,e:
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SITE PLAN
Name �� ���7� u� Tax Map #�3 Parcel # 3�
�division Secdon/Lo #
�SLS�+ca� � . � +�- -1 S
Authorized State Ageat Date
System compoaents tepnsent apprvxfmate cantours aaly. The cvnmctormust 11ag t6e system prior to begianLig the iastallarion e
Iasure thatpmpergradeis mainradned. —
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DRAINUNE
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TANK
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CONTOUR
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LOT 10
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EXACT LOCATION AND AXIS OF
HOME TO 8E DETERMINED
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59.92'
CAROLJNA POWER dt UGHT
HYCO LAKE
Chris and Tamie Jones
Person County. NC