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A23 46
- -rr---^�_. .....�.. � �3_�CJ _, i ax lvtap: Z3 Amount Paid: _��„r,, ,� Parcel #: y l� Receipt#: � � � � � ��� ��� ��~ ���.��� '�--� � =--�. � � � ��r�c-�- IF' ;�.,rs.,.-.:.a.-.:=rr+.wax��m.r.n.11 JE 3L��.�n.11Kt<1la App�ication for Setvices „_ (Saptic Systems and WelLs) ServSces Re nested � ovement permit (Site EvAluation) t'l Conscrurtioa AutLorixation �00.00/��00.00 (if � 600 t�o� (PBe i� clenenrlPnt nn thP tvnN l] Mobile Home Replaament or Bulding Acidition SISO.OU (ifsite visit required) ❑ Weli Perrnit (New/�teptacement) �5.40/$1?5.04 (1 Permit Revisinn c� � a� u, .�a�� 1� � h�.��" ❑ Repair of Elcisttng Septie System ' Nn Chanee Imporcank If rhe i�('onrir�tion i� the appl3ratl�in jor an Lrrrprovement Perrnfi ls lncur�ec� ja/s�r� or the site ls rdrered, �rlien t1�e Lmpravanent Permit rurd theAtrrhorization m Construei shall become invalld 1) Services Requested by: Name: /a tJ � R E� P 1 SK �R1": V Phone #(honnc): q� q- q 3�, - 5539 Addr�ss: 1� t� P � �J 0� t� C--T" • {work/cell): a l�l - a. S q- 3 3 O C.N►�P��_ l+�t� N cr �,�SIU — , 2}Name aad address af cnrrept ow�ner (if differenc iban apptican�t): Namt: cIA��Q pa�L W rin(.�tz C� �nf�Au4 i4,ddress: � 86 3 s�uZ �-1� I�,os_ u� Ni.�:-�, . Sv�rN�a..1�� v P �45� p�t: S 3) Propcxty Descriptioni Lot Size: 3 y. �5 �`�ubdivision: 1J 1 A �,at #: Address ar�d/or directions to Propetiy: M� v �a �.�� 5 m► �� � A c� 'TO l.0 r� CCP.�SS--��-�� J�2ciu+►�. iur� l:.�F-r ou-ro Lu�����crw�n-. FT ON iJ �, � C P2V'fJ��7�pt� - no�u-i-LQ. � I�SSou �-C�S SlG-u � rU PQ.DP���1 �) Proposed i7se and Type o�'Structure: Residential ✓ Business/Type: _ ��,eh hu.�Qk Other Numbar of bedrooms �/ Number of p�ople served �seatslemployees): � f Basement Yes No (w�tli plumbin,g: Yes _ No � Garbage disposal: Yes No ✓ Appro�nate;cze of building fo�andation: Longt}� Width � 5) �iater Supply: Private Well ✓ (Proposed � Exis-cing ) • Community Well: Publie Water System: Are thtr� w�lls on the adjoining propr.rties7 No TYe,g— (p(ease show location on site plan) Note: A complet�d �pplication micst ;rLso inctude: � A plat/site plan of the proper�y �liarshaws property rlimer�ions a�d the size and location of ntl proposed structurex A A signed copy of lke `Lot Prep�ratian' fvrm ver,Ffying that the property is reudy to be evaluated I am snbmitting this application to request services from the person County �ealth Departlutent The inforznation provided is accurate. I un8erstand that if anq site is altered or the inteuded use chaages, alt pe,�mits shall become invalid. • �ignature (Owner/Legal Representative): TJ���-J Date: 4- 2� � � ���� I 1/47 Person Counry Environmental Healtb, 325 5. Morgan S�, 9uite C� Roxburo, NC 3757; (336-59?-t190) i0 3Jtfd O�IIMi3 h1Nf10� NOSN3d 80BLL659EE 6Z �bt B80Z/I0/b0 �- � �� ; �� � ,'" •�_� ,:. .,, µr �... � ., . ..�' v� _ �` �tFr�- - ��s }�+. we; ��''.: �"` . .�„�� ��� � � �" ;��,�, �� .r � r , ..._� -�� �� .. R4!d� .. +. ,, �`'ti' .,�,.� y+k� . � � , = � ... - . < "y" '�p.. .,,.% � �. a ' '�F "'�' � '<' "f � '� � , +s �`'�R �°' � � *. _'i �'� �: ,rM f ' �� � �� 4� s` � -a ..�. . . . ' J- -, R. ��:y � •1Le_'�. • . _ - e' �� ri " v • , � ' A� � �,P - '. - . z' � �. y . . �z � � . �""""' ry � R. . . w .�".. . � � . .. , �. ysc .� � -�� '�`�1 �L.... �+mm -T - x.; � � . . .. _ , R . '+�' . . . . .. . A .w ~'� � . . rY • • • M1 � �. . � ^.,.. _ ] . �` � 6 ^ "" �i _ dr �gy+ � . �! °- t _ .+ � a , _ a � _ +i iw. 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Y ��� �, � � - -. �`e.ri � � "'" �� �� m, � `� ,r — � �� • '� tti ;' _�� , � z'ba ' ��== `� _ ° w �.. e � _ "�s „ � �"" - , � `��� .� . , �� ��'; , il �� 1�' �uia� _ .: �';` �.. '` L �. � �� °� , '� � r� " �� � '! - - . - iF� �Ab ..;� y �..- ' e � . . � ; ��p.,� � � •.i/ - L, :. f` �c.' � . y ,�s... .., ry � ' �+ . . wlkn ... �.^ �,-�. , � . �p ' , , o�g �• �, . T . � : . � a�' ik�� �.'�q� �• � . ^�tl .� �. , � p. � .. .. . , 9i�� . . � '�Y � ` � �'�=� �' . �" ���. 4 �, � w� �, �� �� }: ., ''� . ��' � ` �� � (� T�x fVl ,� � �rcel � ( �� � Su��d�ivi�s�iam -- �*� . .. ,., ,.� ,- .. � _ k - _ 4 � !.. F�h �s�e `S e t!i o n. Lo�t � I�proveffient ��rffiit �'�rmat Yalid �or �'ive 3�e�r No���iration � Type ofFaciliiy: �vi ✓a�Z J�o.s'�,�A. New ✓�ddition �Vater Su�piy GJe1� # of Occupants /1�ax /b # ofBedrooms ProjectedDaily w gp,d. Proposed Wastewater/ System: Z Type: Proposed Repair: !-%� - TYPe� Permit Canditions: a S s Owner or Legal Authorized Stat� Uate: Date: S/—/�-�tf � The issuance of this permit by the Health Department m does not guarantee the issuance of other permits. It is the responsibility of the applicantlproperty owner to in sure that all Person Couniy Planning and Zoning and Bu�ding Inspections requirements are meL Tl�is Improvement P$rmit is subject to revacation if the site. plan, plat or t�e intended use changes. The improvement Permit is. �not :.�; ::.. aifectecl liy a change in owuer.ship_-oi_the-psoperty. This_pe�-mit �vas�:ssued in_compliance with the prav;sious o£the.No�tli�.Gaaralina • ��:::-fLmvs �d ,Ru[�s fap Sesuas�� Treutm�strund.Disvosal Svsterns' (I5A 1�TC�k.�.R18A .19Q0). Neither Persun,�nun,��-..'�ia�:�#he;:::, ��.��nvirfln�neatal �ealtiLS�e�i��'�:.�e�he.septic tani;.syst�m will:A+•,b�:n„�•t�;�nctien'satisfactoniy��fii��'fi�� L°w ,:: thc:�ater�.supgly will3emain..potabie.. ,:._=._.. �. ' . . _ .. . _ `-. ' ' ' . T»..�ri�.. � ��M...� ,a, . ,�::r. : Autliorizatzon to �onstruct'OVastewater Sysiem (�iequ�i�e�d=fo�-�ding Permit) _. ,- * See sife plan and additional attachments (_J. 1 . ." - �� / Propos astewater System: �Z � � Type Wastewater Flow �,g.p.d. .-. New � Repair Fxp i Soil %.'� . 3 g.p.dJ ft 2 � Type of Facility: Pr',�o�e.� s' P n e Basement _ Yes No 'Tank Size: Se�1ac'iank:� �'�5� �ai 1)rainfield: Total Area: I S�o sq ft �astewater System Req�nireynents Pnmp iank• gal G�ease Trap: —'—gal Total Length �� ft � Ma�mum Trench Deptli �,_ an D•C• Trench Width 3 �nimnm Soil Cover: CQ. in Minimnm'I'rench Sep�tion: _� ft �istribntion: ✓ I3'is�ibution �og Serial �istrib�on Pressnre Mana%ld . .� � Specifications: S .,Q� �t�,� �D� � , Antlaorizeai State A� Permit 'i'he type of system perlmtted is Pezmi.t• (�w�e�/���1 �te�resEntative: Date: Conventional V Ac��ted Date: Alternative. I accept *.he specifications of the Daie: PCED rev. 11/10/OS � , �:�� � ���� `��.. V • . .��.!{ J ,�t �T�Tr�v .. . . �" `�.� � �I.J 1`�l 1L � . . � ]�:xa.�n:iroan�m�.�an�ra.Jl ]E�e�m.I�. . . SI'1'F S�_ ��'C$� • . � . � .Tax Map #� Paxcel #_�� ____ I*1s.mc F� �n� . Suk� ' n � Secdon/Lot# � 5�-l�i-d� Authvrized State .Ag�nt ' ^ D�ti� Syste�r cortt,�ortents r�eps�ae�t a�ipruaoi�rate coninura or��y. The colstractar muatfia� ti�ii� sys�sn prlor Sv Legi::ni�ag th� irdstalla�ton to �nsuw that jirn�iep.g�tde �' a�ralnEaitsed , . •,� �,��►A� - (�o'd g/ ' ` .,50 0' `, �►� eV ..'^ • v( 1 , 1 '` �� �l i i �. � � '' �-�a(n �' 0 �w � 1( I�� N. a►. �ra• 39. i f C129.32 � :�/ % ; �6 • j / / ; ; rn5 . , 1� ,, � I I !l �O �7 ' ,7\C OVN / /� ,• n� ,, a�(«�Du� �u, ��n ��� �a�� ������ n1 0 � V� ,-- �I�o' /� y.` Y, , �o, .s:�"� .� ��, , i rT''�, [+� � �C Q� VS ,� �� � u c �S. - � ` �Y�� ? ,.,�h�4� �'�' ,20.5'S' � w �� , � .Y/- 46'. 9. d�9• o L `q w i° �i �' � � y Q� na �+ 4' � � p l.1Uo ip, � �,y � 1� L U �.ol �a,�. yj' a �.W,� � .rJ. re - �. 9/ � � W la W �. .�—' B�• ` . '� \' �� �� . . . . . .�_ . � � � ��.�i _ ��� �J• �,yv�'t ' � _ •Cu".9J. /fl.),� �� ��,,.,..'..�� --'" ��',�� �jo S=lk3i • 47-gS -19' ..._ .. W • S 2/.Y. 26 v--r.......(�t.0 � � y _.`- J' "'ry' �a'�, � ' `1?2. P/ � �'k .t�l. ���Y . ' ' -�'—_.---� .` ` ��O% � /° , �, + � r Jrpr � CA? • �� ff '�'d+-2i_ /�3.�> 6'Y ,7 ' . 6 .J�1 lLG • ' ,t " �1 �r � .���:.`�' • - ...�. �.:� . . �;:. �'��:,;: ...y: •, ,�. '�. � ;�� �'''�'��" ''.' . , ����� , �.,�.�,,.v.y �..:.,.r :E.,. :.: �. � :...: :f: " _l ... ... . .. . ''��� ��%�`:�.:�.�,..: . .:.,.; . ..�. • :..:•. •-,: ,:.,�:+. . • :.:...: .;�;.::..:;.•..•::•'::. �3k.�;�9"77E'3�^.47T`irn.-.iirix ::. ...' : : : .. . . .., �,�•�'L1L� '. ..�. . .... . .. .. . .. ....— .—r-;;.91��:a�#9i �''. � �/'� ��x ,1� ��1 . ���' L�►y� ��� 11:1 5:90...�9:�� SCJL�.t''.+l'9 ��� y�'�JL9.� �a..�.'L' .n 's�v 1L KKJ�m.J 8 Tax Nlap " Parc�l # (� Tor�vnship: Applicanf• . Subdiv�ssio�: r „+ � � ��� �� �����' �'aa�n��y: _✓ Individual �q��naen�: Site Approved By: Grouting Approved By: • Well Log: � Pump Tag: � 9�7ell Tag: � ' Air Vent: � � Hose Bib: � � � Caeing Heig�� ' . Concrete S1ab: �� � � . W�ll Driller: Well 1�prove�d by: ����9e�.�.����ae� Sa� 5I���ch*�::� Commainity Publi� Liner. 'Installed by: _ D�pth set: _ Grouted: I�ate: �iTa#er �ample: Wells m�.st be 10 feet.from property lines. �Iells must be 100 feet from septic systems. Wells must be at least 25 fe�# from any buiiding foundation, Other canditions: Date:. P�CHD r�v 01.�2710� �f ��� o�l � C'. N � � � .� �� c � ,�