A24 101Application Date:
Amount Paid:
Receipt #:
Tax Maa #:
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APPLICATION FOR SERVICES
Parcel #:
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVA�ID. �
1) Permit requested by: (Owner/agent/prospective owner):�� to
Home Phone: ���e -?, �'� - 5000 Address: �'� V S ,�.
Business Phone:-' �C,� �w,, i�. 1.1 C
2) Name and address of current owner. � �� �
�
. S, �
3) Property Description: Lot size: a-�ownship: Subdivision: Lot #
Directions to the property (Including road names and numbers):
7 ���
� Sm; s���Q-� S� �—`S?nL•, Lti-��h� GNc � ��� rr-e �Cv�1
4) Proposed Use and Struct�'� Description: answer each of the followin questions: ��3 S�:r,d�rr �cG� J�( r�.�; p•,
a) P,ro'osed , Existing ,�, Ty�e of Structure: �_ Q- Width: Depth: �
.
b) Number of Bedrooms: � Number of occupa ts or people to be served: � S
c) Basement: Yes , No� Will there be plumbing in the basement?
- d) �arbage Disposal: Yes , No _
5) Water Supply Type: Private �i (new _ or existing , Public� Community_, Spring _
Are any welis on adjoining property? Yes '�No _ If yes, please indicate approximate location on the
. 'site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No_
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLlCATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. -,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STA!(ED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
l C�
ate
PCHD, rev. 06/27/02
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Name � •-� � , c Tag Map # � Z� . P�cel # /'r.►1
Subdivis' � _ � Section/Lot# L� �-
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utho�ized State Agent . � Date .
System camjiones�ts rejirerent a�b�iroxi�trate�contours only: The cmnfractor snust, fTag tlae system1brior to ,
beginning �he i::stadlatiora to insure t3rat ps��ergrade as rnaYntuara�d
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Application Date: - 30-0�
Amount Paid: 1 d, 0 d
Receipt#: � Q 3 R 7
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Application for Services
(Sentic Svstems and Wells)
G Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 d)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
Tax Map: �
Parcel #: �
l��l
Services Re uested
❑ Construction Authorization
(Fee is de endent on the e of s s
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
No Char�e
Important:lf tl:e information in t/:e application for an Improvement Permit is incorrect, falsified, or t/:e site is altered, t{:en the
Imnrovement Permit and tl:e Autfiorization to Construct sliall become invalid
1) Services Re uested 6y: /
Name: ' p r0
Address: 2 � �l�ub ��'% �
z
o�c�p �r'J
Phone # (home): �j % -�7 S
(work/cell): �--�9�� �, �'� P j ��
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size:
Address and/or directions to Property: �
ry S�n'^� ot #: Z
_4 �7,.9 fv_j., o.z- �/ C
4) Proposed Use and Type of Structure: 1 �
Residential Business/Type: Other �vlr.l�'60A/� 0.d� ��� a�
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No _(with plumbing: Yes _ No � Garbage disposal: Yes No _
Approximate size of building foundation: Length�_ Width �_
5) Water Supply:
Private Well (Proposed Existing��
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
(please show location on site plan)
Note: A completed apnlication must also include:
➢ A platlsite plan of t/:e property that shows propeYty dimensions and the size and location of all
proposed structures.
➢ A signed copy of tlte `Lot Preparation' form ver�ing that the property is ready to be evaluated.
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. � � /�
Signature (Owner/Legal Representative):
Date: 4 ��
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
..,
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°�rson County C� �vit�cnm�ntal Heaith
325 S. P�organ Street
Suite C
Roxbo��o, NC 27573
http://gis.personcounty.net/connectgis/Map/PrintWindow.aspx?Map=http://gis.personcoun... 2/25/2009
Application Date:
Amount Paid: _
Receipt#: _
' Tax Map: �Z�
Parcel #: � �
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A�plication %a- Se��c�s (Septic Systems and Wells)
Sea-vic�s Re uested
� Improvement Permit (Site �valuation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d) (Fee is dependent on the ty e of system ermitted)
Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uired) �75.00
C�'Ve31 Permit (Ne�v/Replacement/�2epair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Charse
1) Services Re uested by: �✓�N ►?-���E'S
Name: / p �
Address: y//�7�,2 �yy (,vf�-
,���� /� c/� 2� ��
Phone # (home): ���- �y� -��z,
(work/cell): �/9 %y(o - �3�Z
2)11oTTame and address of current ownea- (if differ�nt than applicant):
Name: �,Q/�-/-l_� 4 �YY! `/ �u,l_ ��"�
Address: y/�vt� ,�2
l�J�i�l-�/l � �it/li 7�� /,T_
3) Progerty �escriptdon: Lot Size: 2�CQ� Subdivision: �,ot #:
Address and/or directions to Property: (2�� SNoPE A�OC 5�1 �ir/G'
,j�ivin2A /[/L ��?�y'�
�
4) �roposed Use an e of 5tructvre:
Residential Business/Type: Other
Number of bedrooms C� / Number of people served (seats/emplo ees):
Basement: Yes No � ith pjumbing: Yes No �
Garbage disposal: Yes No l�
5) Water Supply:
Private Well (Proposed Existing �
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
(please show location on site plan}
N�te: A completed application mc�s� adso include:
� A pladsite plan of the,�roperty t`iat show� p�operty dimen�io�is and the size and locution af all
proposeci structures. .
� A signed cvpy of i6ie `.�at Preparation' form verifyin; tltat tlae pa�operty is ready �o �ie evaluutee�
� am submitting #his application to request servic�s from the P�rson CounBy �lealth �epartment. � understand that
,ii the info��ation provided is flnco�-reet or if #he si#e is subseques�ily altered, or 3f the intended use changes, a�i
permats and app�-ovais shall become invalid. � _
Sig���r� {Owner/Legal
)=
D��e : 2-2�� o �
10/08 Person County �,nvironmental Health, �25 S. �iior`an St., Suite C, RoYboro, NC 27573 (336-597-1790)
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C'�f�OLI�lA GE�E�+L ST}�TUTES, �RL1��j F�R Sc'�ifAC� TR�AilUiEi�? �1�ID D4S�OSAL,
AND •�Ll. CO1�dI3lTit'�NS �F ' T}-�E 1�f8F�01/L�E1�T PE3�i1"t ,A�ID GONSTR17CT1�.(�
AllTHO��IN. �, ^ � - .
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�u�lding Additions/ Mobile I�ome Replac�ments � �
T� Map �:� Parcel#:� Address:
" 3
Approval Requested for: Mobile Home Replacement
� Building Addition
Applicant � -
Address:
Phone #'s:
Permit Located: = yes
Installation Date: --- No
-3 3 Design flow:
--�� %d)
Current Contract with Certified Operator on file (if required): �_
Water Suppiy: _✓�Well
__ Public or Comrnunity
Wastewater system shows no visual evidence of failure on:
(Applicant's signature if site visit is not required) �/_�� (date)
�
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Comments:
�d�ditiou/1�eplacement Approved
�
Environme talXiea specialist
2/z�/n g
Date '
Person County Environmental Health, 325 S, Ylorgar� St., Suite C, Roxboro, NC 27�7;
Phone: 3;6-�97-1790/ Fax: 336-�9�_7808
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Ph�,S•e;Sect+i�an.'Lat k
��r�it Valid for `��
Type of Facility: �,
# af Occupants �
Proposed Wastewater Sy
Praposed Re�air: CC
Permit Conditions:
Owner or Legal �
Authorized State
][�praveluent. � ermit
- - C?uS{��
ter Sng���y e l
Type: �
Type: �4
Date: -�/- oB
Date: Z - to-Q
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The issuance of this pe�nit lyy the H� Department � does nQt guazantea t�e is�+,aT�e of other permits. If is the responsibility of the .
aPPli�P�P�Y owner to in sure that all Persan Co�miy Planniag and Zoffiag and Buiiding Inspections requn�ments are met This
Improvement Permit is snbject to revocation if the site pIan; �pl'at'oi` the intendat use changes. The Improvemeut Pernait is not
a�ected by a c�ange in owner"siup of the property. This permit was issued in compliance with the provisiuns of the North Carolina, .�
`Zaws and Rules for Sewage Treabnent and Drsvosal Svstenu' (7.5A NCAC 1�A .1900). Neither Person �ouniy.: �o�*�:tlie.` �� -
Environsneutal Healtli Specialist warrants that the septic tank spstem m'il cvntinue to fnnction satisfactorily iri the futnre�or�tliaf.
the-water snppty w�71 remain potable. • �
� A�thorizalion to Constrnct �astew�ter syste�m (�,2equired for Bx�aiing Psrmi.t) �
* Ses site plan and additional attachments (_�. ' � . -�
Proposed Wastewater System: � u ..� � Tppe �it Wastewater Flow 3(o[�.p.d. .
New R.epair Expa�si�on � .� Soil L�AR: , Z%5� __ g.p.dJ ft 2
Type of Facility: r�.�ct�e � e�,��,� - � � Basement �Y'es _ No
� ��ast�wate� System Req�aireme��s � . �
iank Siae: Septic Tank:' C X� S�i ��
Drainfiedd: Total Area: sq ft
Pnmp Tan�—gal Grease Trap:------�al .
a�id t �a►'� . . _
Total Length gD� ft 1Vta�mu�n Trench Depth �� in
Trenc� �Vidth 3� �'inmamm Soil Cover: (, in
Dist�ribution: �iistriibntion �oz ��erial Distribntion
sp��ti��:
Authorized State AgenL ,�_
Pernut Fxpiration
The type of system peermitted is �Ca
P�• . ��/�
(�nnetll.���1 �a�r�s�tatave: `"` ,
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N(ini�nrei 1YeElc.�1 Se�at3tiOl1: �� �
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Date• Z - �0-0�1
Acaepted Alternative. I ac��t the spe�ifications of the
,' _
Date: .�� `� � �
PCHD rev.11I10/45._ �
,. .. .
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�- s � The District Health Departmen$
. �_;;:.�.,�.
CASWELL - CHATHAM - LEE - PERSON COUNTIEB '
. • �.. ��
..�-� .....
-. � Water Su1A I and Sewa � e� D'
PP Y g isposal
:,: � � > IMPROVEMEP1Tg pERMIT No
� .,;�.,. p nat �`
i�� r �''� c� Owner: . � � = .. � , _ : �
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��
(�.V��pq Location' � € ? ' �' i
�u ' . r � , _ � � �t .,,t,t, . ; '
Z;'�'�� , f '� • '..i , ' � ��. ' � :, :;( ;���` �'.l ` /' � A
� < � � a�� ; ;. , � " �5/�
� Contractor: � � . #� �' ' '
� —_ C e.�7/4 `.
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Water Supplq: Private f-1" Public u"�. ;
� kJ `^F .� ��� i.., �.
, . --....
' .�.."`-°�-,�`�„':'�s�� �z� �.�...
Sewage Disposal Facilities: No. bedrooms � Dishwasher Dis . �
. posal,;
washing machine, other sutomatic appliances ..
S'�c� °� .�rilE:ox��„ '--�}5,c1,. � Nit� i catipn line:
� �'�• � r a �:Z ,s�} H:
. i r� �'
r �� � a 'r
r�O�thei dispo�al��fa�if ity= f�'+�l�y �. �, : r , �
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/ � �,
� '-----�---"--�--•—.�.
wn'e�-�s�tPF13''"'��d�`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 health haza�
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PR,OVED BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT
STAFF BEFORE ANY ppRTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
� X ! 6� �� �, e
Date approved • Slg� `
Well:
Sewage Disposal• Count�
gy• aigne
/ t it�i�i � —
wne or his representative) i
r'jCertiticate of Completion :
, Date Approved: ��3'.�_
, Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.