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A24 101Application Date: Amount Paid: Receipt #: Tax Maa #: ���T? S� ���� �� — — _ —_ c� � �Tl� �L� �Y � aa�n.a-oaa��-� o�a�a.11. �ZC�m71.��a 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 �:e��,�,� ���� �� ' � -�- � � �Tl�'IC� IE��u-�� � ��.¢.�,.11 ]E 3Im�.Il�. � 5I'I'E S�TC�-I .� . Name � •-� � , c Tag Map # � Z� . P�cel # /'r.►1 Subdivis' � _ � Section/Lot# L� �- .., - � �-L> -�}�' • 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 � � ����� - � � ,� � ��i��-� r�'ai�a�i�on � '� ; ✓ ` �r �' M¢ei,n Man��f . � � �� �` � . � /vll�I�j��tYl !� � `�f'�/Y1 � ' �J�� _r u �r - �aVl fOOVN �i�j r?Yl � �� , '�'^ i � � � .,�v . � �;i .a,^ r',_ .: �'°' ' J -f' , ���� . \��� f � • ' ;� e ` ' ' �`�-+G' � � . , . � f � �� � . C � r'^ . G a � k ♦ � �� j� t j}�� Gi P•�i ,'' f? { 1 � !�' r �...�..a.. .. ���} � • =�.# ; A �_.� € x.M�. - , ���;� �. s� . . J _ _� 1� : � �" � �' / f , 1 �<<; - ,/,1, f� a�.C�� \ � `�:r (��/z' �,�!R t�zrlr�t�. / �� C � �r , / [ \ � ��� 1 �'': �.� � � y ._.._..___._. � �� •�- ; - . j �. �•�______ ','j o-r- �_� .' �, ,, : ;= '� Dn CP���r tt'�v� ��CrS�� . dre�rn�in� � �v� 5'�� l�� .�tS l� vr� ��yt7i��n�. ' f ,j �' fY�t?C�j b�'�Dri � ll�('� r� . L,'i�c��t' P;, 5 r�etvAl � 1 � G: c'nI1 ��f' ,.� - - - � �. ' `'��; . � � -.. ""�. - , _ _ �. � _ � � . �I �`� � � UQ�:t� A"�-t ' � � .c /"'T' � t .�� : :^. Application Date: - 30-0� Amount Paid: 1 d, 0 d Receipt#: � Q 3 R 7 � � �q�� ���_� I�'I�IE�� �� � -,-- �c � �����- I.-C'.:rn-vnai: a:»v-n.:�z-n-n.c.-,.�rn.�.en..Il. IE-�C.c.�.<n.li.d:..ik-n. 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) .., ConnectGIS Page 1 of 1 1:100 feet P�'. �" � t��"1 � t)'�.11'l ��T �ir T � .�j ,, tt�: x c:-c�n^st ve r necr o'ra �c�?�wrtf /�i% 1, 'a ay�ln .vn+ ur.�:rl�sa ara.. er�a�.�r�sm ^til� _�r. .r: tev ass: t at . ate c e att>_ �- o�i ans / ,,�_ � �ata �� cr � a�"`� �,ra� s.aa n r 9 rx-`- c 3t ::�s '�- �,�� �t� r�x^-` ats_t prma � rts�rtiar»o.�.:css ` :flsi.itl te c�rt ,t[ 7.�t""a .xr^s33ia 5t tAtl `4 ntemnn�- c> tz ��n �ta �� Ptn�ei wsarry arau-�t:rc;z+�at ..C�r�si� .s'rzihatntom�<��;� c�s�ine� cr .�^;•. maa °�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 #: � � ����� � � ���� ��� _ �{' C� � � .��`� � � �C:�x�.-1-�L•r.ca�a.,•-,•-�• <c�:ra�t::„.-_a.� ��L<e:-_- �1��1�ia. 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) ConnectGIS Page 1 of 1 1:86 feet �Gl ��� ������� ��� ` ThL^ n �F�: Ca ��tYe r �rcr c r al .�-�r J� '� �� Yh .. Iht j�r ��S _tk� r . �7 ��� � J.T Y.- .. �.a� �t5� Stt i �t) _'� 7. 3!IC � 1 � % \ �, ' ��tn � - ar c' -nac zr• � r � 7" c ��- � �, �.- sr a� x.-.- ��- .rr r r+rmatE � .: c�:� ' n ��y ea c� � � sr-- cs3r t �he • 7t rc�h]-: ;5 t3 n U'I s P�'ljer :Jrly �::,�r2s ra -t ai -- C r.�o cr Ihe In r s:t-�. c�: . taine7 cr , mae http://gis.personcounty.net/connectgis/Map/PrintWindow. aspx?Map=http://gis.personcoun... 3/24/2009 ���� � l� .--�� ���..� � �� .�y�._� � ����- c� � �T� � � T��.—��.�-�.-�..�-� ��.�.�.� ���.�.� applicant: �� �� �� ���� � � o�— �J ° ° �'ll °�IIl l°r'�3�]:s���'�`s�O�il9��� ;" W ��o.o ao ,� . . . . ���� � � � �� � � � � . Syst�m Type (in Accordance Wizh Table Va): ���EZ TH1S SYST�� i-�AS ���� iI�ISTd�I.L�s7 li� CO[�11°LL4�lC� 1NtTN AP.QLICA��� .�t�RTH 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. �, ^ � - . � A rized tate Agerrt � .. �(�� lnstalle�. By: . � : — . � . ,2,Xj.ti�in � i 5 ,'� . . � �� � � aba��`�" �' �� w . � ' ( ; nP� '` -- � � � � . ` d� � . � �`�i ltS C`' ;� a-ah� ;• '$ ��&a a 3 - 2 �-09 � Daie �� � ����;�, .�. . . ��I a���'1^on �'s 20' �/� „ 8 � � ��Z . � ��� .� , L � r1T� y alc� ��ne �� n�c� gd' � �1�d�ion �C�-iC�, r�v. G i (2�i��''. . "� �, �, � �� � � � . �...� .' �,.. t' u ,.�^ � ,� R' y� � ��i," �� � � �n.�'-u��xrn�r�.�zrn.tL-�a,.� �[<��,,.11 � �1-„ � �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) � —� 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 �`nwv.personcountv.neT . ��� � .� � - � o o � 1 1 ', � � , ' s-� � , � 1 N . � � 1 � � CAROLINA POWER & LIGHT HYCO LAKE � � � 420' ` CONTOUR � . 3 2 _ � \ \ � ` \ ���- EXI PTICNG 1PF ACRES � \ P.B. 13 , , •q �c , � �i �� � ` �� `1 ��— ----` � �?a�` ,--- - �, ,` ,-� � / - ' � \ , , ��� � /// � �-__�` ` �� ��� ����'' � ' �NELL �,� / / `\ � � ��__ �����' ���� \ \1 I , _``_ __'_'�"___ -- ���� ` \ I � �� ' 1 � "---- _- / . ---------'- \, � � 1 �f ^r' �� `� ,z.� �,I Z � � Qc��' 1 p F�O 1 \ 1 � Z �7 ` 1 ` 0 . 1 1 ACRE � �'� ��Q O � \ � DRAINFIELD �SS ` \ -- 1\ � ,- 1 � /��/ �— �� 1� \ \ � a \ `,\ ,� ' � \ � q4.3� \ � _-- I ����\ \ 1 � i � _ � � i � � ' _ � ` 420' f � ` CONTOUR J � � � -� � � \ ��� \� L � � _ � � _ � � � � � ��� ��i ���� �� . �rr� v � y d � � � ���� � 1��n.�-v�s�„-n „�,�-��eaa�.�..]l. ��.�.��]�a T��x Nla� ,; �rc�el r ' Su�bdivis�ian , , - � 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 - -�-- � . . .. 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: `"` , � —r__ c'_� N(ini�nrei 1YeElc.�1 Se�at3tiOl1: �� � �ressnre S Date• Z - �0-0�1 Acaepted Alternative. I ac��t the spe�ifications of the ,' _ Date: .�� `� � � PCHD rev.11I10/45._ � ,. .. . � - �- 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: . � � = .. � , _ : � ,, �� (�.V��pq Location' � € ? ' �' i �u ' . r � , _ � � �t .,,t,t, . ; ' Z;'�'�� , f '� • '..i , ' � ��. ' � :, :;( ;���` �'.l ` /' � A � < � � a�� ; ;. , � " �5/� � Contractor: � � . #� �' ' ' � —_ C e.�7/4 `. �, .r . 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 , � ,l t ' . �� . ' � ,. ,v, . , + / � �, � '-----�---"--�--•—.�. 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.