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A24 36Application Date: � d Amount Paid: 0 , 00 Receipt #: %O 3 Z ' �1�� 0 0 Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) 0 Mobile Home Replacement or Building Addition $150.00 if site visit re uired el! Permit��erv�placement/Repair) $30U.0 /$200.0 $75.00 �.�.�.s. f I�IEI��T �:�� lE:�rawaa•�aaA�cn�oantimJl 1[-�[m,a,lld,l�o. Services for Services 0 Construction Aut6orization (Fee is dependent on the type of ❑ Permit Revision Tax Map: /� � � Parcel#: ��o -}-o �aX , , _ . � 0 Repair of Existing Septic System Application: No Chazge/ CA $150.00 or �a I'ue-� �•J 1) Applicant Inf rmation: �_- Name: ��9 1/1ii r ��+'��i Phone (home :�� ' 0.—Oav7 Address: ( � .1' Y (work/cell):3 D ��r�4 , C � '7 3�� 2) Name and address of current owner (if different than applicant): Name: � Phone: Address: , , G 3 � � � µa � � �e�M� � , � o u � Q 6 +O " Ga�rre.'�- 3) Property Description: Lot Size: l� Subdivision: Lot #: �,,, �,,�u Address and/or directions to Property: 3 r�. 1� o u S..sz D��---� ❑ 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) 4) Proposed Use and Type of Structure: ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: 0 Repair to Malfunctioning System Will there be a basement? O yes ❑ no With plumbing fixtures? ❑ yes ❑ no ONon-Residential Type of business: Total Square footage of Building: Maximum number of employees: Maximum number of seats: 5) Water Supply: ❑ New well ❑ Existing Well 0 Community Weil ❑ Public Water ❑ Spring Are there any existing wel(s, springs, or existing wateriines on t�his property7 ❑ yes ❑ no � 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other � Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccuNate, oY if the site}�sequently altered, or the intended use changes, adl permits and approvals shall be invalid. Signature (Owner/ Legal Representative*) * Supporting documentation required. .� a a� / � Date Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot Preparation' form must accorapany any apptication requiring a site evaluation. (10/i l l Pers�n C:�untv F.nvironmental Health. 325 S. Mor�an St.. Suite C. Rnxhnrn NC: �757� ��h_547_»om i �� ?�� — �. � �� IEaa�na-�� -�-�-� �a�.�.�.]l IE--IL�.m]L�76D. I SITE PLAN r I Name •�Al'�ES QwF1.� Tax Map # Aa� Parcel # 310 iSubdivision �� '�V� Section/Lot# S � "�,��..Mca� f1 • Sn�\ LO-�\-1 i Authosized State Agent Date ISystem rnmpoamts repruent appmximate contours only. The coatcactocmusttlag t6e sysrem pdat to beginning the insrallation to ! fosure rhatpropergradeis mainnined. � _ �J al ��7� .:`�xL�� cJ.^'. �i .rt "� �� I�RaSci� 'w�v.. � 3 w� w � �1��til,�c tiv i �'�o . _�. � +�-��--~i 1 : 50 Feet li �� ' �� ?� � �� " � ��v*as��-^ �^-- �sa�.bll IE-��a.Il�lka STTE Pi.Ai�T ii77 ' t�lame ��rE� ��"+�� Tuz Map #�Li Parcel #�� Subdiri�oa �G 't`�►V�c Secaon/I.ot# S t��.it�cJt� ii• S�r��'1�7� ti0-�\�� A�uhorized Srate A� Ds►te � Syarcm mmpoamtr npraect spprozmlau canmcus o�ip. TLe contr�aa�rmrut9a� r6e sysrempdor w begianig� rhe instgllatioa to iosurr thnrpropergrsdeismaiatsiaed i o71 ,.: ss ';�, ; a r I � � . ♦ 5�.i �'�^ � �rc� � �• :r+r�� xl�nel�° :' �� r C��1� � .c � : 5D FQet — - x.� • . Application Date: ' ZZ`�5 � Amount Paid: � �'Qeceipt #: Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Home Replacement or Building $150.00 (if site visit required) Well Permit (New/Replacemeat/Repair) $300.00/$200.00/$75.00 �.; ` ; � �f �1LG�� l � Taa� Map: A � � . � � �� Parcel#: � IEan�asomm �•�* �a��.Il 7EiCo�.Il�l�a Services for Services Construction Authorization (Fee is dependent on the type of Permit Revisioa Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant In�rmation: Name: �1� 1 r t(/�if� Address: 7 G�,U S' 1''j � , Se�NB-rr9, G a 3SL3 2) Name and address of cur�ent owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: ! f�'1�{' Subdivision: s1orP Address and/or directions tp Propert�:�� Phone(home): �� ,�D3--0�0 % (work/cell)�3 — Phone: Lot #: ❑,yes Cdno Does the site,�ontain any jurisdictional wetl ds? Cd yes ❑� o Does the site contain any existing wastewater systems? ❑ yes Q no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ❑ yo Is the site subject to approval by any other public agency? ❑ yes Gd"no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) iN 4) Proposed Use and Type of Structure: ❑Residential ❑ New 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? ❑ yes ❑ no With plumbing fixtures? �1VOn-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 'JS�2, ❑ yes ❑ no � �0 P �0. ` �� 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 p�y �� 3� �6 X 1 cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the si� is subsequently altered, or the intended use changes, al! permits and approvals shall be invalid. Signature (Owned Legal Representative*) * Supporting documentation required. �r�"�m/%� Date 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. (1 n/1 11 PPrcnn C'niintv Fnvirn„mP„tal �TPaltl, 2�G C T�/�nrrtan Ct C,,;+o n n.._.L__._ ,.T., ..-,�.,., ,.... �_.._ .__ _. 1) ' r� � . ' �� J \ � � < <�� \�I �� - � � �..� I 1—I �- .:� I � I� Building Additions/ Mobile gIome Replacements Tax Map #:� Parcel#:�_ Address: �' ( �� r. . S�r��, �� a?� y� Approval Requested for: Mobile Home Replacement CS'�a�e �C+-e5 � Building Addition . Applicant Name: ��4'r�►�-3 ��^� Address: �Q/'z e 45 �t c"^� Phone #'s• S�`�� zz ^/ 3�r„ `70`�'��S Q 9 Perntit Located: Yes � No Tnstallarion Date: Cl�c aw� Design flow: C�� K��t(gpd) Current Contract wi±h Certified Operator on file (if required): �.� Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on � �� (date) (Applicant's signature if site visit is not require Comments: ��n�� s5 %� �aQ � � �C 3� ( � , 4� �ddition/Iteplacernen� Approv�d � � � E vironmental Health Specialist � 2 2�� j Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcount�net ��.sf ��.�� --�- � � � �� rav>n�c-amsn.�rna��rn�.m.Il g��.�-��n WELL PERMIT (New X Repair _ ) Tax Map: 1�1`� Parcel: �b Subdivision: S�kcR� t�Z�v�, Lot: S Applicant's Name: '��c� Ow �., Mailing Address: P.4. 6�,c, 309 L�t��o.^c . t1C. �`1�9$ Phone Numbers: 33b-s�3- oa,�.`1 3»0- `7�- �5`1�i Location of Property: 't ► �E�1�f-. pR 5k� r�c.ctk.s > � � a�s�c flQ �i -a CL-� Si4� �A � Permit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and County regulations governing construction and setbacks apply. 3.) Permits expire S years from the date of issue. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: O�D w�,u.. S�v�� PSwP��( AE A��a�.F-4 Permit issued by: D�.4�ucx�- f� - Si"�� 1ew Well: EHS/Date Location: �� ' �`� Grouting: Well Log: Well Tag: ►I l. 1�' Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Iastaller: Approved by: Date: ��O- ,�� -1`} Certificate of Completion DI,iner: EHS/Date �.. � �I 1 .!'�: Additional Comments: �4�r�c�c �-v� Depth: Grout: DAbandonment: Date: Method/Materials: License #: 33'lb� f� License #: Date: Fti 1% Date Sample Collected: � /� Date Results Mailed: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C Phone: 336-597-1790 Fax: 336-597-7808 Roxboro,NC 27573 11/26/13 WELL CONSTRUCTION RECORD This form can be iucd for siogle or mult;pie wclls 1. WeII Contractor Informatiou: �e��,� e �. P,e � Wcll Contxacwr Namc 3� /� `_%� NC Wcll Ca�ntiaaor Catifiwtion Nu�nlxr 1 �� L Barnette Well Drilling, inc. Co�aay Name Z. Wtll Constrvttion Permit f1: � Lisr a!! applirnbfe xell rnnsuvaion �e u(i.G Cmmry, Sla� Variaxe, etc.) 3. Ndl Use (check well use): ❑Agriculuual �Geothamal (Heating/Cooling ❑IndushiaUCommercial Non-Water Supply Wd1: Injection Nell: �Aquifer Red�arge �Aquifer Storage and Rccavuy ❑Aquifu Test �Bxperimental Technology ❑Geothe.tmal (Closed LooP) �Geothermal(HeatinaJCooline 4. Date R'etl(s) Compicted: sa weI! Locanon: FaciGtylOwncr Nacne Plrysical Address, Cicy, and Zrp �f e nso� Couuty ❑MunicipaUPublic - ❑Rcsidrntial Water Supply (singie) OResidential Watu Supply (sha[ed) �Grourtdwater Remediation �Salinity Barriu �StoTmwater Draic�age ❑Subsidence Control OTraces �Othu(explainund�#2I Remarlcs) �wa� n� � Z �f - �' FacrlityID�(ifappliablc) N 1`,�P ,(r"� D�'f s�ar4e ! � Ace � P�ccl IdwUficahoaNa. jPIN} For idanal Use ONLY: � rt J 0 D rc � Z7S « Z�O f� „s� 15. OU'fER GASING (for muld-nse FROM 1'O DL�INEI � �� y , 16:INIVER CASING OR-TOBING FROM � TO DGMC R. R. fc ft �:�`l-,cl`DL`L'N`� .. .. . . . �, ,� a� yo��o 3 � 1 dlt OR LIIYER" �f a ticaWc .:: lAiC7QiESS MATPR7AL �- a,e� � U G � a�a�� 7F[C[INESS �.� MATERIAL ia ft R � 2 �t � �ovr �' ro nurwnt �`' 2 p� Le�ment fG fc � R [t ft fc. ft LATSIZE TH1C[4VFSS i1tATERIAI. t "F'G.c.t �e 56. Ia6tude and Lond fnde in.ucgreeslmiuutes/sewods or dedmal degrees. ?y �f�aa�: (fwcil Scld, o� Iallong is saScient . � 36 - 3o H ��N 79 - � 3--�.� w � D--n�.-� �„�-��1. 3-/5� I Si�eofCctifial Well Coneattor D�. 6 Ls (are) tho w.dl(s): � a i ent. or �TemPo�rF BY signtng ihEs fortn. / here6y cert�y tlrar !lu wep(s) xvs (,rere) ao.�snr�aed in.aocordm�ci wi�h I3.i NGiC 02G.0100 w lSit NCAC OIG .0200 fYall ConsweNa+ Sca+uldrds a�d tha( a 7_ Is this a repair to as ezuting �weU: OYes or L'4i+t6 copyoJrht* reco+dl�ns beenR++�yfded !° � xe1! o"'ner Ijt6i: is a repair, fiQ o� brown we!! cautr�rion irformariai av+derpta+a +1+e ++aturc ofvie trpa'vrorder �21 remarts suxion or m fht bauE of7ltls�ortn. - T.3. 5'ite� diagfam or addifion�i weLL details: I You tnay asc die back of this p�t tt► provide additional wetl. sitn ddails or weil 8. lYumber of weUs constructedl / cdnstrurxion dGa►1s, yon maY atso.attach additi°nal pages ifne�ary. For muGip(e injection or rtan-water �y wells ONLY wi(Ir the samt tortskuckoR you am submttoneform. SUB61[1TAI,INSC[JG`�'IONS 9. Total well dept� 6elow laad Sarfaee: � Z � (fk) 24a For NI VD.dI� Su6mit this form within 30 days of coinpldion of xell For multiple weUs Ust a!! depthc iJd�'erent (ermnple-3Q?00' and 1(a�1oo� conshuetion to thc following: 10. Statie water level bdow toplof casing: z- � (fL) Division ot Watcr Qnality, Wurma6on Proccssing Uoi; Ijxnrer leve! is above msirrg, iix "+ � 1617 Mai15e[v,iee Center, RaleigL, l`C 27699-1617 11. Borehole diuneter. �� (n) 246. For Iniectios WdL�: in addition to seading tho foiin to the address in 24a �/p �w abovc, also sutsmiE a c�y of t1�is fora► within 30 days of compldion of aell LZ Welt construction mcthod: `'� 1�/�. I�L' 7G J4'/L N canstruction to the following CLG 8t1{��Cf. [b�2[Y. Wb�C� dIIC1 pLLSIt� �IdC.� • . Divisiod olWiter Quality, Undeegroaad injectioa Control Pcognm, FOR WATER SUPPLY WELIS ONLY• 1636 Mail Serviec Center, Ra1c�L,1VC 27699-1636 13a Yield (gpm) �� Method oftesk B�own20 minut � ForlVater SuoWv & Inieetion �Yd�r. Tn addition to sending the form in tha addiess(�s) ahove; also �bmit one eopy of this foiin within 30 days of is�. n;�r«non �. HTH Amoan� '� �� Cill ji eompletion of wcll conshudion to the county hcaltfi dcp8rimcnt af thc county where cocutrit�ted. Form GW-t I�Iath Carolina Dcpadauut af Fi�vitoomeat ud Nauaal Rso�ancs—Divisioo of Wa�er QuaGry Rtviscd Jau. 2013 �! r. ��'�1 �� ne department of health and human senrices ' v i � ; { l '^. E ` � s�� ... S ;S f r�j �. �- I 'E �� E � � i- f � ^r �.n�� r-^� '� � f ;r'.t s, ! � € R F 1 J ��u s Li L�' � P� �J i� � �� i�,' i i E � I{ e;�, i �' � � � 4`'. ,` � ��.; --1 � � --. a^, e.--�,� >-.t r,, ,-, � �—: e �•� � � 'e..,,� 1�� " ;�� t� E,.� j , � i 1� �..-.� kf,i L } �,� I 5•� `,..� �e £ .�=. . k `_ ,,....�" �� t..� '�. `� 4.�' ��S t € � ._i e �: _ c `.: � � �.`•' For lnorganic Chemical Confaminants County: a Name: �'�P 5 '�` Sample ID #: — Reviewer: . �r vt .r � TEST RESULTS AND USE RECOMMENDATIONS 1. ❑ Your well water meets federal drinking water standards for inorganic chemicals. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv. You may have other water sampling results that are not taken into account in this report. 2. ❑ The following substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health levels. The North Carolina Division of Public Health recommends that your well water not be used for drinking and cooking, unless you install a water treatment system to remove the cucled substance(s). Yowever, it may be used for washing, cleaning, bathing and showering based on the inorFanic chemical results onlv. Barium � Cadmium � Chromium � Copper Fluoride � Lead � Iron Mercurv Nitrate/Nitrite Selenium Silver Ma�nesium Zinc —� 3. �a. Sodium levels exceed the U.S. Environmental Protection Agency's (USEPA) Health Advisory level for sodium of 20 mg/1. The North Carolina Division of Public Health recommends that only individuals on no or low sodium restricted diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering based on the inorganic chemical results onlv. �b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porce(ain, etc. 4. 0 Re-sampling is recommended in months. 5. � Re-sample for lead and /or copper. Take a first draw, 5 minute, and 15 rninute sample inside the house (preferably the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source of the lead and/or copper. 6. ❑ The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inor�anic chemical results onlv, but aesthetic probiems such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment system to address aesthetic problems. � Barium Cadmium Chromium Fluoride Iron Man�anese Selenium Silver pH Zinc For more information regarding your we!! water results, please call the North Carolina Division of Public Health at 919-707-5900. 0 North Carolina State Laboratory of Public Health 3�2 Distnct Drve Environmental Sciences Raleigh, NC 27611-8047 htto://slph.ncaublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: ADAM C. SARVER Name of System: PERSON CO ENVIRONMENTAL HEALTH JAMES OWEN 325 S MORGAN STREET 71 DENISE DR ROXBORO, NC 27573 Courier # 02-33-15 SEMORA, NC 27343 EIN: 566000331 EH StarLiMS ID: ES030116-0021001 Date Collected: 02/29/16 Time Collected: 10:15 AM Date Received: 03/01/16 Collected By: A Sarver Sample Type: Raw Sampling Point: Well house Well Permit #: A24-36 Sample Source: New Well Temp. at Receipt: 3.5 GPS #: Sample Description: Comment: New Well 1(Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Calcium Chloride Chromium Copper Fluoride Iron < 24.00 <0 <0 0.10 1.3 < 0.20 4.00 < 0.10 0.30 < 0.005 0.015 Manganese < 0.03 0.05 mg/L Mercury _ < 0.0005 0.002 mg/L Nitrite m < 1.01 < 0.1 7.6 < 0.00 0.05 Silver < 0.05 0.10 Sodium Sulfate 190.00 32.00 250 < � N/A Zinc < 0.05 5.00 mg/L Report Date:03/10/2016 Reported By: Deddie .�tancol' Page 1 of 1 North Carolina State Laboratory Public Health Environmental Sciences �1licrobiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES030116-0082001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: JAMES OWEN 71 DENISE DR SEMORA, NC 27343 Collected: 02/29/2016 10:15 Received: 03/01/2016 08:26 Sample Source: Well Sampling Point: Well house P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htto://slqh. ncpublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 A Sarver Susan Beasley Well Permit Number: A24 - 36 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley 03/02/2016 E. coli, Colilert Absent Susan Beasley 03/02/2016 Report Date: 03/02/2016 Explanations of Coliform Analysis: Reported By: Susan Beaslev ♦ - � '� If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present, the water is considered unsafe for drinking purpose. Presence of E. coli (bacteria) generally indicates that the water has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample received and should not be regarded as a complete report on the water supply. �� ... � �= � �� n-�ar��.��.� ��.l��n April 8. ?016 James M. Owen 71 Denise Dr. Semora, NC 27343 EtE� S:.p�4ic Sti;��nt Replaczr��n� Ta.� �4ap: .�-�-;6 Dzar �4r. Qwen: Un March 29, 20 t 6, you submitted an appiication to the Person County Health Department requesting approval to replace the existing mobile home with a new home. The proposed lacation of the new home will not encroach on the existing well or septic system. The septic system serving the existing home shows no v�sib[e evidence of failing and therefore your request can be appro��ed. \ti'e also discussed your proposal to replace the existing septic system in order to ensure that the ne�� home �ti�ouId be properly served. Based on soil borings between the existing lines, the soil ��ould be classified as U�rsuituble in accordance with North Carolina rules and regulations �o��erning septic systems. The soils were Unsui�able due to clay mineralogy (Rule .1941) and soil ��etness (Ruie .1941 }. No other portion ef the lot was evaluated due to available space. At your request, �ve scheduled a site visii by Kevin Neal, DHHS Regional Soil Scientist, on April 13, 2016. Mr. Neal �� il} pro�-ide an informal review of our decision to not issue a permit for a new septic system. I anticipate we'll arri��e at your propem� benr-een 10 and 11:00. Please tee( free to cantact me if��ou have any questions. � inczs:l� . �� Harold Kellv phone 336.597.1790 325 South Morgan Street, Suite C, R xboro6NC 27573 Request for Informal Review The purpose of an informal review is to insure that a lot has been properly evaluated by the staff of the Person County Health Department. At the request of the applicant, a site visit will be scheduled with the NCDENR Regional Soil Specialist. The Soil Specialist will conduct an independent evaluation of the property and report the findings to the Health Department and the applicant. I am requesting an informal review by the NCDENR Regional Soil Specialist of the Person County Health Departments determination that my property is Unsuitable for the installation of a subsurface wastewater system. Requested by: Name: J �'J'L(�I � L� � �Li%C- fC/ Address: 7l �� .�r� s� �',�, �'v' � a r�� Phone #: ��✓� -- �� -o�a'7 Property Information: Tax Map: -�}� Parcel #: �� Location: %� ']7� � � s �._ 'D� , Signatur . �� Date: `—� Application Date: 3/a9 I 6 Amount Paid: 1 s 6, 0 � Receipt #: ` � d 74 � �� Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 d) Mo ile o Replacement or Building Addition $150.00 (i site visit required) $300.00/$200.00/$75.00 �� ) f �� l V Tax Map: __�'C�,�� `,.,: ► � � � ��,�� Parcel#. � � rn � IE��s��¢�.Il IH[��.Il¢]� �. Q11a•�'J e�O lr C tion for Services Services Re uested Construction Authorization (Fee is denendent on the tvpe of Co �; a � a k�}- Permit Revision $75.00 kepair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: ',��(_yl� / ��N Address: 2) Name and address of curr nt owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Address and/or d'uections to Property: L Phone (home)�� '� D 2 �7 (work/cell): Phone: Lot #: � yes C3 no Does the site contain any jurisdictional wetlands? ❑ yes �o Does the site contain any existing wastewater systems? ❑ yes C�ro Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes Cd 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) 4) Proposed Use and Type of Structure:. ❑ �dential ew Single Family Residence Maximum number of bedrooms: �_/ Occupants: � rJ Expansion of Existing System If expansion: Current number of bedrooms: � ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Total Square footage of Building: Maximum number of employees: Maximum number of seats: 5) Water Supply: ❑ New well �Existing Well ❑ Community Well ❑ Pu�bli�c Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? l.ti'yes ❑ no Please note any known ground water restrictions or sources of contamination: 6) If a ying for `Authorization to Construct', please indicate preferred system type(s): Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑�y I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccur , the site is subse uently altered, or the intended use changes, all permits and approvals shall be invalid. _ ��'� .� oz r /,� Signature (Owner/ Legal Represec * Supporting documentation required. Date 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 applicatioa requiring a site evaluation. �1�/� 51 Per�nn (:nuntv F,nvir�nmental Health. 325 S_ Moraan St__ Suite C. Roxboro. NC 27573 (336-597-17901 �� ` � .!L �L:�1L�� ]Eaa�SA-�TM-�--.aa��:mll ]P-IC�a.2i¢1Fa. .s�.'T,F�1��N. Name ��rE� ��+�•� Taz Map #��i Patcel # 7'� Sub�ivisson �G 'i�aV�c Secaon/I.at# S s.%"�i�.c.kt �1. S�nc't}ia 10-�1�1 Anrhodzed Scaze 1l�nt Date Sysrrm mmpaaents re�meat appronmate canrows oml� . Tha contrnaarmustBsg t6e sysrem pcor ro begianing rhe 3ast�llarion tn iasaro thntpropergndeiamafataiaed . �J� � F' : �� --.- .� �,� . . ' •' :r!:;rr —� ��'•• .. �:: �:.:..'.:..:... .� j � : f , �y1�1' �v�j J ;'�.�� '� .r � S.- �'''� � .� � ;� 1�, j� �. �1c�ck.-+�.+� • �s� w�.. f� ` �w � C�,artc�l.,1c w � ��'ib . , f� :' . �' J., ._ � _ :�`_ ' '�� . i ```'qi4�. . � \ � �' � E . , ,'��\� t � bl � � S � ',,__, '1803 a7 � :,': :'r ' -- � {' "..-�F I �=t '[017 � �:� ( rt : 5D Feet " - - -...� r--►�� !1 / . . il ConnectGIS Feature Report �,9 (�tifjJ�p • ,� 1�. ; ,� _-) C�� I`` u i.�';_ ! C I S �a� te. r. � sri �a�� p,1;2 �� f;, ��s� % � �l� l t�b I Nl-(� �NJ�.c.o�� to7�r ,'; f ri� ��` �- b�`� ,�, -- ---- - ---��. Person Courrty Environmental Heaftl� 325 S. Morgan Street e. �;�s n Roxboro, NC 27573 416 _` , 2�: �y � . �� Pagz 1 of 1 Person Printed April 26, 2016 See Below for Disdaimer ��_ ., �, � . �'� '� � f - ��t . __�_� «fi. � �% � � � N _ �. `.ti,: ,. � i uia� �ci i�u i. �=r-�.0 v rcc� F: , �.,� `�,� - i OG6.32 �q. Feet � ` '� �` - ar.02.:�cres �,- ` __ � 31 �`� ` : l.� � __� �� or Sq. h.9iles ` ' � �, �ty `�,''`� �' � � - � �� % . 50 Feet S N �, 4 - �---�` �`� OTICE: Recently, we have had several users report browser compatibility issues when trying to aaess our GIS website. Typically, the problem stems from users who hev� �cently upgraded to the Windows 8 operating system or a new version of Internet Explorer. We were abie to resolve ihis issue by directing users io che Internet Explore ompatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US/internet-explorer/products/ie-9/features/mmpatibility viev this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGlS has beei repared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system an otified that the aforementioned public information sources should be consulted for verifcation of the information in this system. Person County, Mobile 311, ConnectGl'. ssume no leqal responsibilitv for the information in this svstem. Grid is based on the NC state plane coordinate rystem, 1983 NAD. http://gis.personcour.ty.net/Ccnr.ectGIS_v6/DcwnloadFile.ashx?i=_ags_map7ae5c570b57... 4/?6/2C 1 � � ' / J � � ♦ � > \►: �► < • . , .,. ' . .� � � �� --a � � � �=�.na.�n�:�n�.n�cn,�n�n.��.� �c.��.�.��n Building Additions/ Mobile Home Replacements Tax Map #:� Parcel#:� Address: 7/ 7�,t/e4� �� • Approval Requested for: yC Mobile Home Replacement ��sa� �ig,�•�� Building Addition �Ovi�� Sl� u� �v�� Applicant Name: �� ua, '�/ �� Address: _�f �� 2� �r�r � Ph�n� #'s: �O �✓ � 4 ZZ 7 � Permit Located: Yes � No Installation Date: Design flow: �'� (gpd) Current Contract with Certified Operator on file (if required): Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on: (date) (Applicant's signature if site visit is not required) Addition/Replacemea�t Approved , Envirorunental ea pecialist Person County Environmental Health, 325 5. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-17901 Fax: 336-597-7808 www.nersoncounty.net