A24A 45Application Date• L � ( ��3 ` ( - j� p:
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Amount Paid: � ._...; � • � Parcel#:
Receipt#: � ������
:LIIz� :��•�uz�3��u���ll lH[����:��
Application for Services
Services Re uested
O Improvement Perm�t (Site Ey�luation) � � f � : C�; Construct�On Authorization
$Z00.00/$300.00 (if> 600 gndl - ��` .'s (Fee is dependent on the type of system_permitted
O Mobile Home Replacec�en�nr Building Addition �
$150.OA (if site visit required) '
[XWell PermitlNew/Ret�l�cun�nt/Renair)
ti
. I : D F'ermit Revision
�,.:� ��
• ❑ Repair of E
No
SepHc System
aree/ CA $I50.00 or $300.00
1) Applicant In�ormation: -
Name: ; nC'. Phone (home): s'�', �� --�522-9��
Address: ' ' ` (work/cell):
2) Name and address of current owner (if different than applicant): ' f r
Name: �Cr1C�'� W ► � � : C�;� ' Phone: � � Q - �3 � ^i � .2.
Address: ' � �,
��ie.�c�.r�C�.�tG _ �--- �
3) Property Description: Lot Size: I• e�i Subdivision: Lot #:
Address and/or directions to Property:
❑ yes 0 no I�oes the site contain any jurisdictional wetlands7
❑ yes � no Does the site contain any existing v�tastewater systems?.
❑ yes ` � no Is any wastewater going to be geneiated•nn.the site other than domesrio sewage? �
❑ yes ❑ no Is the site subject to approval by any other public agency7
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentallon) �
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximurn number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: G�rrent:number of bedrooms: -
� Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? 0 yes ❑ no
❑Non-Residential
Type of business•
Maximum number of employees:
Total Square footage of Building:
Ma�imum number of seats:
't_ .
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 0 no
Please note any I�own ground water reslrictions or sources of contamination:
6) If applying for `Autflorization to Construct', please indicate preferred system type(s):
❑ Conventional � Accepted � Innovative � Alternative 0 Oth�r - ❑�►pY
�
I cert� that the information provided above is complete and correct. I also understand that �the information provided is
inaccurgte, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature�bwner/ Legal Representat�
* Supporting documentation required.
� D te
• Permits are valid for either 6Q months or are non-expiring when accomp�anied by an approved plat.
• A completed `Lot Preparatinn' form must accompany any application requiring a site evaluation.
Tax Map:����
Subdivisioa:
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IE �n�a m� aa � m �ca. �.Il 1HC � m ll�l�a
Parcel: ��
WELL PE %
(New _ Repair ) C�- � ��
Lot:
Applicant's Narae: �.Q.r�r.P�{-� %/� l i � a►� � ��o �1i �.�-Pi' W 1�-Q�
Mailing Address:
Phone Numbers:
Location of Property: �%a �� I ��^�S b W'p �1„ �Saa-�-e5 t�' �
Permit Conditions:
1.J See attached site plan for proposed well location.
2.) All applicable State and Counry 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:
Permit issued by:
�New Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Date: -31-1
Certificate of Completion u` ca��,,
t t p� de t.�,�Bl!
' er: g GP
EHS/D
ate
Depth: �
Grout: Zy 1 _ ��
DAbandonment:
Date:
Method/Materials:
J�la�r �ii�5 License #:
License #:
Date:
Additional Com►nents:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
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ply—and sewage ��osal. Afacilities� location; installation and ; y� o..
inust! meet state ana ;local regulations� � ' � ''; .� �:-Y � •
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c�a-and nitii8c'atio n`, line�112[JST �BE '���1�SPECTED ^'AND AE- ,� .a,;••,,; .
lY"'A MENIBER,'OF THE DISTRIC��FZ�i�L�ii:I�EPA�i.T1i�IF�N,'F '� ,' y,; �`
FORE ANY POftTION'�-OF THEc IN,S-TALL- AT�lON{-�I,S�?COV- " o o p
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Location .of well:and. sewage dispo'sal� facilities-�sl�etc��'c� on �back: �j �. �'� � . v� �? ry
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Applicant:
Location:
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T�x M�p � ' � Fa�rcel #
Suibdivision � • •
Ph�se Sect�ion Lot # � ,
Improvement Permit
Permit Valid for _ Five Years _ No Expiration
Type of Facility: New Addition _ Water Supply
# of Occupants # of Bedrooms Projected Daily Flow g.p.d.
Proposed Wastewater System: Type:
Proposed Repair: Type:
Permit Conditions:
Owner or Legal Representative Signature: Date:
Authorized State Agent: Date:
'�7
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Rules for Sewa,�e Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that
the water supply will remain potable.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_�.
Proposed Wastewater Sy tem: �Pt�-��d Type � Wastewater Flow ���g.p.d.
New Repair Expansion Soil LT •3 g.p.d./ ft 2
Type of Facility: ' Basement _ Yes No
Wastewater System Requirements
Tank Size: Septic Tank: �_ � Sf7i�gal Pump Tank: gal Grease Trap: '��gal
�ca�_� R� �
Drainfield: Total Area: sq ft Total Length � R Maximum Trench Depth ��_ in
r o•G•
Trench Width �� ft Minimum Soil Cov : �Q in Minimum Trench Separation: �_ ft
Distribution: Distribution Box ✓ Serial Distribution Pressure Manifold
Specifications:
� �. e
Authorized State Agent: �,_
Permit Expiration
The type of system permitted is
permit.
Owner/Legal Representativefi
Date: 7�- �7-d8'
Conventional ccepted Altemative. I accept the specifications of the
,- . �-� __ _ � Date: ! ��°"_
PCHD rev. 11/10/OS
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��n�n�on�n�a¢�na��.�. ����.�.��n
Tax�Map A ZS'� Parcel # �{s
Subdivision Pi„es[,.,�uel, �st-.
# of Bedrooms 3
Applicant: M; ({ S`(� e� assan �
LOC3t1OII• S�I�I '- ��� ON Z��.� I_n..I I ['�./,..._L Q.l _ �l iLJ rrM D1�.�/t�iAvw,.w1
� O�e�°ati0r� .�err�i�
System Type (From Table Va): Product (IIIg): �Z-
Type V& VI Expiration Date: Type V& VI Renewal Date: �_
,
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditians of the Imprcvement Permit a�d Construction
Au�izoriza�icn.
Scale ,J
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Tax Map: L�i2 /� Parcel #: �
. em ec is ype - ys em ype: �_
Notes•
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes: