A24A 52s
Application Date: 7 1 %
Amount Paid: 00.(JO
Receipt #: I�i'� g�
� � �'02 � e n,
' ` { $200.00/�;300.U0 (if � 600
Q Mobi e Replacement or
$150.00 (if site visit requir�
0 Well Permit (NewlReplacem
$300.OQ/$200.00/$75.00
�er
Addi6ion
i( �T Tax N,[ap: �`i �
�ti'�.`��?��)�� �����1 �1 Parcel#: �_
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I ��'�rn;�n�r�ra�una�oaa�mll ]E�[,a�,�iE�a
riication for Services
Services Re uested
�0 0 Constructfon Authorization
(Fae is de endent on the e of s stem ermitted)
0 Permit Revision
$75.00
❑ Repair of F•acisting Septic System
Appfication: No Charge/ CA $l 50.00 or $300.00
1) Applicant formatio :
Name: �
Address• �
a j) , •
2} Name and address of current owner {if different than appticant):
Name: •
Address:
3) Property Description: Lot Size:
Address and/or directions to Prop�rty: �
Phone {home): 9l4 �� 9— �� �9
(worklcell): _
Phone:
Cl yes �o oes the site contain any jurisdictional wet(ands? -�6 �f
❑ yes �o Does the site oontain any eacisting wastewater systems? ,(jj�G
O yes �no Is any wastewater going to be generated on the site other than don
0 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)
�� /v�
� .
� . �o�S�-
1/�f ,�i�p�roa� �dr,�¢
� �,�0�3 o?�i�� � �/�
sewage? //
1Th �ie/ �9i es �-��Gtdse. .
��4
4) roposad Use aud Type of Siructure1 � 6c�S �OT re�'/� �
esidential ' �
ew Single Family Residenoe Maximum number of bedrooms: �/ Occupants:
Expansion of Existing System If exgansion: Current nnmber of bedrooms:
❑ Repair to MaIfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? [] yes � na
❑Nan-Residentia!
Type of business:
Maximum number of empIoyees:
Total Square foetage of Buiiding:
Maximum number of seats: _ __
5) Water Suppiy: Cl New well � Existing Well ❑ Community Wel( ,�ubiic Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? 0 yes ❑ no
Please note any known ground .water restrictions or sources of contamination:
6) f pplying for `Authorization to Construci', p[ease indicate preferred system type(s):
�Canventional ❑ Accepted ❑ Innovative ❑ Alternative O Other � Any
1�
that the information provided above is complete and correct. I adso understand that if the injormation provided is
rte. t� is subsecruently altered, or the intended use changes, all permits and approvals shall be invalyd.
Signature {Owner/ Legal Representative*}
* 5upporting documentation required.
�
Date
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved ptat.
• A comnleted `Lot Preparation' form must accompany any application requiring a site evaluation.
.- -. .. � . T _'_"___"'�._i TT�..I4L Z'7G C' 11d.....T.+++ Ct Cnita f' T2n..1...rn AI(' �7C7Z 111�_S47_170(ll
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Applicant: �• (Ct4 sb4 CK
Address/Location: S" iU � �
�il,,.G sbovu� �L� �PS�-a
C �,, 1Q�,['� �
Tax Map: 0��/4' Parcel: sZ
Subdi�ision i s�rw ���5
Phase/Section/Lot # SZ
Improvement Permit
Permit Valid for: Five Years � Non-expiring
Type of Facility: l3'►2 PS• New � Addition _
Number of: Bedrooms / Oc upants �/ Employees / Seats:
Proposed Wastewater System:
Proposed Repair: ..QX-Pm
Permit Conditions: � �� lQ `�
�
Water Supply: �� ��
Projected Daily Flow: �o gallons/day
Type: �
Type:
Authorized State Agent: � �✓ Date: Y- z4``l
(X) Owner or Legal Repr entative: Date:
The issuance of this permit`by the Health Uepartment does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that al( 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 is not affected
by a change in ownership of the property. This permit was issued in compiiance with the provisions of the North Carolina °Laws
anrl Rules for Sewa�e Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain otable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Pro osed Wastewater S stem: �Cr'���' oZ`� � V' (�)Type `��'L�Design Flow �� gal./day
New� Repair y Expansion _ Soil LTAR. �� gal./day/ft2
Type of �acility: �i'°�12 ��-P5. Basement: _ Yes �C No
(*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tar�k �� �� gai. "' Pump Tank ` gal. Grease irap ^ gai•
Drainfieid• Total Area 1 y yo sq. ft. Total Length �$� ft. Max. Trench Depth � in.
• Trench Width � ft. Min.Soil Cover �' in. Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution v� / Pressure Manifold
Specifications: Sr � Za"�
Autliorized State Agent: r-� ti`^� Issue Date: Y'ZQ^�rT
Permit Expiration Date: �t`—Z Q^Z2
The system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
�t;:;
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-17914 (rev 5/12)
Site Plan
�� (� ������T Name:
l� Subdivison:
~`��� ���T�T�°�Y
Y
]E��s������Il ]E���Il�
� c� v a�c� �����Q ( so; (
� � �..e.��(.e�.Q �,,.e�
�r4��`��e��
�ot: 52
��_��-Sae.
�
�M
N!
�
,
System Type: � ��C
Septic Tank: 00 � gallons
Pump Tank: `� gallons
. ��'D
,�
is'
20
EHS: i
Date:
ts' �r
� u,�s�.,; �h�e
_' �C°� So; � 5
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ti
g�
0
�.
iax Ma�: ay
Parcel: SZ-
r�r �:c
-Z�'—(
Total Linear Feet.
�, �/ � _ ,�� �
Max.Trench Depth: /�P Scale: _� �
^date: 1) Drain !ines rerreser,t a�pmximate rontnurs. Drain line locations must be rlageed prior te install2tib��
.�..
�} Contact Persun County Environme�ita� Hea�ih with any quest�oru (335) 59i-1790. ,'�
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WE�.L PERMIT
(New 1� Repair_)
Tax Map: a�� Pa{'ce1: J`�2 SZ
Subdivision: i1a� i�or� Lot:
Applicant's Name: �� Pa,.< S b�e,�
Mailing Address:
Phone Numbers:
Location of Property:
,�'eS V thA V UH Ah ri S�"�S
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing conshuction 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:
�iew Well:
EHS/Date
Location:
Grouting:
Well Log:
Wel! Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comrnents:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date: �=��i'1
Certificate of Completion
OLiner:
• EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13