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A24A 68Applic �.tion Date: � �) 7� cY . Amount Paid: p0 . UU Receipt#: �{ 0� ��_`—�� S f ���� �� _ _ = - � � � ���� .7�:. aa vn � ucn �e-n�r�a.v n-n.'6�aa.11. .I�.f �.rn. �.'d�:J�a. Application for Services (Septic Svstems and Wellsl C'r/Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $I50.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Tax Map: Parcel #: Services Re uested ❑ Construction Authorizatio❑ (Fee is de endent on the ty e of svs ❑ Permit Revision $75.00 I❑ Repair of Existing Septic System No Char�e �all °` a ayc�- �� a ., � � � ,� �,�;�- Important: If the information in tlie applicativn for an Improvement Permit is incorrect, falsified, or the sile is altered, then the Improvement Permit and the Authorization tn Construct sliall become invalid 1) Services Requested by: Name: ' ,¢. �^-�5:i� Phone # (home): �-�'—' Address: c� �r�r.� . � , (work/cell): �, � (�L7 O � —�!�"JC� S�e�-n� NC, ���u-�� 2)Name and address of current owner (if different than applicant): Name: Address: � 3) Property Description: Lot Size: 1'• �� Subdivision: Address and/or directions to Pro�ertv: ��7 _�-uh., i^ i� 4) Proposed iTse and Type of Structure: Residential _�_ Business/Type: Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No with plumbing: Yes _ No � Garbage disposal: Yes ✓ No _ Approzimate size of building foundation: I.ength S.5 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 comnleted ap�lication must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that tlae property is ready to be evaluater� 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 invalir�_ Signature (Owner/Legal Representative): Date: 6 (3`a� 11/07 Person County Environmental Heal.th, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ���� � f ���� �� �--- _ ' �-�' � � � � � � � 7La.�Y717� <GD 3Y�.7t'IC11 <L 7L'IL �.2D, � � �L1 �iL � 1L� , /• T�x Map � F�rcel # Su�bdivision � ' • • � �, Fh�se Sect�ion Lot # � � Improvement Permit Permit Valid for V Five Years No Expiration Type of Facility: ���q�Q %�etic�e�c,e New �Addition _ Water Supply �� # of Occupants �� # of Bedrooms 3 Pro'ected aily Flow 3[Qv g•p•d• Proposed Wastewater System: Cc ,a � FZ low or Gl, 4►,., lzo r- Type: Proposed Repair: �.o � ��D Type: / r Permit Conditions: �,�� n a �� � cttKs Owner or Legal ] Authorized State � Date: Date: 7—/� 08 The issuance of this permit by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the applicanbproperiy 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 %r SewaQe 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 funetion satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewater System (ltequired for Building Permit) * See site plan and additional attachments (_). Proposed astewater System: � an�,Type����: Wastewater Flow 3(�o g.p.d. New Repa' _ Expansio Soil LT • Z 7� g.p.d./ ft 2 Type of Facility: ri�q#e �. i�n� Basement _ Yes _ No Wastewater System Requirements Tank Size: Septic Tank: Doo gal Pump Tank: oao gal Grease Trap: J gal Drainfield: Total Area: �p sq ft Total Length 3o ft Maximum Trench Depth (�_ in a •c. Trench Width �_ ft Minimum Soil Cover: ip in Minimum Trench Separation: g ft Distribution: Distribution Box Specifications: Authorized State Agent: Permit Exp: Date: Serial Distribution �Pressure Manifold The type of system permitted is Conventional '�Accepted permit. Owner/Legal Representative: Date: 7— /S—D� ve. I accept the specifications of the Date: PCHD rev. 11/10/OS � � �..-.��,�,�� ��� �1/ `�✓ � . ���� �� � ��_���� ]�, �,.-�-� u- �� �.�.,� �.,��.11 IIE3[ u:;.� ll �1ln �11..11 J W�A1d0�L� .. , I`�1��ne _ /�i�e5 IhnmQSsen _ 1"� IVI�p # ,�_ I 1�I E-1 .l�'�:�'��1 �T �,� - - ��xbdivis' �� ^ �, ;�ecti��/I.,�t# �'_ ._ - - --- 7- ! � " o � �.._._..__ ` ut�.o��d Sta�:e .E�g��n1: ���� �S�f�S`d`c'S�Br' lf)ri°8�t917�°75i,L!3' 91��Y'x'S�'iY$''dY��iVa.7YP9iHdYdP6'C(i�YiPdlfs� 0�9��e �°ht ce��s�`�'oY v�aas�`�Yaa� ���e s�rsafa�a��viie�r• �� �r��e�v�$��,gp ��� Y�l�s��� t�o $a���r�e tlr��is��i�s��sroxd� �:s ��a�a��t�iva�� #,, ; �.���.- . �" ,,w`),� c' ,!.. t,,, ,' I. � s y � .. 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Tap Co:d . • , , � OpsningF�llad Wiik Ti�� �npplY � • Poxtland Ce�tunt Grant • Line • � ' ' Outkt To Dirtnbutiox .� N ,,,„ � a" SCFI40PVC Pipa 4" Conctetc . s .: , •. . � '� '° ' Float Wira� ' � :. • •� . � Floab .�: ,rl�em+ovab1e "��. Float Tree , '. ,� � . : �. r ( �• . ' ', � ;` 1, ;' .,' � oo� GAI�L�1� FU�P T� <:.�. -- . a 3o CT�M � Z9' � i�eq �