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A24B 10
Th e District Healt� Department CASWELL - CHATHAM - LEE - PERSON COUNTIES �--� ��' Water Supply ond Sewage Disposal � IMPROVEMENTS PERMIT No._________ '"" ' J Date_ --' � I �-4% / Owner: - �- � '��1� I C' � �-T� �_ Location:�_ �, : - �f�?[=�•�+ �.�� r/ i � `�:, � �I� � � - i � Contractor: , �INater Supplp: Private Public �_ No. bedrooms �_�Dishwasher� Disposal, A Eii►I�I!__�#i_ �1,���1. Water supply and seK'age disposal � facilities location, n�tion and protection must meet state and local regulations. Septic tank should be Pumped out every 3 to 5 years an3 shall be main tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT ERED ANB PUT NTO USETION OF THE �NSTALLATION IS COV- Date approved: Well: Sewage Disposal: By Ceriificaie of Compleiio • � / Date Approved: � � By Signed ' •. Sanitarian Counter- signed (Owner or his representative) _ (OVER) ., Location of well and sewage disposat facilities sketched•on;back. App�ication Date: g"��`� � Tax Map: ���� Amount Paid: 1� , U� Parcel #: �� Receipt#: S 0 9 8o i � �-- ���. s�- I�I��..� ��T � - � ������ � �rn�cs nn �narTM++ a�+�ca�..�n.� ��.c�,an.Il ��a Application for Services (Septic Systems and Wells) Services Re uested O Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 if> 600 d Fee is de endent on the e of s stem ermitted) 0 Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired $75.00 ❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Services Requested y: Name: '� �vb�S Address: � / S-� �L t Phone #(home): � 3 L Z� U l 3� l (worWcell): 2)Name and ddress of current owner (if different than appticant): Name: Address: 3) PropeMy Description: Lot Size: Subdivision: Lot #: Address and/or directions to Property: C ��,��P. I� �� 4) Proposed Use and Type of Structure: X � Residential Business/Type: Other Number of bedrooms / Number of people served (seats/employees): ��� 3� Basement: Yes No (with plumbing: Yes No � Garbage disposal: Yes No 5) Water Supply: Private Well (Proposed Existing _� Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A comnleted annlication must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of a[l proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am sabicitting this µpglicaticn tc request services from t�e �'erso� County Iiealth Degartruent. I ur,derstand that if the information provided is incorrect or if the site is subse uentiy altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representati e): �,.ti ���`-� Date :�'-/ 2— � ( 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ♦ ; � � � ' �� � � �, � 1 1. � t i. � �ti� � � � ���� J:t_:.-f.�1.�1i.�'��!.Z�l.�.l�Zi��.�.� �t�.i¢�.�IErJL1L � �ann���a�� �s�e�a�n�aa�! PVg��afl�e ���ae fl���n����ffi��n�� Tax Map #:�� Approval Requested for: Applicant Address: Phone #'s: Parcel#:��_ 1Vlobile Home Replacement � Building Additaon C i nc� roU►�cl Poo �� Pemut Located: � Yes i�to Installation Date: �- �j -$'� Design flow: Z�0 (gpd) Current Contract with Certified Operator on file (if required): Water Supply: �ell Public or Community Wastewater system shows no visual evidence of failure on: g-- 1�' 1� (date) (Applicant's signature if sit� visit is not required) � Comments: i� q i N`}�,�i (� SC ac' �S A��Il� ��la�s���a�� �����d�� ��- 8=�5 -� Envir nmental Health Specialist Date 11/15/OS `�.��,.)� ���� �� � � �'`� � ��. ���� 1��-�u•�,m,�-„-,,,����.11 lE���ll� .. Name or� �� S�'� � Sub'��n � Autho�ized State Agent �I'I'E ��'TC�-I Tag Map # � Z� I'a:�cel #�_ Section/Lot# g - i s -f��----_ Date System cbrs��ionents ne�resent appr�xirmate�contours only. The contructor rasust, flag tjae syst�a1bYsor to begira�ing the instadla�iora to ansure that prwperg�ctr� is r�rai�atained ' �aa� 09 � i �h { � ~ l � � p� � � � �a k �� � ��.� �''� r� ��� h k� �' `kaa. �.� � a � p-g ��, . �w�� z-�.�� �� � � ����. ��,+`� +.'�'� �' ��., �cr&'d `%' k�, q� '..� 3yy. ', � qdL � N,���. i,�� �+ 5 L'°�$.Y.���^'S¢ } � .� � ':: " � �� �� ��-� x� � � ��� � 4,Yt�+S�`R�yyf°���� 9F'�`' � _ � `��y'� `F?c����''�'�'r�� 7i'ii �:�� � 5 `� � s-. t _. � � �� � .. iVi f � � ��� _ ,;�`� �• � . �,� �x' t �.-�-` �-,.: r ' � -� �l�'''y�' �. ... � , v'b ' k_- ��, �' c+a#.� " . . � .. -._� ""`�, .�. �. 4 �../ � � I':n"'���` - i`i ��'3 p. � ij ����'��: ti J' (1 ��z 1 r' _i ( 'fii 1 �. �`t` _ :� s + n ��� ' C� �4,3}r.:>, � � K `„�,,, G��.� � � , � �'y , y,H � � �: r�. wc . 7 � i ''.-'} 5 `a- e . � "`'- � l ��x � � �� W� - _ �; � µ�; � � � � � � � - t �,� ' �� '�� �,� � � , , ,�, � .. y�'� � IY i �� , � ���; ��� �` �` S^a. .. � it:: Lti'�� 7�,p1, �i� 1\ �\ � " :l i �'�'z4 ,es . . �� � -, _ , � 4 I -ti. ..,4 � .._ ��''h' � < ' � i s,�"' `�'E,�r�' ¢ � � �.,;; _ ^��a s� „r,} `�� � � � r.s � . � ��� 2� �, � . �� ,,. . , ,. _ ._rv w. � , . �;�� �� .�.,r..-.__. . .. �,. � � � `�� � ���.�� ri�# � �; -5., . , � _z �� � r, y ,r� . � � �� : --� �,E, . �.,a�.� '�q ; � �.o-n' ;� t^"5°n-� � ` � -� �' J k � ;�s.> � I .,} ,y ' `x° "`'. �s �� ! �� 's"�'' � �`�i' .- �' A � �&s*, s �r - 5'.� * & �.. �, � a� ' �g �� � � r .:� �� '�. 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"� �� � ; � � ;4 l � . 3 '�a�w i � � �.0 $ S . r'�� a ._ s� . �, " '�1 ,.� � � �k' . . t � � . t � . . �yw � . .� ,�;,'� �� ` �� y �� '�r y �. . . . +^�^ ' .���n3�.--Shy„j i €i r�.:����' �: � � � �.� �,.x �# 7z��- ��� � � � w� ,t� a�r .�y �rs�' }•r *: � ! u k , F, � ��; � � _� �� �� � p } ' �4� �.y �''l � ". 1 � � � J . +f 3i. :u-k C �r —_ t" �4 l4 %. . - ��'._._ � ' -�- ., � � = s �y, i .' .' � .. �+��� w.. ... . �.r�€` . f � � _. A •---^� . . ti � `« . ..� �.,—,— , ._ ,... .� x... a __^. . � � , . � . 4 f .: Applicallon Date: ��" 8�� � ��S ` �� S Taz Map: AmountPaid: 1 0 . `.,,� � ������ Parcel#: Receipt #: 3 � 7 7 �' ' � � ���� .�unv+aa•�,.*,.*-+,�=nd,mII ��.s���a Services J Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 6��d) Mobile Home Replacement or Bvilding . $150.G0 (if site visit required) � Wefl Permit (New/Replacement/Repair) $300.00/$200.00/�75.�0 for Services ❑ Coastruction Authorization (Fee is dependent on th� type of Q Permit Revis9nn $�5.00 ❑ Repair of Ezisting Septic Sy�stem Application: No Chazge/ CA $150.00 or $300.00 "1) Applicant Information: Name: �4�ril,�S � S�f� lt,�Yv S Address: � ��oo � �, 2) Name and address of curren owner (if different than applicant): Nazne• Address: Phone (home : l 3 � 2 6 f� - v4o � (work/cell): 5' � /— � �q 11 �-1�, � s.# Phone: 3) Property Description: Lot Size: ! _ Subdivision: � Lot #: Address and/or direcrions to Property: �-} � t� u r r� � v 151' •___ � e n,� o � ct ❑ yes �no Does the site contain any jurisdictional wedands? ❑ yes C�no Does the site contain any existing wastewater systems? ❑ yes i� no Is •�:ny wastawater going to be generaied on the site other thau domestic s�wage? ❑ yes C� no Is tns sita subject to approvaI by any other public agency? ❑ yes C�no Are therz ary eusaments ar right of tivays on this praperty? (if `yes' is checked, please pm��ide supporting @ocumenta:ion) 4) Proposed Use and 'I�ge of 5tructure: CJResidential ❑ New Single Family Residence Maximum number of bedrooms: _ ❑ Expansien of Existing 5ystem If expansion: Current number of bedrooms: C] Repair to Malfunctioning System WiII there he a basement? ❑ yes ❑ no With plumbing fixtures? �J yes ❑ no ONoa-Resideatial Type of business: MaKimum number �f empioyees: Total Square footage of Buildin�: Maximum number of seats: "30 X � O �e'�0.C�•ed ���a� 5) Water Su��iy: ❑ New welt ❑ Existing Wel! ❑ Community Well ❑ Public Water J Spring A,re thzre any existing wells, springs, or existing waterlines on this property7 ❑ yes ❑ no If applying for `Authorizatian to Construct', please indicate greferred system iype(s): ❑ Convantional ❑ Accepted ❑ Innovaiive ❑ Alternative ❑ Other ��___ ��Y 1 cert� tl�aF t�e infhrmation provided abc�ve is cvmplete and cc�rrect. I alsv urad�rs�tar:d that if the infurmtttian provided is i-rtaccurate, vr if the�st�.',g is �jul�}eg�e�ly altere.d, vr the irttended use changes, c�IlFerm.it� a::d �rppro��als shall be invali� � 5�nature (Owner/ iegal Represer * upporting documentation required. 7�'� /.� Date Permits are valid for either 60 months or are n�n-expiring when accompanied by an approved plat. A completed `Lot Preparatiofi' form must accompany any application requiring a site evaluation. �� :� ,. ���,�t�r��� � �� �� �, � , �, � � , ,�� , .�' 1� � . � � � ;' ��,,, � s "+ .y^ ��'`� y �� �' �1 ��` �, �- .'.L:•J�S.JZ.`v"il.1i'ttJ_L'1.?I�'7LCF:y7�Z�La�3L�1. iL�1�.�"i<ilL.l�ii..lL.li �a����1��� t�����m��/ I���b�� ��aa�� 3���fl�a���a��n�5 Tax Nlap #: a�} B Parcel#: ( � �ddress: �i b'Q►acz..1�-Y CJq.�v'� � . s�,�► � ��� a�►��� Approval Requested for: Mobile Home Replacement �r Building Addition Applicant Name: ��� R, s�u,�a6S Address: 1,35v Dr�v►o Maot� Ra a.�,ae�a ,� ac� Phone #'s: 33b- a�o - aoob s'8�1- Sbl3 Permit Located: )(, Yes No Installation Date: 5 4- 8� Design flow: ��{o (gpd) Cunent Contract with Certified Operator on file (if required): Water Supply: �. Well Public or Community Wastewa#er system shows no visual evidence ef failure on: 5 ty li (date) (Applicant's signature if site visit is not required) Comments: N'l,��rk�tiw� Fk� S�-�ct�S � Ap4w�v�o �oe 3� X�io �tr���¢���/���fl������a� �.�p���v�ed1 �.,,..Q, Q. .� Environmental �iealth �peciaiist 5 i� t3 Date u Person C��n�� Environmentai =�eaith; 3�5 �. ti:or?an St., Suite C; RoYboro, NC 2 i�; 3 Fhcne: :;�6-�97-??9C/ ra>:: ���5-�9"-7�0� � �v�:���i.�,ersoncoun�tv.i,e� ��� ? �� � ���� �J/� _`'"`"---�r � '� ��` �Z� �� 1�Y ��lvras'.c�1..��aa�B�ca�.�.�� 1�'�L�n���l}-a. - Sl`�"r'. NLA,�I I�?a.rce _J�- 1wi.�--�. S'iht.�,:� -'------ ,,,a.�c ��fvp #f�1� i.: rcel �` �P'Cl Sa divi �on ^_ -- ,------ �e�t+�^/Lc:� �.,.�. � �; - - s l �� _ _-------- �Si,rhe��e� State .9fient �}8T^ �`�.=tcmce:nl.�nentstep;es�ntapp�lx�.ma.,^a-,r_,tcertsciz'y. '�'fiec�;•�ctormustfi:,�t;esps:r.�prial•toh=g%nnin�tn�%�.ss.:il�r�nre lnsure that pmpergrade ls maintained. �v.�s..... _ ��� \o�\�� U a� C�� l tiJx i{ L t� �-t�-Z. �.----�� \-�-, ,�, : . \ ��` � - y�`,, i �..,.--,.—.�--'_.r� � � �- ; � \�� � �\� � � � � � .� ���—'��—".� . `'\ � � �f �.� i � .� � � � �_ . - s �oe� <. ; ' � � �'—��'�'F�s, a�i z � a R �� ���i � s� '.t �� # �,�' h_ Ab�� tc 'i7�r3�: , � � � . �. ����@ .�. � «. � � \ ` '�--,.� '�' � . � � , ` �- `"' . � � � �c � � � � � � \. � \� � '��\ -� �\� .� � . �� �- �? t : �..�\�u \,,�k^ � � a�:,j i .�%� ��� �� \ ���.. A� ��� �O���o\ ti� . � t Z., k �.� x � � �� � � "F'. �s.��y� �� I ��� �� �\ � - � V - y�� � ���\�� A��� � �c.� i � -� � � ��� � s s ` � <"`^. �� � .-e i � ���j�\� � � � \\ ��'j,t \ � � : . � � k ° �\ \\ .. \ '..`"� � � ��\ ������ �� ���A\� �A ��� �f � ���� �� � . �� �y }t �..�"'� � , �' ���'�� -`w:..�l �.A e �« . �A �. �A� ° r � S, v..�, -^' � � I� � � .. 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