A24B 3Application Date: 2- �- 3
Amount Paid: __�
Receipt #:
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Bnilding Addition
$I50.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
��� S (' ���� �� Tax Map: Z�
.... -•' �- Parcel#: �_
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lG�rawna-�man aicaa9�n.9;aa11 1C�I��.112��n.
Services
for Services
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
� $75.00
pair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Inf mat'on:
Name: ,� e� , Phone (hemcj: - �j�� " C"i0� ��%g�j �Ct��i >
Address: 2 2 (�): �c�� - L��� ., (�, ��
2) Name and address of current owner (if different than applicant):
Name: Phone:
Address:
3) Property Description: Lot Size: , 5 Subdivision:
�ddress and/or directions to Prop�rtv: -� 1�1r�
Lot #:
7,
� � u e cr��, 7 � K� oh ������Q�l ' QI�IPr/ t��l.
❑ yes no Does the site contain any jurisdiction I wetlands.
�s ❑ no Does the site contain any existing wastewater systems?
❑ yes �yi Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes C�� o Is the site subject to approval by any other public agency?
❑ yes Q no Are there any easements or right of ways on this properiy?
(if `yes' is checked, please provide supporting documentation)
4) oposed Use and Type of Structure:
esidential
❑ New Single Family Residence Maximum number of bedrooms:
❑�xpansion of Existing System If expansion: Current niunber of bedrooms:
��Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plwnbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage af Building:
Maximum number of seats:
5) Water Supply: ❑ New well [� Existing Well ❑ Community Well ❑ Public Water ❑ Spring
.Ai-e there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please insiicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other CI Any
I cet-tify that the informution pravided above is complete and correct. I also understand that if the infoi•mation provided is
i�accurate, or if the site is szrbsPquently altered, or the intended zrse changes, all perrnits and approvals shall be invalid.
Signature (Owner/ Legal Repres�ntative*)
* Supporting documentation requir�
/2 " / �i�oZ.o/�
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 evatuation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map: �-CZ� B Parcel: 3
Subdivision
Phase/Section/Lot #
Improvement Permit
Permit Valid for: Five Years � Non-expiring c
Type of Facility: �rid�2 Resi�P_nC�, New Addition _ Water Supply: LX15�1✓t
Number of: Bedrooms / Occupants / Employees 1 Seats: Projected Daily Flow: gallons/day
Proposed Wastewater System: Type:
Proposed Repair: �,,,�e Type: �
—�_
Permit Conditions:
Authorized State Agent: _
(X) Owner or Legal Rep
Date: 2-1R-13
Date:
The issuance of'this permit by the Hea[th Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
[mprovement 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 compliance with the provisions of the North Carolina `Laws
and Rules far Sewage Treatment and Disnosa[ Svstems'(15A NCAC 18A .19Q0). 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 wiil
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater S�`stem: ��p � �
New Repair ✓ Expansion _
Type of Facility: Q���Q� �Q,�i��p
(*)Type Design Flow � gal./day
Soil LTA . gal./day/ftz
Basement: _ Yes _ No
(*) System Types Illb, Illbg, IV, and �; require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank �� gal.
Drainfield: Total Area y g o sq, ft.
Purr�p Tank gal
�
Total Length a� ft.
Trench Width � ft. Min.Soil Cover (�¢ in.
Distribution: Distribution Box / Serial Distribution �/ Pressure Manifold
Specifications:
50' �o r,�,
ti
Grease Trap ---gal.
Max. Trench Depth ZZ in.
Min.Trench Separation _N/� ft.
-� - -
Authorized State Agent: �/,,,�._ ��( _ Issae Date: 1�/9� /3
�—� Permit Expiration Date: 2- /q - [�
Tlle system permitted is: Conventional /Accepted ✓/ Alternative / Innovative . I accept the conditions
and specifications of this permit. '
(X) Owner or Legal Representative: Date: �� L'/ �� D/�
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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System cnmponents re, present u�i�iroxim�te �contours on y: The confrrictor must,�Tiig the system prior to ;
begin�ing the a�rstallation to insure that propergrrrde rs niaintained
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Applicant:
Location:
av��n�E�t wN
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Operation Permit
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Tax Map A�`� 4 Parcel # Oo3
Subdivision
Phase/Section/Lot #
# of Bedrooms 3
System Type (From Table Va): 1.' 1� c, Product (IIIg): EZ. F�.c,w
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
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(Authorized Agent)
�'�SS� S�R�.T"
(Licensed Contractor)
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Tax Map: yp Parcel #: p Q
Septic Tank System Checklist (Type II-I� System Type: 1�.3_ `�
Notes:
Pump System Checklist
Contracted Certified Operator (Type IV +Systems):
Notes:
NOTIFIED BUILDING INSPECTIONS:
(Revised 12/09 BH)
Copy of OP e-mail Date: