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A25 10Application Date: � � 13 Amount Paid: Receipt #: A ❑ Improvement Permit (Site Evaluation) $204.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 �� S (' �� Tax Map: 1�� `.....�`� � Parcel#: 1Q . t•�' �. � �� E"�.�rav*nn-�anmm-s�aa4:.en.� ).�'��s..y�,�n. tion for Services Services Re uested 0 Construction Authorization (Fee is dependent on the tvoe 0 Permit Revision $75.00 Repair of Existii Application: � 1� Applicant Information: Name: u�?,�Q`ci�� Phone (home): Address: �!'a-� � work/cell): _ of System / CA $150.00 or $300.00 �Name and address of current owner (if different than applicant): U�-mw� a� Name: `�a�u.� �.,,� Phone: �33i.o�:5`U4- 4 U9 g Address: � �. 3� Property Description: Lot Size: Subdivision: Lot #: . Address and/or directions to Property: ❑ yes 'E$.no Does the site contain any jurisdictional wetlands? $3 yes ❑ no Does the site contain any existing wastewater systems? ❑ yes '�no Is any wastewater going to be generated on the site other than domestic sewage? ❑ 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) (�Proposed Use and Type of Structure: tSResidential ❑ New Single Family Residence Maximum number of bedrooms: 3 ❑ Expansion of Existing System [f expansion: Current number of bedrooms: �Repair to Malfunctioning System �Vill there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: 1�4aximum number of employees: Total Square footage of Building: Maximum number of seats: OS Water Supply: ❑ New well � Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ na 6) If applying for `Authorization to Construct', please indicate preferred system type(s): . � �Conventional �Accepted ❑ Innovative ❑ Alternative ❑ Other � Any/�l Mt� Ls��S c.�s-'� 50�-3�5� 1 cert� that the informatiort provided above is complete and correct. I also under.stand that if the information provided is ina�curate�o�the sit�e is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. �L�u1 ce,�.c Signature (Owner/ Legal Represer * Supporting documentation required. /�3�� 3 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 evaluation. (10/111 Person Countv Environmental Health. 325 S. Mor�an St.. Suite C. Rnxhnrn Nf` �757'� ��`��_Sq�_i �am Application Date: � Z 1 ��O Amount Paid: Receipt #: a �' �� f �� ,V� � 5 0 � -�'' cC � �T1�°�°�Y ��mm��¢�Il ��.A� � I Z Aaplication for Services Services 0 Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Additioa $150.00 (if site visit required) ❑ Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 0 Construction Authorization (Fee is dependent on the type of ❑ Permit Revision i $75.00 Tax Map: � Parcel#: �'7 _ pair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: ��. n _�slf r Name: �� t h�� f} l �;�rz ..'�c: en� �U'r' t%i trt.r,� cv r+'ie j� Phone (home}: i'3G�� -=;a� o Address: �/�3 C� Ct��S�}-, $�-�r�,,;)�, (wor cell : f33C1� SG�- �IG�g �' ' �,� . 2) Name and address of curren owner (if different than applicant): Name: (� r N �{- (sct i � L. o�t� Phone: Address: 4�,1 ��,�;^-�-v,� u-( l� ct m. �c�_ (�, 7c.hu r� .�[� 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Lot #: ❑ yes g1"no Does the site contain any jurisdictional wetlands? I� yes ❑ no Does the site contain any existing wastewater systems? ❑ yes � no Is any wastewater going to be generated on the site other than domestic sewage? � 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) 4) Proposed Use and Type of Structure: ❑Residential ' 0 New Single Family Residence Maximum number of bedrooms: / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: � Repair to Malfunctioning System Will there be a basement? ❑ yes � no With plumbing fixtures? ❑ yes f�l no ❑Non-Residential Type of business: Total Square footage of Building: Maximum number of employees: Maximum number of seats: _ 5) Water Supply: ❑ New well � Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? � yes ❑ no Please note any known ground .water restrictions or sources of contamination: 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Signature (dwn�'/ Legal Represenfati * Supporting documentation required. ate Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �i= �o� � �Z, ��, ; , �f �� .�� IE-�e �-� � � ��.��.�.�.Il I�ZI � �.11�I� Applicant: _� Address/Location: Permit Valid for: Five Years Type of Facility: � Number of: Bedrooms / Occupants Proposed Wastewater System: Proposed Repair: Permit Conditions: Authorized State Agent: (X) Owncr or Legal Representative: Tag Map: �� Parcel: /D Subdivision Phase/Section/Lot # IrnprQvetreet�t Pertreit Non-expiring New Additio _ V4'ater Supply: / Employees _ Seats: Projected Daily Flow: gallons/day Type: Type: Date: Date: The issuance of this permit by the Health 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 tmprovement Permit is subject to revocatioa 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 °Luws nnd Rules for Setivag� Treatment and Dunnsal Svstems'(15A NCAC l8A .19U(1). Neit6er Person Caunty nor the Environmental Health Specialist warrants that :he septic system will continue to funciion satisfa�torily in the future, or #hat t�e water supply wiil remair �otai�le. Authorization to Construct VVast�water System See site plan and aa'a'itional attaer'�n:Erits i`}. a Proposed Wastewater System: AC�,�� (*)Type � r� Design Flow 7-�b _ gal./day Nev� Repair ✓ Expansion _ Soi( LTfiR: �T 1�'q- gal./day/ft2 Type of Facitir,�: d��.�- � Bssemznt: _ Yes �No (*) System Typ�s III6, Illbg, IY, and i/, require periodic system inspections by the Ferson County Health Department. Wastewater SysterlltQqzlirement� �}! ti �'► �`T Tank Size: Szptic Tank gal. Pump Tank gal. Grease Trap gal. Urainfield: Totat Area �(a0 sq. ft. "fotal Length iZD _ ft. Max. Trench D�pth,�_ in. Trench Width (P ft. iVlin.Soil Cover �_ in. Min.Trench Separation ft. Dis#ri6ution: i�is±ributio�i Box / Serial Distribution / Press�ire Manifold Specifications: Authoriz;.�' ,`�tate flget�i: tssae I3ate: /Z ZZ Pe_rmit Expiration Da�e: T'he system permitted is: Conventional /Accepted �/ A ternative / Innovative . I accept the cor�ditions an� specifcat�ons of this permit. '� ,�.e.ctmc,.�,r� `�� "�"" � {Xj Owner or �.egal Representative: �� (� A�,��. lryt �� Date: ��.. � 7 Person Counry Environmental Health, 325 S: Morgan St, Suite C, Koxboro, NC' 27573/ph: 336-597-179U (rev 5/12) ConnectGIS Feature Report �� Page 1 of 1 ��V�1 �� I�� WE6 N��;TI'd�� '� ,'�1 `?il 1�1� � ; Person County Environmen#al Heaith �5��° 325 S. Morgan Street '�� Suite C �. Roxboro, .�C�27573 t.a � , -, .t �- •innc � 4203 ' �:.. 1 b��_��='- `i, f" • t' �r ' . . E��l �g�► �. 1—� +�£ 1'S'[5 G�(lyi"l N� ti":. N ; I� E�A1,� '�" " � Z L�ET� �� ' � " � vuu... 2u ir/ `!'G�✓'/o Person Printed December 22, 2016 See Below for Disclaimer � � , � �,� �, �� CrbNi ^, 3G,� � Y�cc�1/fi '$�CiTv�I Total Length: 238.�� Feet 2931.64 Sq. Feet or.Q7 Acre,, . � +'t � orSq. PAiles •.'��-- - -- ____.___w_.____ � 1916 1 : �0 Feet NO710E: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who hav recently upgraded to the Windows 8 operating system or a new version of Internet Explorer. We were able to resolve this issue by directing users to the Internet Explore ompatibility View tool. This link is to Microsoft's "How 70" for the tool: http://windows.microsoft.com/en-USlnternet-explorer/products/ie-9/features/compa6bility-vie f this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGlS has bee prepared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records„Users of GIS system ar notified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectGI ssume no le al responsibili for the information in this s stem. Grid is based on the NC state plane coordinate s stem, 1983 NAD. /�o?f : � �/G T� ��D'�IG' 1�� /�Z� ,�l �C/G/y'�'� �/�in/�%'fi �/kf F"�20.�i T'/f�✓/G /y� �G/.Lfi��'� �o5y�� v�G�� w�f�[ ir✓,��•o,�/ . http://gis.personcounty. net/ConnectGI S_v6/Down loadF i le.ashx?i=_ags_map32f4c23 fd73... 12/22/2016 �-�-�-.� � ��. sf ��.� �� I -�" ��aa-��a.�an��a.��.Il ��.Il�II1� Applicant: Location: Operation Pern�it Tax Map �� Parcel # 11� Subdivision Phase/Section/Lot # # of Bedrooms System Type (From Table Va): � Product (IIIg): �•z- ��o c.� 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 conditions af the Improvement Permit and Construction Authorization. (Authorized Agent) ��0�1 (Licensed Contractor) 1S�lnl 1.L� t�f�� ( '�t�S V�, O �S��KS � Cl.y�rtiT�r.D �, T�� Scale �"�5 PCFiD, rev. 12/14/12 / � !� (Date) 2 � t� (Date ` l �ti`�� , � � �� I �o' � '�' �j�"r.i� q�� I 4 `�. 4� � �_----[!7.•-�--• ,p„ �z"c,X . r� � �� Z v��S G�'�`x�o, = �b �T� Line TOi31 I �o � X G�D Tax Map: ��i Parcel #: �I> Septic Tank System Checklist (Type II-I� System Type: � Septic Tank InitiaUDate State ID & Date: Capacity: Tee and $lter � Baffle � � Vent 6 G �Riser Outlet boot Perm. Marker Distribution D-box levels set) ✓ Serial Pressure Manifold LPP Notes• � Nitrification Lines Inif UDate Trench Width: � ft. � y � � Trench Depth: in. Total Length: lP0 ft. Minimum s acing: ft. Rock de th/ uality Dams/ste downs Grade < .25" in 10') Cover (6" minimum) Setbacks From wells Pro erty lines Foundations/basements SurfaceWater Other: � Pump System Checklist Pum Tank InitiaVDate State ID & Date: Capacity: Riser (6" min.) NEMA 4X Box Model: Piggy back plug Haxd wired Alarm functioning Mounted on ost Above grade (12") Conduit sealed Pressure Manifold Number of ta s: Size and sch: Contracted Certified Operator (Type IV Systems): Notes• Tank Com onents Initial/Date Pump model: Block (4") Nylon retrieval rope Float tree and attachments On/Off float swing: in. Alarm float (6" se aration) Anti-si hon hole Check valve Threaded union Gate valvs Conduit sealed Outlet sealed A proved and secured riser Su 1 Line Size and material: in. sch. Length: ft. _ __ __ _ _ _. , � z l i b' 13 � t� K,r,E L�. U a�►-\ s� -tv ,a� �.L.�i.. '�.�f�ct. ;�s ��-�' 3 a��c e� '� �.l.k�.-�,., L�cq, �c�, � t5 �c e w.�a •�� . � '�W[. �t�E�t ~ c.�C7�► prai, b- brt�� {j;��,L,�� t.., ` �.-� �c.o�. ; '"t'i�fl '�,4c,v, i,�v �►sY►,.1�b �--�r�E. �� 15ta�1t�. �tc.a� �ovr9 ��rc. 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