A25 181Application Date: 7 �-2 �
Amount Paid:
Receipt #:
0
;/Improvement Permit (Site Evaluation)
l�(T�. JH/$300.00 (if> 600 QUd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (l�tew/Replacement/Repair)
$3 00.00/$200.00/$75.00
��. ; , ) f ���� ��. V Tax Map: /�-Z �
��- � � ���� Parcel#: ��
IE �� a- � � � � � ¢�.11 IHC � �, ll ¢]�
Services
for Services
Construction Authorization
(Fee is dependent on the type of system permitted)
it Revision
$ .00
v Rep r of Existing Septic System
�� plication: No Charge/ CA $150.00 or $300.00
1) Applicant In rmation:
Name:
Addres . /6D � _
e,uoro� /`1 7 3
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Desc►•s�tion: Lot Size: �Ql�.1fi Subdivision:
Address and/or directions to Property:
Phone (home): _�3�� �i -r'1� ���5
(work/cell): �1U�- Q�Q`�
Phone:
Lot #: � ZS ��j
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ 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 � �
❑ New Single Family Residence Maximum number of bedrooms:
❑ 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 ❑ no
❑Non-Residential
Type of business:
Ma�cimum number of employees:
Total Square footage of Building:
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 property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other 0 Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccury�e, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
Apalication Date: � �� � ��' Tax Map: #:
Amourrt� Paid: I o . ,. . :
Rec2iPt#: � 31L}� � . ParcQi�#:
����5� I�I�I�.���T .
� �����
. �������:����.� ��.�.��� .
. APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFiED
CHANGED OR THE SITE IS ALTERED THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT
SHALL BECOME INVALID. N e e� �
���
1) Permit requested b�l: (Owner/ entlprospective owner): a� �' �
HosnE Phone: �y -� o�- � Address: b0 � � (`
Business-Phane: �'�i'9- �S�'�S« � �-3 hu�-`"
- �- U
2) Name and address of current owner: � l� �`�
�.� ����Qy -nv,..� � L , �5��
3) Property Description: Lot size: Township: Subdivision: Lot#:
Directions to the property (Including road n mes and numbers): �� u. G�v
G , ,s SC���� =�.
-�` � Gi��y
,� s'�t:a�i.� L� ,q-ss GJ ' y'��a.�� v
4) Proposed Use and Structure Descr tion: answer each of the following questions:
a) Proposed _, Existing _, Type o f Structure: W i d t h: D e p th:
b) Number of Bedrooms: Number of occupants or people to be served:
c) Basement: Yes _, No _ Will there be plumbing in the basement?
d) Garbage Disposal: Yes � No _
5) Water Suppty Type: Private _(new _ or existing �, Public_, Community � Spring _
Are any wells on adjoining property? Yes _ No _ If yes, please indicate approximate location on the site plan.
6) Does the property contain previousty identifled jurisdictional wetlands? Yes _ No _
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WtTH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE S1TE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
faciliti be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
be me in alid. �G,/, / %a -�- ��
��
Owner or Legal Representativ'�. � Date
(�wCi� �"' b
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SITE SKETCH _ . � g 1
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N e���c,f�e-(,JGc.� [Ct.G� .Tax Map # a5 Pa�tcel #,�"�`J
S b Section/Lot#
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Authorized Sta.te Agent � Date
System compostents r�eps�esent appy»ximate cantours only. The contractor must g the system prior to
beginning the iristallation to insune that proper �ale is rnaintained �
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SITE SKETCH
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Sub ' isi Section/Lot#
la a�-o �
Authorized State Agent Date
Syste�n corrtportents represent a�iproximate contours only. The contmctor ntust flag the systena prior to
beginning the installation to insure that propergrade is maintained. �
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* � }�ERS�N C�U�l�Y E�IVIRflNME�i�'AL NEALTI-i �
. PL�4S� S�E� A�'�C�iE� �L4N Ft)R WE�.L SYTE LAY�L9�
T���: �as p�� 3� �
Townsfitp
Zoning .
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�a� s-� N R, .ConCord-Ce.��D 2d� ��_I
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subatv�s�on:
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ccc
Story F4rm {�ouSc
Well Permit '
� � : V Individual _Community Pubiic
�ae of Water Supa v
Reauirements•
Site Approved by C� -3��
Grouting Approved by � � "�y'a'�
Well Log _ . �
Well Tag
Air Vent
Hose Bib
Cancrete Siab
Weli Dritler.�' xs^^a�
Well Approved By:
Date•
**See Attached Site Sketch�"'`
Wells must be 10 feet from property lines.
Weils must be 100 feet from septic systems.
Welis must be �at least 25 feet from any building foundation.
`C�c��--� c� P�-�'- � �
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Othercondiiions: �'�` �n���� ��n a��� S�ac,�n onS�Kcf�� �- Fla��cd on Si�tc,
� O�- .%vwEa �L�C�..
- Tn 5 -��. I I �
—� r` O l�� �/1�1 re. � Gn ��� � F e'as � n�"
-� Wtll Sitc. cc;�..ppr�Jtd �y �S►rn,G�ccr
�j�,s�d e� -r�� c�bove. Gritcri�;.
PCHD, rev.1'1/29/99