A25 208+_.." " ��''!h.�'s.?'.'�....�.r. .�> .�.��.rL .♦ . .�. . �.v c� .. ..ta. < ...+.a_ .a� ._. k'.'u.ri._.. ..+a� ry..A;._ �i�.+:w>'"YY.�V��'i'.�e..r'L:...c..�..:'L.a4� �..-1��_'y.Js._..-t:a.......r.��!1 .`... u..�...ICX�G.1�4enr
Aopiication Date: '"1' � Q�
Amourtt Daid: a-�Q, DO
Re�i� r � Q� 76
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,4Pf�tICATiON FaR S�VtC�� .
i a• �Vlan �
�ar��! �:
1F THE 1MFaRMA7TON iM TNE APPLlC�Ti�R! �i�R ,�,P! 1MPRflVE�E�T Qt�r lViIT iS INCaRRE�i' ��AiSf��En
CN.�t�Gc�. OR T�-iE Sf'i� IS .�L7'�i�E�. TNE?rl T�-lE liViPROV�i4fIE.�IT P�.�il�l'i' �PSD ,�iJT}lOR1ZA�ON Tfl
CDPlSTRUCT SHALL BE�aME INVALlD. .
1) �ermi� requested by; (Owner�ageriilpras�s�iive ownerj: '"G� lt%S�/'�'!
Home Pfiane; �9-85�f� Address: D9 "� f e� Y�1. �,Z
Business Pt�one: �7- �f 79R ex�'�2� � � /YC ?7�7
2) ,�ame aetd address of cvrrent awn�r: £.u�tfJ�
. . ? 9� 1' ' f�S �/7.
� , iV� d7�"� S�
3j �r�Qesiy Description: L.nt s¢e: �Q� Township:
Dire��ons to the prope (Ind din road names� nd
� .v...i � .__ �s,��., .� _.
��� ����y�
�i\,�Q �Vl \ �
`� J
�
d) proQosed Us� anr3 Struc:ure Desari�tion: answer ct� af the follnwing questions: �.
a) PropaSed ✓ E:is�ting , T�pe of Structure:�zci ��ZQ Width: 7U t De�th:�
b) i�umber of Bedreoms: �_ Number of oc�s�pants or people ta be served: ,�_
c) Basemer� Yes , No ✓�Nill tttere be plumbing in the basement?
d) 6arbage Disposal: Yes , Na ✓
�) Ulla��r SuQQly T,�e; Frivaie ✓(nesnr _ or e:.istin4 ✓), Fubiic_, Communiiy .. Spring _
Are any wells on adjoining property� Yes_ �lo _ If yes, piease indicate approximat� Iecaiion cn ihe
�� 'site pian. _
"vj Does youP prope�iy c�n�in p�viousty isd�r�tain�d jue�sdi�ion�l we�iarads? `tes_ �o �
Pf �SE �10'T'E THE FaLl.OWI(VG:
� A PLAT 0� T�dE P4iOP�iY OR Sa'T� ���A! 1VillST BE SUflMi'lT=i3 WI�'}�i i�-i1S �6'�LiCA i iDN.
? PROP�TY LlN�� AND Cfl�Pl�S MUST HIE CLE:�IRLY ilAr4R��. �
Y TNE �ROPOS� LDCATION OF .�1! STRUCTUE�S i1fiUST SE ST.4KE� OR �,C�c�.
y i'r!E SiT� �YIUST BE R�ADILY :�►C���SiBL� ��R ,4iN EllAA�..iJA770Pd BY T}iE HF�LTN i�E�ARTiUiE�lT
STAF�. �
I her�by malce appiicauen to the Per�son Cauniy Health Departrnent fo� a si�e evaluaiio� �cr the on-�ite sewage dispos�l
system ier the above-desc: i�ed property. I agre� �ai the c��tents or this apoiicatibn are true ,�nd repr�s2nt the m�:imum
�c;iiiies 'to be piacad on the property. I underst�-�nd iT ihe si�e is �liered or ti�e intenderi use cnanges, the permn snall
oec�me irnati�.
Cwner cr Lrg�l Re�rss�n�iive
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on ti�e
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Ap�u�xo c�ca��saoo o��ao.00
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I+rame: �aL � t.�-.�� f.J� �d3�
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�� �'a�B �d ad '�sS ca� c a'�t� (a� ��� �a� �g3�r?,acaII$):
i�a�te:
�.d.�cess:
Phona (hame). ..(.��� � � `' i� =LL.
(urorklcelij: fl`'�7�� ��-' t ��3�
J
Phone: � �{ ' � �i2._._-
�} �_ a��e� �e�^��ao�: I.of 5�;: _�_�.____�n�clF,tision: �ot�:
� ddress andlar directio�ts to Froperty: -
Q}r� ��no �oes t�e si�: couraia s� ju�diciionsI r�retia,uc�?
II ye,s II ao Daes �e sita aaniain auy �sting �ra�wa�r systems? ' �
L� yes � uo Is auy vrasiewater �omg to be geuerard a� rhe sit� o�r �an dome�tic sew��? r� r^'
Q y� II nQ 3s #hesite snbjectta appmval bjr au3► ott�rpublic ag�nc}�? l. `
� yas CE no Ar+e t�ere auy easemems orrigIit of�vays on this �erty? ' ,�-�-^A`
("rF�►�' is �heck$t� 2�lease provide snpporting docume�atian) �` lJl�lM� v
z3) ���°a��se� U�� a��'�'�� r�> �i�ts � ° .
���i¢'en�I �
CI Nec;► Sit!� Fami�y R��id�ce i�fa�im�m number a£hhedraoms: '
Q Expansioa af Casting S� - If expsnsion: Curt�tn n�tber af bedmoms: _,,,,. .
Ci Repa.ir tv i�ri_aIfuac�ioniag 5ys�m WitI iher� be a baseut�t C! ye� Q cw Yif'�h plt�m�ing �? II y� C[ ru�
�i�Io� �desf�3 ' .
�Ig O��S; T0�'d�.�7`ClIi3TL'�OOt3�P. Q���Dl�. r
11A '�.roa� ttrtt m�abet GCFempIcyee� ii/l�iB1�II DttmbEr Of SeaL�
�) '�1A�s 5�€��g3+: II New tiveIl II Exisiing �eII D Community �eII Q Publie "i�►jater Q Spriug
13.2E EUELE 2Ety E�S�g �518115, sA��� OF 4AS[�Ag t�'�681'�III� OI! i�2IS pFDj?6TEy`� II ye5 Q IID
�}! � &ri��+`7 �L� G��' l�i��� 2� C.is�J��.s9 ���i �7dC��`�T'4'�tS ��'iL ���a
� C�AV8t1E1011dt 01�.CC8j]t2d Q�i.O�V$ Q AI�II13ilY4 Q 0� ��=Y
I c�tr'fy thcrt tlze �or�tia�� ' ed ovs ir cvmplete and co;rec� I also �tders�id iFurT ljthe i�Pr�mio�,�'ovided i�
ircaccu� sue aite�ed, ar the inten�'ad �m changes� aZl pe�-ni�s arrd crpprmtals slTall be ir�va?id. �
G a�.y - _
Eg��re tow�l R�er�ve� �3a
� S'upg�ttg docamentation r�qnired.
� �� � � � e� &� ��€� a� � ������ ���� �e�v��a��� �� s� �p��� ��
� A L'£}E4�]�'.�+ s�OZf�P�1�F�Ff1Ft9 ?V �iII II{ii6� ��S��7j � �'���g.C���? a ��� � �e �'�a�.
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� � ♦
T�x M<�� I � F�.rcel � ! �
S��rheilivi�s�ioia
Ph��s�e'S�ction ot �
Applicant: �� � l/%� 5� 1'J2-2y
Location:
c -e-�s ` G , r� 2/'� r
Improveanent Permit
Permit Valid for � F,i,}' e Years _ No Ezpiration
Type of Facility: 7 B New !� Addition Water Supply l.✓'e�
# of Occupants J'�2GL�C # of Bedrooms � Projected Daily Flow '3�c� g.p.d.
Proposed Wastewater System: �y���F-r�i.��. i . Type: �°�
Proposed Repair: �c(� (�,x.� '�,.� ( Type:
Permit Conditions: �P Sr ��� S �'�e'h
Owner or Legal
Authorized State
Date:
Date: —� 2z��
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperly 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 for Sewage Treatment and Disposa! Systeras' (15A NCAC 18A .1900). Neither Person County nor the Environmental Hea�th
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable. ' �
�Autho�ization to Const�uet Wastewater System �Reqnired for Building Permit)
* See site plan and additional attachments (_).
Propose Wastewater System: ��t.���"-� � Type�'i Wastewater Flow ��� g.p.d.
New � Repair_ Expansion _ p�� Soil LTAR: � 2� g.p.d./ ft 2
Type of Facility: �. 1�.� . Basement _ Yes � No
Wastewater System Requirements
Tank Size: 5eptic Tank: CUc��gal Pump Tank: gal Grease Trap:
Drainfield: Tota1 Area: � sq ft Total Length �gv ft Mazimum Trench Depth �g
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Sepazation: -(
Distribution: � Distribution Box � Serial Distribution Pressure Manifold
Specifications: �
Authorized State Agent: �
Pernrit Expira.tion
��. ( ; s cy,,�', .,-..
�
—ZZ—f�
' ✓(,P S ,
g�
in
ftD • C.
l( �� �a( .
Date: �-(� 2 Z � �
The type of system permitted is � Conventional Innovative Alternative. I accept the specifications of
the permit:
Owner/Legal Representative: � � �t�---- Date:
PCHD7/30/2002
�
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DEE WESIEY P �P3��
p.g. 141, ,
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r�/ �1.?'�� � o PLAT CABINET 13 �
j�lrl��C•�► u� PAGE 996 /
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c�L( ar�f-s ����''� s�sd e� a.�f- (-e� s� C�o' �'►-��,-, w-e��sr
� �� �
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����;�� ������ . . <<_ �
`_- .,- ���T1�T7C� SC�� < C - (�
]E�-�a-mmm-����.Il ]E3L��.7t�I�
. S�'z'�.�S��rC� �a �
Natne lJ� -�JS�mre- Tax Ma # � °�' � .Pascel # %�
. r
Subdi n � Section/Lot#
� �2��
� tluthorized State Agent � Date . �
System components represent approximate�contours only. The contractor mustflag the system prior to
� beginning the installation to insure that propergraaie is maintasned �
����1 �� �LYGf �� (4��
���. v � `iJ ` J' � � � �
I���a-��.�n�.����.I1 ����.�.�11�
Applicani
Location:
.. . Lo -� i 5 6►1 � r
v
�x M�p � F�rcel # � :
Subcilivision
Ph� e Section- ot #
# of Bed�rooms
�► '
��' _� � � �� -.,` �
. System Type (In Accordance With Table Va): 1� a!�
TH1S SYSTEIIfl HAS �EEN INSTALLED tN COIVIPLIA(VCE WIT3i APPLlGABLE NORTH
GAROLINA GEiVER�►L STATUTES, RULES FOR SEVifAGE TREATN(ENT AND DISPOS,4L,
AtdD AL:L CONDITiONS OF THE IIVIPROVE11�EiVT PERfV11T AND CONSTRUCTIOf�
AUTHORI�►TION. �
� .
Authorized State gent
. ,
Installed B .
�I2Z16� -
Date
Date: . � 2Z D�
PCHD, rev. 07/29/0�
a
�E��iC �'A�� aGV����`�30� ��E��C�.��? {�y�e 66 � � �
Tax Map #�iDZs Parc�! # Zo8' Sys�em Type (Tabie Va)
Owner/Applicant �' �,� � _ p.,,�om� Subdivision
Address/Location Se�lPhase Lot #
State�ID/date S't�3-/�(Z/Z/-
Capaciiy �D�'S—/a,pb gai.
Tee and Filter
Baff1e �
Sealant
Riser (if applicable)
Tank Outlet �eai
Permanent Marker
• Pum� Tan�s
��
� Water roof /Sealant
Riser
Water Ti ht
� Puenp
Checic Valve/Gate Valve
Alarm visable and audibie
Electrical Components
� Rate m �
A roved Pum nliodel
Blocic Under Pum
Pum Removal Ro elChain
. � Distribution System
� Serial Distribution
ressure ani o
Low Fressure Pi e
A r. Pi e I�lateriai and Grade
Vaives
Trench �dth " , `� ft.
� l"rench De th in.
T,rench Len th � S ft.
Trench Grade �
Trench S acin �
Rock De th and Qual'
Dams/S#e downs etc.
Pressure Laterals �
Hole Spacing �
o e �ze
Pipe. Sleeve
� •• ,� , ftes�uia'�d�Setback�-
From� Welis
From Property lines
Structures/Basernents
itc es ratna e a s
� Surface Waters
Public 1JVater Su iies
Vertical Cuts >2 ft.
Water Lines
. Vehicle �Traffic �
I
Coenrn�nt�
�lRight:of 1�
Other
� Recorded
" -) 5 K-22
pcf�d rev, 3!'i3/0�1
Tax Map:,�
Subdivision:
���,sf I���.���
- � � ����
��ra�n�r��a�r�n¢3na��.Il ����.�Q:�
Parcel: �g
WELL PER:M�T �� ��
(New _ Repair.� )
Lot:
Applicant's Name: C�r�-Q�t.Q %.JSr��P C% �a'�`'� �Z�'"°�S
Mailing Address:
Phone Numbers:
Location of Property: ��( 1 fs /1?C��s �j; (( �,Qc�
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by:
�1ew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
rv�e�
Date: ( T �d "�5
Certificate of Completion
�iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13