A25 219Application Date: 13
Amount Paid: � p o0
Receipt #: i 71�„� 1
oU ���i�
I �� $' �fq� � ���, ).f J.L Jl.eJ.l�.� �.1�1 �
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�— ]E�.��nn-������.�.A 7HI�.�..n�.la.
<.0.r�1
A
RS.�mprovement Permit (Site Evaluation)
5200.00/$300.00 (if> 600�pd)
� Mubile Home Replacement or Building Addition
$150.00 (if site visit re�c uire� __
G �Vell Permit (New/Replacement/Itepair)
$300.00/$200.00/$75.00
for Services
Tax Map: Zs�
Parcel#: ��
Services Re uested
❑ Construction Authorization
(Fee is dependent on the type of system permitted}
a � Parmit Revision
$75.00
G Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: �r
Address: Cl, Z c��
�1�ktn��ro t �L �-ls��-I
2) Name and address of current owner (if differeni than applicant):
Name: � �9 � LJ, r� (� C�
Address: �-I X � � ` � t
c.�.rncl r_G� 1v c a1 ��-i �
Phone (home): 33(4 " sq� - Q �SL%
(work/cell): ��( Q - -Lr,03- 33�a �
Phone: 33( Q- 5v3 - 33�c'� '� G'��"�`
�8��ca.�
�%�S �'r
3) Yroperty Description: Lot Size: Suhdivision: �1 o Lot #:
Address and/or directions to Property: � � S,� i�,l c C��� S i 1 l (Zn� � rn c>�� �1 �- ��3�3
� yes �'no Does th� site contain any jurisdictional wetlands?
❑ yes 0 no Does the site contain any existing w�astewater systems?
❑ yes � no Is ar.y v�aste�vater going to be generate�' an tre site other than domes:ic scwage?
G yes F�7 no Is the site subject to approval by any other public agency?
Q yes I� no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supnorting �ocumentation)
4) Proposed Use and Type uf Structure:
DResidential �
�New Single Family Residence Maximum number of bedrooms:
❑ Expansion uf Existing Systeni If expansion; Current �iumber of becirooms:
� Kepair to i�ialfunctioning Sysiem Will there be a basement? ❑ yes � no With piumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business: _ _
Niaxitnum number uf employees:
Totai Squaze footage of Building�
Ma�cimum number of seats:
5) Water Supply: ❑ Iti'ew well �Existing Well ❑ Community �'�'ell ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? �Dyes ❑ no
If applying for `Authorization to Construct', please indicate preferred system type(s):
� Conventional ❑ Accepted ❑ Innovative ❑ Altei�native ❑ Other ❑ Any
I�.ertify that �e information Frovided above is con:plete and correct. I also undarstar:ci thal if the ir formatiorr pruvided is
ir.accurat , or if he sitc is ubsequentl altered, er the 'ntefided use changes, all petmits ard approvals shall b� invaiicl.
. •
ignatu e(Ow er/ Legal Repres n ive* Date
* Supporting do umentation required.
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)
Application Date: � `%
Amount Paid: �' , 00
Receipt #: �L�L-
�-� ���3
Aa
0 Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 Qnd)
0 Mobite Home Replacement or Building Addition
$150.00 (if site visit re uired)
❑ Well Permit (New/Replacement e air
$300.00/$200.00/ 5.0
���+ f I���.� ��
������
�f"�.�rav nn-aDm�vxa�.=n4":an..n 1H��,�s.II��Ln.
tion for Services
Services
Tax Map: �! �
Parcel#: �_
E,ua� � �e �� � �
—�—n vJQ�.Z��,S
,
0 Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name:
Address: q
�a�r,�,C� � 27�7K
2) Name and address of current owner (if different than applicant):
Name: C /; c /!% a � .
Address: /I'! c c
L
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property: $7/I j
c� �o S�vr� Si ��L. l�L �I c az � 5 ia'I: l
Phone (home): �jZ'L — � � ��
(work/cell):
Phone: 33 L� .��� — 33 (2�
Lot #:
T/.�P
�] yes ❑ no° Does the sit6 contain any'jurisdictional wetlands? '" �
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes O no Is any wastewater going to be generated on the site other than domestic sewage?
0 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)
��
C0»'1 jD��;�l�'�
l��lJ� W�%►�
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? 0 yes ❑ no With plumbing fixtures? ❑ yes ❑ no
�Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well 6d"Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? 0 yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. 1 also understand that if the information provided is
inaccurate, or if the site is subsec�rently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owne�,egal Representative*)
* Supporting documentation required.
s�'-)� - f y
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)
_��, s f ���.� ��
� � ����
3[���n.a-��� ����.11 IE���.11�I�
Tax Map: a� Parcel:�
Subdivision _
Phase/Section/Lot #
Appticant: (rHAR.UE M. OA��! 3"Y� _
Address/Location: �� gh Mc t��s t�wL P-��o ___�_
Improvement Permit
Yermit Va1id for: Five Years � Non-expiring __
Type of Facility: 3- (3Q.. 4{cust New � Addition _
Number of: Bedrooms �_ / Occupants (�'��N mployees / Seats:
Praposed Wastewater System: cc,��c0 w 7S� �uc.-�,a�+�
Proposed Repair: (� zS Ze ucr�
Permit Conditions: _�
g£.P�j11� T t�Q`c
Authorized State Agent: �cx._
(X) Uwner or Legal Representative:
�Vater Su;�ply: �im.�10 ���. ��
Projected Daily Flow: 3b�o gallons/day
Type: 'IfS. �,
Type: �S 6
`
Date:
Date:
The issuance of this permit by the Health Dep�rtment does not guarantee the issuance ef other required permits. It is the responsibitity of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if th.e site ptan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in complianr.e with the provisions of the North Carolina `Laws
a�rd Ru[es for SewaFe TrEatment and Disnosa! Systems'(l5A NCAC 18A .1900). Neither Pzrson County nor the Environmentai
He:�lth Speciali�t H-arrants that the septi: system wi.l continue to function satisfac#ari:y in the future, o; that t6e water supply will
remain potable. _ __ __ _ — __
Authorization to Construct dVastewa#�r SystQrri
See site plan and additional attachntetzts (��.
x
Yroposed V�'astewater System: Acc.tPtLO wl �'�v �D�tct�e� (*)�'�pe � 6� Design Flow 3�_ gal./day
New 7� �eYair _ E:cpansion _ S�i( L"f'�R: O, a:i gal.!da}�%ft2
Type of Facility: 3-�i.���r.�. ��t�t;�. ��,�t �s�D�.�cE. Basement: _ Yes X No
(*) System Types Illb, Illbg, I �; und V, requirz periuslic system inspeciions by the Person Cuunty Heu[th Department.
..�» �m�
Wastewater System Requirements
Tank Size: Septic Tank i'ooa gal.
Drainfield: Total Area �U $d sq. ft.
Trei�ch Width 3 ft.
Pump Tank —' gal
Total Length 3ba ft.
Min.Soil Cover � in.
Grease Trap —" gal.
Max. Trench Deptl� �y_ in.
�L1in.1'rench Separation � ft.
Distribution: Distribution Box� / Serial Distribution j� / Pressure Manifold ___
Specifications: �-Ltt�iES � q0 �E�Et'_�c�,' �`� Aooirv�` �iti. C��,�R.. �Qu�0.F-A ' '�� -��1•s�v..
M� Ezt �� f� � u � Q.�t� ��r1�v.. c.s��v� s�,�►�c.Y �vv �`r ti►� 5►�44�,� ��a�
Authorized State Agent: �QS��cI� A_ 5r�rN► Issue Date: S'1�
Pcrmit Expirat�on Date:
The system permitted is: Conventional %Acce ted i\ / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: � Date: Ci �/I
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, !'VC 27573/ph: 336-597-1790 (rev 5/12)
���, sf ���.� ��
� � � ����
I���������.¢�.11 IE���.Il�ll�
Taz Map ,�a5 Parcel # a19
Subdivision
Phase/Section/Lot #
# of Bedrooms 3
Applicant: CNA�.I.IC M. C�X�1� �'�.
Location: N••n sn a�� cJ�o f,�aw►•� ci�o v.� —� OO dr�o c�c�cs c��v.. t�o ��n
o a� n,�Ac+� '�o ��� s'i .�, a. M,.�.s
� O�eration Permit
System Type (From Table Va): izL 6 Product (IIIg): �z Fww
Type V& VI Expiration Date: �1 p 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 of the Improvement Permit and Construction
Authorization.
pt.�Ric.►� P1,_ Sr�c�
(Authorized Agent)
Mtii� L�w►S
(Licensed Contractor) �A '
�
,.s
�
:
.o
� �
�
Scale i� i'S
PCHD, rev. 12/14/12
a
� 3 �� �
� ate)
3 �3 1
\ Date)
�
�
�
�E����
�,a�5
�.�L��, �F �.. ��.�a
s�+�.. �r�►a� � o Aax .
�i. Sv44�.� t�.\E
Q�wLn. u,�E
�' 3' pc�.5�.
�y�y� a�
�s f►� �
Line Length
f 1 aa '
a '
�
3 ��o`
� c��. 31e4'
Tax Map: � Parcel #: a119
Septic Tank System Checklist (Type II-I� System Type: ZII 6
Notes• .
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes• �
�`��. S f ���.� ��T
.___., � � ����
I�`�,a �►�a�� � n.-� � �tE�.Il 1Hf � �.11. �Ih�
WELL PERMIT (New_Repair�
Tax Map: A as Parcel: a�9
Subdivision:
Lot:
Applicant's Name: ��� ��a �C� c'�. �A'�.�'� "�L•1
Mailing Address: rl�lg`� v��.�,�v� RO
RAxoc� , ac. a'�1��1�
Phone Numbers: 3�.- R355 33b- So3- 33b3
Location of Property: �i a$�l `1 Mc.b�Et.S M�� '�Oap
Permit Conditions:
1) See attached site plan for proposed well location.
2) �111 applicable State and County regulations governing construction and setbacks apply.
3) Permits expire S years from the date of issue.
Otl:er Conditions/Comments: "'�' l..�t•1'�,�'�
Permit issued by: 0��� •A- �+"�c� Date: 5� 13) i�
T
CERTIFICATE OF COMPLETION
New Well Inspection:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Liner Inspection:
EHS/Dat�
Installer: �1A�e�
Depth: �
Grout: -
Well Abandonment:
�HS/Date
Completed:
MethodlNlaterial(s): _
Well Driller: ( p�Q(/ W � Za� � I.icense #:
Pump Installer: License#:
L i r��r
�Approved by• Date: � ���T_
Date Sainple Collected:
Yerson County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date Results Mailed:
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
��, J J � J1 1.L.CI � ��1/ 4��
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Jiiaavsnsosaan�aa�m� IF"�rOra.Il��ia
SITE PLAN
Name II�RPa-� M. QAtL1.E'( �i�-• Tax Map # Pazcel #
Subdivision Secdon/Lc}t#
tY�t.Rac� t! . 5t�t� X17 ►3
Authorized Stzte Agent Date
System compoamts represent appmximare conrours oniy. The cnneracrormusrflag tbe system p.dor to begianing the insrallatian to
fnseue r6atpmpergradeis maintained.
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p v�„(L AP.�1��F�'��
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'" EIP
TABLE
3.
& MARY
ESTATE
E9-430
-61-5
2843
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SITE PI.AN
N�e (;}1q�i,��t. I"1, OA�•�.`f � Tax Map # Pazcel #
Subdivision Secrion/Lo
�c.4.R1G\ /� • 51'`�Ci'��
Authorized SGite Agent Date
System components represent appmxrmate coatours only. The coatraaor must f7ag t6e sysrem pcor ro beginning the insral/adon ro
insure thatpmpergnde is maintained.
LAMBERTH &
EVELYN HAMLETT
D.B. 155-677
RECN 1650
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