A26 105' Ja�-OZ
A�plication Date:�� Tax Ma #:
Am�unt �ai�: / G
Receipt #: Parcel #: 6 � �, J
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APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT, FALSIFIED
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Ownedagent/prospective owner): L-arr� �. �.q�C�.S
Home Phone: 33(n- sq'7-aq�� Address: 34f��t YYlc�r-�ov�- t�`cllfc►r►� 1Rc�
Business Phone: 91� � 41�U -q 3U� t�o X I�r� Vl , C� �1Z �7 �
2) Name and address of current owner: c�C�uv�-1�1 1� ��o�
3� (o�t YYIo o�t ^ l-Z.x 11 i� nn �Z
�c��ll�ov�o b'1 �C+ 21 �S`7 �l
3) Property Description: Lot size: .��Township: �S.tnn j�f'�Subdivision: Lot #
Directions to the property (Including road names and numbers): �to o�� C��ub L.ake- Rc +-T: L,� v_�t__ Ci��
1.-4KE- Rd• �o -}o eano .�- �T.R� on 1^(lorfort� !�1 '►�m o�� z r• ` 1'1 t�li�lti
�„cl� NGv��ori c_�L rZ, c w��ll b� s�c�n h�:ase, cv� I� -I- .
4) Proposed Use �ri�d Structure Description: answer e�ch of the following questions:
a) Proposed �, Existing _, Type of Structure: (J-/a-�2 s.-�, �.. Width:� Depth: y�
b) Number of Bedrooms: Number of occupant people to be served: � �/ � 2 0 ,��
c) Basement: Yes_, No Will there be plumbing in the basement?
d) Garbage Disposal: Yes No _
5 Water Su I T e: Private V new or existin �, Public_, Community , Spring _
) Pp Y Yp � — 9.�
Are any wells on adjoining property? Yes_ No _ tf yes, please indicate approximate location on the
site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBL� 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
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid.
Owner or Legal Representative
Date
PCHD, rev. 06/27/02
��� s.s� �������
_�..�_--� . . � � ���-�-
1���a���T� ����.Il ��L��Il��
Tax Map #�i�� Parcel # � �J�
Existing Sewage System Report For: Mobile Home Repl cement
� Addition Type: a 2. � �c
Requester: �-Gl r r y �� E�t-KCS Home Phone# S/� ay ,�
�i(R� n'lo��ton Pu.[(iav►�, (�d. Business# �j� 4G0—�308
�'?'lorf�n - Pc.c.111 a rn 2d Lo� on ���' l3ox #���oi
Original Permit Located: 1� Water Supply: Pr � vafc („� C l �
Septic System Designed For: �Residential Business Other
# Bedrooms � # Employees Other
System Type: ��VC�t�lt�i.( CxruU��ank Size: �i0� Nitrification Line: -T��X3�
Date Installed: I r(J�o ? Certified Operator Required: N�
On-site wastewater disposal system shows no visual signs of malfunction on a3��,
Permission is granted to: ���� Q/1 O f fct c,G� c.c� �I a ra 9+� �F �n �ar"9 e�xt'S{I !1 �, Qc n.
Comments: K t �
i«i Pitd by �Hs.
� F adc{i �'o �/�' Frt�n� St p-ti�c �..s
��otti�� (.��' �'I 6� re�c�.;r�cl
r�c.ciJ��nq_ Gz Ctr�l Fl��fc OF �C�tapallC�/ �
�errFj/ fJ(� �cc��oOM Gi.c��i��`Ons.
Environmental Health Specialist � ` Date: � a —� a
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.The Dis�ric� Heal�h �epa���e��
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Vt�a�er Supply �r�d Sewage Dispos�i
IMPROVEMENTS PE IT No.
Date
Owner: h � '
,' ��' i � � ��
Location• 4 • _L
-�r�l '�3 �, �"� �r -
p� Contractor: �`�'���'�'"� �
�
Water Supp1T: Priv�te ✓ Public
' �o� � �.
��.� �� ��
v
.• 3ewage Disposal Faeilifies: No. bedrooms �� Dishwasher, Disgosal,
washing machine, other au omatic appliances
Size of tank: NitriAcation line: �lrrt'-rk'�t
Other disposal facility:
Water supply and sewage 'disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
' tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVEI} BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE IPTSTALLATION' IS COV-
ERED AND PUT INTO USE.
Date approved:
Well:
Sewage Disposal:
By:
Ceriifieat� � Compleiion
� �
Signe (�r . ' , ;� ..z �fi
Sanit ian
` �,
Counte - .C� ��-� �,��°�y *
aigned• ` � -
( er or his representative)
Date Approved: BY�
Sanitarian
(OVER)
Location oi well �nd sewage disposal f� cilities sketched on back.
'� ��{- �-�� � � c�.�-���
Application Date: �— Z —I 2. `�� �� ��q ���� Tax Map:
Amount Paid: ►•� � Parcel#:
._..., �. � ����
Receipt #:
1E:�m� aa-�a*,.,�+,�,an.tian.ft IHL�e.s,lld.�n.
Services
0 Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
�^ i SG.00 �if site visit required j
❑ '1We11 Permit (1�Tew/Replacement/Repair)
$300.00/$200.00/$75.00
for Services
0 Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
�75.00
0 Repair of Existing Septic System
Applicatian: No Chazge/ CA $150.00 or $300.00
�) Applicant Inf rmation:
Name� `t�L +�a� 5�"�.�,�"%�
Address: ��� 1 !-(v ) ! .� �� � .
��. �.,.�1, �1c. a �� � 2�
�) Name and add ess of current owner (if different than applicant):
Name: �a�. �5
Address: 3�c� . G( �' rRol •
�, nre, �s'1
Phone (home):
(worWcell): __aj 1 g— d4� a- 34o S
Pr.nr.e:
3) Property Description: Lot Size: Subdivision: L�t #:
Address and/or directions to Property: ,3 �i (p q �(e �-�h �u� ���� ,
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wzstewater 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?
❑��es 0 no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4�) roposed Use and Type of Structure:
aResidential � �
❑ New Single Family Residence Maximum number ofbedrooms: �� X 1 � (�0�/G�
❑ Ex�znsion of Existing System If expansion: Cu�-rant r►unber of bedro�ms: �
� Repair to Mzlfunct;oning System Will there be a basement? 0 yes C1 nv With plumbing fixtures? ❑ yes O no
ONon-Residential
Type of business:
Maximum zumber �f employees:
Total Square footage of Building:
Naximum numbe; o: seats:
�) Water SuP�ly: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properly? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
f7 Conventional ❑ Accepted � Innovative ❑ Alternative ❑ Other 0 Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate,�or if the site is subsequently altered, or ihe intended use changes, all permits and approvals shall be invalid.
�gnature (Owner/ Legal Representative*)
* Supporting documentation required.
�v ��9- l�
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.
!1(1/1 il PPr�nn f`.niintv F.nvirnnmpntal NPalth ��5 C Mnraan Ct Ct�itP C Rnvhnrn T�T(' �757Z f22�_co� t�nm
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�7C]l.�]L3C'�3La7r71C�t��ICIl.¢�.JL ���•�¢�
Building Additions/ Mobile Home Replacements
Tax Map #: � Zc� Parcel#:___�O5 Address: �a rr e �
,
Approval Requested for:
Applicant
a �dre�s:
Phone #'s:
Mobile Home Replacement
� Building Addition .
V No
Permrt Located: Yes
Installation Date: � �� Design flow: (p (� (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: v Vi�ell Public or Community
Wastewater system shows no visual evidence of failure on: � 6- 2� - � 2,T (date)
(Appiicant's signature i� site visit is not required j
Co�-nents:
Additi�n/Rep�acem�nt Approved
Envir nmental Healt Specialist
I6—z�— 12
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www_personcount .y net
10/28/12
ConnectGiS Feature Report
°�Welcome to the Person County GIS Website. ConnectGlS has been prepared for the irnentory of real property found within Person Courrty, and
is compiled from recorded deeds, plats, and other public records. Users of GIS system are notified that the aforementioned public irtfortnation
sources should be consu(ted for �,enfication of the information in this system. Person County, ildobile 311, ConnectGlS assume no legal
responsibility for the irrformation in this system. Grid is based on the NC state pfane coordinate system, 1983 NAD.
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