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A26 111, _ , �' The Distric� Health Q�pa�riment � CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPRCSVEMENTS PERMIT No: Date�� Owner: ' Location: ----- �_.,..�.� �`� �� . Contractor: � > � "�� Waler Supplp: Private —�,� Public � Sewage Disposal Facilities: No. bedrooms �� Dishwasher, Disposal, washing machine, o er $uto atic appliances � Size of tank: �< < r�' Nitrification line: � U � �' ir ..� 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- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO iJSE. , � Date approved: Si�ned Sanitarian Well: �. Sewage Disposal• Counter- �� ,��.f-;. , signed `� == - B3'� ( wner or his representati e) Certiiicate of Completion Date Approved: / � �' �� ' B : �L' � �� Sanitarian (OVER) Location of well and sewage disposal facilities sketched won back. 'i i WELL PERMIT ^ ( � Caswell-Chatham-Lee-Person Counties i • t--' i. DATE ISSUED: ' � TF� RILLED: COUNTY: ��-}v'� -, .� OWNER: ROAD/STRF�ET: ADDRESS: .PER D AFT • Y :AR ' � DRILLING CONTRAC R: �.. � NAME ADDRESS WELL CONSTRUCTION Distance from Nearest Property Line Distance from Source of Pollution Total Depth: Ft. Yield: � GPM Static Water Leve : Ft. Water Bearing Zones: De t. Ft. F Ft. Casing: Depth: From�to ' Ft. Dia er: � Inches TYPE: Steel Galvanized Stee1 If Steel, does owner appr Yes No Weight: Thickness: � Height Above Ground: Inches Drive Shoe: Yes: No: Were Problems Encountered in Setting�he Casing? Yes_ No_ If "yes" give reason: Grout: Type: Neat Sand/Cement: Concrete Annular Space Width Inches Water in Annular Space: Yes No / Method: Pum ed P ure Poured y Depth: FromP to _�� Ft. Materials Used: No. Bags Portland Cement Weight of 1 bag lbs. If mixture (sand�ravel, cuttings) - Ratio: to ID Plates: Yes o Chlorination: Yes No 4 x 4 slab YesZ No �; . • �-. I '�0 �' ��`tl�� J��T��`� i+�►'t�7v� . y� �I l�:J�!'I • 1�i� �� I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATION SET FORTH BY CASWELL-CHATHAM-LEE-PERSON DIST. HE�i EP I`' i'; �,�v Signature of Contr tor Date FOR HEALTH DEPARTMENT C REASON FOR NO INSPECTION: i�%f� � = ; ,; � ; � �l? Sani� tari n' Sketch well locatian on reverse side. Use points . :;�„4 !�/? ��.�_;. �` �I �:�'�',-} �r,� ,,;1.. ,,� s Signature � Date established reference '� // /�^ t ,> � �.�� l..J': n -- ----..._. ,;-��_,,_ � . , _ � _ _ ., , � � � ,; � �- �- `. , � (�i -""".,,,� e'(�^ r � .. �._. \ .. W ..� �-'... �r'�---- �_ � � ' � `' ` � � \ N/ ,I � `/� i ��y„ � � � t � , 1 \ ' J !�f R � / �. �.• S `.� \ . �'\ ..,�.% � . . . �� : Y� ".i'r +�,. t , � ' 7^�, � �4 `% . . �., j � V �/� tf r' ' . /` � / f ' . , /� � � �1 _._� \ , � ti � r�.. 4,-� _ "' � ;� ,.`�,�iy ; d �) '1� � !'1 � V . .�.... 0 > , � Aaplication Date: a– � 7�06 Artiount Paid: 1 0�— Receipt #: a � r�3— � �b Tax Map #: � � "' Parcei #• � � � Person Countv Health Department Environmental Health Section . APPLICATION FOR SERVICES . IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CHANGEO OR THE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. �1fi"Pe�rmit reques d y: Owner/�gentlprospective owner): � DU � b Home Phone: 3 lJ Address: n Business Pho e• ( � 2) Name a�d address of cuRent owner. �I/� 4� V�� (bN a � - n �o ��S 3 3) Property Description: �ot size: �. AC, Township: � � Directions to the prope� (in� d�g road�mes�nd 'E I P�a i2?) � Mi 4) Proposed Use/� nd Struct e Description: answer each of the foilowing questions: a) Proposed �, Existing � / b) Stick Built �, Modular �, Single Wide 0, Double Wde 3� c) Number of Bedrooms: d) Number of occupants or people to be served: � e) Basement: Yes �, No if yes, # of basement fixtures: � Garbage Disposal: Yes l� No ❑ � g) Dimensions of Proposed Structure: Width:� Depth:.�iQ �F a tav�ke b ed rod �u � h°� � �, 5) Water Supply Type: Private �(new � or existing 0), Public �, Commun'� , Spring 0 Are any wells on adjoining propecty? Yes 0 No'�'If yes, location Please Indicate Desired System Type: (systems can be raaked in order of your preference) Conventional Modified Conventional _ Altemative Innovative Other (specify): CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPLICATION I hereby make applicatio� to the Pe�son County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the conte�ts of this application are true and represent the maximum faaGties to be placed on the property. I understand if the site is altered o� the i�ended use changes, the peRnit shali become invalid. i understand that as applicant, 1 am respansibie far identifying and marlcing property lines, comers and making the site accessible for the personnel of the Person County Health Departme�t to conduct thei� evaluations. l understand that I am respansible for notifying the Health Department if my property contains any wetlands as designated by the Army Corps of Engineers. �o�o s�, �� - �1- o 0 Owner or Legal Representative Oate PCH�, rev. 10/12/99 S� E Person County Heaith 0epartment Existing Sewage System Report For: Mobile Home Keplacement _ � � Addition(�qq,j�(ZG�� j'�1�� l�uy�c�� J h�iv� Requestee: �� I/II ��lln Ho¢�e Phone#� � �Z'Jr (',�I��JD��J' .l V�I,Ir. Businessx J'r —Q % ��i1 r �� i��7�J' 'Pax Map,ur .. � _ . . _ • • ' • 1.��r��%L��/.i��/L/��1�L��.�i�s��L�tI%�1�� I � Original Permit Located 1 Septic System Uesigned �'or: _ Kesidential __� E3usiness Other {specify? # Bedrooms Z # Employees Other Uate Znstalled IZ �!/ �_ �tater supply /�V��t-t�f Type of 5ystem Nitrification Line �,��1 �C ?J� Tank size �' bDQ Certified Operator Required /Ulfl � On site wast-ewater disposal system slzowes na visually apparent malfunction cn 2-�''(� Yermission is granted to: t��i��) ��1 ��{��' r According to the attached site plan. Camments: � ��1�� w�de•�s�atv�e�rc� � Env ronmental alt .$�C.. rs 9�a�,� � ca�tiv�u� wr� Sl �� U � a PERSON COUN"I'Y HEAL'TH DEPA.RTMENT WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT Tax Map #�"� Parcel # t� � Zoning Township I f�' �"l�� Owner/Contractor�� n� llnc� Date � "23 -00 Location/Address 57 Subdivision Name Lot# S.R.# / 3UGI A 1714 SEWAGE SYSTEM SPECIFICATIONS ✓ Lot Area� GI�YP Size of Tank /� D00 C'�I�. Mobile Home Size of Pump Tank `� ;ss # of Bedrooms_,,� Nitrification Line �-�'in�x 3� t 75� X�' Permit Void after 60 months. Permits may be voided if site Well and Septic Layout by,� Comments: IMax Depth Trenches�Gli' � W/ D, Permit Void if not in compliance with zoning regulations. � altered or intended use changed. Date Installed by Approved by. Comments: Date Installed by Approved by This report is based in pazc on infortnation provided the homeowner or his/her representative in the applicadon submitted for this pernu� The environmental health specialist is not responsible for false or misleading information contained in the application The envirommeMal heafth specialist is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading statements provided to him in the application. Neither Pecson County nor the environmental health specialist wazrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:l�vnipro�pemutsam O 1/95 rev.1.0 ORIGINAL !�� Application Date: '?"�� Amount Paid: � Receipt #: q3� !3 • LJ`�'� . Improvement Permit (Site Evaluation) ' $200.00/$300.00 (if> 600 gpd) Mobile Home Replacement or Building Addition $150.00 (if site visit required) Weil Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 ��",�f ��. V Tax Map: � 02� . � � ��,�� Parcel#: � IEan�aa-o�*,r,r„�aa��.Il �C�mIl�a tion for Services Services 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) AppGcant or atiy�} • Name: 6U � �JJ � � 0�•� Address: (Z,�o 5 i C� 1 2) Name and addre of current owner (if different than applicant): Name: �� m � Address: Phone (home): ��i'si�` l%d �1� (work/cell): 33ti v5 �I � Phone: 3) Property Description: Lot Size:1(� Subdiv' ion: Lot #: Address and/or directions to Property: as ��ts '� %{ a� � LI ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes I—�'� Does the site contain any jurisdictional wetlands? �nQ Does the site contain any existing wastewater systems? �� Is any wastewater going to be generated on the site other than domestic sewage? 0�'n�o Is the site subject to approval by any other public agency? C�'fio 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 �Ror�} i�G re�i 3 �� x ❑ 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? O 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 ❑ Existing Well ❑ Community Well ❑ Public Water O Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes � no �f applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ qny 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 the intended use changes, all permits and approvals shall be invalid. Sigfi2iture (Owner/ Legal Representative*) * Supporting documentation required. �l�d �-lS 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/l li Pt>.rcnn C'nitntt� Fnvirnnmantal �Taaltl� 27G C�/Tnrrt�n Ct C,,;t�. (` n,._.L____ �rr, n-,�.+.. ...... -..- --..-_ Application Date: Amount Paid: Receipt #: ---•— Improvement Permit (Site Evaluation) $200.00/$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 ��`� ) f �� . V Tax Map: ,�- 2 G ,�,., •• �� . Parcel#: � IEanwfln-�ma.a.aanaes.n�mll lE ilcis.11�l�n. Services for Services Construction Authorization (Fee is denendent on the type of Permit Revision $75.00 Repair of Eaisting Septic System Application: No Charge/ CA $150.00 or $300.00 � 1) Applicant I or atio Name: p �S �i ��M . Address: �tuo fS � t9n� G � �� y 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: A dress, d/or dir � Y''�1 ' Lot Size: � A Gt� Subdivision: � ctiq�s to Property: 7�o a Phone (home�:.��".S �/'v��b (work/cell):3 - 0 '� Phone: #: ❑ yes no Does the site contain any jurisdictional wetlands? ❑ yes �� Does the site contain any existing wastewater systems7 0 yes L�no Is any wastewater going to be generated on the site other than domestic sewage? �❑ y s 0 no Is the site subject to approval by any other public agency7 s ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documenta tion) 4) P r o p o s e d U s e and T y pe of Structure: . ❑Residential ' ❑ New Single Family Residence Maximum number of bedrooms: / Occupants: 0 Expansion of Existing System If expansion: Current number of bedrooms: � Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑Non-Residential Type of business: Maximum 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 Please note any known ground water restrictions or sources of contamination: �,o X � o Ga�"°`� ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional � Accepted 0 Innovative ❑ Alternative 0 Other ❑ Any I cert� 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. � D� D.,�',�- _ y��y-�� ignature (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 e.valuation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � � 1 � , t:, �► ► { . ��` � �: � �� .�..��.��.��.�. ]I��.11�1�. Building Additions/ Mo6ile Home Repiacements Tax Map #:_� Parcel#: ff/ Address: 925� ��oo ,,�,��,:� ,�. �� .7�2�7� Approval Requested for: Mobile Home Replacement � Building Addition S� Appficant Name: '17�av�%� �i j,,�� Address: Phane #'s: � Permit Located: ✓ Yes No Installation Date: _ /9�iZ Design flow: � (gpd) Current Contract with Certified Operator on file (if required): � Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on: ' y (date) (Applicant's signature if site visit is not required) Comments: Addition/Replacement Approved Enviranmental Hzalt ecialist %7 Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net 7�1.33 April 24, 2017 TaxParcelPublishing ��y�� ;' Person County � c `�°�`� -� - �� fr _1'� I , f r � ; �. Person County Environmer�#al Heaid� r` 325 S. Morgan Strteet ,y' Suite C f` Roxboro, NC 27573 �� 1:1,128 0 0.0075 0.015 0.03 mi r'--r' —r-T—t—��'�—�-1'�-1 0 0.015 0.03 0.06 km Esri, Inc., Persm Cauntyy GIS For Reference Ony -Always refertothe origirel swrce. Persm Courty is not respmsble for the use, misuse, or m'sintapretation of this irformawn , � •. � � ��►!4. , ..;.�s` • ' � � �� ' � ��¢� ,,�r7�l1,�]�,n'•fi.A. �.�11C�,�:71.7L��... Building Additions/ Mobile Home Replacements Ma #: �t Z � Parcel#: < <� Address: �2 5 �jro��S �?i r � Tax p l �� v,,� � a.?S i Approval Requested for: Mobile Home Replacement � Building Addition . Applicant Name: ��u5��s 4��' «�'''� Address: SQ'r-c-e �S 5' �� Phone #'s: 5�'' D 6� 5 0�(— z� Z g Permit Located: � Yes No Tnstallation Date: %7— �� Sr2 Design flow: � y� (gp�) Current Contract with Certified Operator on file (if required): �� Water Supply: D� Well Public or Community Wastewater system shows no visual evidence of failure on: —�' I S (date) (Applicant's signature if site visit is not required) � Comments: �-�''�''� 5� "'� (�u��k' 2�� C 38 � Addition/Replacement Approv�d n„�� l,we,� E vironmental Health Specialist vi �i- %Jc ve (,, . �( � �—( S Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-17y0/ Fax: 336-597-7808 vwvw.�ersoncounty.net ConnectGIS Feature Report i: I��,_ I�IS 'NEB H�r5t�•I�• �is�za ;;r' �� (_ y/t � � P � d�a� � 8 .2 9 4� ,. �:. . .. `�� \ =; ' "D / c�,p �`, � ��``'� � c,�� Page 1 of 1 Person Printed April 30, 2015 See Below for Disclaimer �.. �� ,,r = ti' '. � F,'r.. :\��_ f ' "�\ ��'II'- ,oa '�,� � � - _ ~��t _ , �� . % �,, • �. : .�- . ., � , �, lr'�i' � �?;�a ?.t �t:.; �_--' / �' � `tib '- �� °, ` ,/ � � +��'--- -- �� ;'"r - � �Cl Feet S /` � OTICE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who h� cently upgraded to the Windows 8 operating system or a new version of Intemet Explorer. We were able to resolve this issue by directing users to the Intemet Explo �mpatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/emUS/internet-explorer/produds/ie-9/feawres/compatibility-vi 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 be �epared 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 �tified that the aforementioned public information sources should be consulted for verifcation of the information in this system. Person County, Mobile 3ll, Connect� �sume no leqal responsibility for the information in this system. Grid is based on the NC state plane coordinate system, 1983 NAD. �lll��:��/��?IS.��CI'�l)I1CC1U111�.I1CL��C)IIIICI'l�i�� :��)(l�\ll�l)�1��I�t;.�1S�1X��1 � �1�� Ill�l�lC-�Cl�)C-�h�i��l��)... �i(�`��)�J