A26 131_� ]
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:Person County Health Department .�
�-' Sewage� System Irnprovements Permii
►aLe':�_• �Ttus Permit Void Aftsr 5 Yeats Peimit # `'�
Kvner: �,� � �.�—��— � --'��' �C'
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oeation/Dic�ections: ! ;: ..
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_- �, -�
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ubdivision Name: L.�t # _ �
ot Size: � Type of Dwelling. !�,�r
� ' I
�ater Supply Private: � Pubfic: Co�►munity: �
�edrooms: � Garbaga Disposal � i
asemeni ' Basament F'ixriu�ess �, +.
au
�TFQRMA BY-� ' '
ilniiat13t1: owna a tepcesmtative
:EPAIIt: REEV UATION: ' .
ize of SepticTank: L4�� gallcros Size af Aunp Tank: �
fitrificaaon Line• �T '���� ._.
�pth of S6one:: 12 inches
�1ax: Depth of Trenches:
►ltemadve� System: , Com. Pump LPP Pump �
:CI113i�GS:: ' ' f 'F � /
: . . � • X , - }- -
�/�pVl � -• c.�•� � -•.;—ti. ;.r � 1 f..- - �
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)ate Well Approved: Well should be 100 ft. from �ny..sewer system
�Y — Sanitarian ,
h
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0
tY � Sanitarian . I
°� � ,�tTIFTCATE 4F COMPLETION H
:ontractor. � �,��..e�n� �
—=----------- ------------- ��
�ewage System location, installation, and ptotecdon must meet state and local �
egulations. Septic tank should.be putnped out every 3 to 5 years and shall be maintained
y,; owner in such me�mer' as not tn creste a public health hazard. 'Septic tank and
dtiification line must� be..inspected and approved by a manber of the Per'son County
iealth; Depaztrnent before any portion of the inskiU.ation is covered and put inw use. If
6e:site plans or intesuie�i use chenge this pernue is subject to nwocatioa
G.S. `130 A-335� •
.ocatiqn of sewage disposal sewage system sketched on bxk.
�' —
(OVER)
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Application Date: �1 � �� � (' ������ Tax Map: � "Z�
AmountPaid: `.►•� l Parcel#: � 3
Receipt #: __r�� � � ����
�".�ran-aa-�anmraaosnd,m..Q .����,�.��'!in
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 d)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (1�1ew/Replacement/Repair)
$300.00/$200.00/$75.00
for Services
Services Re uested
O Construction Authorization
(Fee is de endent on the ty e of
❑ Permit Revision
❑ Repair of Existing Septic System
Application: No Charge/ CA $ t 50.00 or $300.00
1) Applicant Information:
Name: rl>�l.�./Qilii 6�/�0 � �
Address: � 7' GUKi.—,uo�
� u�E�� ifilscL�4� .G. Z7S�l
2) Name and addr ss of current owner (if different than applicant):
Name: � �G G!><!e �-� .
Address: 543p p,2f�
r�oxt3o�,Q �t(G 27�'Z
3) Property Description: Lot Size: .2•9C� �Subdivision:
Address and/or directions to Property:
Phone (home): �� /,3'7�
(work/cell): �%!�- ��3 -�(a
Phone: 5"`��1- �3 /.3 6
Lot #:
❑ yes �o Does the site contain any jurisdictional wetlands?
H�yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ,0'no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes � Is the site subject to approval by any other public agency?
❑ yes � 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:
O Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential g X 3 �
Type of business: Total Square footage of Building: �lo� ,��✓
Maximum number of employees: Maximum number of seats: � 0 r v'
5) Water Supply: ❑ New well YJ 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 0 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
inac ate, ite is subsequently altered, or the intended use changes, allpermits and approvals shall be invalid.
�-2— i
ignature (Owner/ Legal R resentative*) Date
* Supporting documentation 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/I 1) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
, _ - � G �� ��u�� jrn�� �s
Person County E�ie�f#h pepartm�nt �
VUefi Perrnit �
Owner�� Ttusmem�it Void 3 yeats �7
I.acadon/Duecuons:
j' P� � � A�a�
Subdivision Name: _ � .
Drilling Contractor. -- �'�"��,!' .
w�.t, coNrrRir oN ►v
Diswnce fcam Nearesc Property Line :Distance fmm Souirce of �N
Pollu6on :
Total, Dcp t Yield: � GPM SEa6c Water L�wel . • F�,
�.
Water Bearing Zones: DeP F�. .. FL �,
Casing: Depth From t 1 to �� �' mte� � Inches
TYPE: Stcel • .. Gatvaaiud Sterl✓
If Steel. dces owner � No
W�'�� TW�� Height Above Ground: �,,�}i�
Ihive Shoe: Yes ' No
Were Pmblems F.ncountered in Setting the .�ating? Yes ____ ._ No,
Lf "yes" give reason • / _ 'ty
Cmout Type; . Neat emenc__,,.� Conerete ��
Annutar Space Width � lnches
Water in Armular Space: es .. Nq�,_
IVlethod: Pomped Poured`�
Depth: From � to Ft
Materiajs Used No. Bags PartIatid G�nent Weighc of 1 bag
lbs.
ff mixture (sartd, gravel, cuttings) - Ratio• �
ID Plates: Yes � _ �16 .,.�. .�
I NEREBY CERTIFY THqT T'HE ABOVE XNF�RMA'I'ION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCfED CC .1�DANCE WTfH ULATIONS SEf
PDRTH. BY THE PERSON COUNI"Y T EP
�� 6 QZ �
Sign�°f�pn � 1 Date
Issued
San;tarian's Signature Date Compteted
Sketch well Iocation en rever,e side.
L
ConnectGIS Feature Report Page 1 of 1
Person
': �� �-• � � Printed September 02, 2014
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assume no leqal responsibllity for the information in this system Grid is based on the NC state plane coordinate system, 1983 NAD.
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