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A26 131_� ] ^y...'' w :Person County Health Department .� �-' Sewage� System Irnprovements Permii ►aLe':�_• �Ttus Permit Void Aftsr 5 Yeats Peimit # `'� Kvner: �,� � �.�—��— � --'��' �C' �k oeation/Dic�ections: ! ;: .. � �� _- �, -� ,• 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..- - � � • . r— )ate Well Approved: Well should be 100 ft. from �ny..sewer system �Y — Sanitarian , h � 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) z � K 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 ,ti, � ,. See Below for Disdaimer - � �� ,- a . . � y� ��� �L :r �. •. f � � a \ �. �` � �i J' - ��A�b k . , , L � �{ '�p� �.EJ� \ � .,� � . . k� .3 � . ,� � . . ��;:' ,��4 � . . . 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Y� ? �4 � 4 ' s P �t af � �* .. i ,�:�. . �` � :�� �{ � �1 '� t �' ` � s'� � t� � �. �t . � . �4 a z i 7. , t x , � � .i� � � � ���¢� � � � ,� s ���, r �a� � r � ,.r i ���tz � �' ,� i���� w ' � ti a ��� �'A►� , � �ps f it � 5 � � f'� � � ', t� �{ � t r 7 �� S � '.� ,/�� 1 , �'�°� �� � _ a�. r�, ; 4��� � � : p�� a : z z}x,. a � a �, : ��. ?�!- j �� �` � ��i a . '� �4 � ,�� � � � �� ��¢ i �' � � � � � � � e� t � .; .. . _? _.-...�� .` o- i , �i � '� �. t� � v�-.'4 � �C.. � *z � #� � ¢ £ . �� � �u'°�� 13ds j:�l �'>�� LLR� . � � �i �..� � � � .'. y d �2� t � d a 6A $ �. S x �i �_ �,r� -t ULI FCCf �" 5 ���, �� �� ��� t � s �� �� ��q ���r. � — ;� - � � � '•� - 9: � , , ' 1� � 3 � ��� k NOTICE Recently, we have had several users report browser compatibilit, usues when trying to access our GI�S :,ebsite iypically, the problem stems from users who havi recently upgraded to the Windows 8 operating system or a new version of Internet Explorer. We were able to resolve thls issue by directing users to the Internet Explore Compatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US/internet-explorer/products/ie-9/features/compatibility-vlev If this does not solve the problem feel free to contact us at the number listed on our maln page. Welcome to the Person County GIS Website. ConnedGIS has beei prepared for the inventory of real property found within Person County, and Is compiled from recorded deeds, plats, and other publlc records. Users of GIS system an notified that the aforementioned public information sources should be mnsulted for verification of the Information in this system. Person County, Mobile 311, ConnectGI assume no leqal responsibllity for the information in this system Grid is based on the NC state plane coordinate system, 1983 NAD. http://gis.personcounty.net/ConnectGIS_v6/DownloadFile.ashx?i=_ ags_map4bbe3d03e431... 9/2/2014