A26 177 & 49Appl►cation Date: �- �� -� �
Amount Paid: ��
Receipt #: $ �-i ( .�
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n for Services
Services Re uested
Tax Map ��
Parcel#: ��_
�P� A� z�
�f�y
Improvement Permit (Site Evaluation) Construction Authorization
$200.00/$300.00 (if > 600 d Fee is de endent on the e of s stem ermitted)
AZobile Home Replacement or Building Addition Permit Revision
$150.00 if site visit re uired $75.00
Well Permit (New/Replacement/ltepair) Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Applicant Infor atiori: i 7
Name: O/1J/1� f � LGh ,/'� �Gr Phone (home): _ �=�J'�
Address: (work/cell):
2) Name and add` r��of curr t o er (if ifferen�,t n appji�ant):
Name: /DflJifi� E/�, � � �
Address:
3) Property Description: Lot Size: ��S bdivision•
'�d�dr�ss nd/or directions to P�r,Q perty: ����'��
Q / )'I�A� � Gl�.� .�e �.L Lf: „ Q�. � .-. �
Phone: ������ .3—.S��i
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#:
❑ yes �C�^i o Does the site contain any jurisdictional wetlands? i�U - i-
❑ yes �To Does the site contain any existing wastewater systems? �
� yes �'no Is any wastewater going to be generated on the site other than domestic sewage? �(,(�
❑ yes 8-rltt Is the site subject to approval by any other public agency? ��',py�
❑ yes f�-�"Are there any easements or right of ways on this property? l
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Re ' ential
ew Single Family Residence Maximum number of bedrooms: �
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Wiil there be a basement? ❑ yes �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: L�3-I�ew well ❑ Existing Well O Community Wel� ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes [II.uer—�
6) If ap,�rlying for `Authorization to Construct', please indicate preferred system type(s):
��onventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ 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 subseque�tly altered, or the intended use changes, all permits and approvals shall be invalid.
�
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
��/�- /�/
Date
• Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
• A completed `LotPreparation' 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)
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�. � , � �
�` �--� �•'�/' (� � �� � � �� .. _ � , ;:._ � � � � nsuring a healthy environment ��
\�
�.1. � ]i']l.\i''Il ]C` QA 1L71.1Y'SY"11. Q--�7CA.t��11. � �� <{:,,�iL�. t��t;71.
July 23, 2014
Town & Country Builders Inc.
P.O. Box 1171
Roxboro, NC 27573
RE: Site Evaluation Application Dated 5/20/2014
Dear Mr. Winstead:
The Person County Environmental Health Department has a policy that states any
application, which has not been acted upon for 3 months becomes void, and any fees paid
are then forfeited. Our records indicate that an application was filed on 5/12/2014 for an
onsite wastewater (septic) permit. Our Department conducted a site evaluation on
5/20/2014. We have not yet received a surveyed plat showing the lot with proposed
house location along with my septic system drainfield area and system layout. No other
communication has been received from you concerning this property. If action is not
taken by August 20, 2014, the application will become void and all fees forfeited.
If you have any questions concerning this process, please contact Derrick Smith of the
Person County Environmental Health Department at 336-597-1790.
Sincerely,
dJ.,,�R,. 4 �-
Derrick A. Smith, LSS, REHSI
Environmental Health Specialist
Person County Health Department
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
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