A26 190Apqlication Date: �-�d"�°2
Amount Paid: l�b�.L�
Receiat #: -��;;�
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► 3 �'0
Permd -
Person Countv Heaith Deuartment
Environmental Health Section
APPLICATION FOR SERVICES
.� ::, S��i�es �tequssteii�:. �;
I - 5150.00 ❑ Well Pertnit (Ne�
Lot) - 3150.00 0, ExlsUng System
(MobAe Home ReplacemenUAddiUon)
Site
Tax Map #:
Parcel #:
t
a
1) Permit requested b:( w edagent/ rospective owner): ����� �E oo �,� e.�/,��.'�'�j �<YI, !�; ��
Home Phone:�'� --�� _'��7 j�q Address: / vv v2 � �r�h�
Business Phone. . D67 J v ,' �.-� gc� �
2) Name and address of current owner. �)m << �� � D c%�
3) Property Description: Lot stza: �" � Township: 04'IS� /.,h' L� f o4Jn�i'�,.P .- �.�� /104 :,3
Directions to the prope (Including road names and numbers): L��v� iV 1� o v�✓ �W S7
�c� ' • F — a - �Sn �JS� ���� �.t;
v' l; C Sc o - W,cvLI'� � � s�G,z� -�li.rc�- Nv�
4) Proposed Use Structure Description: answer each of the following questions:
a) Proposed���ng ❑
b) Stick Built.�f, Modular 0, Single Wde 0, Double Wde ❑
c) Number of Bedrooms: �1 d) Number of occupants or people to be served:
e) Basement: Yes�`6�No � If yes, # of basement fixtures: U •
� Garbage Disposal: Yes-�'SNo . y6`tvht. �f -fj-a .
g) Dimensions of Proposed S�ure: wdth:,� Depth:�
5) Water Supply Type: Private O(new 0 or existing �), Public 0, Community �, Spring 0
Are any welis on adjoining property? Yes � No 0 If yes, location
6) Please Indicate Desired System Type: (systems can be ranked tn order of your preference)
_Conventional ,_,Modifled 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 SITE PLAN TO THIS APPLICATION
I hereby make application to the Person County Health Oepartment for a site evaluaBon 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 faalities to be
placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand
that as applicant, 1 am responsible for identifying and marking property lines, comers and making the site accessible for the
p nel of the Person County Health Department to condud their evaluations. I understand that I am responsible for notifying the
ealth epa ent if my property contains any wetlands as designated by the Army Corps of Engineers.
�u— �o ll b Z
0 ner or Legal Representative . te
PCHD, rev. 10/12/99
Application Date: 02 �`T -�0 Tax Map: �02 6
Am�unt Paid: 02 0 6. 0 O Parcel #: ��
e Reczipt#: � ��? 3c�
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Application for Services (Septic Systems and Wells)
Services Re uested
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d) (Fee is de endent on the e of s stem ermitted)
0 Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Charee
1) Services Requested by:
Name: � � /� �-�, L. /1�1 ov �t.�'
Address: � 2-� D v c.l� A� • i�v �
2�C �vu� ., .NtJ. C, 2 � r�� �
Phone #(home): -�3 �- �5'S- y' � c� �
(work/cell): 4 "�' � - C o � �
2)Name and address of current owner (if different than applicant):
Name: ,lY1 0 0�s 1,�,.,o �,t�� �� �L c
Address: / � � p ,, �o �,, ,r. /,�,
6 v-u � �,/'U 2-� �-z y
3) Properly Description: Lot Size:1 ' 2 3„$.ubdivision: Lot #: �
Address and/or directions to Property: ��- � y S`7 � �� �� v�,� ✓„r /�-, !�(� S c�.v..L
i3.�1'�.�.� �i�► ✓ � ��s � .►-L,,,�,—N,,� ��c.�,�.�-� 2�,
�.
4) Proposed Use and Type of Structure:
Residential � Business/Type: Other
Number of bedrooms y / Number of people served (seats/employees):
Basement: Yes No _� (with plumbing: Yes No �
Garbage disposal: Yes No
5) Water Supply:
Private Well �Proposed Existing _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No _
Yes `� (please show location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall 6ecome invatid.
Signature (Owner/Legal Representative): ����— Date 2"—� ' �
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applican�
��i'Illl� ��Rd �0� � �+'i4@ �8 J
Type �of Facility: (3 � �
# of Occupants # of Be
Proposed Wastewater System �
Proposed Repair: 1>� Q n
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T�x Map � �.rc��l : �
Su+bd;ivi.s�ian � � '
�h�:s�e:S�ct�ion:La�t �
v
1�ffigD2'09@3IICII� �B�lIPIf - .
lY0 �1i3ti0II �
New �Addition �ate� ��p�pip � � � � .
s � Proje�ted Daily Flow y� g.p.d.
. T�e:
� � � Type: _
� . - � - �, �- S�� � .
Permit �Conditions:
Owner br Legal Representativ � e: Date:
Authorized State �Agenr /� � Date: ! b
� The issuance of tiiis pe�it by. the Health Deparanent m does not wazantes the issuanca of other peimits. It is the responszbility of the �
applicant/pxoperty owner to in suze t�a# all Person Caunty Planning and Zqning :and Bnilding Inspeciions requir.ements are meL This .
Improvement Permit i� subject to revocaiion if the sife pIan, plat or the intended use changes. The Ymp�ovemeut ]Permit is not
ai%ste� bp a c3iange in ownership of the property. This_ permit was issned in complianc�.with the prnvisions of the North Carolina
`Zaws and .Rules far Sewa�e Trem�ment and 1�isnosal Svstems' (15A NCAC 1�A .1900). Neither Psrson �onnty nor the
Enviranmental i�eaith Specialist' warrants tlxat the septic tank system wi71 cantinue ta funciion satisiac#orily in t�e futnre or'tiiat
the water supply wi'll remain�potable. - . ... � . - .
Authoriza�on #o Consfr�ci �Vastewater Sysiem (ite�nired for Bwiding Per�it) �
* See site plan and additional atta hments�%�• ,�Z: �jW :
- . - j _.�� . ' �� .
Proposed Wastewater System: �'""'` � C��� ��' Type �� Wastewater Flow �:p.d.
New � Repair_ Expansion _f ' D,, � Soil LTAY� J a S g.p.d1 ft 2 . .
Type of Facility: �i �� 0`� � • Basement _ Yes � No ' , .
,
. � : �a�te�vater Systean �eqiai�ceu�en$s �
�an� Siz�: Se�#ic '�ani�: � 0 �� �mp Tank:
�rai.n�eid• Total Area: %��C� se� �.Tota1 Leng#h �� ft
��e�aci� i�idtB� �_ fi �'s�u�a Soill Cover. �_ in
�3istribui�on: i� �3ii�tribn#ion �oa� Serial �istribntion
speci�cationsi ��(�'—�1�C �,�i �'� l., �l
; � i .�., l'„ � r.,. �.�_ a�
gad Grease'Trap: gal
� N$asi�nffi Trench Dept3i �� �
1dlinimu� Tre�ch Sep�ration: � ft
Pressure tilanifoid
��ci� �/ I.�.C�S. n /� � --
r ( XYL7�
Autt�Orizesl S�ate A.gQnt: .
- Permut Expu
The type of system permitted is C�nventional � Acc�te3 Alternative. I accrpt tiie specifications of the
permit. � .
i�w�e�/��bal �8�p�'esE�a�ave: Date:
' pCSD rev. 11/lfllOS
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Name r
Subdivis'o b> �Yy d v��-
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Authorized State Agent
SITE SSETCH
Tax Map # � °2 � Pascel # � R �
Section/Lot# �
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Date �
System components represent apprnximate rnntours only. The contractor must f lag the
system �prior to be�innin� the installation to insure that pro�er �rade is maintained.
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WELL PERMIT (New�Repair�
Taz Map: � 4 Parcel: l��
Subdivision: Qir� c� � Lot: �
Applicant's Name: ,_ -�v►� �jc�c�-e
Mailing Address:
Phone Numbers:
Location of P' r�ope,rty : S � � �t � �-+ `�' ��'�
�l / i u�2 l�- i�( l� er rK •
Permit Conditions:
1) See attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply.�
3) Permits expire S years from the date of issue.
Other Conditions/Comments:
Permit issued by:
n,
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�-Cvv-�„�
Date• Z��� ll c�
CERTIFICATE OF COMPLETION
New Well Inspection:
� EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller•
Pump Installer:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
/ �
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
License #:
License#:
Date:
Date Results Mailed:
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08 -