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A26 209��, s f ��.� �� )[�+e��a��,.-„-r ��.11 IE�L��.11�I� Applicant: ��(� ti CC� �I Address/Location: 4 i�t � Permit Valid for: ive Years V Type of Facility: r Number of: Bedrooms � / Occupants Proposed Wastewater System: Proposed Repair: /� CC � Permit Conditions: Authorized State Agent: _ (X) Owner or Legal Rep Improvement Permit Non-expiring / , CP� New _ Addition ✓ � Employees �y Seats: _� Tax Map: �� Parcel: 2.�q Subdivision Phase/Section/Lot # Water Supply: � S� W el l Projected Daily Flow: D gallons/day Type: � Type: Date: %Z -/3'/Z, Date• „�/7 / Z, The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements aze met. This [mprovement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules %r Sewaee Treatment a�:d Disnosal Svstems'(15A NCAC 18A .1900). Pleither Person County nor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (�. Proposed Wastewater System: �C� (*)Type __�(� Design Flow �(�� gal./day New Repair Exp nsion Soil LTAR: �J �.3 gal./day/ftZ Type of Facility: c�jva� eS� e►1CP. Basement: _ Yes _ No IV, and Y, V the Person County Health Wastewater System Requirements ��p�-+on ',,,, � C� 5{,;n 1 Tank Size: Septic Tank � gal. Pump Tank gal. ^vrease Trap `4` gal. Drainfield: Total Area U� sq. ft. Total Length 36o ft. Max. Trench Depth � in. d,c, Trench Width �_ ft. Min.Soil Cover (e in. Min.Trench Separation � ft. Distribution: Distribution Box / Serial Distribution �/ / Pressure Manifold Specifications: � �� Authorized State Agent: Issue Date: / Z�/3-/ Z Permit Expiration Date: /Z —!3 ""%� _ , The system permitted is: Conventional /Accepted / Alternative / Innovative . I accept the conditions and specifications of this permit. (X) Owner or Legal Representative: Date: % 2" %�"/ L Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) ��'� �� '�� - �-.� �� °�iY lr''1C71'�S'Il]i'a��rn ir.r�. �B]Lli¢1fl.lL � �J,�p21.�19"� . ll��L �.�L 1 V� . s Name �'�r� � � L� Ft�t I l Tag IVIa.p #�Z� Pa:tcel # Zoy Subdi ' ion Section/Lot# %Z-12-l2 Autho�-ized State Agent Date System cvm�roncnits a-��resent a�hproxa�tau#e�contours on�►, The contractor »aust, fZug the ,syster�a praor to e inmir�g il�e irlstall,�'i�� ta ansure �ha�proj�ergrncde is �rsaintai�ed � t � fi o �1 � ..1.✓� 5-f a I � ��h�� it'w � � S�►v1 � �-�G�o' �' ec:�'�J (G-ruve��ss /ZS � ��1�c:� �� , /i-jxsl-�oi-1. F�' j i i1 ��Gff" i,� ?�� r16T �; � t't1C 1'D c"�(�1 � �,� �f`��Y 3�;- �� x�s�;� 011 � ��r'��rn c�c��-ha►� , � - � � � ►�oi a�/� 0 i�on �Z � Kz�. ci rbrir��a�� .�c�`._50 � exis�;,�, iin�. �ti�ti� Cur� he l�z�f �n us�. a � �P . �P�i ��— C� 00� fo�'a1 �� 'a�� li�� Of ��U � a� �tc� }� �ir� G��' xt � 35b �% �� ! o�,L rr --{� `r, y��' zx�S�h n�� fan K c��r f�z�ot�fi v� f� I�aKe su�e i f � 5 a�5c��" �� ai�� 1� i.`'t'�1 G� i�'� � , dGYv�t,1`��, . �� -� �-�i�� r'',��'r�'� � � ��.s� ��.�� n.�•-n� � �n�na. � �n.�a�.11 IFZL � �.IL�IL-n. Tax Map 2� Parcel # 20 Subdivision Phase/Section/Lot # # of Bedrooms 3 Applicant: M ar; a tt a i� ' Locaiivn: �i D iviora — Oueration Permit System Type (From Table Va): I Product (IIIg): � Z Type V& VI Expiration Date: Type V& VI Renewal Date: This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. (�-i�1-�3 (Date) C�-l�'l.� (Date) Tax Map: � Parcel #: 2-Gq Septic Tank System Checklist (Type II-I� System Type: � Notes• Pump System Checklist Pum Tank InitiaUDate State ID & Date: Ca acity: Riser (6" min.) NEMA 4X Box Model: Piggy back lug Hard wired Alarm functioning Mounted on ost Above grade 12") Conduit sealed Pressure Manifold Number of ta s: � Size and sch: Contracted Certified Operator (Type IV Systems): Notes: Tank Com onents InitiaUDate Pum model: Block (4") Nylon retrieval ro e . Float tree and attachments On/Off�float swing: in. Alarm float 6" se aration) Anti-si hon hole Check valve Threaded union Gate valve Conduit sealed Outlet sealed A roved and secured riser Su 1 Line �Size and material: in. sch. Length: $, ✓1 � Etipplication Date: Z/ Z/ 2 0�)1-� `�� S AmountPaid: p. U� ��0. �,._.••. �� Receipt #: �1 I G7� ��-SI � �%�� / , �',T , �� IE:nav aa•ax.uamcn�aand,ml� IHL�,s.Ild,� (�j�O'�# �0 4' `T G1L, Application for Services Services Reauested 0 Improvement Permit (Sife Evaluation) $200.00/$300.00 (if> 600 gpd) 0 Mobile Home Replacement or Building Addition $ I SG.00 �if site visit requiredj ❑ 'Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 Tax Map: /� Z C� Parcel#: ❑ Construction Authorization (Fee is dependent on the type of system permitted) ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $ I50.00 or $300.00 1) Applicant In%rm tion: '� Name• �� , ,/'�/ u u i � Address• 2 � ..rK _ .•�! � dX � .�r/ �. Z �s� y � 2) Name and address of current wnfr(if different than applicant): Name: _�uii �IDG 1� Address: .S �„ ,�r , G Z7 7 Phone (horne): . � .� � _ �.S'y/- y2� 7 (work/cell): 33� �- S� �- Z �i � y �t:or.e: 33�-3ZZ — D8y f 3) Property Description: Lot Size: 2. U 3 SuJbdivision: Lot #: Address and/or directions to Property. L� � y� . SC %N LYttit �� _. ___ ❑ yes C�o Does the site contain any jurisdictional wetlands? ❑ yes Q no Does the site contain any existing wastewater systems? ❑ yes C�o Is any wastewater going to be generated on the site other than domestic sewage? O yes C}�io Is the site subject to approval by any other public agency? ❑ yes F�7-� 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: � ' C1Residential �� X � r�� ❑ New Single Family Residence Maximum number of bedrooms: � �-1 �� X y�� h��r��"� �Exgaaisio� of Existing System If expansion: Cu�rant r•�mber of bedrooms: Z 3`t �+� Zt�� ja�(°.a.� ❑�epair t� Mzlfun�tioning System Will there be a basement? 0 yes �o With plumbing fixtures? ❑ yes � no �Non-Residential Type of business: Maxim�m number of employees: Total Square footage of Building: I�zximu:n numba; o: seats: �) Water Sup�ly: ❑ New well �xisting Well ❑ Community Well ❑ Public Water 0 Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If a,pplying for `Authorization to Construct', please indicate preferred system type(s): Q'Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other CI Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if�e site is� b�sequently altered, or the intended use changes, all permits and approvals shall be invalid.. Signature (Owner/ Legal Representative*) * 3upporting documentation required. /� r/�/� 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. (10/111 Person Countv Environmental Health. 325 �. Mor�an St.. Suite C'. Rnxhr,r� Nr ��5�� z�_So�_i�om Zvy ��. � / � � 1 � V>. ti� � - : ..'.' '. .. '; � � �1c/ � � � �,?i,�n.�n��°��.amillc�.�n�.��ti.�. �c��.�,�� Building Additions/ Mobile Home Replacements Tax Map #:�� Parcel#: � Address: ��b le;+�a r'Q �d . n�[ �nro A I Z7�? � _ Approval Requested for: Mobile Home Replacement � Building Addition Applicant Name: A - ��J_ � � ! 1 Address: �i 5�1 � Sev� ��-r� %��oro 1�1C, Z�� 7 3 Phone #'s: ,�Q-3" Z- o�'4t( _ .�R R— �� q� ��u—i�doYe� Permit Located: Yes V No Installation Date: �. Design flow: Z� (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: / 2-/ 2'/2 (date) (Applicant's signature if site visit is not required) ct�'�S ��f 6t 0 Ton ,) ` 3�0� ��{� �9ravt�eSS ) Can e i n 5(-a e Gnci p-!' W�` �e 2x( �h ��c� I� n e Abanc�a Comments: d�f� o n 2��r�x i n^a �� 5a' � Ara v� � � on � �� 3�' x Zg'�Afa�� ad�l�fion � �-�on r Se,e Si{� SKe-�ch � Addition/Replacemei�t Approved � Envir nmental Healt Specialist /2-12-1 Z 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 -y�e �50 � �c�S-f�nq •J