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A26 21
w Application Date• �/� 7 � 7 Amount Paid: o20G .UU Receipt #: ,�� ��������� ��� �unvn saDnaaaacaadeaIl IHI �cn.� d�in Annlication for Services Services Improvement Permit (Site Evaluation) ` �200.00/$300.00 fif> 600 eodl ❑ Mobile Home Replacement or Building Addition $150.00 (ifsite visit required) ❑ Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision dlay S � �v�� �,. �e� ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Informallon: Name: �,�,.n T. R; �t H� 6r . —� Address: 3 Fo x 1 ti t r fv�, �+ �u � �.G�, ,/� �- i-%% 1� 2) Name and address of current owner (if different than applicant): Name: �Ii� Rqm3t� EXccaf�v -fzr Robcr-k S�w�xH � Address: Phone (home): q 19- z57 — 77 3� (work/cell): Phone: y I a���s 3) Property Description: Lot Size:_ _�� Subdivision: r/� /� Lot #: Address and/or di/r�ections to Property: u�,.� y 5°1 �! ��• ���t-,�„o — 4� a�pprb �, r�.r �e s-F-u�� r es�.i- Q"`- I-,lI" \VV� 1"�l��l�tH'1 I�c 1'iCT i"N� v��� M�aN'���f\(.� �[� 1 b`IU CJ�V O/I 1�tT ❑ yes C�no Does the site contain any jurisdictional wetlands? ❑ yes [�'no Does the site contain any existing wastewater systems? ❑ yes �id'no Is any wastewater going to be generated on the site other than domestic sewage? � yes �'no Is the site subject to approval by any other public agency? ❑ yes �o 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: CJ�Residential Ne�d w Single Family Residence Maximum number of bedrooms: a / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes Q'no With plumbing fixtures? ❑ yes E� no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: M�imum number of seats: 5) Water Supply: [�New well ❑ Existing Well ❑ Community Well � Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properly? ❑ yes ❑ no Please note any lmown ground water restrictions or sources of contamination: 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ 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, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Legal Representative*) * Supporting documentation required. 9�T/ �% Date • Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. • A compteted `Lot Preparation' form must accompany any application requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) I ' � , Person County GIS 5. = � ; � . �', r:. :... y � iF . , �, t ;� `� �' T � � �' ` � . ''' �'�• . ,, t F �!'* .'�" .�� �t { 4it, �, � �`a' � - 4r�:, .. . , '}� .` . , .r� "�� . �+t. ,, c _ , r` 'h i', r.Aa+' �.' �� +� y, �� ( y �! � f.�[� � y i:y-.7 `� `��+� �� xf � y,- . i` � _,a_y�r�.c� . r ,,...R=' .� p� ) . ^.��"4,� . . S. I �,' t4r � .. .1 . y. �9 y�a * s . ����. �` ,�ii . 'tr s.ro'� �, -,,� � . :� . �� � t1,+ � � . 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RI' �"`„ �� .� � . � -a• y� � � � F f `i - � �'� � � � �; ' � 11 � ':- .c-�'. �iti- ',�i - � �.�s 4 1°.,"r'.� .. .�.. � s�-i�.�.{�� '�rt.`1 �t�i,Y , � "y � - , s �tt �y- +._g ��� �. �, �. � '+6� F� ` � �. 'jr+1 � . t � '�i�' `{' .... , . I,�, • a .� � �' ,:i�� �� �..'1 � � l t a �{�, ,�i}�.,, `�'T'�+� _ ~ y � ��� ��,� •T ��, �, �_• } ;��� :;��r ��� f�f 1' /� . " t- � � � t y � ,! '. + . ' l �� � � .�''�y �N:� L - ` / \� � �y� � '� � �•' +�.\ R�` . � � . �.t:� S� � � 1`�i �� � � i� '+ � . ` .V"` � S � � ��, <. � � � . ��T�%�'i.� . _ ' 'i�� `�1.'RK� �W��-<��� � �f '�_:f;, �' k ` . � ��` • �. . . •,s�i*Ar � � t 4: � ;�•, � � � � .� � � � . � „ . . ;� r,:; � *-� � � a;`^ t :�1��� � �. � , � i h . . t , , � F _ � "' ` � y� � �1CD,OT aPe �son �County G!I�S? G'ity�-of Roxboro '�<. :. . _ -- Legend E-911 Addresses Easements Conservation Easement Utility All Other � � �fi , 'p��` }� o w� r 5��t e��' ;L , c c c., ��� .. 9/25/2017 Tax Parcels N Feet � 0 160 320 480 0 0.03 0.06 0.09 Miles ���`,S� ��1�.� �� � � � ���� 7:F�s�.�a-��� ��,.��.?L IF-IL��.Il�7� Applicant: Permit Valid for: Five Years Type af Facility: Number of: Bedrooms ' / � Proposed Wastewater System: Proposed Repair: T�v ld�ap: � P�rcel• � S�a��i :�isi�n Phase/Section/Lot # Improvement Permit 1�`on-expiring ��New �/ Addition Employees / Seats: ii Water Supp]y: Projected Daily Flow: gallons/day ype: -'?" O Type: "=t;Y� � Auth�rized State Ageni: _� c (X) Owner or Legal Representafive: The issuance of this permit by the Health Department does not guarantee the issuance of other r:.quired permits. It is th� responsibilin� of the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This [mprovement Perniit is subject tu 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 for Sewage Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neitber Person County nor the Environmental Health S�Cecialist warrants that the septic system tiviil continu� to function satisfacto:;iy in thc future, or that the water suppfy r�idl remain otable. Authorization to Construct Wastewater S3�stem ,i'ee site pl�n and additional attachments (�. Proposed Wastewater System: � �"�� ��/(*)TYFe Design Flow �t� gal./day New Re air Y ansion Soi( LT��� • 30 gal./day/ftZ ✓ P — P Type of Facility: �+31� Basement: _ Yes ✓ItiTo (") Syste�n Types Illb; Ilibg, li ; �rnd V, require periorlir system inspections by the Person Cor�nty �lealth Department. Wastewater System Requirements Tank Size: Septic Tank /jb6 gal. Pump Tank �"' gal. Grease Trap '� gal. Drainfield: 'Total Area f�0 sq. ft. Total Length �t00_ ft. Max. Trench Depth ��� in. Trench �1Vidth 3 ft. Min.Soil Cover !P in. Min.T�rench Separatian _� ft. Distribution: �istribution Box K/ Serial Distribution X/ Pressure Manifold ____ Specifications: �EE �f� �.���— Authorized State Agent: The system permitted is: Conventional /Accepted �i Alternative / Innovative . I accept the conditions and specifications of this permit. (Ir) Owner or Legal Representative: Date: �= Person County Environmental Health, 325 S. Morgan 5t, Suite C, Roxboro, NC 27573/ph: 336-597-179Q� (rev 5/12) ����,s� ���.���� �--- � � ���� IE������m���,.Il IE33C��.11 �]� WE� PERMIT (New RepaBr_) Tax Map: � Parcel: �/ Subdivisio : Appticant's Name: �p � % , ��. Mailing Address: Phone Numbers: Lot: Location of Property: t %/JL''�'�!/ ,�2��,�r�/ �b Permit Conditions: 1.J See attached site plan for proposed well locataon. 2.) All applicable State and County regulations governing construction and setbacks apply. 3.) Permits expire S years from the date of issue. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: Permit issued by: Date: %D /v Certificate of Completion ew Well: � Di.iner: EHS/Date • EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Installer: Approved by: Additional Comments: Date Sample Collected: EHS: Person County Environmental Heaith 325 S. Morgan St.,Suite C Roxboro, NC 27573 Depth: Grout: DAbandonment: Date: Method/Nlaterials: License #: License #: Date: Date Results Mailed: Phone:336-597-1790 Fax:336-597-7508 11/26/13 �`,;,J� �����A. V � � ���� lEaaviso�n�n�aa�mfl ]E�emE�fln CA��r��/ ��� F���1►O Site Plan Tax Map: �lP Parcel: � Name: E • Address: �/%C1G 1�,._//l'/G �7� Subdivison: Lot: �t��JE \ CF� ��� �L� I `� �DO �