A26 216Agp!icwtiun Date: fl9 23 ��
Amount Paid: O O 0 U
Receipt #: 1�:� S I 3
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
0 Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
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�lication for Services
Services Re uested
❑ Construction Authorization
Fee is de endent on the e of
❑ Permit Revision
$75.00
Tax Map: �
Parcel#: �_
?'t° uk
Cu.`�- �
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
�) Applicant Information: �
Name: 1�15�" 1(1Gi � �� 5
Address: �\�' Y�eS �Y'
� �r�• �ac� Nc a�5�
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home� 3 �� S� � q � � � � �
(work/cell):( ��(�� g ' 8 at�3
Phone:
3) Property Description: Lot Size: ���, Subdivision: Lot #:
A�e��nd/o� irections to Property: �17� ,�t,t� C1 Cv � Qr.Y�Li �-�Ic9 L�� �721 ��i
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❑ yes 0'no Does the site contain any jurisdictional wetlands?
❑ yes G�no Does the site contain any existing wastewater systems?
❑ yes GYno Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes Gd�no Is the site subject to approval by any other public agency?
0'yes ❑ no 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 --� �
f�7�iQew Single Family Residence Maximum number of bedrooms: � / Occupants:
❑ Expansion of Existing System If expansion: Cunent number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes GYno 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: �'New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes �no
Please note any known ground water restrictions or sources of contamination:
6) If applying for �Authorization to Construct', please indicate preferred system type(s):
❑ Conventional � Accepted ❑ Innovative ❑ Alternative 0 Other ❑ Any
I certify 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.
�ignature (Owner/ Legal Representative*)
* Supporting documentation required.
C� • at3r ��
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.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applicant:
Taz :Yiap: �� parcel:�fv
Sub�i :�is:en �
Phase/Section/Lot #
Improvement Permit
Permit Valid for: Five Y s`� Non-expiring
Type of Facility: New � Addition Water SuFP�Y� �✓��
Number of: Bedrooms �/ Occupants !s / Employees / Seats: Projected Daily Flow:� gallons/day
Proposed Wastewater System: �i�,� r� Type:
Proposed Repair: �� Type:
Permit Conditions:
Authorized State Ageni: __ c
(X) Owner or Legal Repressntative:
Date:
Date:
�
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is th:, responsibility of
the applicant/property owner ±o insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a chaage in ownership of the property. This permit was issaed in compliance with tf�e provisions of the North Carolina `Laws
and Ru[es for Sewa�e Treatment and D�cnosal Svstems'(15A NCAC 18A .1900). Neither Persoo County nor the Eavironmental
Health S�ecialist warrants that t�e septic system wiil contflnue to function satisfacto:;iy in thc fature, or that the water suppiy will
remain p�table
Authori�ation to Construct Wastewater Systetn
��ee site plrm and additional attachments (�.
Proposed Wastewater System: �,/,�„0 ,*���1 �Dt���i i'�)Type a� Desi�n Flow �_ gal./day
New � Repair _ EY ansi n_ � Soil LTAR: •� gal.Iday/ftZ
Type of Facility: '�i� Basement: _ Yes �/ P:o
(`) System Types Illh, Ilibg, Ii ; crnd V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank �dG'� gal. Pump Tank '—' gal. Grease Trap — gal.
Drainfield: 'Total Area d0 sq. ft. Tota1 Length �� _ ft. Max. "french Depth ?�- in.
Trench �Nidth .� t�. Min.Soil Cover _f� in. l�iin.T�rench Separation 9 ft.
Distribution: Distrihution Box ✓/ Serial Distribution ✓/ Pressure Manifold ____
_ _ . , -- � • --- -- — ��i
Specifications:
Authorized State Agent:
�
[ssue Date: !!/�!! 7
Permit Expiration Date: !i � y�
The system permitted is: ronventional /Accepted ✓� I Alternati�e / Innovative . I accept the conditions
and specifications of this permit.
(k) Owner or Legal Representative: Date:
.�.
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-17�Q� (rev 5/12)
Tax Map: � Z�lP I
Slte F�Ia11 Parcel: �/lo
��.:.5� ������T Name: _ l3�aT1 Pll� EU. t5. Address: �2GL�� 1� � R_W 4�C.,.�.
`^; �' � � ���� Subdivison: N � Lot:
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System Type: �
Septic Tank: DDD gallons
Pump Tank: %, gallons
Total Linear Feet: �C�DD
Max.Trench Depth: �_�L"
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EHS:
Date: Z
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Scale: �� C�D �
Note: i) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Health with any questions (336) 597-1790.
Additicnal Comments: �
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https://gis.personcounty.net/TaxParcelViewer/ 6/23/2017
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��m�va�r�a:a�ra�nm�rn.�m� ��ca����n
WELL PERNIIT
(New� Repair_ )
Tax Map: �v Parceli�
Subdivision: ,�
Applicant's Name: �/ �/,¢- ��J`��
Mailing Address:
Lot:
Phone Numbers: — 3�) �g3 � 7�l0 �
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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.
4.J Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Perrait issued by:
�Tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Dritler:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date: �/ 7
Certificate of Completion
Ol,iner:
• EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Nlaterials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597•7808
11/26/13