A26 57:
�
H
O
a
�
w
U
�
a
z
�d Persan County He�ith De�t
�25 S. �torran Stre�i
A q� o u n t p a i d �� 0• Ro;cboro, N.(i. 2���s�`a P
Receipt �� � Q
Gqtxrier'��2-�3-15
� � � � � APPLICATION FOR SERVIC
)s.�.,.F s a� � i �, 2� � uu x. tLf x' alw° i°iK�'�i "`a.�ie.S:r�� �.
� x 5 Y.. y r �.1: S +, .:' ,� 4 e * "� ,, e � � `°`� ..
� :�»� F i3 � �� Serytchs'12equesEed� �
�,.. �sa . ,
zx,.w,o...v�"��r.� K;<,:w-�ewt:".R..»,se.,:?.,:,...�:�.aa. s.•S�s ,e�w�`�wr..:a-.-..zw.;.;�„e.� > =ar«e.w <r,.
.�. . . .. . .. . ...
�mprovements Permit. (FstablishedlRecorded Lot) _ Reinspectic
/1��99
Date
of Existing System (Loan CIosing)
Impxovements Permit (Unrecorded Lot) Repair/Replace existing Septic System
� Improvements Permit (Mobile Home Replace) _ Permit for New Well
Im
_ Bacteria
Permit (Addition)
_ Chemical
_ Replace Existing Well
_ Petroleum � _ Pesticide I _ Lead ��
l. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospective owner/agent: S7r'���/� ����� Width: a d
Address: ./a �a _ Sdfl�_ l� r,�/i,�ISTE�JO �.°1�. Depth: / o 0
�.c�c o�o. C �7 s 3 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
Home Phone #: S 99 -� � s?
usiness Phone #: 9>9 - S._�� ` �fa'�.S
2. Name and addre�s of,current owner: 9. Water supply t5 pe:
' private f�public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
3. Property Description: Lot size: 3��C�FS
. Tax Map#: %� a�, 10. Type of structure/facility: Proposed: xisting: Q
Parcel#: .5�7 Type of dwelling:
Township: v/i✓�- �, �. House: (�Mobile Home: Q Business: ❑
5. Directions to property: State Road #& Road Type of business:
ames,�tc. Number of Employees:
�c,�c1G ' ST �£ 1�. �,G�lf o�l MAu�,'cE �A���Cs Number of bedrooms: �_
l M� onl ��� f-«' � Qt.�� �F arbage D�at? Yes ❑ No 0
Basement? Yes ❑ No .�If so, # of basement fixtures:
6. Number of occupants or people to be served: �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORN�� ur� ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'Son COunty Health Departmeni for a site evaluation for the on-site
sewage disposai system for the above described proper[y. I agree that the contents of this application are true
and represent the maximum facilities 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 before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the even[ I have not
deIivered a survey pla[ of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signcc� Owner or Authorized Agent
�
a
w
�
a
�
�
B 2914
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # �% Parcel #_
Zonin� _ Township
Owner/Contractor
Location/Address
Name
Z
� . - ���"l�
�/�. i� r I ��
G�' ��.� � . -
�•�:%�i � ..�_ 1 � G /'r
SEWAGE SYSTEM SPECIFICATIONS
Repair ' Lot Area ,> (' , Size of Tank J Z� /��',% �
SFD Mobile Home Size of Pump Tank—�
Business # of Bedroom� Nitrification Line 1 �
� Max Depth Trenches �
Permits may be voided if
Well and Septic Layout by,
Comments: �� (��,•n�
� . ��II� ! - � � II� ' � � � • � � .�'�%�.��/ .�i�� . ��
ell Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
dividual Semi-Public Required Slab _
�blic Replacement Air Vent
Site Approved
Well Head Approved
Grouting Approved_
Comments: �f o C. r�
Required Well Lo�
Well Tag
Date Installed by Approved by.
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditio�s on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
V,'R,�y''�'� a' ��'�1W/,r.�-rilf+v,�~ .� .. '�7`�..� �
�"FL'�Cf.r.i Y4.f�i�ss'.�+ H,� �t'� b�S�,�t� 1
.�� �r•.�r�N+� �,�,��r to .�'rc��iy%�,� �i�.i�i„ , ?�
�''2r.� �' M►w-i `Jt�°" �H�r''��>L �3 :�M'�'r •a�'�:
R ' . �, ��'P �', ' ,�` d,ycr' _ i^
�,��'+'�,. ��`�"t� �¥',� �� .�� kt �ijtr �" �T��4�"a-� � s .' ,
�: S �Mik \ ��, ` '.�" '�,Tf ,f+' ! t s 't ,�'.
.r� 4 G: � i�- yi i � .x
.� . .. .'�: 't'. ��idr ��,*- Sa t�� �,... yry, t��2`�t�.r "�''R.i�4 .
� �.v�:�.�7�"�.Lx� �b �i L,�;i� • �.`r'' � �.1�}.., y,��,,• .'* , r
�� ,�'4, �,j �±�,, T` r� �y'�t � r �f9�x f�"'=
,� s.� i�
.:T r^�=� ,�'�?a.d'�,��n�,.;F. `�s e3."�d; �� �k;���
t l,�;:�_,C' .r•p.h �L'}� � a, �`.
�t � �,��t7 °"�2��ra^a�. h,�,°���iy4Tii�� . NM�` ♦��.� h� - `'s%k�
?#r� ��,�'�-,r'�� ►�'�%3 ' �i ` � ,�s }f�j�. k�,� �: -r
. i�I�i-S�ySee�}��.-l�S.�' -+�'7,�L`-�`&. '�' 1�
�,,j�r,�•
�t ��Ls=?�•�A�'Ri.�i'!.) . � :7i',
:'.''J'����.T'�..'�,i�'N� ''" f'� ;a
� ..J,- t" .<� e ��'..'d. 'y �
y �Y
y� r i R � I
4���`��^� "�7„� .^i�Si��}�aw� ��il,� yi a• �• a _y
1��� },,� +��r� �„ . ��,� t a . �� � �M i :t
: � �, � ''� �C'r }� � 7�� � : '�;' ..�.- L '�.S f r-4x . �„ Y•�("
..� "�, � � t ` �.-<
�,=hJ������lti"" A'�,�1 .�. f'L `�� ...y'uN �����
k . r R �'� 1�`'�h .{,'��„ . � :� 7�•� � � ��'f�y��� '` 4 3 � +e. .'�!. � � ,ic
^��k�•l';- �Y� i�j�.µ..� 1�i � � ��y . y?.CY'3s�t�y.7���. . �y
�,�x^4t'�F��'�,t..l' �""s ' • � � �� ,P �� ' 7j `��y , F � �S'
�_��'����..�J x,` r'•�r
y'�",i;?`r v �}••� ` '� �. � • F �
•- •e ]� � i�iR��ff . • v¢� �
���� �.� "•�+ � � J � I� • . •
a "r7 t
:E.r � 7F�rf i ,ye � •
...� J: .7.:
F-. �.
� I
C'v • �
¢ ° i
`
:`,�c'r � ' �� �
-r. • •
•
�
�/ ��
lu -�;��
I'J�, �
-��- `�. ��� P
�r_
Application Date: l0 � 2_D� �
Amount Paid: 1�0. d 0
Receipt#: � �nJ c��
� ��� � � ��.�.� ��
� � ___.. � �� � � ��1`.�"ICa���-
1 IJ � J�.��.r][11.�N']L]L: �C:DIIT.fl'Lt.T�['�'.+J1T'R:.GII.�l. Il.y.�L�.'7.GRLL.Q::ILT.
. Application fo�- Service� �
(Sentic Svstems and Wells)
G Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 d)
Mobile Home R�eplacement or Building Addition
$150.00 (if site visit required) �
� Well Permit (New/Replacement)
$225.00/$125.00
Tax Map: �d�
Parcel #:
Services 12e uested
G Construction Authorization
(Fee is de endent on the e of
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
No Char�e
Important: If tfie informatiat in tlie application fnr an Improvenee�:t Per�ntt is incorrect, falsifted, or the site u altered, t/sen tl�e
Improvement Permit and tfie Authorization to Co�estruct shall become invalid
1) Services Requested by:
Name: S%��f��it(
Address: �,2 �"/S Q
�:�o C �75'��
Phone # (home): � � -�� - ��3G
(worlJcell): - ._S"/- 8c7octi
2)1`tame a�d address oi current owner (if different than applicant):
Name:
Address:
3) P�operty Description: Lot Size: �_ Subdivision:
Address and/or�directions.to Property: �_� Z M�}uF_'�c.F ;
4) Proposed lUse and Type of Structure:
Residential �_�_ Business/Type: Other
Number of bedrooms 3 / Number of people served (seats/employees):
Basement: Yes No r/ (with plumliing: Yes No _�
Garbage disposal: Yes No ✓� .
5) Water Supply: •
Private Well �(Proposed Existing ��
Community Well: Public Water System:
Are there on the adjoining properties? No Yes
#:
(please show location on site plan)
Note: A comnleted annlication must also i�:clude: �
9 A plat/sile p[an of the property that shows property climensions and tlze size and docation of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing t{tat the property rs ready to be evaluaterl.
I am submitting this application to request seY-vice§ from the Perso�► County Health Depa�-tment. The
information provided is accuraie. Y under�tand that if any site is altered or the intended use changes, all
permits shall be�ome invalid. � .,,,. , . o,,.
�igna�ure (Owner/Legal Representative):
I)�te : � .� �
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
�
�� . �
�
� 1 �
�ti� � 1�
� �����
.:T._:�'�li.�.�.'�Di9i! �i1C'R t�i3CA.'�.� � .�i��
���� �.da��tio�/ �I�bil� �o�e ��la����n�
Tax i�1ap #: A zc�
' .�•ac• ; - .� :�i _R. •
���: 5z � �
�/ ��-Home Replacement
Building Addition � "
• . . «.: � .�.� - � �. � , .L ,.
i
.. . •� :.. � t r.i � �.
.
.. ,. . �
'���- • � . . ;..i
PQIIll� LOC�C�: V �C5 . �O .
Installation Date: I(' 8- q 9 Design $ow:. �''f' g0 (gp�
Cusent Contract vvith Certif}ed Operator on fil� {if reqiurer�: �
Water Supply: '✓ �7ei1 � Public or Commua�iiy
�7astewater system shows no visual evidence of fa�uie on: I o- R- 0 7 (dat�)
��. t�Plicaio�t's signat�e if site visit is not ze�ire�
' � ���iitio�e�ia���t �iP�rovesi
- � . .
� � /o- 9 -0'7
Enviro entai� Heaith Speciaiist � Date
11/15/05
.����� � ���� �d. V .
� � 'l.� � 'LJ 1'�l ��
lEyav�iy-�a*,•,•.•mm.�,m.�. ]HC�all�l6.
SITE Sl3�TCH � .� . .
Name _ S�i�.n.�,en I��ir�{' � Ta,z Map #.��Pa:tcel # SZ-
Sub ' . � Section/Lot#
- /o-9-Q7 .
Authorized State Agent . � Date .
System cvmpo�ients s�eps�erent a, p�rroximata�contoun only: The confiwctor must', flag the system�rior to .
beginning ihe installrslion to ss�sure that propergsr�de u maintair�ed
�.ata�"arn �5� �n�t G S 5��
, � Y
`l� � �Yon� we�l G✓� /2ef,�J
� o�S� sr'�
,z� -so Z
::;= o
;-..� ,�.
:�� Q
N:I
:��y�� .r� -',~...
� � ✓..�� _. �
r , -� J ./t� >
. �.._, -��r#'
:� , �, . . _�'
:� _ �, �., � , ..�i 1r�f
FX�s};n�-
8U� �dinQ'
yd, � Q M�k<
�
� ,
,
�, ��9���
_ _ � .�o �ar�i
I COu Q��,�
�t� , '�I olra�-�e ��
.�Yi�� • � 1� ,
dr�`� ��iG
�,� �W� `;n�
�9�.zS1_`
'.. • . ��; �.;y; �� ;;��.I
1 �':
I � �.� I�`' t ' ,' ��
� ^t � , ,``,I. . � � .- ��� ` ��@
��.'- q
1 - " l' �
��
�. � `i � _� _. _ .
.-. .. � \'� J _„ . _.
'`_. ,
.� ��� �. � � .�.�_• .� . 1 . . . •`'.'� . .
r, - _ .
�!��. � _.,_ j _' .i. _ ' l:•{���., '
;�� = ., • Gi'�``� ,_ _ _ _
.�f . -- -�� - -
=- - �-__ � _. ._ ._
�= � - � E�
_" . , \�/ .�'7
._ � ~oV � ..�
" . "' (
_. _ � it _
. • : -� . � � _
.. , � '�
~- - - --- - - �� �
,, �_
_ � - - - �,- ..�
. �", _ - ..
x..._ . ,.
� ` .
�
� •- - - �
� - � - - - • �
�
�v �• �.�v {�