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A26 7Application Date: Amount Paid: Receipt #: Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Home Replacement or Building Addition $ I50.00 (if site visit required) Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 �� ) f �� Tax Map: � al�. � _.� • � Parcel#: �_ �� 7Lsavnn-oanzaacaatmll ][-jlumIlQ:IIa ilication for Services Services Requested Construction Authorization (Fee is dependent on the type of system permitted) Permit Revision $75.00 Repair of Eaisting Septic System ►/ Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: � � Address: p3 \ t�irv�S �-�f e . 2) Name and address of curre t owner (if different than applicant): Name: 'S 4r,.s— C� (,t��f � Address: 3) Property Description: Lot Size: �_ Subdivision: Address and/or directions to Property: � Qo c�1 �.� �,� , _„ , _,. � , ,.�.-� .,,a.. r�.��,. �a _ � Phone (home): ��Q — �►CL—� 114 (work/ce�: �3�=503 -ol� t3 _ Phone: Lot #: �_ � ,. . ` ► .� v _ -�, � r � r ► yes G�'no Do�he�s�te contain any jurisdictional wetlands? ' � o°,� ❑ yes C�'no Does the site contain any existing wastewater systems? ❑ yes �d'no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes C�'no Is the site subject to approval by any other public agency? ❑ yes C� 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 ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: � Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? � yes ❑ no �n-Residential Type of business: � �� Ma�cimum number o employees: q.�,� t�_l�_ Total Squaze footage of Building: �j��, Maximum number of seats: 1 5) Water Supply: ❑ New well [�'�isting Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any 1 certify t e information provided above is complete and correct. I also understand that if the information provided is in cu or if he site is eque tly altere , the intended use changes, all permits and approvals s all be ' alid. . �4� ��•Z.� %�� . Signature ( ner/ L 1 epr tive*) Date * Supporting documentation req ' ed. • Permits are valid for either 60 months or are non-expiring when accompanied by aa approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��.s� �� 7[�e��a�� .Il IE��.Il�1� Tax Map: n 2�2 Parcel:�_ Subdivision Phase/SectionlLot # Improvement Permit Permit Valid for: Five Years Non-expiring Type of Facility: ,�,; �p SS New Addition _ Number of: Bedrooms / Occupants i Employees �% Seats: Proposed Wastewater System: Proposed Repair: Permit Conditions: Authorized State Agent: (X) Owner or Legal Re Water Supply: Projected Daily Flow: gallons/day Type: Type: Date: '7- 2(� _l Z Date: �he 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 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 change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules for SewaQe Treatment and Disposal Svstems'(15A NCAC 18A .1900). Neither 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 aitachments (�. Proposed Wastewater stem: (*)Type � Design Flow Zoo gal./day New Repair � Expansion _ Soil LTAR: , 3 gal./day/ft2 7:ype of Facility: {�US� ��c�� I o�� Basement: _ Yes No (*) System Types Illb, Illbg, IV, and V, require periodic system inspections by the Person Counry Health Department. Wastewater System Requirements ��s�i � TanK Size: Se�tic Tank I�S00 gaL Pump Tank ------ gal. Grease Trap �----gal. Drainfield: Total Area �_ sq. ft. Total Length �_ ft. Max. Trench Depth Z�'Z�in,,, Trench Width �L ft. Min.Soil Cover � in. Min.Trench Separation � ft. Distribution: Distribution Box v!' / Serial Distribution / Pressure Manifold Specifications: Authorized State Issue Date: ?�( 2 � Permit Expiration Date: 7- 24-/7 The system permitted is: Conventional �pted �Altern ' / Innovative and specifications of this permit. �� (X) Owner or Legal Representative: ' _. I accept e co ditions Date: �-�v �� Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) • '��,�� 1` "��/ �� • � ti � �4 ^� � � v7� i V �y� �L3�Tn7[`��n�emm�B]la�.1�.JL ��p.84y� . . .. . :� � SITE ��TCH �� . Name � 5� oc,� e� , Ta,g Map # Zl� � Pa:tcel #� . Subdivision _ � Section/Lot# � `7- 2(0 - I 2 � � . Authorized State Agent . � Date . System components rte�iresent u�iproacimate �contours only: The contractor must, flag the system prior to , beginning the i»stallation to insure that propergmde �s maintained ��,s.f ��.�� IE��a-��•-T-r ��.IL IE��,IL�I� � Tax Map �(Q Parcel # % Subdivision Phase/Section/Lot # #.arf�e�d��g�s �0 P�M�,�n /f ,S_ _ I ._ � _ ' �� ►u.��e�. ��'.�� • ..- . .... ,�. „r�! � �� Operation Perrnit System Type (From Table Va): � Product (IIIg): EZ 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. (Authorized Agent) , � , S{Yf.'P� (Licensed Contractor) � rS�' � �S g,� _g`S Q�� 5 e��,5�y�t� `�W�nS i3� d;��r � F�n�' 5'� ��g i�oo Ga��i�„nl�- �-3a—�Z (Date) 1- 30—�2 (Date) sew►v►'a �, Scale: �e � v � � a v S cD, V " �� "� :• • .. i Tax Map: � Parcel #: � Septic Tank System Checklist (Type II-I� System Typ . Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes• NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP e-mail Date: