A26 74ApE�lication Date• ��� � ��'� ��7�?7 `�� ��' ������ Tax Map: d
Amount Paid: � o � �"`' _� `... -" ��- � � ���� Parcel#:
Receipt #: � �D
� lE�.�cn� nn-xnT*n*•-��xn.9:an..11 JI�Cc».)I4;Ln.
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tion for Services
Services Re uested
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d) (Fee is de endent on the ty e of system ermitted)
Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (1�Tew/Replacement/Itepair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: ��-,4c�(r y �� � Phone (home): S9 7-���i
Address: 7 S CflnGor�� CL �� (work/cell): .Sq2— 37�/�j
2) Name and address of current owner (if different than applicant):
Name: �Qrz„� Phone:
Address:
3) Property Description: Lot Size: Subdivi
Address and/or directions to Property: l 5
#:
❑ yes Does the site contain any jurisdictional wetlands?
'�yes ❑ no Does the site contain any existing wastewater systems?
❑ yes `�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 �uo Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
(/1�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
on-Residentiai /�" (X �� < k� j �'�C
Type of business: Total Square footage of Building: `C'v u,t �t,'�
Maximum number of employees: Maximum number of seats: �
5) Water Supply: � New well �isting Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properly? ❑ yes 0 no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Acceptcd ❑ Innovative ❑ Alternative ❑ Other 0 Any
I certify that the information provided above is complete and correct. 1 also understand that if the information provided is
inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
�'�� �3
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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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r
Application Date: � - -- %
Amount Paid: �,q-_.
Receipt #: n/ / �
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A
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$ I50.00 (if site visit required)
❑ Weli Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
�..��� ) f ������. V Tax Map: �� �
._.. . }' - Parcel#: 7 �
. -�- (� � �.T1�°�"�Y
�..�mv-nn-ananmra�aa4;,m.n )L"��e.�..�d:in.
tion for Services
Services Re uested
� Construction Authorization
(Fee is denendent on the tvne of
❑ Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Inf rmat'
Name: t
Address:
�'��� N G. 2 7d 7y-
2) Name and address of current owner (if different than applicant):
Name: .�,,.,�r�
Address:
3) Property Description: Lot Size: ''Z'S /�GSubdivision:
Address and/or directions to Property:
Phone (home): �I� .�. ''3 � ��'%
(work/cell):
Phone:
Lot #:
❑ yes �� Does the site contain any jurisdictional wetlands?
❑ yes � 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?
❑ yes �-n6 Is the site subject to approval by any other public agency?
� 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:
�IFes dential
❑ New Single Family Residence Maximum number of bedrooms: �_
❑ Expansion of Existing System If expansion: Current number of bedrooms: ����
O Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? •C7'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 C�'hxisting 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):
Cg't,onventional ❑ Accepted 0 Innovative ❑ Alternative ❑ 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�ubsequently altered, or the intended use changes, all permits and approvals shall be invalid.
(Owner/ Le�al Representative*)
�` Supporting documentation required.
4, _�3 . ��"
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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applicant: j�,r�d lt�,�l l��rJ�►'
Address/Location:
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Improvement Permit
Permit Valid for: Five Year � Non-expiring
Type of Facility: '3�� ���5 New Addition _
Number of: Bedrooms �/ Occupants�/ Employees / Seats:
Proposed Wastewater System:
Proposed Repair: A('� _�1 u wt D
Permit Conditions:
Authorized State Agent:
(X) Owner or Legal Representative:
Tax Map: � Parcel:�
Subdivision A-
Phase/Section/Lot
Water Supply: �' � `
Projected Daily Flow: 3(�D gallons/day
Type:
Type: -� :J
Date:
Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements aze 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 t6e provisions of the North Carolina �Laws
mrrl Rules for SewaQe Treatment and Disnosal Svstems'(15A 1�1CAC 18A .1900). Neither Person County nor the Environnnental
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: H(�('��� /(Ju ►r0 (*)Type �� Q Design Flow 3(� 0 gal./day
New Repair Ex ansion Soil LTAR: .J . 2� gal./day/ft2
Type of �acility: '— Basement: _ Yes o
(*) System Types Illb, IIIag, IV, and V, require periodic system inspections by the Person Counry Health Department.
C�d �Q � �`i ( ,�,�> Wastewater Sy�stem Requirements
Tank Si�e: Septic Tank �?�_ � sfinq gal. Pump Tank,'TD .Op_ gal.
Drainfield: Total Arza �nRo J sq. ft. Total Length ^ j�la0 ft.
Trench Width � ft. Min.Soil Cover _� in.
^vrease Trap —�-gal.
Max. Trench Depth � in.
Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold �
Authoriz�d State Agen� �U� [ssue Date: �- �.�—/�
Permit Expiration Date: �(- 23- Zo
� �`
The system permitted is: Conventional /Accepted� / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Tax Map: Parcel #: Da e: Y- 28-(�_
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3� ft of line x 65 gal. per 100 ft = = 100 = 23 gal
75% x gal = j�_ gal per dose 3� gal per minute (gpm) = Flow Rate
�'ricHon �ead
�oss: �]_ft per 100 ft of supply line x^' 0 ft of supply. line =100 =���ft
ft x 1.2 = � ft of friction head
I�tanifold Size: 3' y " Force 1Vlain Size: Z" PVC
iotal �Dynamic lE�ead =��ft of Elevation head + 2 ft of Pressure head +.�ft of
Friction Head = ^- 22 TDH
��mp Requirement: �_ GPM @ ZZ� ft of Head
�rawdown: _��al per dose = 21 gal per inch =,� inch drawdown per dose
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b" Cover • ' , Access Cover- •• , ' ' �. ' 1 i
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+1" SCH 40 PVC Pipe -'' ' �
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Hip�t Watex .'�laxrn Level �
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High Level - i�ump On -.��
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Threaded Gate Valvie
Zip Co
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Block
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Concreie Riser
6" Separation
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Supply � ' portland Cement Grout
Line • � '
Outlet To Distzxbution
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FJoat Wire� . � �
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SITE PLAN
Name
Sub ' ision
Authorized State Agent
Tax Map #� Parcel # ��
Section/Lot#
-Z3 15
Date
System components represent approximate contours only. The contractor must,Jlag the system prior to beginning the
installation to insure that propergrade is maintained
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Building Additions/ Mobile Home Replacements
Tax Map #:—,��� Parcel#: b7jL Address:
Approval Requested for: Mobile Home Replacement
_ ,� Building Addition � X�'✓'�jiG�;�'9
Applicant Name: _�,���/ _����
Address: ��5 �'�C�� ��'�-
Phone #'s: �I7 �'�f �4� �,�� `�
Permit Located: Yes _ /� No
Installation Date: Design flow: (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: T�j � (date)
(Applicant's signature if site visit is not required)
Addition/IZeplacement Approved
,
Environmental H alt pecialist
Da e
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 wwwpersoncountv.net
ConnectGIS Feature Report
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Person County Environmental Health
325 S. Morgan Street
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Roxboro, NC 27573
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