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A26 88 & 158The District Health Department f L CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal y,�/�IMPROVEMENTS PERMIT N . �Date OWner. Location: �`- � '" . , ��-1��- � C1 . Contractor. � ' Water Sapplp: Private � Public Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal, washing machine, other suto atic appliances Size of tank: �� Nitriftcation line: �ther disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years an3 shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTM STAFF aEFORE ANY PORTION OF THE INSTALLATION IS CO - ERED AND PUT INTO USE. , _ ` Date approved: Signe Sanitarian We1L• f �r Sewage Disposal: Counter- By, signed (Owner or his repr a ve) Certificate of Completion Date Approved: �� By: Sanitarian (OVER) Location of well and sewage disposal facilities sketched on back. NOTE: � sketch of installation showing lot size �hape, location of house, septic tanks, �s, water supplies, etc. Note special problems existing on lot. Wra�in measurements in order that installations may be located at later date. Note location of water supplies on adjacent lots. „ s �. .�- �3�, S �� 130� Application Date: � �a Amount Paid: ) 0 . � Receipt #: 763 46 j� �-�aozo Au L.�'j, ).� ��l.d�� l � Tax Map: /`� �, � ._,., � � ��,�.� Parcel#: � �".nawna'a.um�.uxa¢-��n4:an..1� 1�'j�m�,]Ld,�. for Services Services Re uested ❑ Im 6ement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if> 600 d Fee is de endent on the e of s stem ermitted) Mobile Home Replacement or Building Addition ❑ Permit Revision $ I50.00 (if site visit re uired) $75.00 0 Well Permit (Kew/Replacement/Repair) 0 Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: qSe� r Pn Phone (home): Address: �Q q � s i� V (work/cell):( 3� " q—��r3 T '"7�- 2) Name and address of current owner (if different than applicant): Name: � Phone: Address: 3) Property Description: Lot Size: ��-� Subdivision: Address and/or directions to roP e: P �Y Lot #: ❑ yes ❑ no Does the site contain any jurisciictional 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 ❑ 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: Cwrent number of bedrooms: � Repair to Malfunctioning System Will there be a basement? 0 yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential - - Type of business: Total Square footage of Building: �t� t�Q rc�� e Maximum number of employees: Maximum number of seats: J 3 6 x�� 5) Water Supply: � New well ❑ Existing Well � Community Well � Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on � is property? ❑ yes ❑ no � 6) If applying for `Authorization to Construct', please indicate preferred system type(s): 0 Conventional � Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inacc�rate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. re (Owner/ Le�l Representative*) * Supporting documentation required. --� � � � 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) � ,� -� �� : � ; � �� `� . � � ; �. l� :� � � ( 1 ..� !� b � d + .a'^ � � �� y `� ' ! �+L V � \�� T--�,�,�z�-,�.��=�.�n��.�.��;.� �l .�-�I��.�.Il �.i� �a��d�� 1��/ IY��bn�� I�a�� fl��a��n�� Tax IVIap #:� _ Parcel#: $8 Address: � 99 �� 1��R.�c � ' 1�c,'�oCt� , �.Cr ��15`l'i Approval Requested ior: Mobile Home Replacement —� Building .�ddition Applicant Name: '�'�o�,� WK�� Address: � Phone ,#'s: �-�`�- 483�, Permii Located: x Yes No Installation Date: $-tx ►�S3 Design flow: � (gpd) Current Centract with Certified Operator on file (if required): Water Supply: �_ Well Public or Community Wastewater system shows no visual evidence of failure on: 9-1`1-�'} (date) (Applicant's signature if site visit is not required) Comments: �Aee�aya�. h►�. 34�j xy�' w '�U.1ha�� ` I��eas�n Gat�F. fo�.ir�o�.\ 1�ysc ►��.1, -A' h�r�.c�a�• �1F I� 't-`j' �� S'�.Pre.. Lt� ��a� �� .,�.� Q. �. Environmental Health Speciaiist 9-t�-�� Date PPrson C��un�i Env;ronme:�tal :�ealth; 3^5 3. tiiorQan St., Suite C, RoYboro, NC 2 i�;`3 Fhone: ��6-�47-??9Cl ra::: ��-�9�-iSO� � �v�;.�v.�,ersonc�uirt��.i;e� � �� )� �� `'.�' • �-.� � � �CT1��["�Y ��iaaosns�.aa�sn�aica�m�. IE�'B m�¢�T` SITE PLAN Natne �AS�1� WREaa T�x M�p #�b Pazcd #�$ Subdivision Secrion/Lot# DCR�c�. �. s�rn� 9-►'1-� Authorized State Ageut Date System compoaents repruent �ppmximate coatours on/y. The conrtaaormusrtlag tbe sysrem prior to begianing the installation m insvre that pmpergrade is maintafned. Application Date: I °?3`0� � A�ounX Paid: l Q• U Receipt�,-''• � a a i 3 i,�� S , f� ��.� �� ', � - 3�7� - _ �i ��i°7�� 7E--�:, n-n -a-n 1c-acx� arn.-uaT�.�-s a-n. tL-.cn. �1 7E�L .c�.cn.Il: d: 7l-n. Tax Map: � �� Parcel #: �_� � SJ � � tU Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if> 600 d) (Fee is de endent on the e of s s Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired) $75.00 � Well Permit (New/Replacement) ❑ Repair of Existing Septic System $225.00/$125.00 No Char�e �,a,�b�' � � wt S- Important: If the ii:forfnation in tl:e application for an Improvement Permit is incorrect, falsified, or t/:e site is altered, then tlie Improveme�t Permit and the Authorization to Construct shall become invalid. 5ervices Requested by: Name: ��N r� E��i l- _ Sacl E`� o rJ Address: �q � S�3.A q�-.S 1'�A � H �� .c . a� 5�y Phone # (home): 3 � 6" �°� �'1' �l �-7 `� (work/cell): 3 3 6— S a3 -=�317- - 2)Name and address of current owner (if different than applicant): Name: S-A �. � Address: 3 �' A � 3) Property Description: Lot Size: d Subdivision: tJ o Lot #: Address and/or directions to Property: a% Acce, c 57 N o��'� --. i L QCcokS I`�f�,Q-� R�. �' M�.�e O� lx 4) Proposed Use and Type of Structure: Residential �� Business/Type: Other. . Number of bedrooms �_ / Number of people served (seats/employees): Basement: Yes ✓ No _(with plumbing: Yes _ Nq/� Garbage disposal: Yes� Approximate size of building foundation: Length� Width �_ �5.}�Vater Supply: Pnvate Well � (Proposed Existing � Community Well: Public Water System: /� Are there wells on the adjoining properties? No Yes v (please show location on site plan) Note: A completed application must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying ihat tl:e property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. . Signature (Owner/Legal Representative): ��,,......1��7, _�Date: �^a-3' �� 11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � INITY MAP GLENN C. DILLON D.B. 138, P. 578 D.B. 169, P. 486 � IS \ � � � , � �� \ � \ � \ o �� DONALD W. CILLON � `\ � � D.B. 174, P. 377 � � \ ` � � �\ c',� � \ \� o \ � `� o � i � � � �` � i � � � \ \ � �� \ \ � i � �� i i � \ � � � . � � � �� , IS . �— � � ' J� ' �� . i � �� 1 4w � � � �� 1I.�1�.�J�.�OQ�'i3'11 �"f'itf"11�i��.�� .�1. 1L�i�..11��ria �aai�c�i�ag Ad�ations/ 19�o�i�e �offiae �e�flac�s�e�fl� Tax Map #: �a'�p ��' %`S$ �� i �� Co�,.bi.-,(' Parcel#: � lats} Approval Requested for: Mobile Home Replacement � � Building Addition Applicant Name: �C P� � fl�-�, �- • S'�-� P�� a'� Address: 9 Qr-o a � r /�0 4 d 7c�oi-a rvC, a-TS7 Phone#'s: ��'°^-,P� 33�-S9s-�a79 (�Qi� �3�-Sp3-a��7 Permit Located: � Yes No Installation Date: � 3/� o/�� Desi� flow: �d (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: ��a' S l�� (date) � (Applicant's signature if site visit is not required) Comments: � 2 e S !^ � I� v i ��i�+`� �� v.n e t ' � ✓►-� I o �e P S'j� �c� q.'�i o�, �..,�,��J -d _ - _ S a� G �� `�. �-, i� . a- s r'�" n�7' �P �J ` �� P S�nT�� S�'�%i'�, i� •�-, a .t �-r � P �J . : . �r�d�i�o�tep�ac��n4 App��ves� �-�-, ��-9" �� '/�-,51�� Environmental Health Specialist Date 11/1�/OS ��v�,� � �I��' � � � � �-= - - .��'�vn�--�T-� �ID.'a1S�'^'..ww�C�YmJL ��.1� �'�".� �.'�•'£�T� _ �ll Co-tbi� p „� t�, L, ��,F ��-d ^ � T� �� # iv`�'��s � g� � � S � �w1� ts �� rP e .� Sulidivisioa . ..�rnon,/Lo O �%/�S �' � A,visorized St�te Ageut . • Date . Systzm aim�onen�s re�ss�s�t a�ro..-�e�wmtaurs os+1y. Tve w�r ;rarrst, flag the rysteminz°r �o be�man�ing the imsta�n to ?nsu�'s ��1D��'a�e ir �taiued .� � / Jr /� �'� S�ooJ � �� i5'�-i.� � S9-r u c �I-��P qg� � � ��°� ��6pos ea �-}-ru c�'v�Q sG�.�� e �7 s � ��'1� Sv I ) %�P 7i�dM `t�-tP /� os r°� y , c� P �� S`�"� ��t v�P -i-o �'�P Q� i s�i, � Sn�oJ' � G i-o ., l� \ � �"`'S�" �a7" cl1S/`�J� t�(-rP o�r�i n 1 '' ? i P 1 U fi —� P S, �S �-►� � ��s �-tU-, s c� li i-}eF (�(7 �nP%�• i � /j S�P�_ f� " ^��'O^.�.r-./c / �'��—S�� I%90