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Application Date: ��3�� '' �} (�
_ � , ti—..�� �� 11- �� `LJ'
Amount Paid: dC -"V � • r •—._•`•"
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Receipt #: �- ,,,„„���,�,Il ]E-7C�,�,D.;�
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d 7717 Z- Application for 5ervices
5ervices Requested
Improvement Permit (Site Evaluation)
' �200.00/�300.00 (if> 600 snd)
0 Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Wetl Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
1) Applicant Information: ,
Name: "—_�' '%�
Address: •'� �' �7 = � � � � � %�
Taz Map: �
Parcel#: ��.
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
Phone (home): �
(work/Cell): ���h; S f�� � �,�1� y7
2) Name and address of current owner (if different than applicant):
� , .S�) �y- ���
Name: � � Phone• > �� �
Address• '�� J)'d-,�-�Q� �� '� ►1't
3) Property Description: Lot Size: Subd�visio : Lot #:�_� `
Address and/or directions to Property: �r 1i �h �� ��� �'�'� s���� n� -1
❑ yes . no Does the site contain any jurisdictional wetlands7
❑ 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:
�R�e�s�dential ' �
'I�PTew Single Family Residence Maximum number of bedrooms: �_/ Occupants: �
❑ Expansion of Existing System If expansion: Current number of edrooms:
❑ Repair to Malfunctioning System Will there be a basement? � yes �no 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 O 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 ❑ Other �Any
1 cert� that the information provided above is complete and correct. I also understand that :f the information provided is
inaccurate. the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�—,��/ %
Date
* Supporting documentation required.
• Permits are valid for either 60 months or are non-egpiring 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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� PLAT OF SURVEY
CARL R. OAKLEY
CUNNINGHAM TWP.. PERSON COUNTY, N.C.
DECEYBER 2006. HAMLETT-JENNINGS 8 ASSOCIATES
212 S. LAYAR STREET, RO%BORO, N.C.
NEAL C. HAMLETT L-2465
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Applicant: �los� + �,�s°"' ��
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I�pr�ye��r.t PPrr�!it
Permit Valid for: Five Yeazs � Non-expiring __
Type of Facility: j'✓3�2 I�P� New � Addition _
Number of: Bedrooms �/ Occupants �mployees / Seats:
Proposed Wastewat r System:
Proposed Repair: -�C���,
Permit Conditions: �e Si' � Sr����
Authorized Sta.te Agent: --`���
(X) Owncr or Legal Representative:
Tag Map: ��P Parcel• � �
Subdivision
Phase/Section/Lot #
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V4'ater Supply: ���
Projected Daily Flow: 3 G� gaIlons/day
Type: �q
Type: �
Date: � ^ � m'�(
Date:
The issuan�e of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applic�nt/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation iC 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 t6e North Carolina `Luws
n�rd Rules for Se►�agE Treatment and Dunnsal Svstems'(15A I�TCAC l8A .19U0). Neither Person County nor the Environmeatat
Health Specialist warrants that :he septic system will continue to fanciioQ satisfa�torily in the future, or ihat t�e water supply wi�l
remair potable.
Authorization to Construct Wast�water System
See si�e picrn and addiliaf�al attachments � ).
�.
Proposed Wastewater System: 7��(�]�t�� '- as (. �
New � Repair _ Expansion _
Type oi Facifii��: �� I I�s.
(*)Type � Design Flow 3 �° °_ gal./day
Soil LTf�R: � 3 � gal./day/ftz
Basement: _ Yes 2C No
('�) System Typ�s IIIb, Illbg, IY, and V, require periodic system inspections by the Ferson County Health Department.
����� �
VVastswa±er System 13eq!�irement�
Tank Size: Septic Tar.k �n��gal.
Urainfield: Total Area OO sq. ft.
Trench Width 3 ft.
Pump Tank � gal
Total Length �d� ft.
Min.Soil Cuver � in.
Grease Trap "� gal.
Max. Trench Depth 3 g in.
Min.Trench Separation � ft.
Distribution: Distr�bution Box� / Serial Distribution__ / Pressure Manifold
Specifications: �� Sr �� 51���
Authoriz�d State t�gar.t:
Issue Date: �--� n '`t 7
r-
Permit Expiration Date: ��(v - Z
7'he system permitted is: Conventional /Acezpted �/ Alternative / Innovative . I accept the co�iditions
and specifications of ±his permit.
{X) Owner or �,egal Representative: Date: '�
Person Counry Environmental Health, 325 S. Morgan St, Suite C; Roxboro, NC27573/ph: 336-597-1790 (rev 5/12)
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3 0 �i� � ��lYOI.( Q�0 l,(,'�. SITE PLAN 2 �>
`� Name � '��s0i.� ( vL S Tax Map# I t Y' Pazcel#
� �z �j.n � t,. � Y� C� �� _ /„ ^ 0 , Subdivisi Secdo.�/L,ot# ` -
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Authorized State Agent Date
�J e I �.,
��,( � � �Q`'L ��9 S�]7V 0(► 'j'� � System components represenl approxin:ale contours only. The con�raclor musl flag the system prior to beginning the
< < instaf/ation to insure tha! proper grade is muintained.
Note: An Accepted system may be used in place oja conventional system witho�t permit authorization or modificalion.
Tax Map:I' � �
Subdivision:
���,�f �I��.���
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IE��s���m��.Il IHL��.11�]]�
Parcel: Q3
WE�L PERNIIT
(New Repair_)
Applicant's Name: , JpS� �I- Sa�., }�-�C� �t S
Mailing Address:
Phone Numbers:
Location of Properiy: S�ar� �r� �'P�'
� � l (o w �il-i t/`e.
Lot:
ur � ��� �'3 S�
u S—Q
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Permit Conditions: , ` �"
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction dnd setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable w ter supply
Other Conditions/Comments: __��c�l��rP+rJ — cvKSr'� �S�`� S'�e � C4' �+ks
Permit issued by:
�Tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:.
Additional Comments:
Date Sample Collected:
EHS:
Person Couniy Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
� �''"`2�
Date: � "� � � � �
Certificate of Completion
D[.iner:
EHS/Date
Depth:
Grout:
DAbaudonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 fax:336-597-7508
11/26/13