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A27 146
Application Date: 02 - I �- I 6 T� Map: �� 7 Amount Paid: I�� 0. 0 C� Parcel #: � Receipt#: a a � -��� ����_ � ���� �� ���� �� 1G��u �-��,.-�,�, ���mIl IE��.�.11�lla Application for Services (Septic Systems and Wells) 1) Services Re uested b• Name: " ,S - Address: l - aG `��A �, � . k� e . a����( Phone # (home� �I l� �3 � - �{'�o� . (work/cell): �'j'� O �9„1- -1 (.� (o� . 2)Name and address of current owner (if different than applicant): Name: .�- -et' Address: t,.}�_Lyc�h,�n 1-s„�.� (k� Ro� h�rD +.�1��� S'14 3) Property Description: Lot Size: Subdivision: Lot #: Address and/or directions to Property: �1,�0`✓� Cj'l � hn_ W � n ' �--�� {r - l� �. 4) Proposed Use and Type of Structure: �'��a�•'�� Residential Business/Type: Other �� w�, yn � ic,J P� Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No _) Garbage disposal: Yes No 5) Water Supply: Private Well (Proposed Existing _� Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A completed application must also include: ➢ A plat/site plan of the property that sliows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or i e s� is subsequ tly altered, or if the intended use changes, all permits and approvals shall become invali . Si nature Owner/Le al Representative). Date :��g ( o� � g � g 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) P:. � � A �� „ t ��; �. �_f 'A�'i� � � i : '��'y: �.�♦ � .. f' � (� �� p � �� .. � > '1.��� (': -�� _ a'i^'T�j'+J. -� t �' *, � �a � . � ; A ` i '+ `�' �+'� � � -r� } '' a . � r� � • ��''�s �('� � �' ' ; �� ti _,� �� .. �� � �+ �i _5 `",� � � �� � � ��` � �� �Lo-� ,"F � � � �o �'�i'' � � \ f ' ' ' -3 � i ..4. y, � � � � � \' . .. $ . � ` . >• ,y � �� � �� .. � � � \ �. �� a j � .. 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Y� •• - � -f, f�lG �,� ♦ ik # �L +1�'T , ~v� ,. w.. , , ��;' ��'� n'$d • + �'� �'�'�" � ` j �.. , . . .� :- . . , �4 ' 1,�:� '� ~! �J , , � �, �� � j �4 �= s r �� ;, ' � �p �� ,�� ;Fa � �y �-' y : � 1 � � ��a ' ��' � ��� - � �� . 4 , , �" ,�. ~ ' r � i a � . �, � : �4� *t- ,� � `» al . ae M- � �� tw �� F � `� ��I�ib� � �. � . . `« � � ���� f''+i� I _ w ry ,� � 3' y�—� . y , a � � ; � . � �.�'. � f ��� �`` , ' . �►`. � � * . � ,�'" �. k, � � .,.,..����� � ,��,�� ��� � � �' . y }�Y':y`` p.'va � ''�.''��"� � �~_ �y � � .. : ' a� � _ �,.. . . �3 '� + � t��. ,ly�, �� . ;yT' - -- - � - . �" _' � .,•.� � — — - - ---`:�,�.'�i►'- �---- � �--- - - ►; 0 f � � � �� � . i �.. � , d n� +, � \�,• ,�J � ' � � � �0;� J.L 1i J,i..:.T.lii�1.�T�.�f�,.�i .�ai.(��i7i.�.�..11 1S. J_l�'i�.���Ji1L �i �u�n��naa� �s��a��a��/ PVg�����e ���ae fl��������n��n$� Tax Map #:� Approval Req�ested for: Parcel#:_1�e �obile Home Replacement uilding Additaon �.. .u- I L . � ♦ " ��,. ''• � '� �♦•'� � ► / i . . • ► �f� - / / i � / : Permit Located: Yes No Installation i�ate: - - o Design flow: 3(� U(;pd) Current Contract with Certifie erator on file (if required): Water Supply: Well Public or Community Wastewater system shows no visual evidence of failure on: 2' �(� -/4 (date) (Applicant's signa.iure if site visit is not required) ���n�no���la���a���� Ag���°�d�� � -17-/a Env' onmental Health Speciahst Date 11/15/05 : . '.����,I / / • . J.l.lJ���� t � `�, Y +�^ � � � � � ]� �-� u- � ��, � �.�.11 IH[ �.�.11 � -- , � � Natne _ I��t;1L' ���' Wr� i�r ��� rs Subdiv-t� - - - , i /_- i,,�;�„�._ �� -t� �Autho�ized State A�ent �I'rE 5I�'I`�I� ;� Tag Ma� # -�.' 7 .Pa:�ce1 �,�,�� �ection/Lot# �_ � j�-/� Date sy��� �a�po�� ��res�a app������o�::o�� �ty: The cont�actor nasrst, f%ag the system prior $o ; beginrair�g the i�istal�a�ion to ��sure thaf projiergmde as mari�tained 1' , Ai►��"at n i�, �; ,,-� ;,�;! C �`` - � � � !M � ►� i m. � �1 �'i �'om i� ` � �,:.�,�y� ���.s� ���� �� �--= -� �����-� I��aaa-��� ���.�.11 ZE-3L��.IlvE� WELL PERMIT PLEASE SEE AT�'ACHED PLAN FOR WELL SITE LAYOU'I' Tax Map #: _��;� Pazcel #/-/ � Township D` ��- L�� �( Applicanr �/ v(�L� ���CC,� 1�O �►-P�f S Subdivision: Section: Location• I � L �C S S�D c'C_ . 5 nl l �a ��e 7_ I� �i ,-._ _ ,�.I , „ l �/ \ Ty�e of Water Su�n1v: Reauirements• � 3�� _'� Individual Comtnunitp Public Site Approved by � �' 0� Grouting Approved by ,� /�Z� ��7'.�� Well Log �n� l�•-l;�-D� Well T '�S Air Vent C'33 u- 0�4 -t� Hose Bib Concrete Slab C..� Well Driller. �v'a� Well Approved By: Date:y' a� �`� '�°5ee Attached Site Sketch'k* Wells must be 10 feet from propertp lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from anp building founda.tion. Other conditions: PCHD, rev. 09/07/01 • rr• Aaplication Date: �"�b� � Maa #: G O Amount Paid: ___ .��— �Rece�i t #: �� #•.�C �.�591 APPLICATION FOR SERVICES Tax Parcel Services Req ested Improvements Pertnit (Recorded Lot) -$200.00 Well Permit (New/Replacement) -$225.00 ❑ Improvements Permit -$150.00 Construction Authorization for Septic Systems- (Mobile Home ReplacemenUAddition) $150.00/$200.00 ❑ Repair/Repiace Existing System Permit ❑ Permit Revision Fee -$75.00 IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT. FALSIFIED, CHANGED, OR THE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATlON TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: (Owner/agent/prospective owner): (�w.v.otl�- Home Phone: �,�1-�a9�r Address: � �- wq Gb d,v Business Phone: Qia- aS�t-'1�g �p,�;t.�f .� �-'ti �"� i Q.a tey� �v"��t2 S�.u�„�,1 ►Q�iT� 2) Name and address of current owner: � wsST G�n*6N S'[ �;20 .� �.'15 ? 3 3) Property Description: Lot size: 5,'LyAc. Township: Ul tv-e. h� � 1 Subdivision: Lot # �Directions to the propErty (Inclu�/� in�g road namns and numbers): �V� `['t Zo �l Z$ UtfA'".l�vTS� n. � �QJa.� 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed ✓ Existing _, Type of Structure: 1.t�.�, e Width: 70' Depth:�! _ b) Number of Bedraoms: 3 Number of occupants or people to be served: �_ c) Basement Yes ✓, No Will there be plumbing in the basement? ✓ d) Garb�ge Disposal: Yes�-�; No � '� 5) Water Supply Type: Private ✓(new ✓or existing�, Public , Community_, Spring _ Are any wells on adjoining property? Yes ✓ No _ If yes, please indicate approximate location on the site plan. 6) Does your property contain previously identified jurisdictional wetlands? Yes_„ No ✓ PLEASE NOTE THE FOLLOWING: 1 A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. 2 PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. 3 THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR _�` [��f ���� �� �.� � � ���� I���n�- � ��.�: �. �.�.Jl IE-3C � �.]1 �]� Ta�x fu1�E� �i Par•cel � , Sl'Ih(iIVIS�I011 Fh���s�e SecMt�ion Lot # Improvement Permit Permit Valid for �Five Years No Ezpiration Type of Facility: � B(L S�� New ✓Addition _ Water Supply ` �'Cr, # of Occupants M0�(� # of Bedrooms �_ Projected Daily Flow 3�_ g.p.d. �� Proposed Wastewater System: ` �.p ` Type: Proposed Repair: C� �,�9 ; �.� V P.�-� �o✓L.Qi TYPe� �6 Permit Owner or Legal Representa ' Signature: Authorized State Agent: �- S Date: � � ��'� 3 Date: The issuarice of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are me� This Improvement Permit is subject to revocatlon if the site plan, plat or the intended use changes. The Improvement Permit 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 Sewage Treatment and Disposal Systems' (15A NCAC 18A .1900). Authorization to Construct Wastewater System �Required for Building Permit) * See site plan and additional attachments (�. Proposed Wastewater System: qrQ�� �- ��p/1 V.n�; � TYpe -u—b Wastewater Flow �g.p.d. New t/ Repair Expan ion Soil LTAR: � 3 g.p.d./ ft 2 Type of Facility: 3(��- �� Basement �es No Wastewater System Requirements Tank Size: Septic Tank: �� gal Pump Tank: gal Grease Trap: N� gal Drainfield: Total Area: �� sq ft Total Length �� ft Mazimum Trench Depth a`f in Trench Width � ft . Minimum Soil Cover: _� in Minimum Trench Sepazation: � ft Distribution: Distribution Box �rial Distribution Pressure Manifold Authorized 5tate Ag Permit m�in�- �,le.m�J; Date: Y — Qf Date: < —�(D �� �ist The type of systexn permitted is 1/�onventional Innovative Alternative. I accept the specifications of the permit. ���� � � � � `v � Owner/Legal Representative: � Date: g — ���,5.� II�I�I�.� ��T � ������ . I��,�a- � ��.��.��-Il IE-1L m �.Il¢]la. SITE SBETCH � N�tne ��.�$�i � I �� ��� Tax.Map # �1 Paxcel # �y�O 4 Subdivision .. . Section/LRt#//�-D v, —��k � �� .f7.titlibtized State Agen�— Date Systen: compoHents hepresent approximate rontouri only. The coniraiMr nrustflag the system prior to beginaing the ixstallatinn to i�rrum thdt r»nliergmde i.'s lrtai�tained � . Is � �� � s� o " s � �e's . m m� 4ss• 8�• e 2 � (� �°�[ � � �j� b IF` IF ' -"r � �� IS � T�� -� � V `�,8�• I T�TAL �F, 1'3jg 16? IF �6' ��- C � CORNERL `9' F �5 + IS �`� �'i-o�.�,Se. .5��s an �f1o�, . .L7Q52m-e,n�-1- ��uM��1R . �eeP �a.r►K c�- \e2s�- l�-J ��-, i�.�►��-�. � ;� Mee�-I- � NS o,n s; te.. �r:ec� +o 1 �15�1c���Q:�� on o��2 Lj�' -�� m N N � J N � � O � -1 D rn r ` S8� • �� 1 •N IS IF � 94 � �_ _ - --_ ' - - —_ 32.27' 31.22' 206.00' - — NS hg S80' 05' 1 S' W_ NS_ __ �- . ���.�,_ SR 1306 60' R�W h•� �� � ���� �� �y�i��� �~ � � ���� I���.��-n-n „-,����.Il.. I���.]l.-�. APPlicar� �c�� a- � - .. 4". Location: s� n� � � rzz ? � �. ��� '� v a . � (ril .-,,.�.- ck.� � �t a't�. � �1x ivl:a,� . P�rcrel r . �,. 5���rh n ��: i���r.� n .^ P�h:�,•�P����ecti�an �La�t � � . ���r�at�oi�: Per�'�llt . � � System Type (In Accordance Wiih Table Va): �� • THfS SYSTEAA l-11�►►5 BEE�i IA{STALLED IN �COMPtIANCE WITH Ai�PLIC�►F3UE NORTFi � CAi�OLdWA GEAIERAL STATUTES,. RULES .F�6� .$EW�1GE ��'i�EEAiMEHT AM� �DISPOSAL, e4ND ALL COPIDITI�IdS � OF TH� IMIPf�O�ENT ' PE�flIT . AND COi�S'9'RUCTiON �1UTI-IOR{?�TION... .. � :.. � •. . ..� , __...�. .� ��•��Q,-o�!'. '. � : Autho ' d S •Agent . . - � .� • • • : � : �Dafe • • - . . lnstailed By. �� ' • .. Date� c I � aq -�y � . . "�-- . � g� � . . . '7'Ss `/a. . ' '_ ... -. :' � . . � . . . . •� ' � _ • � � . . . l03' . • ' � �'7'�Yx .. �,g,�� • ' �. � • . : ' . ' • . . - ' -�`$"�a ' • ..• ' . �- . • ' 1�`5 _ -...__... _... :,- • _ . . . • . : - . ' . � . � . • . . �f►y,, • `' � � - ...- `:.. -•-- �--: . Ca�1�a-�3� �� � . . .. � . . . � c�yy.� Y �' . � . _ . - s�n�la .. . ��sr i�� � ��ti�' � �3-1� a . - 0 D � Y V c � _ . rC��_ rev. G7f29/02 s��c-z��� i�s���c�� c���s� ��� �i - nr� Tax Ma� #� a? Parced #�y C� System Type (Tab�e Va) -�-a � Oume�lA�Qlicarrt �1..���. �- ��, tz,��¢�, Subdi�ision AddresslLncation � ��-�-. �- SeclPl�ase L.ot. # � - , . Se�tic T'ae�k n c�fi�n nes rat�e . . St�te iD/date s��- �� a��a�la-o3 ✓�3s ��- Tr�nch Width ft. .,�C�3 �t ��� Capac' . P �s -�oo� . gaf. ;� Trenct�. De in. � . ' . � Tee and Fiter �� Trenc#� .Ler�gth fi. Baffle Trench Grad� � � Sealartt Trenct�. S acin � � Riser �fi licable � Rodc De th and. Qual' Tank Outlet: Seal �� Dams/Ste downs etc, - . � Pennanent Marker � Pressur� Laterals � � : Pumq� �Tank � Hole Spacing . � . . tate e � � o. e. .. . . . • . . . � . - Capaciiy . al. Pipe Steeve . � - � � - � - Wate roof /Sealar�t � Tum stProtectors � . . . . � � Riser . � �Required Setbac�cs � . Water Tight � � � Frvm .1Nells •..� � . � -a��ti C'� � . . Purnp � From Property lines � - . . . � �taedc ValvelGate Vafire . ..: .Structuresl6asamertts.:: • �-• . � . � ip on o e . � � rt es � raina � e � a v .� � �- � .� h�oatslSvviiches .: . . . . _ � . . j . -SurFace` Waters � . . _ . _ . .. � . .. r . Alarm visabie and audibie Pubiic Water S lies � Eiec�rical Componerrts . Vertical Guis- >2 ft . � - Rate m Wate�- Lines ' App%�ed Pump Niode! . Vehide Traffic � Blodc Under� Pum Ad cerrt�Systems � �� Pu Removai Ro e/Chain. Easeme�rts/Ri ht° af ltilays - . �Disiribution System �the�. Seria! Distribution '� c_� ��� EasemeMs Recorded . � . ressure an' erator r�tract Low Pressure Pipe • Tri-Partate Agreemerrt � A pr. Pipe Material and Grade • Vaives • � � Cornfnerats" . - . � - . , pcf�d rev. 3113101 - ��� S f 1�-�' � ��'. .l��.� �U.�..� ' = �`� cC cC� tC.U.�:( �.r` �'r �x�n�w'7�n-•CY 11T.JL7�:n.•v- ��.-�.tL.:�4 i'l 7.C�.C•c.:n.]l �c:il:n. Owner: ,;.,,.: ,.;J :�' _� •O 3 ( �c;�. ;�.�� G�,w�c� 1 �� � �� t ��.�� �r �' 1: �.� U�C�li�C� C��UOC�1 __� Ll —�=� w�u��ob •i :�� ►�t:�1� � ��:����i �� � �..00c1C10I1' ��p �lt r7L`C,��«� � Subdivision: Lot I6 - ,_ l���cll Coxi�cx•ucfiou Distancc rrom ncaresc Pr�perty Linc (Nl�iniinum 1(; 't� r"..,..�...__._._ Uistazicc fxoni Scptic System (Ivlini�i�unl GO icct) Total Dcptil: ___�__ ft Yicld: 3___ Gi'M Static W:itc:r L�ve:l: �.�_... l� Water Dc:uinb Zoncs: Dcp[h �'� - tt �t � it _=r _ I't Caszub: Dcpth: rrom_(�_ �o �_ ll. Diamctcr: _(2;��,,, ill . v ` Type: Galvanized Stcel � _ Wei�ht: �� ':'hickncss: � I��i�;l�t abovc Ground: _�� it� Drivc Sl�oc: ./ Xc:s No �1,�y problc:ms c:��c�uilc�rccl wliil� sc:��in�; casi��;.;'? __ Ycs �No (�'�C5" b1VC fC1S011: ------- Gzout: Neat: S:ll1CUCCIlI(:11[ �� COIlCi'Cl'C GCi1V(:�ICC111Cl1t �1.nz�ular Sp�cc Widt!1 �_ inche;s V��:ircc in A,tzitul;u Spac� Y�s `� No Mcthod of Grout: Pumpc:d Pre:ssurc ' 1'ourcd `�� Dc:ptli '�.to . rt. iYXacczisls �Jscd: No. II�,gs Portlaud ccmc:n[ �. Wci�;ht ��'1' t Da;; _�_____ I'auuds ; It mixtluc (sznd, ��rzvcl, cultii��s) — J.Zacio _� to � IJ� platcs: �cs No �} x�E slab �-�.'cs r„ Nc� uz•illiu�� Z.c��; 1,c�c:iCiou Ur:iwiiib a� ( b,ercby ecrtifY t�iat thc aUovc in�on��,atiotl is conect and cllac elais wcl! was c:�nscruc�cd :n accordance with regulations 5ct �ortll Uy tllc Pc:r�ot� Coutity 1•lcalth Dc�artmcnc. .� '"' �% � _�a- 03 �`-�� . _,.. ��� r�,�.,o_,�.,� ��:tc� � Si�,atuz'C Q� Cox�tr;�ctor �.' _ ��n��r, ..,, nt I� sln�