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A27 163��, sf �� - - .. c��..T�� J.C��a�a��v�aa:n.-n��n-��.IL ��.�.11��a A��plicant: �tJ%.`1 �, . Ql Address/Location: S�� QA C� v�o_�wcc� c�t�__Pr�� N�t Improvement �Permit Permit Valid for: Five Years X Non-expiring __ Typc of Facility: S►a��E "�ar��f P.Es. New � Addition _ 1Jumber of: Bedrooms �/ Occupants (,"�/ Employees / Seats: Proposed Wastewater System: A c Proposed Repair: A �c.E�EA %ww° Ae.cr�t`tf.0 Permit Conditions: M►air�2Y �-�. o� Tax Map: A�'1 Parcel: ib3 Subdivision i�v�e.. �� Phase/Section/T ot # 1$ �.oa6 s�o� Water Supply: �,ivprc�, W�u` Projected Daily Flow: 3��o gallonsiday Type: 1"''►.S 6 Type: �D6 Authorized Stat� Agent: ___ __ Q. _ Date: $� 1 (X) Owner or Legal Representative: Date: __ The issuance of this permit by the Health Department does nat guarantee the issuance of ot�er re�uired permits. It is the responsibility of the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspectiens requirements are met. This Improvement Permit is subject to revocation if ihe 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 an� Rules for SewaQe Treatment and Disnosal Scstems'(l5A NCAC 18A .1900). Ncither Yerson County nor the Environmental Nealti� Specialist warrants that the septic system will continue tc� f�nctir,n satisfactorify in the future, or that the water supply �vitl rcmain potable. Authorization to Construc� V'Jastewater System See site plan and additional atta;.hments (�. � Proposed Wastewater System: � c,c�.�,p —25'/ i�eciue-+iar► ('�)Type �6 Design Flow 3VR gal./day New � kepair _ Expansion Soii LTAR: �.30 gal./day/ftz Ty�e of Facility: 3� �¢,och S�.1t,� ��.`t �.s►O�c10E Sasement: _ Yes X No (*) S,ystem Types Illb, IIILg, I �; and [; require periudic system inspeciions by the Person Countv Health Department. Wastewater Sysiem Requirements Taiii: Size: Septic Tank I'�a'0 gal. Drainfield: Total Area q Od sq. ft. Trench Width 3 ft. Pump Tank '—' gal Total Length 300 ft. Min.Soil C�ver (� in. Grease Trap —"" gal. Max. Trench Depth Z� in. Min.1'rench SeparatioTi �f ft. Distribution: Distribution Box X/ Serial Distributiun, X_/ Pressure Manifold Specitications: S� Authorized State ageni: l..�ta� S : � TT1s-�n�rto � Issue Date: �a8� 13 Permit Ex�iration Datc: The system permitted is: Conventional /A:,cepted �_/ Alternative / Innovative . 1 accept thz con�itions 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/l2) . , (�u►1e�) f ' �� Application Date: gr°17+) 3 `�� S� ��q �� Tax Map: /�.� 7 Amount Paid: 0�0� �. .� •�i- Parcel#• I� 3 Receipt #: � �t � � 5 5 rJ �• � � �� . �1�II3'VIII`lDII]II3�Can4ia� �Hlc,ea�l7a � � lb�U Anplication for Services Services Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) �-�+� � Mobile Home Replacement or Building Addition $150.00 (if site visit required) WeU Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 Construction Authorization (Fee is dependent on the type of Permit Revision Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: e G, n� Address: I! Z� �6 ( u� h� r� C�;- � J+Af.� � �o,JL�sa. �,r�..��4/ ��Zg'02 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home): S�% �`��/ z� i�%�% g� (work/cell): , 3•4-� �e. Phone• 3) PropertyDescription: LotSize: �,5 rriSubdivision: I3��ye✓' C�^Qe� Lot#: 1� Address and/or directions to Property: ��r,,,,��. Q� , I r� -f- e �� C.o►+1c, s�.�-� ('o�� ✓`�'t' �►�' o� � liea-vr✓' C fe�� ❑ yes pro Does the site contain any jurisdictional wetlands? S¢ e P JC wy � yes 0" o Does the site contain any existing wastewater systems? �g`' ❑ yes �o Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes � Is the site subject to approval by any other public agency? ❑ yes � Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Ty�e of Structure: L9'�esidential 3 ew Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedro ms: ❑ Repair to Malfunctioning System Will there be a basement? � yes no With plumbing fix�.ures? ❑ yes ❑ no ❑Non-Residential Type of business: Total Square footage of Building: Maximum number of employees: Maximum number of seats: 5) Water Supply: Ly"New well ❑ Existing Well � Community Well O 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 I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subseguently altered, or the intended use changes, all permits and approvals shall be invalid. � Signatdre (Owner/ Legal Representative*) * Supporting documentation required. �—zL~�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) �� Sf ��.�� `�= ' c��CT�T�� )�.m1.�nir.^ams�a�n��n.��,�. �rc��m�.��n. WELL PERMIT (New�Repair� Tax Map: .�a�____ Parcel: 1�03 �ubdivision: �v�� C�� Lat: �$ Applicant's Name: �0�1,i,� ro. fl�x�l� Niailing Address: lt�.�1 �.b�v.a cC• }4�uust�iae�, � V�A 2Z $�'Z. Phone Numbers: s�v -- 44�.- o�b Location of Property: �.�+�► �d► 50S a� S59 �i� c.�,�l. 4Y,w�! o��- ��b s�v� � Permit Conditions: 1) See attached site plan for proposed well l�cation. i) All applicable State and County regulations governing construction and setbacks apply. 3) Permits expire S years from the date of issue. Other Conditions/Comments: � Fernnit issued by: c�„�, (�. � Da�fe: S o`i$ 13 CERTIFICATE OF COi�IPLETION New �eil Inspection: EHS/Date Location: Grouting: `'Vell Log: Well Tag: Pump Tag: Air Vent: Hose F3ib: Casing Height: Concrete 51ab: Well Driiler• Pump Installer: Well Approved by: Date Sample Cellected: Liner Inspection: EHS/Date Installer: Depth: Grout: �'Vc1I Abandanment: EHS/Date Completecl: M�thod/Maierial(s): _ License #: License#: Batc: Date Results Mailed: Person County Environmental Health 325 S. Morgan St., Suite C� Phone: 336-597-1790 Fax: 336-597-7808 Roxboro, NC 27573 8/1/08 `��, �� J.Le�� ^ � � �� .� aao�as�aaaaa.Baa�m�� r0m��1ia, � ��S Si� Qv�� 1 ti1 SITE PLAN Name � _ °". . � _ ' y""�"`' Tax Map #�� Patcd # i b3 �Subdiviu 'iX�v��.. Cl�.E-►L- Secdon/ ot# 8 � 8 �8 �3 Authorized State Agent Date System compobeats teptuene appmxfmate cnntours on/y. The conttactotmust Dag r6e systemprlor to begianing rhe insra//ntion ro insure rhat pmpergrade is maintarned. tJvCt,—� �=�f3�t4-3� � � 2�O.00i� tirC� t�l.�0� s.��-��-��-� ��. �R�' �, s�s-�.� ' 3 l��olr /;�'c✓� - � -• � 7 � � � � � ' � � � .a;.� . � � ��-42-G -�'C9..�; \ .fi4� . L T� �� ;�,, ,:�%`' , ' 300 l.tw�iA9�. �"T Gf $ (.Acc�p�o i�i�►cc> � , o� - C3.3o ��t� � �t M��J►�h�� s�. ��s�at5nac� �-t�i C��t�b � � , , i� �� o/� ��••��e � . �A�� .La �,��' o � , E �� o �`�� • � �� z Q �� a ��r `� v� \ � � � �,Q - "' t _,.�°� ��`� �� . �� P�. -� �a►�kv..�-rv�.l M� • i�.��o w� ��. c:m�c�o� . �� . �. �e��s . �� ,a�e�' P C�tJ w` C�i �s�ar�S �3e- s��- ��q�