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A27 197,�, <.,..� ...... . . .. . .. _ - - - - , � . � ;..., ._, .�. , . _,.,- .. _� . . .a. _ x.. ,_ �... . . � . . _ � ��- �Q,�� t-��„�. � �� 2� �z �� SIi3.�,,5� C�a�.�� v av� ��-►Jb `^'� u. . ��/�� t� �t� �i t'`►�� '�.!i �-,�w � ��-� . .� a �" :�=:w.. ,� niication Date: �� "� Amount Paid: -Od �ec�iat #: �� P�rson CauniV Nealth Department �nvironmental=Health Section�° �. . APPLICATIOPI`FOR SEiZVEC�S Tax Map �• ParcEl #• IF THE 1NFORMATION IN THE APPLICATION FOR AN IMPROVEMEiVT PERMIT IS FALSIFIED, CFIANGED. OR THE SITE IS ALTERED THE9V THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALlD. � �.,`2�J�-� �?�'-�� C.�4�/D.�'C��-S .��t1�_ 1) Pertnit requested by: �(�n n�a9e�ntl ?,r,o�,s� e,ctive owner):�f. LcJ;c.�rsa-/» .Z3- S Ti2��`- Home Phone: '��_3G� -_� �l ��`l Address: � 2-� 5 2C�3 cx� 7-S�✓� f2� • Business Phone: �3G� - 5�7'9 -l3Go R�`%�Ct� o - ��• �'�S`�3 ` ��-�,G'C ,., 2) Name and address of current owner. 5�'nC i�'-S ��C 3) Property Description: �otsize: j�K'Township: ��J l,�g w�S � Directians to the property (Including road names and numbers): 7v �Tp - /2l G1fT — �lo '7b ! �S T Lt` i�z- l''�-•�� /',..., /' = .� : ,— /�/5z�i'� r3v, i �.L"7` �- ,I_� F� �� t��i� � �W� � �' �% DHnJ Q• LcJ/�5�7�-Q �p, 'h1 �, � -t�L/U�%Z !�� d3�� R� 4) Proposed Use �nd Structure Description: answer each of the foilowing questions: a) Proposed p� Existing ❑ b) Stick Built �, Modular �, Single Wide ❑, Double �de ❑ � c) Number of Bedrooms: d) Number of occupants or peopie to be served. e) Basement: Yes �, No �7 If yes, # of basement fixtures: �� " w..:..v ,. , _ ..... .fl-,.-�arbace. Di.��as�;: Y�s 0. No � . _ . . _ _ _. �. _ ,,., .._�._.�., ....w.._ ..,.. , r .- .., ... ,... -. _ � g) Dimensions of Proposed Structure: Width: Depth: 5) Water Supply Type: Private 4� (new � or existing �), Public 0, Community �, Spring ❑ Are any wells on adjoining property? Yes ❑ No 0 If yes, location 6) Piease Indlcate Desired System Type: (systems can be ranked in order of your preference) _Conventional _Modified Conventional _ Alternative. _innovative Other (specify): CLF�4RLY STAKE ALL CORNERS APID LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION � ( J�`\` . �. � �U I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represenY the maximum faalities to be placed on the property. I undersiand if the site is altered or the intended use changes, the permit shall become invalid. t understand that as applicant, I am responsible for identifying and marfcing property lines, comers and making the site accassible for the personnei of the Person Courtty Health Department to conduct their evaluatians. I understand that I am responsible for notiiying the Health Department ifi my prop rty tains any wetlands as esignated b the Army Corps of Engineers. � � �i� M �- �- 2 d , � Owner or Legal Repres n ative Date �� -�� J�f1 ��Q sC ��C ��L(� ii'^,� e� PCHD, rev. 10/12/99 � ' rlpplicatton �i: . Taz llrp �: .. . • Parcei �: - � Par�son Caunty. Haalth Departrnartt , � Environmantal Hsalth Sactlon ' $IT� SKEYC9�.. i (fc�;l/��u� , - . � . .Appuoane. Name su slonr8ect[ordt.o� , �Auttt StetaAQant Date . " � qppicadnr�s cauloras oer{� Tiu caabacfur arud fiqs tLrs sytf� �'�� prlor M bstfnnbi[ tbelruYeAafion to Gti�aif fkafDroP�Xrade isMalsGrieed- � `, .. . . . . _ __ ..---- -T- --•_ _ .. . _ �_ __.�_......�_..._�_'._ �_.., ��OYW. O /^\ � u U W W t � - � N � LL � �G 'Wo�� .�, n_ <zo�� ti � -Q O�. �. O 2 � �� , n ZCWr ' 3 Q % 50{•1I'2f'E TD�gI'SB� �im�« — —'$R _ ,.o,• ' ��V�3 � - ,� _.- �. To sa iaaa � Y o�� —__—� � _ \ �6YT ;H7Z.. . .� /� �puY: 1N3W3Sb'3 � �u�� k t�� SS3��d,,�09 �, W � n � P y icale: � �� ' ; s 0 v � F�3�S�(d C�t�NT'l E��I�Rt.�NIVIlE�I�,i4L HE.�Li'�-3 . ��,s� S�� A�C�1E� �'�►N Ft�ff� �IIE�L Si'i� l.A�1019�' �} a � � �,�,� � 1 � 7 . . Taa 711ap 9: � � ( � �rtg _�.__ Towa�(p �/` U . . .. . - . APP�� i' � i� Gl / 1 � ,r D I-� � , _ . . �, � n , �� Well Permit Tvae of Water Suaulv: Individual Community Public Requirements- . Siie Approv by _�1�� Grouting proved by � � `?� � Weil Log WeU Tag Air Vent Hose Bib Cancrete S1ab WeII Dritler• Well Approved By: � Date: **See Attached Site Sketcfi** Wells must be 10. feet from property lines. 11.11e11s must be 100 feet from septic systems. Welis must be �af least 25 feei from any buiiding foundation. Other conditions: � � PCHD, rev.11/29I99 1 r �� i�i:i;sur� �:uuri�i��' i;ii��ii:ui�rit�iii�ni. iii.n�.�r�� I ��IIC: �Z..�.!'1..��1.� c:>>vi��r: ._t�. � l_J�.�.rn , . � rp�. _. ... . . _ __..___.....--- . _._ . 51:�1 --- __ _ .. . .c><��tiuii/1)i,-cc(i�>i�5: - --G�f:.Ler_..(� ... ._.. . . ._._ ..a1'1.11_...1-�.�.1. . .� .�.��Qr..��....C�s�1------� .......__...------ - -----�-�----�-- _ ._.. - ------ .._..._. _ ..--- --.. . ---- �--.._ _... .. .. .____ _._.__._.___.._.--- ----._. ... . � Sulxlivi:�iu�i N<i��:: .�.' - .....---.... l:)rillin�; C'onir��ctc�r: --- .. . --�--- ----- --------------- (_c�t lf--- -- - -�-� -Lk.,--��.h__..�,t�_�7--� d --------------�------------------_ Wf_i,(_.c�'�")N�"f}t(7C"1'ION 1)is�.u�c� I�r�,in Nu,irest 1'iu�>�rty l.,ii�c.------.------ — I�)ist<<�icc trc�iii Source c�F Nu l l u t i c� n,�-C2�------ _-- ' � "Cuta! Uci�tl�:��.—_ l�t. 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IF �nixturc (sa�icl, �ravel, �;uttit��s - Ra�iu: (' !`. c ) '?� _ 1 c ) ll�) l'l.tics: Y�S----�' j`jc� -----_._ . --�-----.-- �i X �� sl�►�� Y�s .__r��---�-------- ----- _..---�----- --------._---__.__. _.._ _-�- ------�—[)R1I.��r�r;_�.c-x=; _---------�--------._----�-----__ n� �� --z----- -- ---- - :.-:- - ---� ----------------------------....___--- --....---- -�- -�- --------- � �. r,�,�� r��, r��►�� »�:s��> >�� — ----- --.. � ----- -. -�--- - ------- -- --..- ---.--.---- ------ - --. . . . -- - --:. _ .. _ - ---- _ .. . .._ _ ,. . . . . .. .. . _. - -------�--- � - .- .---- �o . ._..._ . �r_� �eh �c�c � - .. ...... .. . .... __ ..__-.--- --��-- --�-� -�.! ...._ _�nccan.,`�-�._ .._ ... _._._..-- - ...._...._...._ . . . .. ..... ---- --. ._ .._____ -`��- ----- ��.5 ---. _ C�. _r.�hf�:�:�...------ - ._.... __ .._. r tIt_Rr_•13Yc:1.tt'1'lr�Y�t�tl��i��l'[lf: �l�c)Vl; INFOlt1��l,�'i'Ic:>l� 15 C:OItltl:c�� 1' f�Nl)'i'liA'i' 'l'[1(S WI:(.I. 1'�AS C�(:�t•JS'I'IZI1�:'I'I;I�) 1i�1 Ac~(�c�1z>>��rrc��: \�VI"I'll lll:(�UI..A'I'1ONS SL'•"I' I��O!t'1'il I3Y�"l'l ll. i'f:l��,c �i J c�c>t1�J'I'Y I11:�1i:t'il i�l:l�t�lt'I't�-1t.rd'I'. �i�;ii�i�ui� c�C�' iir,ic:�L� I . �//� (l1 1 �,�i:_ li�"'. �!A .� � Y-� y �� A lication Date: Amount Paid: O. D Receipt #: Tax Ma #: a Parcel #: � -L 7 ��_s� �I�II�� T - - _ ��- ��.��u-��m�.-�,.��.-,��.�n �r��.n�n-,. APPLICATION FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT,_FALSIFIED, CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: (Owner/agent/prospective owner): w � � � � �''�'` 'J • ST�O � � Home Phone: 3�[� _ ��f —�Z.� Address: Z./� lZe�i3��'SGH/ �E'D • Business Phone: 3�1� � S��—/ 300 �7r� a3v�o , NC •�'7 S7� ��.�.cc? 3 �C� -��4� -�s9��1 3�r� c- 2) Name and address of current owner: 3) Property Description: Lot size: Township: �I��v �l� Subdivision: Directions to the property (Including road names and numbers): G� /S� G��t ��=t-f c� z �_ _ �",� �i aLivi D. GcJ'��✓�T�i►�D .E'l�, --LCrZ� E��lLb� r„� o � . �o�; r — J�'�w�- �• �.v��a;,5' f.�� co�}�'� �� . 4) Proposed Use and Structure Description: answer each of he ollowing questions: a) Proposed _, Existing _, Type of Structure: b) Number of Bedrooms: Number of occupants or people to be served: . c) Basement: Yes_, No Will there be plumbing in the basement? d) Garbage Disposal: Yes _, No _ �� Gi�C ��'? �,� � y' � � Lot Width: Depth: �.4G%l� ��Ni4�,5 �� 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: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the prope�ty. I understand if the site is altered or the intended use changes, the permit shall become invalid. 1 c�11 ��.�� . 5�,��- �� f � Owner or Legal Representative ate PCHD, rev. 06/27/02 Application Date: 11 � 1 � '� � ��.�� (�� Amount Paid: �00 . C� �U� Receipt #: q u I o3G '� �� c+��' 33 7� IE".�raa-an-�ma*,•,�*�znU:,a�.I� IC�I�e�,IlffaLu. A 6r Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $i5G.00 �if site visit requiredj 0 '1We11 Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 tion for Services Tax Map: � o� � Parcel#c Ia � �� X�� Services Re uested ❑ Construction Authorization (Fee is de endent on the ty e of s stem ermitted) ' ❑ Permif Revision $7S.00 ❑ Repair of Existing Septic System Application: No Chazge/ CA $150.00 or $300.00 1) Applicaat In%rmatio Name: � 1 a�a�sS Address: i-{1�{ (`(��11 �1l %v�C.l�cs(c�, r�G ? �5?�i 2) Name and address of current owner (if different thau applicant): Name: _��1Q-c 11t.�0 —E �u,SC-�-il � o�n an Address: 3� Property Description: Lot Size: Subdiv►sion: Address and/or directions to Property:_ e.o 1r,; ❑ yes ❑ no ❑ yes ❑ no ❑ yes O no ❑ yes ❑ no ❑ yes ❑ no Phone (home): �j�.Q � �Joia' � 3�� (work/cell): _ _ `3?�� - �3- �-1 �;3� Phnr.e: Lc�t #: • ,,:-- Does the site contain any jurisdictional wetlands? Does the site contain any existing wastewater systems? Is any wastewater going to be generated on the site other than domestic sewage? Is the site subject to approval by any other public agency? 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 dential ew Single Family Residence Maximum number of bedrooms: � � fixpansion of Existing System If expansion: Cu:rar�t r,•anber of bedrooms: ❑ R�pair to :�4zlfun�t;oning System Will there be a basement? 0 yes ❑ no With plumbing fixtures7 � yes ❑ no ❑Non-Residential Type of business: Mzxim4m number of employees: Total Square footage of Building: Nzr.imum numb�: o: seats: �) Water Supply: ❑ New well L7 Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted O Innovative ❑ Alternative ❑ Other ❑ Any I ce�•t� that the information provided above is complete and correct. I 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.. �� -( c��i� _ [(-rCo-c� Signature (Owner/ Legal Representative*) Date '� Supporting documentation required. • 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) Per��c � � Application Date: �'3 �" � 3 a =�� S� ��(��T �L1�b V Amount Paid: � 00� UO j , G ._..; * • �„�- � � �� Receipt #: �I �.�. ! (,'iR '� l 8 �' �.nnwna•ananmrn��n.daaIl ��ai..�d.��. °► 4l I�d Application for 5ervices Tax Map: � � 7 Parcel#: � q 7 Services Re uested I vemen rmit (Site Evaluation) 0 Construction Authorization $200.00/$ 0.00 if> 500 d) (Fee is de endent on the e of system ermitted) ❑ Mo eplacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired) $75.00 � Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 �) Applicant Information: p� Name: � C� . � Phone (home): ��I 7 — ��O Address: (worWcel l): J�l o"� — � � 2) Name and address ofy� rrent owner (if different than applicant): Name: TO,1�'O� 4�0..55 Phone: Address: 3) Property Description: Lot Size: (p � i� Address and/or directions to Property: _ ❑ yes ❑ yes ❑ yes ❑ yes t,�'yes no �.no ❑ no �A Lot #: � `� 7 r Does the site contain any jurisdictional wetlands? Does the site contain any existing wastewater systems? Is any wastewater going to be generated on the site other than domestic sewage? Is the site subject to approval by any other public agency? 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 I�.New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current niunber of be ooms: ❑ 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 � Spring Are there any existing welis, springs, or �xisting waterlines on this �roperty? ❑ yss ❑ no 6 If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Acc�pted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the informution pravided above is complete and correct. I also understand that if the infof�mation provided is inaccurate, or if the site is szrbsequently altered, or the intended arse cha�zges, all permits and approvals shall be invalid. ,� �L��iy�.`,-P �l JVv�-e-� Signature (Owner/ Legal Representative*) D e * Supporting documentation required. 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) . �Application Date: 02c( 1.3 Amount Paid: !�I jq Receipt #: O Improvement Permit (Site Evaluation) $200.U0%$300.00 (if> 600 g�________ obile Hunie Replacemenk or Building Addition $150.00 (if site visit rec�uire�__v 0 Well Permit (New/Replacement/12epair) �300.OQ/$200.OU/�75.00 ��s Tax Map: �� / ' j �" � �� Parcel#: Q `_= �- c� � �J�vI[[°� ---�—� ��rn� na-cDanaxatsm.d.ea.11. )f-3lc�.�..11�.:�a. �lication for Services Services Reauested � Construction Authorization (Fee is deaendent on the type of ^u Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Infor ation: Name: (,Z 5 S Address: ( f�Y\,� C 2) Name and address of current owner (if different than applicant): Name: Address: h'��. 3) Property Descriptiou: Lot Size: `_ Subdiv Address and/or directions to Yroperty: �_ Phone (home): 3� -3aa—��j�c( (work/cell): lQ - 5s3- ya3a Phone: Lot #: � R<� �-�. Nc. a-r�� ❑ yes Does the site contain any jurisdictional wetlands? �yes no Does the site contain any existuig wastewater systems? O yes o Is c�ny waste�vater going to �e ,;enerated on th� site other than domestic sewage? ❑.�es Is ihe site subject to approvai by any other public agcncy? ❑ yes Are there any easements or right ef ways on this property'? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: OResidentiat ❑ New Single Famil;� Residence MaKimum number of bedrooms: _ � Expansion of Exi�ting System If expansi�.n: Current number of bedrooins: ❑ Repair to Malfunctioning S�stem �%Jill there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no I�� + �Alon-Residential (�,� �� Type of business: Q'Jd�%e-- ��tl� __ Total Square footage of Building: Maximum number of emrloyees: __ A�Iaximum number of seats: 5) `Vater Supply: ❑ lv`ew well �Existing Weli ❑ Community V�'ell ❑ Public Water ❑ Spring Are there any existir.g wells, springs, or existing waterlir.es an this property? ❑ yes CI no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ lnnovative ❑ Alternative ❑ Other � Any I certify that the inforniation provided above is ce»iplete and correct. 1 also unde-rst�nd that if the infvrniatiorr provuled is inaccurate, or if the site is sa,�bseqtiently altered, or thc intended use chan�es, all pertnits and approials shall be incalid. Representative'") * Supporting documentation required. 5-a�-�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) ,�„ ,�o� S �.� I301 uw ua�x u��ne ues VICINITY MAP F n � O � r.�,te c�eaiv,t . P-.R:�:9 LPJM1IT �•- : <,..,, :.. ;�,.,y �f:�...s.:;s;'; � ; . . " ��.,� . . , ...' :. •:' ... •. � : .( t '.:.�....� .:.l�.i:�.. . . 1 :t7 e:ye.:lpei� . ,��et.ell�t�.o�kr�:l. i•�. �. .�i�? :• _L�.:.�� •:... . .. i s � wwr �,; Y f.i_±:•.� �73. ':. , �au« �u :::ti N0. CEtT� N�U[US MC TM7 C!Q &i6 CHOHD C- 1 19•00'O1• 290.00 90. 17 fl.53• N00'77'0!•Y 9A 73 -.�� "' n:.�<ili GUt��U:+h Pch;xyV UAiK �..r�n�.S�tinnu.€rr_ ... , certily Ih.d umir.� my ;u{•'nnsion +inJ :t'n'�l�o�� e6�s man xas Ctawn ffa �n, �clual held surv� and lhal Ne •vuH ol ctowie is ��e,aav� . .. .Vilrwv� Ilry A,IIY.I �INJ SCBI fA15 �9 dJY 01 _nPRiL _. l9 09 �.P.. e. .�,4�,,,,QJ�t.4'l.l�6.� It..y,i�fnrnd Land tiuNa�rc NORRI CARUIINA, Fr.RSUN CUUNI I f,y'EMOY �YNN IiONU �GEN fRYI Notiry YuGfc Jo hereM� ce4iry lhaL .'�n� c imw.E r r Si.r��ya. Fs�s-, � :�;y a;:;ca�cJ I:r�cre ntc I?�is %1.,� .,aa ,v.knqwleAgE. t�iQ d'1C J%tCLi^•1� GI IIIC IOfe({Ui11Q inshum��nt Yli�n2s: r.:y hand and rOCarial SC01 IhiS ...!4 day Of naHn. �� 09 ,M�C Commi;siUn expin:s..@�L4i`99_.._. Wv/ w�`11.'i5'N�k['� _i�.l2�.�'x.� f11I5 PLAT M�5 VPlV�HlO [N �CCO(IOAIKf. %[7M 4 S {7-30 A$ /UW.�nE0. N WILI.IAM 0. Sfii01'E � fn U 60'R/W —+-j Q r / �O . aySp� C',k�/�:' •�N/ ��iii;y��!°% ! sen�� : �, isnes � : '•, y'�YI'�vty 7�3 �'%Fa� C naM�;`�� PlA7 UF Sl1RVEY FUR W I L L I AM B. STROF�E & L I NUSEY B. 5"fROF'E OLIVG hIILI 'lWP. , PERSON COUN7Y, NC APF2IL 1989, hIALL—HAMLETT & ASSOC. NEAL C. hIAMLETf L-2465 r_,. _.`_._ �o� • : °_-_- -wr _ �ae• aae• �ao• SCALF 1' = 700' sa niw 1306 I �o 1= I )�� I // �� "" J NF I WI ._ Qi y;� �"� � � J `� � �_. ._.._ ... _ --- � . -- �, �, + p,�,t�� ` . �0' 11TE Tfi1ANGLF . 2� �$ s.is ac. � � �;� � �� `_J 60' flM � N09'tl'20'W � t.zo' —___""'__ Sl9�77'N•Y — . _ V _ Ny, 91�.�t• � ' I � �N. �S, ' .cr,��ro • waw rauw O INON SEf NS O Npq,sEf Hr' • ruti ra.ND M� O ��EYA�IC�L POMT � CONGPCfEMMqJMENi /OHN 0. YINSiEAO III t KAY P. YINSTEAO 1 l'I� r h ll b� U 911� 1 i � i �M (Yl ANL I I�N � .<l l l p� 'nE VMOIt��I SiqwM �xD 0(f[�I�CO �C�[OM �' rn �e [vu o• o�eo aeeu+nrn i �� .��a �u�ri. .iou�E+ or� oeeo, a 1•�GC f (VC)'M[tfY/YbOvl��i�IS�� OI SUlOIV�IOM�Y 1(ON) ��F! CONSf�t. rSl�l�IS� InF MIVIMUM BVIl01MC�llnt5. �MO D[UIC�1� Y� �_LE�f� M�LRS. F�fCMENIf� �I1RR5� Of��[II OYlH S��Clf IU >�n�.lC o� ��Iv�IE USE �7 MOt(D. IM�iKf 1(L[) ��l��Er,c!��i� zr4T 1nE 1�M0 �S SMO'rN �2�[OM If yl�Mlw �i aeomsio. �roui�non aunto�u�on m ��c�w uw.�., xoer. u�o�.i��. � rf� , iv W Lf� ��'] �n-r^— � �� '%%' � fQr,r� '=i_'..... ov�ti737.._._. _: . 1 i29[!� C[111:�Y 1�U( TN[ fu801viSI0N h�t �S Of�ICiCO I�ENEq� rA5 YC[V C��M�['! flw�t �tOv�l �utSJlxl 10 ��[ I[�SOM CWMi• SVODIVISION �£WLAt10NS. � ��. �9 --t .1°1------' � ;�"��V.� lQ��f�'�n..,,�. _��. sf ��..� �� 7[�e�.�a��,.-„-„ ��.Il IL��.Il�I� _� Applicant: �g� Address/Locat�on: Improvement Permit Permit Valid for: Five Years Non-expiring Type of Facility: �{iv�.�P �c��1�Ce, New �Addition _ Number of: Bedrooms �/ Occupants 6/ Employees / Seats: Proposed Wastewater System: Cc Z% Proposed Repair: � U �,, �,p Permit Conditions: „ ., Authorized State Agent: (X) Owner or Legal Re 50' r Tax Map: � Parcel: � � 7 Subdivision Phase/Section/Lot # Water Supply: e X S Pro'ected Daily Flow: gallo day � Type: Type: , _ .r � .,,11 �L ../ - - Date: The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibiliry of the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are 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 the provisions of the North Carolina `Laws a�:�l Rules t'or Sewa�e Treatment and Disposal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental 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 astewater System: W u o u )(�`)Type � Design Flow �� gal./day New � Repair Expansion Soil LTAR. � Z gai./day/ft2 Type of Facility: �v�� ,�i�(eh�p: Basement: _ Yes _No (*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person Counry Health Department. Wastewater System Requirements Tank Size: Septic Tank � i bd0 gal. Purrip Tank 1.,� gal. Drainfield: Total Area %5q o sq, ft. Total Length �� ft. Trench Width 3 ft. Min.Soil Cover �� in. Distributioa: Distribution Box / Serial Distribution / Pressure Manifol S Authorized State Agent: � w'pu�� irease Trap �-�---�al. Ma�c. Trench Depth� in. o �C , Min.Tr nch Separation � ft. d � �n n 2J� .. �♦ n. ,n .rf�- i�A/�/'n lI �� Issue Date: �� - 20 -12 Permit Expiration Date: /� �- ZD -►'7 The system permitted is: Conventional /Accepted ✓/ Alternative / Innovative and specifications of this permit. (X) Owner or Legal Representative:� _. I accept the conditions Date: l2 Z Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) .. . :�� -1��.�� . � � � � �� .�. ��. SITE SB�TCH Name . � Tax Ma.p #� Z7 . Pa�rcel #�_ Subdtvis _ � Section/Lot# - —� ��( 2 . . utho�ized State .Agent . � Date . . :, System componenrs represent a�iproximc�t'e�contoura only: The coniractor must, flag the system1Drior to beginning the instaTlafion �to insure thut propergmde rs muinto=ned _ � .1 �.. �;,: ....: :.,:,.- ;:.:: . `'�c.-�[.� �� , � �,; � :�,.. � _ � ;� 1}. �1. . ;� �..�,;. ; • .�.�,;'._: 5 ' 'Z � :�,'.�:: ' �.�il�' ~' `t: �i:�y.i..� ��. . . �,.� �, '...,.� . �':�� .•:��'ti:'�:� �M . 1 . ., �'• r • , ' � .. .� f � S . '7Y' . . : i,\ . '.': �t )� T� y '.: ..i i . . . '�.�' `i�..J1.��l.,�q.�iYA. ' !. t '.?' I t � �'! . M S f ( 1: . � : . � f r ri � 7 � , � '� � i i f; . . . - .ti� ,�3.. � : - ' . '1:.:: —I--n��` a I �r/ S�fV1 � . � ` ,,. l� � , • � r .�.' ` ..�:jtl'' f.�. !.;' �:S�..k'� i'i{. . �i. . y.'^� • T 'S ; 1'/y ^ i ' J ) - lV�/ ��' ` � 1 •, + .'� � I_�, �) 1 t 1 gPt �?�-�6.� , i +, . ; $ ( . .. _�,.�a' � �d .� �urn� ` i.f.i `1 +:ti�: � ' .. • �F''.,� �)'i -- ��'' -}YenC� . . : � . , � �� : ��. _ ----� _�� ' ' : " � , �1 _ � ,5` �r�w,�1��Q(f� ��[I' . . .: . '� .','' ,:(":_.:,r'±.� . .. .� ��:'.;, :•;..:�. : •. � f' � f ' . ' . . . . "' � �•.', '� �'��;:f .��•,`r.!. J/IA C�;�+ .1i.' •� Q� � Y � , r ` '. . 4: �,.. I . . � O+ � ,: , ..:.j..;,. �'` p� �i � �� ia (' � , . .�, ; m ��`4 : � Z� �, . � ' . � . ��Z `i .. .' `}�QnGjt�25 S�ou�d �� . .�:,:. .;. . , . � . � ;, �(�f,�o� h �'i � l ��ah�� c n%�� . : .. ' : �. �o �: ::;� �1a�u� So � . . . ; � �. _ .�=a ( � l : . 3 ��, � - � � � : � . � �; �::;.� . � .. ��: '�y ,'1 . J� � �.. � , '��su,�.: .��.. .+ � -�.;`,' . � ��(� :v� = � �, .. . � p iibl�: 1� k. . �d� � .. . . r�i � ��. �I � . , . . ::�:�:�..� ��-- • .. • �: �` �:� � . , =i.�� '' �'., . • � :� � � �. � �e- �� al c�o��. ��i .e� -. . - ,._}: . � �� a no�a�� . . , � � ��:� - 5 ' � ' �'.�: . . . . . •:I i� 1. �i : .;. } .y�� . �5.. � 1'� . , � ti �'. .. R z t ��. i 7: . , '� .. '.�"� SC�L� : �' �- �oD � � . � . � � � . . , i ��(ai ��acn 5� on� wf� �m � �� '� s�s�� s ��;�.� � I�l�� -�-. � �fl �T�'1��Y 1�;�-�a ��.��.11 ]HL�.�,ll,E� Owner: Tax Map: Parcel #: � Date: �/- �!� Z 1Li�e Tap �'ap (Sc�) Tap �'11oFv Line b,ength �'1ow /%o� # Dia��te�(�ga) { m) : ft) 1 �. � � � o . 05 2 � 130 3 4 � 5 6 � 7 � 8 9 N � �0 � m .5��0 ft of line x 65 gal. per 100 ft = ; 100 =��gal 75°lo x gal =�� gal per dose �Q_ gal per minute (gpm) _�'low Rate Friction �ead �oss:��`�ft per 100 ft of upply line x'�' 3.SD ft of supply.line = 1Q0 =��ft ft x 1.2 =� ft of friction head IO�Ianifold Size: 3"� " Force 1Vgain Size: �" PVC �otal Dynamic IE�ead =,�_ft of Elevation head + Z ft of Pressure head + g ft of Friction Head = Zi� TDH P�mu Requirement: 3b GPM @ 2�.2 . ft of Head Dra�down: ��i gal per dose = 21 gal per inch =.� Z inch drawdown per dose �.�� :r:. �� :� � ��:,�.� '' ' = � :_��t0 � -- • . � . . . . • ,,. � � ,. , I I I I ,.. ■[(�l�oe_�0o e o- -<-�- - - - -�-� - -o- - 1�1 1�1 ��1 1�1 -,, iii��i�iii��i�i��iii�iii�i�iii .... .. _ ..... ***��+��.lN.�.�N.��N°!�.!!!!l��.!! � ■ ■ ■ : ' - : :1 ' : : : Y' T�V� ��m� `� s � a 5iz4 / � Taps No. T�ps off ane side `jx ior ta in D�ii� siu s�,» {apg 1" tg z 5 3 9 � �t 11 " Flow er Tap Si.e illcrteria! r'7v��' GPLI t� �� Sched 30 �•S ;, ,� ` Scired �0 i.: ;, " Scl:ed 80 l0. I ;,'• Scliev "0 11.. �.�h i �,�� j'�� ~ � �./ � �� a�v-a�c-��,�-„r„ ��ra�.en.�. ��.'�.��s Sloped To Shed Water b" Cover • � .. Izdet Fmm Septic Tank 4" SCH 40 PVC Pipe , NEMA 4X Simplex Contml Panel � I-1 4" X 4" Pressux+e Treated Post � 12" Sep�ation � n�� co�t ^ 1 �• � Access Cover• .• ' � � ' 1 • i . _ _ , f �, ; � —T. ;. ► � � � ';� : • �' • . : �,. Opening Fi7]ed With ,. (4n{i Siphon Hole ` Portland Cement Graut �� H�) Cl�eck . Valva - High Watex Alarrn Level � (6' Sepazation� , Hig�t Level - Pump On -�.t� „ , '�Vapoz Lock �� Hole T�x �Fl�� Z P�rcal # ' � �ihciivisi•o►� f'Irase;S�-CflOIl�Lot # Duct Seal Hoth Concreie Riser � Ends Of The Conduit � . -` 24" Muiizsaun - ,. ., b" Separation Threaded Gate Yalve • • Union . �,��Poitland Concxete Crraut Mastic • - • : . ti;. _ - , . Zip Coxd .� Opex�ing Filled Witk • Ties Supply ' portland Cexnent Grout Line •� 4utlet To Distzibution �(-Nylon 2" SCH40PVC Pipe • � • Dxawdrnvn �Up ��) � � '. ` Law Leval -Pump Of�' � • PumP �• Pxecast ConcrE:te Tank 4" Concrete ,.; (MaterialStzen�th>3500PSI) Block . � ., . • . .•`: . : • ,. . __ .'.". •:.. •. . .'` : Float Wire� � � .; Fioat� l,�; . % �Remova�le • • � F7�iat Txee ' � ,r i - � .,. �. � • 1 .• �. ' . . ��DC� GAZL{�N I''U1VIP TAl`+T.T� � , -1� �u L a . � D ��'�i. �� ` � `�"Z} �' Application Date: 7'� �'� L �� S f �� Taz Map: � Amount Paid: ',�.00 .�..; "�r- � � ��.� Parcel#: Receipt #: I 7,�2 93 � �'�.�saawna-�aaaaaoua�ra� �c3iaIl4�ia ilication for Services Services Requested ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) _ �Well Permit (New/Re cen $300.00/$200.0 /$75.00 1) Applicant Information: Name: Address: �idR4 V : 2) Name and addres� of current Name: Address: � ► h�Cy2 3) Property Description: Lot . Addres�nd/o� direct�a 0 Construction Authorization (Fee is denendent on the type of ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Annlication: No Char¢e/ CA $150.00 or $300.00 Phone (home):. `, � (work/cell): 3�n ��3r� �3� different than applicant): Lr, ].�� Phone: '�3ie " '�� " �Z,�`'7 Subdi #: ❑ yes O no Does the site contain any jurisdictionTwetlands'! ❑ yes ❑ no Does the site contain any existing wastewater systems? ❑ yes ❑ no Is any wastewater going to be generated on the site other than domesric sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency? � b ❑ yes 0 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: DResidential ❑ New Single Family Residence Maximum number of bedrooms: / Occupants: ❑ 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 ❑Non-Residential Type of business: Ma�cimum number of employees: Total Square footage of Building: Maacimum number of seats: 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ 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 I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, the �su�sequently�te�d,,�or the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Legal �reser * Supporting documentation required. �`�� "� �P � 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. . ✓ � . �� ' �^ � � �� 1.1. � ��i.��.,,:�i�.�.��.� � .�i�.L.�� Building Additions/ Mobile Home Replacements Tax Map #:� Parcel#: Q� Address: �r �� ( , C Approval Requested for: Mobile Home Repl cement �_ Building Addition �b�,,rQ_ �,,Q, /)p� � cJ' - - 1- � Applicant Name: �9✓�r �Q S S Address: S�rvt�2- Qs 4`� a'i`e- Phone #'s: �22-131 $83 �-1�3 � Permit Located: /� Yes No U Installation Datz: 1' Design flow: r� (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: date) (Applicant's signature if site visit is not required) �.J S S r'�� 1� `� `�� i �t �(� Comments: ��, AdditionlReplacement Approved � � �v�f E vironmental Health Specialist S�a�`�3 Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www,personcounty.net ��ss ��.�� 9e�a-wn.a-��,•-„-„ �sa��.Il IE�¢��s.Il�Ila Tax Map � Parcel # lq7 Subdivision Phase/Section/Lot # # of Bedrooms � Applicant: i 'A,2,a, '�s __ __ Locanon: ' _Y_____� � � • Ou�ration Permit System Type (From Table Va): 1 � Product (IIIg): ��,�� This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and D�sposal, and all conditions nf the Improvement Permit and Construction Authorization. A �r � 7 (Authorized :Agent) (Date) � LElnl � � _ (Licensed Contractor) ^,�siGs �-'�2-A� �.l-F� �- p (Date) a �`S�r�3 � �. ti \ � �n � oD� f' Sb` � ��-r� �� - w 7� 'r'� �'Y � ►�- t��-r� : �� -� � � �� ► � �� '— � ��a� � . �PQ2.ax � �r TP�+��Gt�+ �� r� � �,� CJG�1 h� '�� r �e ��`..�'�� !t�/%�' +��' �fi y�fa.r'r'�� o-1'��'€� ��'� �✓� �ru�'�'"r�i.��P /�s✓ . ��..�%�0% �:�i� ��t'�� %�/'✓r/✓�3�� o f.�-/.:f�.�� C�� lfr��' C'a��r� � �� C C' Scale: � Line Length t 1 p v ti►�o 3 �30 � 3� Total S30 ��,��ss- ��.� �� \�� IE�,.��-�.-,�„ ��.�.Il IL��.I1�I� Applicant� t '��+, �A�� Location: �r,��-�+t� �� Operation Permit Tax Map �27 Parcel # /q7 Subdivision Phase/Section/Lot # # of Bedrooms � System Type (From Table Va): �� }� Product (IIIg): � z��r� This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. c� � � • �, (Authorized Agent) (o S L3 (Date) a Lc�n1�� (Licensed Contractor) �',�tiGS i- ��t ►�1 � � ,�- P (Date) �1!-�'%r3 .�� u� � I' Sb` w� _� WGz.+— P �r d 7 ��-�� - �� 1�� : ��2�� -L�ia-; ►� S ,�c��:r� '�i +.1•�� — `�c '��.1t� �' . --�Pa�c «" -re�,ac�{- �-iro� S � �" d2.�� N �� -��..ic.��/5 $G `' ��.� Con/{�Gf� �7lC?�i:�i�L%� �%''✓� Co.u�4��'il�sa �i� ��f�1/ /�D t�� l7iCh/!✓�1&.��/ �o f,�/.Ni��l� ��t q s��G� �,�c� �� ✓r Scale: -- I� Line Length � ►� v ti�o 3 t 30 �} D Total S�D Tax�Map: �27 Parcel #: iq,� ` Septic Tank System Checklist (Type II-I� --� Notes• Pump Tank State ID & Date: �- -� .� lo- ��- �z. Capacity: �-S l�,c � Riser (6" min.) NEMA 4X Box Model: �E Q��,Q�,S Piggy back plug Hard wired Alarm functioning Mounted on post Above �rade (12") System Type: Pump System Checklist InitiaUDate Tank Com onents � Pump model: .�G'f� i Z Block (4") Nylon retrieval ro e Float tree and attachments On/Off float sw�ing: in. �s (, s( Alarm float (6" se aration) Anti-si hon hole Check valve i Threaded union �a t, Is� �3 alve A s (, Conduit sealed Outlet sealed _ _ pprove an secure riser Pressure Manifold t�A s�( s j Number of taps: Size and sch: ►� k� b Contracted Certified Operator (Type IV +Systems): Notes: Su 1 Line Size and ma�erial: y in. � a sch. i,ength: L4id r ft NOTIFIED BUILDING INSPECTIONS: Copy of OP e-mail Date: (Revised 12/09 BH) InitiaUDate 4 ��` ;1 �� rawn�c-�maau�ncn.a��ra��.Il g'�co�.��a Tax Map: �% Parcel: /�7 Subdivision: WELL PERMIT (New_ Repair �) Lot: Applicant's Name: �� _ j Mailing Address: Phone Numbers: � v"' Location of Property: Permit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and County regulations governing construction and setbacks apply. 3.) Permits expire S years from the date of issue. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: Permit issued by: v � QNew 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: Date: � l � Certificate of Com letion ��T� "�4 �2C- P L'JLiner: . EHS/Date Depth: ZS� Grout: �7�r� l� DAbandonment: Date: Method/Materials: �� i 2a�S License #: License #: Date: Addiiional Comments: Date Sample Collected: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C Roxboro, NC 27573 Date Results Mailed: Phone:336-597-1790 fax:336-597-7808 11/26/13