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A27 198
Apolication Date: Amount Paid• Recei : • Tax Ma #: � ParcBi . L �.���?_ � ���� �� - - . �C � �T1��T�� -�L-� sa.�va.�.m--'- --"-� �eaa�.m.71. 1L�o.�a.7I.�]Ea. APPLlCATION FOR SERVICE5 � mc� nh� �-t�.�,��u� 1) Psrmii requested by: (Ownedagerrtlprospective owne�: "$ `ti— � � Home Phone: '33 -�R °t ^ g�2.�A Address;, 2,�� Qc�i3t-�2'ts� o• Business Phone: 33L- soc.[,-.SR at � �c�G'gv,�a .�. . �a�1. � �'�oo ,7'7 �-r'-} 2) Name and address of currertt owne� ���'"�� ��b-g ��� /�.GWt �YHC� 3j Property Description: Lot size: ��s Township: Subdivision: Lot # Directions to tfie property (Indudtng road names and numbers): � G� <5 �3 t,�a �sr- � k..7- D� �lJX-a�s,2o - �1�vn�cx . � �,,� 1� L' T �fjV p .Wl/���.r��n� 'ZZeI�iiJ P�drJ�,LT—�CsG TO CST' L�J-T /�Q7SL�i1P7-�9'f.l" /c� � . . <sT fK�°�'� �i2«� � c-c-cFT a<5 ,�2 ,�.p , �'��-�jc1L c�c�c.��r,ws' 4) P'roposed Use and Structure Descriptian: answer each of the foliowing questions: .... ' a) Proposed . . Existin9 ,�,, Type af Strvcture: Width: � Depth: ��' b) Number df Bedrooms:' . Number of occupants or people to be served: 2��c 3 � ��� C) Basemerit Yes ,�No �II there be plumbing in the basement? . d) 6arbage Oisposal: Y`es . No _ 5) Water Suppiy Type: Private ��++r _ or existing�. Public Community� . Spring � Are any welis on adjaining property? Yes No � piease indicate approximate locatiori o� the . site plan. � 6) Daes ycur property corrtain previously identiflad jurisdictional wetlands? Yes_ No ✓ PLEASE NOTE THE FOLLOVYING: ' ➢ A PLAT OF THE PROPEitTY OR. StTE PLAN MUST BE SUBMIT�ED W1TH THIS APPLICATION. ➢ PROPEi2TY UNES AND CORNEi�S MUST� BE CLEARLY MARf�D. -,. ➢ THE.PROPOSED LOCATION OF ALL STRUCTURES MUST BE STi4�D OR FLAGGED. ➢ THE SITE MUS� 9E READILY.ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENi` STAF�. � . � � I hereby make applicatian.to the. Person Caunty Health Departrnent for a site evaluation for the on-site sewage disposal system for the above-described property. 1 agree that the contents of this appiication are trus and represent the maximum facitities to be piaced on the property. I undecstand ifi the site is aitered or the intended use ct�anges, the permit shall become invalid. ` � � . �''� % ��� Owner or Legal Rep errtative � Date PCHD. rev. �6127102 '� S � �%h�i�. ��/ /c- / ' //`�`/ -� � o Y� �R."�r� � . i�D � Q _ 5 � . � ��� � _ � � . �_� _------ � �`--- -- j �, �.� _ o - � � 56�D P V vU � . . �� �P��S � I �, i � - � ��� � �� ���� � ��� �� T�x M�� : Parce�l � '� ' Su�bd!ivision ' � i�) [ � I � 1 � , . , , .. � , , , , , , � , I I I i � I., Phase- Sect+ion'Lot # • . � / `.i � �• � � !ii .ii� ,.. Improvement Per�nit Permit Valid for � Five Years _ No Expiration Type of Facility: # of Occupants Proposed Wastewater Proposed Repair: _ Permit Conditions: # of Bedrooms Z ' ��GF - /�/5%�f64��N Owner or Legal Representative Authorized State Agent: New Addihon ✓ Water Supply �� G� Projected Daily Flow Z C� g.p.d. Type: i,�p � Type: � ��/� G'D/✓�� .r� s�' �`sr?-/��o Date: -- � --0 4 Date: Z � The issuance of this permit by the Fiealth 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 Inspecrions requirements are met. This Improvement Permit is subject to revocation 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 Sewa�e Treatment and Disvosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Authorization to Construct i�Vastewater System (Aequired for Building Per�it) * See site plan and additional attachments (_�. Proposed Wastewater System: ��' ��� Type .�L� Wastewater Flow Z�d g.p.d. New Repair� E sion _ Soil LTAR� •�_ g.p.d./ ft 2 Type of Facility: � i�! Basement _ Yes �No Wastewater System I�equirements �li5n�✓g Tan Size: Septic Tank: '/DOd gal Pump Tank: � gal Grease Trap: gal Drainfield: Total Area: 7T�0 sq ft Total Length E� ft Ma�mum Trench Depth /$� in Trench Width 3 ft Minimum 5oi1 Cover: �_ in Minimum Trench Separation: 9' ft Distribution: Distribution Box � Serial Distribution Pressnre Manifold Anthorized State Agent: Date: d Permit Expiration Date: Z � 1 The type of system permitted is Conventional �_ Accepted Alternative. I accept the specifications of the permit. ` ' � _ � S �� � Owner/Legal Representative: Date: PCHD rev. 11/10/OS ��"� i� 1 "�w'�.. :���;�� �1�' ��.��� � . � , ► ���� ���T�.� �. ���.�.� ���.� 5��. �����: Nam.e OG7� �1/o�.rr� �Tq-� f,�s✓rXG�E� Ta� N.tap #_ ���.Parcel #/455 Subdivision � Section/Lot# Authorize tat t � Date . system components r�pr,�s�t �proxirnate�c�ntours on1y. The contractor must, flag the s,ystem jJrior ao begr.'nning t3se irrstallation to insure that propergrade i.s maintarne : . �$•�A f li'•` QT�: ,tjU/4D//1�4 �� --$��� —' _'� - �sn,fq S�P�� T�-N",� � ���p � o�.lc� � o � ��s� �— � - � w/,�.� � �� ��� z,, $ . � T:�a�s Co���r' Z�� �c►�-�o � 5�i piy ���J� �UtL4it�1 T��G � I (� ��e�o +� . I � ! — � . ��C�S't'� N� TAJV tG. . , � rruM� f' /�✓��OLCf �o2io2\ L /it/5�///�t/� ���4i�L� Scale: - , � , ,�-„�� ��-fr� ��@�✓Jir� �y/ls �%�?'� �'a� �� r y��- �i'�i� �e��� �N �y� ��i�,fi�/� ��� �c��- /�✓�iGif T�� � OZ,�inorrl� � Gr�v�� �✓or � ir✓sr�u�o i�/ r�ffy ��. � �r �� 6��,r-�,,,,;� �f�/j�l2 l.t,/Lli �f ��I vi r��� ¢ �d°a -�y iv-�/� ��/fL /�'r� ,�" D'�►-/�'ir►I � o � �r� ,C,�iL � �� y �l1/ Tt¢fi ¢r��' /�✓T�� C��. /dvo� ��� ' �'�li���/� I � /pD0 %�t��W � '�'�•�1L 2�p Git/. fT %�CG�j���� �Zs LT�� � �'� ��n%C� PG�, �ev. 09/�2/01 �-�Ms . 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Scale: le '76 l2ECN: 3163 P/N:9986-00-34-2015.000 SUBNO: -999 ACRE: 3.75 CALCACRE: 3.5 I 6075 G 884G TAXMAP: A27 198 NAME: OLD NORTI-1 STAT6 LANDSCAPES INC NAME2: B/LL/NGADU: 215 RO[3ERTSON RD C/TY STATE: ROXBORO NC Z/P:27574 DESCR: 3& 75/100 AC SR 1306 LANDVAL (IE: 45500 BLDGVALUE: 147862 OTHERBLDG: 44G00 CURRF.NTVAL: 237962 SALEVALUE: 8000 SALEYEAR: 89 DEED600K: 203 DEEDPAGE: 688 PLAT: 5/512 TO N NSH/PS: 108 !D KEY: 14281 http://gis.personcounty.net/connectgis/Map/connector.aspx 5/17/2006