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A27 234
z Person County Health Department � Sewage System Improvements Permit Date: This Permit Void After 5 Years Permit # Owner: SR# /30� LOC8U011�D1IeC[IOi1S: r vJ Subdivision Na + ' �' � Lot Size�'�Z Type of Dwelling: Water Supply: Private: _� Public: Bedrooms: �_ Gazbage Disposal Basement Basement Fixt INFORMATION CERTIFIED BY � Environmental Health Specialist: ow�er � REPAIR: REEVALUATIO : '��l Lot # Community: ' — � n�� � ------------------------- Size of Septic Tank: � Ob� gallons Size of Pump Tank: Nitrification Line: 1-1 n(') ��� j Depth of Stone: 12 inches Max Depth of Trenches: Altemative �ystem^Conv. Pump LPP Pump , G "lSl9 Z � " � Date Well Approved: Well should be 100 f� from any sewer system BY Environmental Health Specialist Date Sewage System Appmved: BY Environmcntal Health Specialist CERTIFTCATE OF COMPLETION ,� Contractor: � -------------------- ---- � -- � b Sewage System location, installation, and protection must meet state and local � regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained by owner in such manner as not to create a public health hazazd. Septic tank and ni!rification line must be inspected and approved by a member of the Person County � Health DeparUnent before any portion of the installation is covered and put into use. If ,� The site plans or intended use change this pernut is subject to revocadon. ` r (G.S.130 A-335F) � L,ocation of sewage disposal sewage system sketched on back. - � i (OVER) . _ , _ _ I NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located at�later date. Note location of water supplies on adjacent lots. �lj (2) ■■■■.■■.■■■■■■ ■■■■■■■■■■■. ■■�■■■■■■■■.■■ ■■■■■■■■■■■■■ S■■■■■�■■■■■■..■■■■■■■■■.■■ �������������� ������������� �������������� ������������� �������������� ������������ �������������� ������������� ���������������� ������������� ������������� ������������� ��������e���� ������������� ■������■�����■ ■��������n�■ ■������������■■�■���■�����■ ■ ■��m� S �Z� �.�0 � PERSON COUNTY HEALTH DEPARTMENT !` -,. �; WELL AND SEWAGE SITE, LOCATION 1MPROVEMENT PERMIT � ' "J � � � W V � a B 2177 w Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shail be issued until Authorization for waste water system construction has been issued. Tax Map # ,� � � Parcel #_ Zoning Township Owner/Contractor (�c�o S Lacation/Address ��41� ��. rCnh r� A Subdivision Name Y-C; Date K _ � � � r� S+e�al �/ a5�{tDm�`S.R.# Lot#�_� SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area Size of Tank_�_�'3� SFD � Mobile Home Size or Pump Tank ��4 Business # of Bedrooms 3 Nitrification Line L��7 �X3 � Max Depth Trenches �- �( � � Permits may be voided if site is aitered or intended use changed. Well and Septi�ayout by GL l a..r Comments: 5�.. � ` � Date I 3 d....�'R`Installed b_x.�;,� ��z�c�-�_ _Approved by. ell Permit Paid Individual ✓ Public Site Approved Well Head Approved Grouting Approved_ Comments: �OD .� WELL SYSTEM SPECIFICATIONS �� � Semi-Public Required Slab Replac ent Air Vent � 3 Required Well Log � Well Tag 3 I _ A Date 3 3 Installed by `�%(/�;�j � Approved by Tnis report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. 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. c:\amipro\permit.sam O1/95 rev.1.1 ,, ,, ��� rF y�`�• ��iT . ��� �o' .� ��� y S85• 7�34" �46.69' E ` � i ; . 1 �� 0 IS �� /� it' • �. S85•27'34"E 215.00' � ��\ - � , • � . . �. � :�\ ^o . , . . . � � 1 ,� "' � . � ' STERLING 8. KNOTT. , ' . o � � i D B. .129. P. 577 . : v �� _ , � � . . � - • . ,r� � � : t� : . , a ;o � . . .:2 . � � � - � . _ ' - � ' � . . . . . . . ?'., a _ , ' ' � .. ! �.�,� . ./ ' V .• ' , � . . , '� b y ( 1.. .:'� �, � / ` . . �� a�', � ,�:, . . � ,� � - , � ,, . � ��L , r ji � , i i �. a. ; �' �� ( . � ,� �-, `; , .� � �r '- %ti `'� 0,�� J � P . T OF� TRACT. A . � , r � ���. � r � - . � • �r� � �� .� � u; �.G.�.� � � n c,a� ;*;�F P 9„ P 27. .. . �,�., . ,- u � � , ,�� - K , 4 �f �`� �,� IS ; . � —+t/ t i' t' ,� t R 1 r.. � 1 ti v k �; � . , ` r..,N ,� � U,(5L f� ,; " - , �zR�..� �Yr � . 4 � � ' �}� ,I ._ . . .. Ci�t"�'3 � �,� 4 f :.� `� i t �. �1' / � y �, �� • �� �r . . C '0 / /� /' G!V:..� ., �V� r �•' f . , . . _ t ~ � r �J � �� � � r° � � `, � i��� �'� .� W i t [ � ,a . , '. 1305: � � `. IF ^�'�`D ' � � .�r ` _ . � s� . \,.� ��� � <�� �, . �� � .�; '� ;��,�-�,r . _ . � : � \ �,,°j ` =— - �p � - - � ' � � , -� . - _ Q � o ��` � ; _ �' , . . . �� . . _ . r . '• " ��` � ' _ IS .' � � � � 0 = 11-07-12 MP ', � � � _ � R � 992.03' . - �� _ . . � l = 192.54' 1 6. 53, � f � - - � I ' LC = N75'32'S2"M N81'06�28N ' ' o� 192.23' � � � NS N8 14�.��� � ' ` � . v � ' �t- ���8�28�hr +� ��- � ����, � S� �3�--__�_ NF , .. . ��� ; ��,1���C p�s 6 so � ----_._ � R�w . -_ � 'i ..�`. . :.� . •A � ' I ' I �FLEMMIE RAY LONG I N+ •�� � I �� . �� �,.. �� p2, o5'E / . �';;.� ` N'� �. � �;J;` 'r,, q6' 12 . ,:.. � «:.. , �" � " � �rR_ � \ '�li��l,'t�;; } •1�' � x{ y� i ! %' ♦ L'ri ` �. 9 � �s�� \ ���; , �,,r' � 9-- (� \• �iS �`` � � ;. �\ \ � A� V \ � �•�� EDWIN T, LONG � �� �` � `� �o� � � � � � . � `� � 0� �11�Or� /.. � � \ ` � ���• ��� (Y R , • /• � _� `� � � � , . O �_ � sf6� `� , - �9- 1.99 AC. �, .� '. - �� °o.'°F �. `� `;��, �- - �. 6' �� . � , .� � Sh��g'!•b5 �?�.'�� `� `� < . � ^ �r � �? \ �' . \ � ` ` 1,68 AC, � S • .� . • \ J \ ����� � � • t - O•� q� � - A ^ �`\ c� ?� �ai w'�'�' � . `� ��� � / � �s4o� o � � °�'��y 2.i2 Ac. �� � �y � �ti� o . ��. �, �o ��: �� r�?f� �� \ � 0 O 2J0 AC. , � i.96 AC, Application Date: � " � -� � Amount Paid: )� 0. 0 O Receipt#: <} (�80 3 4 r,��a�.� ��-,� S� �I��..��� = ' =� � � u�����.r 1�� n-nwn n: .�caien.�ra-n.e� �rn �:.en.11. 1�-�T �r.�.en.I1. R>.)la Application for Services (Sentic Svstems and Wells) ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 d) obile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Tax Map: � � 7 Parcel #: a 3 � Services Re uested � Construction Authorization (Fee is dependent on the type of sys � Permit Revision $75.00 ❑ Repair of Existing Septic System No Char�e Important: If the information in tlie application for an Improvement Permit is incorrect, falsified, or the site is altered, then tl:e Improvement Permit and t/te Authorization to Construct sha[l become invalid 1) Services Requested�y: Name: ,� V r�l�l U1lS r t./Gr�i' Address: /�-(� c� L. o�ti5 Sfo� E= Q• /Zo�'la�r�✓o �tiC ��57� Phone # (home): 3,310' �� '/73 S (work/cell): /— 9�q — �'/ 3 �/ — 3 O�Z 2)Name an address of current owner (if different than applicant): Name: �1���2 C /t P-C.�/ lJZ-v/1 �Pa2 Address: / / C/ 2vGJ,o/1S�/�li �c OrY�d//O l�/-C . 2 7S% �% 3) Property Description: Lot Size: �� �� Subdivision: N� Lot #: C� Address and/or directions to Property: .p � .� � , ,o �e �. e 4) Proposed Use and Type of Structure: Residential � Business/Type: Other c� eC� Number of b drooms 3 / Number of people served (seats/employees): Basement: Yes _ No �(with plumbing: Yes _ No � Garbage disposal: Yes _ No X! Approximate size of building foundation: Length l/� U Width 3D 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 annlication must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of al[ proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying tlzat tlae property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is $,ltered o�the intended use changes, all permits shall become invalid. � � �� � � , Signature (Owner/Legal Representative): 11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� � � �. � � � �� � � a w � � � ���� �7�3.-�-m�'���'�'TM cC�'�.�a..11. ��,�..��. �a��� �������/ �I�bi�e �o�� ��i����#� . Ta-� 1l�ap #:_�� Paa�c�i#: 1 ' . A�provat Reque.gte3 for. � obile Hc�me I��la�ment . � _ ���Bnilding �iddition � ' � .i . � .P�plican� �e: � Ad�ress: • ' � , o Phone �'�: � Permit �Loeate3: ��'Yes IYo . InstaYla�aoat Date: - — D�gn $oev:. �_ �SP� Cza�nt Cantrac# �vvith Certi�e�]. Op�rato� oa� �� {if r�:�amre�: . Q4T�tez Sxapply: V i�Te�1 � Ftiblic or C� �7astewates system shows no visuai evi.dene� of fa�ua� on: �' q' D$ (�) ��. {Appiic�t's si�e if site visat is nc3t requ�e� cQ��: l�Ke� � . l�o'x 30' � �1e�,� �n �a�� � h� � � � � ��d.a�a�����s.���at ���a�v�� . _ _ �-9� � . EnvirQ ental.� �3eaith Sp ' � Daie � 1 �1�/a5 •�\�� J�� �1' '•�� V � f �{ �{ ��w' Y _~ V � �7�/ �.�i] �V 1L � .1GilCa'�Il�[`am�•,� v-n-n �a3�.�.JL .1L.-7L�.�..LL7GI[b ��� � ee c -•��� Name �n�Rcli�ec, Ta� Map # Z7 � Pa:tcel #� Subdivi ' n _ � Section/Lot# _� �Q-�-o�'l � Autho�ized State Agent . � Date . S_ysterra cor��imnen� ��a-esent u�,�ir�zi��cont�asas ova�: 3'h� coa���r �raaas�, fYas� #he syrs�es�a�ir�or t�m , begivanisa� t3�e irasta�asa to srssaare tdaat prolbergrx�rde a� �csin�iais�a� � -enc�e t��- �v Sca ��, . i�i�:r,:,urr c��i�����rti� �:rvvi.icc�Nr,::N�i�r�i, u�,ni,7'tt � ; . � , . ►dl•:I.I. I.uc; : . . .Da [e:= 02. -� 3._-� �' �tiVI1LI": .�u� ��J'�ws� . Loca[ionjl�ircctio».•• - � ,..� � , ... _._____ SR ,� -� �•� �h I �/��� �}-�r:�:� � . . � �—d � —� � .� ii �) I ! � � r o 1�---- � ... . -- - ' . - 157UI�1 .��ll��l�;: _.__.--•-- Dri ilin s7 __ ___ ,, CUI]L�"�1CiU.[": _�1/�T'�1 S Gcic, f(. � - ....._------�...0[ �� ' _ 1..�.r,_l. ��. n_�__�-...1_`1.�._ 1��1�;1.f . C�'( )Nti_I'I:l!(�'1'I(�N � Discar�cc from Nca,-csc 1�1-o��c,��y L,i,��� _�,� ����.-- lli:;t:�I►cc Crom Source Pollution�_ w� of ' Total Dep.th: � I�t. �'icicl: � > �� ` - Water Bearing "Lones: Dc tl� m�.__ ..�_-._ _-- C'1 M .�ta�ic Wa[er L.evel � ��I r-r a --g _ ��►.__ ��� .___����.--��.� r-�. � ���. Fc. CaS1Il�: �L11: 0171 ' . ' TXPE: Steel ._-------�c>._._. �f_3 ---�: �- Dian�cic�-: � 7nches ------------- C;:ilv:it�izccl Stccl �- . Xf Scccl, docs owncr apprc�v�:: 1'�::; "—..� . . . � Wcig}lt. • --___..._ Nc� --�.�_ r.� 111Ci�J]CS;,. . llrive Shoc: Ycs--- `i-- N���'�.I-Iclght�Abovc Ground: i_`�nches . VYerc Problc�ns ��icountcr��cl i�i .�c:�tii1Z; tlic C,�sil�i;'� �'cs ' � . , . -- .Il „y�s' �;ive: rcasc�ii: -----_ No • . Grout: ;I'ypc: Ncat -------------- -�- --...._ -�------ ---- -- ��. .�:lll(���..C:1] �— •.'•- Annular. Sp�cc Wi�lth 3 11'n�_ . _ _Coricrcte ' ' � �;.� �[� �chc1 �'�':� Watcr in Anni�l.ir --� -�. __ -_-- � Sj�.�c:c: 1:�::: ..__ _ Nc.> �--- � Mc[�iocl: I'urit�x:c�; _. _ 1'rc::.:ur�: . .__..__ ..---- : llcp�l�: F .._..___. _..__.. 1 �,�.�r��cl� �- .. . . , , . :.. . rOn1 . _ 1 � ► ------ Materials U .._.._..__. .. � � --I•t' . ' sccl: No. ��i.igs .l'c�►[l:u�d Cc�ncnt_ � - �, ba �' . Zf mi;;turc S11]C�, �; - . . - — Wc� �1it o.f .1 ��. ; � �t� cl, cul����,;�;) - lZ•�tic>:------.. �" t �--�-lbs:�: Zv 1']:�tc ` _ � ',.':'�� s: Ycs N�, � . ,. �� � �� ::lab ���ti_ . � -- Nc� .._ :. • ; � • . ._ __ _ _ _ .- . --- _ _ ... ���I:I 1.l ,l NC; I..(?���__ . �� ---------_ ---- _ . _ � -- _ From`-- -----��-�-------__ _... ...._._ - _�.... . . � o l:c,nnation llcticri tion � - - .._:. _._._. _...__. _ � :��; - -- :�.�__�;--- . � --�.—_�a____ � ------ --.. � ; � _.__��_n � � ..------__ _�o _ ._�-�,.---�____._. _ _. __ --.- ------ ,; - - - --- ---s�.,�`. ,�d� � _._._-.-_ ��' . - . — - . .��'.._ _r._A- � . -F- �. -------- ----.... .-----..._--____ _ � z H EREB X CEI�TIFa' Tf-I.�'1. .l.l I L.�]3 () V 1; .�� . THTS WELL WAS CONS"1'I: UC"�'k:1) ([V �,CCO1��D �f 1'I'!ON IS CORIZECT AND TH% ;�, FORT�I BY�T�-I� PEIZSON c�'�UNr1'1� [�Ii:n1,�i'I-I DLI n1: [�w�TI-I REGULATZONS�'S�1' � .. . _ �LN I . .;� �/ /�/ ��:�� ; .�. . . _ c�l,/ �_�Y. _.. ��%�f' _ � �i�;��.�[i�rc c�(�(�on��,��:tc,r �— �= ��-��� Dat� . -= �:,