A27 245Application Date: `� _v +O � Tax Map:�: �� �
Amount Paid: -. .. , - 2 ��
Receipt#: ���% . Parc2i�#:
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� APPUCATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT, FALS1FiED,
CHANGED OR THE.SITE IS ALTERED THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT
SHALL BECOME INVALID.
1) Permit requested by: (Owned r): /"//a ��hecJ � a w+�r�� e
Home Phone: .599-�1P�12 Address: f�0. Sox La+f 1
Business Phone: _.549-H771 (�?cx6�ro� N•C, 27.�'73
2) Name and address of current owner:
.-
3) Property Description: Lot size: .D Tawnship: ��ve �% Subdivision: Lot#:
Directions to the property (I�cluding road names and numbers): �
. 5 mo�a 1?a�.
4) Proposed Use and Structure Description: answer each Qf the following questions: �
a) Proposed �, Existing , Type of Sttucture: %lr��d�/!ce- Width: 31�'i�Depth: �18 �,
b) Number of Bedrooms: .� Number of occupants or people to be served: 2
c) Basemenr Yes _, No�Wili there be pfumbing in the basement? .
d) Garbage Disposal: Yes � Na L
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 an the site plan.
6) Does the property contain previousfy identified jurlsdictional wetlands? Yes _ No /
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLlCATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARI�D.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR ELAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTi1AAENT STAFP.
I hereby make appiication to the Person County Health Department foc a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this appiication are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shali
become invalid. � �/ L� . . / �
Owner or Legal
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Ta.g Map # �`� Parcel # ��
Secti.on/Lot#
�-`��-g-02
Date
System components represent approximate�contours only. The contractor must, flag the system prior w
beginning the installation to insure thatpr+npergrade is maintained
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Applicanl
Location:
Ta�x N1aE� � P�rc�el #
S��hclivis�ion
Ph��s�e Sect�ion Lot #�
Improvement Permit
Permit Valid for �Five Years _ No Ezpiration � �' �� ,
Type of Facility: ����� New �ddition _ Water Supply �
# of Occupants �(� # of Bedrooms Projected Daily Flow �p_ g.p.d.
Proposed Wastewater System: �Q. ��i p� Type: 1T� 6
Proposed Repair: ` ' Type: ��
Owner or Legal Representative Signature: Date: �o
Authorized State Agent: Date: - -�p
The issuarice of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permlt Is subject to revocatIon if the site plan, plat or the Intended use changes. The Improvement Permit is not affected
by a change in ownerahip of the property. This permit was Issued in complIance with the provlsions 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: jJl,t,mp5i�►.IIO�,�i('.�(11�(�'I�il'ype ,�,� Wastewater Flow �g.p.d.
New �� Repair Expansion _ Soil LTAR: g.p.d./ ft 2
Type of Facility: �(� S�� Basement _ Yes �P�o
Wastewater System Requirements
Tank Size: Septic Tank: ���gal Pump Tank: �� gal Grease Trap: �� gal
Drainfield: Total Area: ZO sq ft Total Length � ft Mazimum Trench Depth v�0 in
Trench Width � ft Minimum 5oil Cover: � in Minimum Trench Separation: t ft
IDistribution: Distribution Box _�erial Distribution Pressure Manifold
Authorized State AgE
Permit
The type of system permitted is ��on�ventio�l
Date: VJ �-(��
Innovative � Alternative. I accept the specifications of
the permit.
Owner/Le�al Representative: Date: S/O O
System Type (in accordance with Table V
The system has been installed in compliance with ap�
Disposal, and all conditions of the Improvement Pe
wastewater system will function properly for any �
Authorized State Agent:
ort�i Carolina General Statute, Laws and Rules for Sewage Treatment and
mstruction Authorization. Issuance of this permit does not guarantee that the
of time. � .
Date: / �� �
PCHD rev. O1/23/02
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Applicani
Location:
T��x Nl�p � P�rc�el #
S�ubci�ivis�ioi�
Ph�s�eSec�t�io�a'Lot #
Operation Permit
• . System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAR A GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, �
AN A L CONDITIONS OF THE . IMPROVEMENT PERMIT AND CONSTRUCTION
AU HO IZAT . � . �� �Y .
fV E.f`"�"� l ��` �� .. . .
uthorized State Agent Date
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Install By: pd - _Date: � ��`�%
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PCHD, rev. 07/29/02
SE��IC TAiVK INSPECTIO(V C�lE�9CLIST (�'ype il - IV
Tax Map # Parce! #���� � System Type (Tabie Va)
Owner/Applicant GL Subdivision
Address/Location � ec/Phase Lot #
State ID/date
Tee and Fiiter
Baffle
� Sealant
Riser (if applicable
Tank Outlet. Seal
Permanent Marker
Pump Tank
Z
Waterproof /Sealant
Riser
Water Tight
Pump .
_ _ �. Check ValvelGate Valve
Anti-siphon o e
�. FloatslSwitches � �
� Alarm visable and audible
Electrical Components
Rate (aom) �/��,,
Approved Pump Model
Block Under Pump
Pump Removal Rope/Chain
Distribution System
Serial Distribution '
ressure an' o
Low Pressure Pipe �
Appr. Pipe Material and Grade
��$ Z Trench Width
� Trench_ Depth
� � Trench Lengtt
� nz Trench Grade
Rock Depth and Quali
Dams/Stepdowns etc.
Pressure Laterals
Hole Spacing
o e ize
Pipe Sieeve
ft.
in.
ft.
�� Required Setbacks
p2 From Weils �.
From Properly lines
�3 Structure.s[Basements
- �tc es rainage ays -
. _ ._....� ..... Surface Waters . .
Public Water Supplies
Vertical Cuts >2 ft.
Water Lines
�� Vehicle Traffic
Easements/Right of W�
Other
Easements Recorded .
ert perator oni
Tri-Partate Aareement
Comments
pchd rev. 3/13/01
Application Date: 3— �i � � 3 ��� �� ����(��T Tax Map: J^�� �
AmountPaid: � ._,. .�•�- �`'L �� Parcel#: �
Receipt #: J �3 �{ (, i (� ��� � � ����
�.�rov nn-aDanv.xn.ae:.aa.daaJl IHIc�.m..IL�la.
A
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 if> 600 d)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
0 Weli Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
tion for Services
Services
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: ��rmch-�d �i ��G.Cc�
Address: �q58 Chub I�,kQ ��l
'�1�. C . Z�5'� 4
2) Name and address of current owner (if different than applicant):
Name: _ ��;c �a��,� c
Address: Z"�33 S�n.�a '`Ze �c�
�o �1�,� . N. C . 2.�-�- �i
Phone (home� 33� ) 3Z2- I$aZ
(work/cell): C33 6 � _50� - 3�-3 �
Phone:C33G� 5��- Z{�-��
3) Property Description: Lot Size: �•� Subdivision: i�� o Lot #:
Address and/or directions to Property: Z�-33 Secr,o�r*, `��j
❑ yes � no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
0 yes ❑ r.o Is the site subject to approval by any other public agency?
❑ yes ❑ 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:
❑Residential
� New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number uf bedrooms:
0 Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
c 0.�r �O ��� j f3 �er�ze
ONon-Residential Z y x Z Z �1
Type of business: Total Square footage of Building: `� x t,
Maximum number of employees: _ Maximum number of seats:
5) Water Supply: ❑ New weil ❑ Existing Well 0 Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applyiug for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert�� that the ir formation provided afiove is complete and corre.ct. 1 also understand that if the informatioft provided is
i�zaccurate, or if the si� is subsequently �red, or tlie intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
3 I3
ate
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)
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Suilding Additions/ Mobile Home Replacements
Tax Map #: A.�h Parcel#: �IS Address: a733 �h� �0
Approval Requested for: Mobile Home Replacement
X Building Addition
Applicant Name: RaY+�w�1p D��ua►a�
Address: 39s$ c,Nup u�x�. f�+►o
Faxaes�� t�i C o1'� 59 �}
Phone #'s: 331,- 3�- � 8aa- 33b- 5��} - 3'13b
Permit Located: X Yes No
Installation Date: $-8-ca. Design flow: 3eo (gpd)
Current Contract with Certified Operator on file (if required): ��A
Water Supply: X Well Public or Community
Wastewater system shows no visual evidence of failure on: 3� �3 � t5 (date)
(Applicant's signature if site visit is not required)
Comments: �+►A+�-s+4�w� A�, .5tCbAcks ' As�+c,v� c��oeT �' t.�� �a�c
At�vE Ex� sn �S. � Corl=es� P�+P
Addition/Replacement Approved
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Environmental Health Specialist
3 13 �
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-?808 www.personcounty.net
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SITE PLAN
Name �►Y r+at,0 Dt�.upp.p Tax Map #�� Parcd # oi4$
Sub_divi �',o n Secrion/Lo #
o�l+.Y Q_ 3�13 13
Authorized Statc Ageat Date
Sysrem componurts rcpresent sppmadmnte contours oa1y. The contractormustllag the sysrem prior to begianing the insr�!l�tion m
iesure rhatpmpergradeismaintained.
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