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A27 250Application Date: lb--I6-�� Amount Paid: n'� � Rec�ipt #: 17 1 �t ( �Xr o� � �d � � • -b 3 - �' 1` �1�'���� ������ = _-- ������ �ffi�a�-��T-r-� ���.�.Il �E—�L��IL�I�. APPLICATION FOR SERVICES Tax Maa #: /�'� ParcEi #: 2.:S�b yK � �.� � �-v �e�-`�" , ��y�-� J�� IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT iS INCORRECT, FALSIFIED, CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZ,4TION TO CONSTRUCT SHALL BECOME INVALID. - 1) Permit reque ted by: Owner/a ent/prospective owner): �A �1 VvP � f Home Phane " � Address: � 2 Business Phone , ' $y �Cs� G � • C��rren�i' 2) Name and address of current owner. S�� 3) Property Description: Lot size: ✓ Township: Directions to the property (Including road n es and numbers): I'^�.crn �.c✓�� �,�-� ��in � �.Li i Lot 4) Proposed Use and Structure Description: answe ach of th fol owing questions: 3 S� a) Proposed ✓, Existing , Type of Structure: �e�; ���,��-jti` Width: � x Depth: 5s(� � b) Number of Bedrooms: 3 Number of occupants or people to be served: �_ c) Basement: Yes ✓, No Will there be plumbing in the basement?�l�3Cs d) 6arbage Disposal: Yes No �/ 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 L1NES AND CORNERS MUST BE CLEARLY MARKED. , ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED 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 b placed on the pro nderstand if the site is altered or the intended use changes, the permit shall become ' ali . Owner or Legal Representative D e PCHD, rev. 06127l02 A�plica�n Date: 10-10-01 Amount Paid: 0200. O a Receipt#: 3 4 � �F2 S ,� �. �--���� � � 1L 1!_'a1!_\l� ��_ �`! — --r-=�= � � z�r��-�r°��r ZE :��,.v-v. a-.ra ��„�-,._K� ,L-�. �.�.:11 IE��L�.n.�,..11. a�lh.. . Applicaiion %r Service� . � (Septic Svstems and Wellsl Services l�epuested Tax Map: Parcel #: � �.� 11 � .f-p M� � �� �- �Improvement Permit (Site Evaluation) C Construction Anthorization Y�' $200.00/$300.00 (if> 600 d) (Fee is de endent on the e of s stem ermitted) C Mobile Home R�eplacement or ]Building Addition ❑ Permit Revision $150.00 (if site visit re uired) � $75.00 � � Well Permit (New/Replacement) ,'. ❑ Repair of Existing Septic �ystem $225.00/$125.00 No Char�e Important: If the informatian in the applicativn for an Imprnvement Permit is incorrect, falsified, or the site is altered, tlien the I�nproYemer�t Permit and the Authorization to Catstruct shall becvme inva[id � 1) Services R�ec ie�ted b�: � Name: �j sp (� � l b o c n Address: p S r I� � Phone #(home): �ro Jr� 9- a$ y7 (worlJcell): �'�3� S $�� $5 B'T 2)Na�e and address of current ovvner (if different than applicant): Name: Address: 3) P�operty nescription: Lot Size: � Subdivision: Address and/or directions. to Property: 4) Prop��ed IJs nd Type of Structure: � Residential � Business/Type: � Other Number of bedroom,s. � 3 / Number of people served (seats/employees): Basement: �es ✓ No (with lumbing: Yes No _� Garbage disposal: Yes No _„� 5) Water Supply:/ � . Private Well ✓ (Proposed Existing _) Communiiy Well: Pubiic Water System: Are there on tlie adjoining properties? No Yes Lot #: S (please show location on site plan) Noie: A completed application must also include: � 9 A pladsite plan of the property thatshaws property dimensions and tl:e size.ar�d location of nll proposed structures. ➢ A signed copy of the `Lot Preparation' fnrm ver�ing tha� the property is ready to be eva[uateri. I am submitti�g tbis application to request services from the I'erson County I�ealth Depa�tment. The Pformation pravided is accuraie. g understand t�aat af any fite is�/%��ed or the intended use changes, all ermits sha[1 become invalid. �� ` �ignaiut e (Owner/Legal Representative): ��//v" ��� Dat� : !I 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) •° � . i�l���� Y , � 1�. ltidl �� 4� �.J ��;. V �. . .�ya.� � �...� � „'� �✓ � ���� 1��.�s�-�-n ,,.,,-„ <e��.�.11 IL��.�.Il�Ila • .. .,, �.�.nei . . . .. � � �,�:�Ti���.� . . � � . .��A , ` Tax �la� � � �rcel � � SUIbf��IViS1011 � � � � �� Ph�se,S�cti�on.La�t � � / %prave�ent �ermit Par�t 'Yalad for V�ive Yeaa-� I�To �nr�tion / Type ofFacility: ��ivni-� ��Si �.e�c�, New �/ Addition_ # of Occupants �� # of Bedrooms Projecte3 Daily Fl� prpppsedWastewateiSyStem: �CCe �Z-�ncJolC'_�nnn��efY2 Proposed Re�air: A � r�� �� � ' Owner or Legal ] Authorized State i�ater S�pP�y �%�_ g.p.d. Type: �4 Type: � Date: �e- �v –a 7 The issuancs of this pemut by the Health Department in does not guataatee the �s�+��se of other permit�. It is the responsrb�7ity of the . aPPli�aP�Y owner tn in sure that all Peison Caunty Planning and Zo�g and Bw7ding Inspections requiremeats are met This impcovement Psrmit is sni�ject to revocation if the site plan;�pT�ti''or'the intended use changes. The Ymp�ovement Permit is not a�ected by a c3iange 9n owner`siup of the property. This permit was is�ued in complianca with the provisions of the North Carolina, .: 'Laws and Rules for Sewa�e Treabnent and Disnosal Svstems' {�.SA NCAC 18A .1900). Neifiher Person �oun#y�: ntor�;t}ie.`' � Environmental �ealth Specialist warrants tha# the septic tank system w�31 cantinue to f�ctian satisfactonly in the futnre' or'tliaf . thewater supply will remain potable. � • � A�ntiiorizaiion to Construct �astewater Systeam (�tequired for Bnilding Permait) � * See szie plan and additional attachments (_�. � .-. Proposed astewater System: j�CQ�� C�Z �f ot� o� ��,r+�,�y�� 'Ij.'Pe.�1L1��— Wastewater Flow � Pn g.p.d. New � Repair Expansion ' .� Soil LT�Y1Z: � Z� g.p.dJ ft 2 TypeofFacility: �('c,ra�e, �,pSi�Qr;rp � � Basement t/g'es_No , � ���t�wa�e� 5yste�m Res�uirements . '�ank Size: Septic Tank:' DOD gal 1'nmp Tank: gai Grease Trap: — gal .. ]�rai,m�fieid: Total Area: � sq� �it Total Length ��0 fft ' 1Vtasimnffi Trencl► Dep� ,�_ i� ' p, C . �re�c� VV'idth � �aim Soil Cover. � in 1Viiniffin�ri Trench Separation: 2_ ft �ista�ibution: �istri'bu#ion �oa Serial �istribntion Pre�sure 1�lamifold . . ,� /�7 , / Spe��IOIISi �l-� � '�rr—'��f rY1 nnC1 I SJI � (t �7�P t- ��-Pr Sl/S�P�� ' . -. Autlaorized State A� Permit Date: D - 0 - Date: The type of system perruitterl is Conv tional Acc�pted Alternative. I ac�ept the spe�ifications of the Pe�mit• (�w�eerL���l ���aa�s�ntataqe: Date: ��/L O ' PCffi� rey. 11110I05.- � . . tl _ � A�p Lflc 8 Y �'--1�� � � 1� � �, �� ���� � i � f � . � " � � � �.T�� ��'� � �. �'' �.-��.�-ao�^- -�*�*� ��.�.�s.� �`���.�.� �� � �t�: — —� I_ ., N . • ' � . n}}( �N • * P � [`C / � L7E[] (l I V'I � i O tl i, ♦ i L� i!/ - �.���i.�`ic�i, at .� R a•r : . ,d r�:�;m.� ��� . , - .. . r �i i� .. . .. . � � � � : s�st�m T�p� (]n ;�rdanc� 1l�t't�h Ta�t� �a�: �) � • . � � � ' ' `z� ��-� . �►� s�� � �� ����� �,� ������ �-�-� ���..����..� ��� . ��,�C3f:.d.9��. C3�.'a.�L aT.�;"iUT��, �Li�.�S F�� ��i��G� ?Ft�T�&��d"i' �� �!�#'�1�,1..t . Ad�D ��:i. � . �.1l�9ii��S • C�� '� T�l� i��'4�flid��3 P���' �,1� �fl���'3'RUG i�la�i �1�"i'�����ii��f. � . � . . � . . • . . � . . . �t-.�o _ o� - � _ a�no t� �a��� � � . � fl� ' . � .; � � . . . �r�� ��::�^ Ca//� � - --- -- � o�: /-,/� -�� ` ��i� T.�.e�� �P�����`��f ����� � ��� �� m � . . T� Nla� � ,���_ P� # _� . � S�s�n T�p� (i"ad��� ��) C{ Q � QqiV�3�ff,��]��ic�il�'�SC1�) �' �rn : ��C}iV15��S1 � Add�ress�.�x�fi�n ��Y�� ______;_ � � : . —�.� �� — ', - • � . � . � � �: � � � ^--� � � � � --,-� � � -� �� 9 �� C.\ o -��= � � 0 �-�.T,� .. . �'� �� � r ;. � ���f �P �� �� _� �. : �. � � ,� C� {� � �� � � �� 0 :������ ������� . , . �—,.. cC � �CTl�T7C� ]���u-.m� ��.�.11 ]E3L��� Name �a5 ch W r� b�n Subdivision o ' n Auth �ized State Agent SI'�E S�TC� Taz Ma.p # /k21 � P�r.ce1 � ZSo Section/Lot# 5 10-3u-o7 • Date System camponents rr�is�esent a�iproximate�conlours o�ly.� The contmctor must, flag the system ptior to . beginning the i��rtaAation ta is,�sure that pro�ergrrxde rs marntained - .� �. �� � . � , '� ���`� �„ � � � a _' •::t tr {v .rv{ t • ••{ • .• . ♦.��;.'�v �'��•• 'Y��.`: . i51, , . '`.'n�.. ..y.•.. ,�-::�•�'. , •L•• � , . _ .`.,,r�t.">,'�.. Jl.. . �i�::Z.+4: � ,:..v � �:• • �wti . • f'l�n}' . ;•:•� t" .. . ��"�; �� N'i .'i.��,Y��;����� w�t..�-n..:� :f,.��...... .:• , , *:...::.:�,a'' . ;.. , ��'•kR'-7!P .'.ix.:: ; . . ' • . " S��ea` t+'w`+•': ,-�7�-31.�.'1F • ' .. . . � .... �+�s'���` ;� �� .147�]m: � Y►�I:J1L.Ig.I �J�JIAL%� � ,. �JLJ�1'�A711J � m' m' �.� Y�� � n'rw ! y�� V7 SJ a• u� 1J8.H. '�.'J ��� 8.J 1 Tax Map �_ P�1 # 2So Tbwnship: �-- .Applicant: S,�w W � _� �n �, Sttbdivision.�_�< < -r ► �r� l�/L . -�r��A � Lot # S . Lacation: �� 1 �rx= „i -�-.�� Q�.� � , �e of �a� 5aeppYy�O Tndividual �q�eaanen#�t Site. Approved By: _1 �routing Approved By: . Well Log: � � ' ., (o - 0 Pump Tag: �S �-k.�r o �,1 �e.= • -�-,s`� ((,�� Well T�ag: > �,,� . o, Air �lent: � $ose Bib: � � Caeing Height: Concrete S1ab: � Cammtmity Pnblic Liner. • 7nstaiied by: � . Depth set: ' Gmuted; l�afe: . . Water Sample: � �U'ell Driller. �va,�5 .. WeIY Appruvec� by: � �2�" ti"-Y � —o- ���*9ee.��ci��d �ite S�.eic�t���� Wells must be 10 feet from pmperty linea. V�lells muet be 100 feet from septic systems. �Tells must b� at least 25 feet from any building foundation. . Other canditions• � c c�s,� '5-�--(-� S{�iE"f'[` E� Date:, � l �� � PCHL re� 01.�7/0� �..w.. . . lZ/ /2@ � 1Q:17 3 6977n 9 �,P�IIw�Tv iJ�N'RO PAfiE :�,��:�:;�'�� :��� ��T�►��i �,...._���� � (� �L�I �+� � �, :"��,iz.c 1 _ l ( t tr ��..i�.r.�...,.�.�: �.M�1Wr+ � � '� — 6 �� R' Orvnq: • � � �4$�� 1�1 � �D 3iu�iivwi�e' ,�.�.�� Dl�p� Praad �t 1Rv�eqr � {�� �p � � r � .�4.� Q Yted���,,,, � ���i�""�'_i�e""�'�oir t,fr.t: � �Va�r !� 7� tl��lt _f�, a.__. � _�..� ��...... �t --�---- D�tro� � �- b�,,,.,,' !�, D� i� ZYD� C�l�nea�f�d—�sl ,�..,_,,, �' Wii�it: Tlttai�: �_ 8� tbrw Ci�d: ._L� +b D�r1.� �: �_,_„M � �7' p�ta� �r�od wr�cli� � �fsr! _Yw � No �t''�s" irs � Oe�oats � �__._ � `� C°e�= ....._.� d� .r.___._ A�t�r �eo+ �v'sd�,...�.._.._ mai� rv.ar !a llt�ler a�war �Ya .,�.,,.�-�to Irteclo�d oi Cira� lt�nptd _,,,,_ p�,�,a� �„� .._. �g► .._..� to ,,,c�.� Ps. ril.atiar uow, lV�o. � �+ori�d ow�t W p� tt a�ol�e (e��,r,w�3. ��Mib ,� b 1!� '"� � B% �i�: ..._.'=a -,. � 4 � 41{�1 � ...,., Pae L��rs �� � � �.�.. � I��t1I�d by� �� Loe�eoe Dra� � P�e�a4 Co�meg► �� u aroe�oe! a�i �t dlit �it ea�� �e�ord m iecardwww M►it5 �� kc :aeb �l1 i� �o � � „� (�� n � � �■■t �i► 3.n.li�o. coea�r: � �� �� � �;� � � -.�..,.,.,_,� ; N�etb�t: �''� � �t: �.,....�? �nt � 2�rai�Y o��jr e�t � p�p wai i�,iod oM sLss M111�ed ea�lodd ao�ooM�� � tAt !� Covnty Watl A�u1M fu �lhet on t!� dsto otd s�t � oopq oi �n rco�d �es beea pe�i�d eo ti�r �►�tl o�r. � I�tal�r M�atsn 1D�t -,-.�.____ �D r�r O1/27�