A27 250Application Date: lb--I6-��
Amount Paid: n'� �
Rec�ipt #: 17 1 �t (
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APPLICATION FOR SERVICES
Tax Maa #: /�'�
ParcEi #: 2.:S�b
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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
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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� �
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�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)
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SUIbf��IViS1011 � � � � ��
Ph�se,S�cti�on.La�t �
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/ %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.-
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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
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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: � � '
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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
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���*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.
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Other canditions• � c c�s,� '5-�--(-� S{�iE"f'[` E�
Date:, � l �� �
PCHL re� 01.�7/0�
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