A27 251Application Date: � 02 � 1�
Amount Paid: � •
Receipt #: ) 7
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Ap�
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► • � - Parcel#: �
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7C�ea�*asmr*��TM*!c����.11 ]H[c��.A;E�n
tion for Services
Services Requested
provement Permit (Site Evaluation) Construction Authorization
$200.00/$300.00 if> 600 d ee is de endent on the ty e of s stem ermitted)
0 Mobile Home Replacement or Building Addition D Permit Revision
$150.00 if site visit re uired $75.00
etl Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Applicant Inf rmation: --
Name: S�2 � u2 Phone (home): 6 ' f�``�J
Address: (work/cell): —'
2) Name and addr s of c rrent owner (if differen than applicant):
Name� ,S cu �+c- �i Phone: 3�� —� 7`� ��a
Address:
3) Property Description: Lot Size: �
Address and/or directions to Property: _
o ��
#: �'
❑ yes no Does the site contain any jurisdictional wetlands?
O yes � Does the site contain any existing wastewater systems?
❑ yes Q.no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes � no Is the site subject to approval by any other public agency?
❑ yes O 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 Structurei
❑Re dential '
ew Sing(e Family Residence Maximum number of bedrooms: �/ Occupants: �
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? � yes �no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residentiat
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: �New well ❑ Exisring Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no
Please note any known ground .water restrictions or sources of contamination:
6) {f��plying for `Authorization to Construct', please indicate preferred system type(s):
I�(Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
l �
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the sit is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
� �� � � � ,�,.
Sign ure (Owner/ egal epresentative*) ate
* Supporting documentation required.
• Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Taz Map: .�' Z7 Parcel: �� l
Subdivision �o i (i N ��i S
Phase/Section/Lot #
Improvement Permit
Permit Valid for: Five ears � Non-expiring �p
Tyre of Facility: � �' New �/ Addition Water Supp;y: W�^L�.�
Number of: Bedrooms �i / Occupants_(�/ Employees / Seats: Projected Daily Flow:�Qgallons/day
Proposed Wastewater System: �� G�-� Type:
Proposed Repair: -� �� Type:
Conditions:
Authorized State Age
(X) Owner or Legal
Date:
Date:
The issuance of this permit b� the Health Department does not guarantee the issuance of other required permits. It is th;, responsibility of
the applicant/property owner to insure that all Person Gounty Planning and Zoning and Bailding Inspections requirements are met. This
Improvement Permit is subject tu revocation if the site plan, plat or the intended use changes. The Improvement 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
a�rd Rules for SewaQe Treatment and Ilisnosal Svstems'(15A I�iCAC 18A .1900). Neither Persoa County nor the Environmental
Health Specialist warrants that the septic system wiil continu� to function satisfacto: �iy in thc future, or that the water s�ppfy will
remain potable. _
Authorization to Construct Wastewater System
��ee site plan and additional attachments (�.
x
Yroposed Wastewater System: ��/✓�i,rt���� ('�)Type�_ Design Flow �� galJday
New ✓ Repair _ Ypansion _ Soil LTAR: •?�� gal./day/ftz
Type of Facility: Basement: _ Yes ✓No
(`k) System Types Iilb, liibg, IV, crnd V, require periodic systerra inspections by the Person Cor�nty Health De�artment.
Wastewater System Requirements
Tank Size: Septic Tank �G� gal. Pump Tank �-- gal. Grease i rap gal.
Drainfield: "Total Area �� sq. ft. Total Lengtl� �� ft. Max. `french Depth � in.
Trench �Nidth .� ft. Min.Soil Cover _� in. Min.T'rench Separation � ft.
Distribution: Distrihution Box �/ Serial Distribution / Pressure Manifold �_
Specifications: _,��(fl� r
Authorized State Agent:
The system permitted is: Conventional ✓/Accepted r' Alternati�e / Im�ovative . I accept the cond'rtions
and specifications of this permit.
(k) Owner or Legal Representative: Date:
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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System Type: ,�
Septic Tank: �000 gallon.
Pump Tank: � gallons
Total Linear Feet: ��.D
Max.Trench Depth: 7li "
Name: �
Subdivison:
��as�
Site Rlan
Tax Map: �
Parcel: Z5�/
Iress: d6� ���,�f�
Lot:�
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Date: "
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Scale: �(�
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Health with any questions (336) 597-1790.
Additional Comments: �1 ��f�� //d �
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WELL PERMIT
(New r/ Repair_ J
Tax Map: �7 Parcel: �•; /
Subdivision: b<�,c/G ; F'����. Lot: _�
Applicant's Name: CAr��-�/ ��-�.�.��3
Mailing Address:
Phone Numbers:
Location of Property: i S
Permit Conditions: "
1.) See aftached site plan for proposed well location.
2.) Atl applica�te StatE cmd County regulations governing const�uction and setbczcks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Coraments:
Perarit issued by:
�New Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air V�n±:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Addi�ioh�l Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, iVC 27573
Date: �
r'er�tificat� of f'or�pletio�
� QiLiner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
Lice�se #:
License #:
Date:
Date Results Mailed:
Pnone:33b-597-1790 Fax:336-597-7808
11/26/1"s
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A�aitcation Date: [���p�'-f- . Tax Maa #-
AmountPaid: ,Q6r.�d
Re�i Pt #: s'L �� 3� Parcel #•
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APPUCATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEAAENT PERMIT 1S INCORRECT. FALS1FiED.
CHANGED OR THE SiTE� IS ALTERED. THEIN THE IMPROVEMENT PERMIT AND AUTHORIZ�►TION TO
CONSTRUCT SHALL BECOME INVALID.. �
1) Permit requ ed :(Owneda �entlprospective owner): Ll � �
Home Phone: " 'To2 Address: ! li
Business Phone " 5 � : �f/� $'�'3
2) Name and address of current ovmer. Si�/1/I�
3) Property.Description; Lot size: ��/��1"ownship:p!'✓2-Hr Subdivision:�e ' Lot#
Directions to the property (Induding roa�i names and numbers): L��<h�l,�,� /. t���- -� '
��A I�'.o 1 la��t � Jl�leL7�'1 � l.o /_�1,[l�, -t1�e_L..�-f � 5
� [.` 'f'��n- �--� .
4) I�roposed Use and Structure Description: answer each of th ,foilowing questions: �
a) Proposed �, Existing , Type of Structure: on+�- �� ,�}- Width: Lf'� � Depth:��
b) Number of Bedrooms: � Number of occupants or people to b served: o't '
c) Basement Yes . No t/ Will there be plumbing in the basement?
d) 6arbage Disposal: Yes . No 't/
5) Water Suppiy Type: Private �, (new �/ or existing�, Public� Community . Spring _.
Are any weils on adjoining property? Yes_ No � If yes, please indicate approximate location on the
'site plan.
�6) Does your property cantain previousfy identified jurisdlctional wetlands? Yes_ No �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPEi�TY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLlCAT10N.
➢ PROPEiZTY L1NES AND CORNERS MUST BE CLEARLY MAR�D. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAI�D OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBI.E FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person Courity Health Departrnent fnr a siie evaluation for the on-site sewage disposai
system for the above-described property. I agree that the contents af this application are true and represent the maximum
faciliiies to be piaced an the property. i understan�j if the site is altered or the intended use cf�anges, the permit shail
became iny�fid,/ // „ %/%
or Legal
/ ��
Date
PC}-1D, rev. O6127/02
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Applicant: �i ��(QM W R�ih��
.
Ta�x N1��� " P�rcel ; '
S��nc�iiivi�s�ion � y.: �
Fh��se Section Lot =
Improvement Permit
Permit Valid for X Five Years _ No Ezpiration
Type of Facility: , '� New � Addition Water Supply e� f
# of Occupants �'�la7� # of B ooms � Projected Daily Flow �� g.p.d.
Proposed Wastewater System: � �, �
Proposed Repair: t18,�,�'vu.�c.
Permit Conditions: �P�Pa �i � �
Owner or Legal Represe
Authorized Sta.te Agent:
Type: :�R
Type: .�ct
Date:
Date: � �p�v
The issuance of this permit by the Health Department in does not guarantee the issuance of other pemuts. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections 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 `Lmvs and
Rules for Sewage Treatment and Disposal 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.
Autho.rization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_�.
Proposed Wastewater System:���l,s�, t Type�� Wastewater Flow � bp g.p.d.
New � Repair Expansion _ Soil LTAR: ��� g.p.d./ ft 2
Type of Facility: ���� ,eS , Basement Yes ➢� No
Wastewater System Requirements
Size: Septic Tank: ��� gal Pnmp Tank: gal Crrease Trap: ga1
field: Tota1 Area: �6o sq ft Total Length �'� ft Magimum Trench Depth %Si �� in
eh Width _� ft Minimum Soil Cover: � in Minimum Trench Separation: � ftf� -G
. `�. Distn�bution Box � Serial Distribution
Specifications:
Authorized State Agent: ��
Permit Expiration Date:
�
The type of system permitted is �Conventional
the permit.
Owner/Legal Representative:
Pressure Manifold
Date: ��a �� �
Innovative Alternative. I accept the specifications of
Date:
PCHD7/30/2002
���`�.s.f I���.���T -
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)-�' �cn�na-��aaaa�x��.en.]� 7E7���.Il�lla
SITE SKETCH
, ��
Name 1 ' Rtr✓t �� � � Tax Map # � � � P cel # °�
Sub ' 'sion "✓i't `� r-� Section/Lot#
���
Authorized State Agent � Date
System components represent approacimate contours only. The contractor must, flag the system prior to
beginning the installation to insure that propergrade is maintained
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