A27 339Application Date: � �7 �,j
Amount Paid: � Q , O _,_____�
Receipt #: �3
�-� � � 3 �- Au
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
`��+5� ���� ��T Tax Map: �
d' �� Parcel#: 33 1
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al°..un.w�i saa�ea �rv.n �co �en tE�ta ll 7C-�I e: m� d:�
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 I�r fe�nation: n r, �
Name: O �.�� 1 �
Address: ° � ►
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2) Name and ad ess of cu t-ent owne/r (if different tl�,gn a�licant):
Name: ��- '�j' �' � N6 / �- 9Q � N% 1 n,f -��C�
Address:
M,Q S �
3) Property Description: Lot Size: ,� C Subdivision�r �
�Ad ress and/or directions to Property: s� �
Y ✓li (�-n-,,,C' �` .(1 r. V't�- _ Q..!- , � .
Phone (home : O ' �J ✓ � � �'" � � K1
(work/cell): �� � � � �j
Phone: ��' 7 Ss �i �
-�owS Lot#: c�
�lnr�c�a� � �i : J.��C
�.� n rnc� (`� /�kS�'��' �'cl�
yes no Does the site contain any jurisdictional wetlands? �'e �� �` �eG- /',� a..)�',� C
❑ yes no oes the site contain any existing wastewater systems?
ir� V�,
❑ yes any wastewater going to be generated on the site other than domestic sewage?
� yes no site subject to approval by any other public agency?
0 yes o 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:
OResi ential �
ew Single Family Residence Maximum number of bedrooms: / Occu ants:
❑ Expansion of Existing System If expansion: Current number of bedroorns: �
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes Q-��e—With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential �
Type of business: Total Square footage of Building:
Maximum number of employees: Maximum number of seats:
5) Water Supply: ew well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes � no
Please note any known ground water restrictions or sources of contamination:
6) If appiying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
that the information provided above is conzplete and correct. 1 also understand that if the information provided is
zte, the site is subseque ly altered, or the inte changes, all permits and approvals shall e inval d.
�
Signature ner/ Legal Representative*) ate
* Supporting documentation required.
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.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
ConnectGIS Feature Report Page 1 of 1
http://gis.personcounty.net/ConnectGIS v6/DownloadFile.aslix?i=_ags_map458b2b04d484... 1/5/2016
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Applicant: �b
Address/Location: S7 ►� 7
Permit Valid for: Five Years �
Type of Facility: '
Number of Bedroo '�j / O cup,
Proposed Wastewater System:
Proposed Repair: c �
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L�c S
Improvement Permit
Non-expiring
.�� New �Addition
[� / Emnlovees / Seats:
Permit Conditions: n;�.}g;,, all srl��c�it
Authorized State Agi
(X) Owner or Legal
Tax Map: �� 2� Parcel: 33q
Subdivision �Q��o�a�u.�
Phase/Section/Lot # <,
?
Water Supply: �� � �
Projected Daily Flow:�_ gallons/day
Type:
Type:
liate: /— � — / (�
Date:
The issuance of this permit by the Health Department cioes not guarantee the issuance of other required permits. It is the responsibility of
the applicanUproperty owner to insure 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 is not affected
by a change in ownership of the property. This permit was issued in compliance with t6e provisions of the North Carolina `Laws
m:rl Rules for Sewape Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmentai
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water sapply ;vill
remain potable.
Authorization to Construct Wastewater ystem
See site plan and additionttl attachments (�.
Proposed astewater System: �,,,lr �7� 7., P.�-�•o%o„ �us�.✓i� (*)Type� Design Flow ��_ gal./day
New � Repair Expanston _ Soil LTAR: . ZS gal./day/ft2
Type of Facility: '� �, ` Basement: _ Yes No
(*} System Types Illb, Illbg, IV, and V, require�2riodic system inspections by the Person Counry Health Department.
Wastewater System Requirements
Tank Size: Septic Tank �� 6nr� gal. Pump Tank — gal.
Drainfield: Total Arza 8Q sq. ft. Total Length �_ ft.
Trench Width 3 ft. Min.Soil Cover� in.
Distribation: Distribution Box / Serial Distribution V/ Pressure Manifold
i�rease Trap gal.
Max. Trench Depth � in.
Min.Trench Separation
� ft c .
Specifications: S lhr� v� /,'tiP (/���_�,�r�P� �iofar[ ��,� is r,1r�Qllo�l,
Authorized State Agent:
Issue Date: �/ — � /G
Permit Expiration Date: �/��—Z/
Tl�e system permitted is: Conventiona( /Accepted V/ Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) 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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S1TE PLAN '
Name 1 � Tex Map# QZ1 Pazce1N 3.3�
Subdiv' Section/Lot# 5 •
� . 5_
Authorized State gent 1 Date �
Sys�em components represen� approximate contours only. The conlraclor mustJlag the sys�em prior to beginnrng the
installption to insure that prapergrade is maintained. '.
Nole: An Accepted system may be used in place oja conventiona! system wi�hout permir outhorization or modification. /
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WELL�ERMIT
(New�/ Repalr_)
Tax Map: � Parcel: � 3 �j
Subdivision: �n-�c �li(ra�o:.,�S Lot: �
Applicant's Name: �,-,.,,�,,, i(nl i H s{�a�
Mailing Address: f q� � S re (�d.
��c���. � 27s�Y
Phone Numbers: _�aq - uNo� �9 2 - /4oc�
��Y�ay �
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Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expi�e S years from the date of issue.
4.) Issuance of a permit does rot guarantee a potaEle,water supply
, , , ,
Permit issued by
�Tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additio�al Com`nents:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S, Morgan St.,Suite C
Rnrhnrn NC 7757�
Date: f - S-l��
Certificate of Completion
Di.iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
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