A27 34Application Date: � -��i -I 3 `��.5� ������T
Amount Paid: j O,� �' v
Receipt #: �3 7�1� � �' � ����
�':�mv+aa•aaTM��+�+�e�d,m.l� �c�mIl�.
Application for Services
Services Requested
❑ Improvement Permit (Site Evaluation)
$600.00/$300.00 (if> 600 gpd)
CJ Mobile I�ome Reptacement or Building Addition
$150.U0 (if site visit required)
❑ We11 Permit (New/Replace�ent/Repair)
$300.Q0/$200.Q0/$75.00
0 Constructiott Authorization
(Fes is dependent or. the type of
0 Permit Revision
Tax Map: � � 7
Parcel#i 3�
Na Pern� � f �
�oUud -
❑ Repair of Existing Septic System
Application: No �hargc/ CA $150.00 or $300.00
,r'
� : �1) Applicant In rmation:
Name: �o�.�es ��15�{�,r c�"i'�n_, �,� _
Address: laSb`� N.�((., �i?; n(�. �
I u��ac�ri �-� (�� i � a-
2) Name and address of current owner (if different than applicant):
Name: ,✓� � 17 l i�� o... w�.
Address• S o�¢.,r��nc�,.._ �.0.
� �2�x h� �� rver a�� � �
Phone (home): � )g - `�3a - (0 0 3 S�
(work/cell): Q 19 - 01 �c� - 3� o S' �
Phone:
3) Property Description: Lot Size: �� Subdivision: � Lot #:
Address andlor directions to Property: 3 S� e�a r� ��—
❑ yes o Does the site contain any jurisdictional wedands?
�s 0 nn Does the site contain any exisdng wastewater systems?
❑ yes Q.aa' Is any wastzwater going to be gei:erated on the site other than domestic sewage?
❑ yes ❑ no Ts the site subject to approval by any other public agency?
❑ yes �-sr� Are there any easaments or right of ways an this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed ilse and Type of Structure:
❑Residential
❑ New Single I'amily Residence Mar.iarum numEer flf bedrooms: 3_
❑ Expansion of Existing System If expansion: Current number of bedroems:
❑ Repair to Malfunctioning System �ViII there be a basement? CI yes ❑ ne With plmnbing fixiures? ❑ yes ❑ no
❑Noa-Residential
Type of basiness:
tvlaximum number of employees:
Total Square footage of Buildin�: ol ��C o�� �jQ���
Maximum nur�be: of seats:
�; 5) Water Supply: ❑ New welt �ting Well � Community Well ❑ Fublic Water ❑ Spring
�� rlre there any existing wells, springs, or exysting waterlines on ihis properry7 ❑ yes ❑ no
If a 1 in for �Authorization to Construct', pleas� indicate preferred system typg(s):
� PP Y g
❑ Conventional ❑ Accepted ❑ Innovative C1 Alternative ❑ Othzr __�� ❑ l�ny
1 cerl� fhat tre ir fnr.ntaiion��rovia'ed abnve is complete ancicc�rt�cl. I also c�ttd�rst�xnd that i{the informatio•rc provided is
inar.r.urate, o,r, �the site is subsequently altere�, or the intende� r.�se chunges, all pErmits and crpproi�als shall be ir.vali�?
S�nature (O�vner/ Legal Representative*)
* Supporting documentation required.
��
Date
o Permits are valid for either 60 months or are non-eapiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
� � � � �,��
., ,: �- 1 )= i i
� `� I� � �, t � .
�.� 1 ,
�� .� �� �� � ��
y � , a .-r .9""
�.�'� � �� � ' �1� � �1 �
�,:�.z-�-s����_��.�.�A�.�i<� .',l '�-����.�.11�::�
�a�a�d��� r�����m��/ I���bfl�� ��a�� ���nfl�a���a��n�5 �
Ta.� IVIap #: q a�1 Parcel#: 3�i Address: 3�' �� s�c�a� Ro
Appraval Requested for: Mobile Home Fceplacement
�( Building Addition
Applicant Name: ��hEs �a.-�-�x�cz►a�.� '�v�. p�wt�► b' o�ivc� l�i�ar►s
Address: -
Phone ,#'s: 919-`13�- b�35 y�q• �80 � 3qaS
Permit Located: Yes )(, No
Installaiion Bate: 11t�K►�a�..� Design flow: 3�� (gpd)
Current Contract with Certified Operator on file (if required}: _�_ ,.
Water Supply: x �ell Public or Community
Wastewater system shows no visual evidence of failure on: '� as �� (date)
(t�pplicant's signature if site visit is not required)
Comments:
� � y x �$' 6A�.
�c�,s � . Ca4�. �GK(J
� 33b� S9'1- IhqO ' � � --
�tr1������1��������a�e�at ��pu-��v�e�l
o�.�,,x. Q. �..
Environmental Health Speciaiist
as' 13
Da e
Person Counrr Environm��tai =�eaith; ��� �. ti:orQan St., Suite C; RoYboro, NC 27� � 3
Fhcne: ��6-�97-??9C/ ra;:: ��6-�9�-7�OU � tv�%,^,�i.�,ersoncoun�tv.i,e�
���� � ,�/���j�� / I �\��
W`' `\_ v � �6 V Jl �
J�a-a ras�aaaa'n�::zn�-�.]L 1L3i��u.��I�n
SITE PLaIV
ilame ��5 �r�t�� - twt: A�Al, � V�•-�v,t1 1�x::i4C�,y T�c �?ap #�� Parcel #��
S �� i�n � �ection/LGt# �
+i . • `i � �S l3
<: uihorized St;Zte A.gent Date
System components represerit approxfm�te corrours only. The contractormnsr llag tbe sy,rem prror ro be�ig the instal/ation to
insure thatprnpergradeismaintafned.
I �<.
� �� ��� �
9�n�....n�n,?�n�n.�;�.11 1I�I��ll�l�n
Building Additions/ Mobile Home Replacements
Tax Map #: 2�1 Parcel#:_3N Address: 38'ZS ��nfa �,
Approval Requested for: Mobile Home Replacement
✓Building Addition
Applicant Name: 1.�Gt�g P� �)/ CD M P � o�
Address: 4����c��� Pv� � r �,,� �r�
������ �(!. C� �73�13
Phone #'s: �� • �"03 - 33D�
Pernut Located:
Installation Date:
�
Yes �o
Design flow; 31 a (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: �ell Public or Community �
Wastewater system shows no visual evidence of failure on: -I a- l _(date)
(Applicant's signature if site visit is not required)
l�
Addition/Replac�ment Approved
�
�
Envir ental Health Specialist
Jo - lo�ri
Date
Person County Environmzntal Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcounty net
��� l f ���.��A �
---' t� � � ���� '
I����-������mIl II�[��Il�ll� .
i ' y.
f'. '� ..
���';
L�d •a.,
.�; _
,I --__.____
Site Piar.
Name: �
Subdivison: _
Tax Map: �?%
I Parcel: �
I—
ress: 3� 2� ��'►'IOtQ Fd.
Lot: I EHS��.,`
Date: %D–/D�–(`�
r �-.
� .k t. ' ��„� �ja"" : ' i $�;, ` ` ;� i �"' ".��'
, � � ,� , „�t
i �: M }
� , � .. . �ti k �{.:. .. . .. ' f ..w✓W Y��,f•_.•r _ .
� �r' �
, ; `. ,� Si..� ..sf/'.n-� ' .
A �
� r , ' .'
....;.,.�' f �, .,, � � � ���:
� e^" ,,,t• �. � � .�„ �,.�� _ ..,� _
; � .
. • .t. , : ' �
�� ' ' i
_. __ _ ' �} C; ;;' � -7 ' -
r (�
e a �� �,J 1,; � � � ; . . � ��, , ;
� +�.. ���i �r " � ,�� / / � � .� . - ..a� ��-.
. . �` �.� F I z ici � ��';� . .
. �
- - � � � - e� ( `-� Q.; �`,y �
�
_ I " ! ��' `� �, � ----% `�'R�..,,� _
� �: � . .
�;`-= � � f +� -+�
- � �.
RS _ �a
,�
� � �
�� - � �
�
.,
� � ". ___---�
���.�s� -
��l�rf►��, '.:�
�
� ;���
��.1 � -
. . S- ��. �.�_\
i� .
� ��
, , �.�-
, �
o ��� / �
�, . �,��:- ..
rn
rn
. ., �«; . �. t
, �' �,.'�� " � � �,
t � 1�'t ��, _ �
tem Type: I - –_ -- —
Septi k: _ gallons
Pump Tank: gallons
Total Linear Feet:
Max.Trench Depth: " j
I
�.
� � F ��_: �
vrl.r ' .
�
�� ' ��
�
�
� � � �,..,,. - _
�_ F
� �w
_�._
�
''� OI
Scale: _�1
Note: 1) Drain lines represent approximate contours. Drain line locations must be f�agged prior to installation.
�� Coniact PEf5Gi1 .r.:�Uilt`y ���Vi�01'll��:di �E��.�i'vV�ih �^'/ y::e�tions ,?36; SQ?-l��C.
t
Additional Comments:
�
s
�