A35 141Application Date: �a3�) �
Amount Paid: a00 ,00
Receipt #: 70 3 N 9�
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❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
0 Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (l�iew/Replacement/Repair)
$300.00/$200.00/$75.00
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for Services
Tax Map: p►Ss"
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❑ 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 In r ation•
Name: 1 � � �/�
Address: � � n G
�7 t7�f
2) Name and address of current owner (if different than applicant):
Name: �
Address: �
3) Property Description: Lot Size: � Subdivision:
Address and/or directions to Property:
Phone (home):
(work/cell): T.
Phone: 919 �- � S 7 (�� % ti
Lot #:
❑ yes �'no Does the site contain ariy jurisdictional wetlands?
0 yes I�no Does the site contain any existing wastewater systems?
❑ yes �no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes 6�no Is the site subject to approval by any other public agency?
❑ yes L�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 Structure:
�Residential
ew Single Family Residence Maximum number of bedrooms: _�
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes mfio With plumbing fixtures? ❑ yes �no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well L�" Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
J
6) If �pplying for `Authorization to Construct', please indicate preferred system type(s):
E�Conventional ❑ Accepted ❑ Innovative ❑ Aitemative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or„if,the � is su�quently alte�ed, or the intended use changes, all permits and approvals shall be invalid.
3`�fiature (Owner/ Legal Representative*)
* Supporting documentation required.
9-/7� �
Date
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.
(10/1 I) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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October 3, 2014
Mr. Kyle Shelton O'Brien
72 O'Brien Drive
Roxboro, NC 27574
Re: Application for improvement permit for property located at 906 Oak Grove Road;
Health Department file: Tax Map #A35, Parcel #141
Dear Mr. O'Brien:
The Person County Health Department, Environmental Health Division on October 3,
2014, evaluated portions of approximately 3.07 acres at the above-referenced property
that accompanied your improvement permit application. According to your application
the site is to serve a two bedroom residence with a design wastewater flow of 240 gallons
per day. The evaluation was done in accordance with the laws and rules governing
wastewater systems in North Carolina General Statute 130A-333 including related
statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative Code,
Rule. 1900 and related rules.
Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina
Administrative Code, Rule .1940 through .1948, the evaluation indicated that the site is
UNSUITABLE for a sanitary system of sewage treatment and disposal. Therefore, we
must deny your request for an improvement permit. The site is unsuitable based on the
following:
Unsuitable soil topography and/or landscape position (Rule .1940)
X Unsuitable soil characteristics (structure or clay mineralogy) (Rule .1941)
Unsuitable soil wetness condition (Rule .1942)
X Unsuitable soil depth (Rule .1943)
Presence of restrictive horizon (Rule .1944)
X Insufficient space for septic system and repair area (Rule .1945)
Unsuitable for meeting required setbacks (Rule .1950)
Other (Rule .1946)
These severe soil or site limitations could cause premature system failure, leading to the
discharge of untreated sewage on the ground surface, into surface waters, directly to ground
water or inside your structure.
The site evaluation included consideration of possible site modifications, as well as use of
modified, innovative or alternative systems. However, the Health Department has
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
determined that none of the above options will overcome the severe conditions on this site.
A possible option might be a system designed to dispose of sewage to another area of
suitable soil or off-site to additional property.
For the reasons set out above, the property is currently classified UNSUITABLE, and no
improvement permit shall be issued for this site in accordance with Rule .1948(c).
Note that a site classified as UNSUITABLE may be reclassified as PROVISIONALLY
SUITABLE if written documentation is provided that meets the requirements of Rule
.1948(d). A copy of this rule is enclosed. You may hire a consultant to assist you if you
wish to try to develop a plan under which your site could be reclassified as
PROVISIONALLY SUITASLE.
You have a right to an informal review of this decision. You may request an informal
review by the soil scientist or environmental health supervisor at the local health
department. You may also request an informal review by the N.C. Department of Health &
Human Services regional soil scientist. A request for informal review must be made in
writing to the local health department.
You also have a right to a formal appeal of this decision. To pursue a formal appeal, you
must file a petition for a contested case hearing with the Office of Administrative Hearings,
6714 Mail Service Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form, you
may write the Office of Administrative Hearings or call the offce at (919) 431-3000 or
download it from the OAH web site at http://www.ncoah.com/forms.html. The petition for a
contested case hearing must be filed in accordance with the provision of North Carolina
General Statutes 130A-24 and 150B-23 and all other applicable provisions of Chapter 150B.
N.C. General Statute 130A-335 (g) provides that your hearing would be held in the county
where your property is located.
Please note: If you wish to pursue a formal appeal, you must file the petition form with the
Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS
LETTER The date of this letter is October 3, 2014. Meeting the 30 day deadline is critical
to your formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative Hearings,
you are required by law (N.C. General Statute 150B-23) to serve a copy of your petition on
the Office of General Counsel, North Carolina Department of Health & Human Services,
2001 Mail Service Center, Raleigh; NC 27699- 2001.
Do NOT serve the petition on your local health department. Sending a copy of your petition
to the local health department will NOT satisfy the legal requirement in N.C. General
Statute 150B-23 that you send a copy to the Office of General Counsel, N.C. Department of
Health and Human Services.