A35 173Application Date: G —�i ' ��
Amount Paid: � 0, 00
Receipt #: 021 g t 3
V 1 _�
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
�150.00 (if site visit requiredj
❑ Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
��,;,�f ����'LJ�. V Tax Map: /4' 3 �
�.. ,- �.�- � � ��,�� Parcel#: � � 3
ll`-.][Il`i 7I.Il�QD.II7lIIh1at�3T.U:ffi�I IHLtC�i.81..11.'L'1"11.
�lication for Services
Services Re uested
0 �onstruction Authorization
(Fee is dependent on the type of
❑ Permit Revision
$75.00
0 Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant In rmation:(`
Name: �' J Gc.,� S
Address: �v �
2) Name and address of cu ent owner (i diffe ent than applicant):
Name: � L�c.v,� ��� 1� G li..,., �-�'v�
Address: `7/� �,�,� G���v��
�.c�%�r'�� h/L. �� S —7
3) Property Description:
Address and/or dic
7l� oxt x
❑ yes
�es
❑ yes
❑ yes
❑ yes
Lot Size: S ��. Subdivision:
Phone (home): ��� )1 �����
(work/cell):
Phnne� ���— �� % �%a�
Lot #: _
❑ no Does the site contain any existing wastewater systems?
�� Is any wastewater going to be generated on the site other than domestic sewage?
C�-(io Is the site subject to approval by any other public agency?
d1,ao Are there any easements or right of wa}�s on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number ef bedrooms:
❑ Repair to Malfunctioning System Will there be a baserneiit? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building: j�%���
Maxi:num number of seats:
5) Water Supply: ❑ New well L''f Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
1 cert� that the information provided bove is co plete and correct. I also understand that if the inforntation provided is
inaccurate, or if the site is subsequen alter the intended use changes, all permits and approvals shall be invalid.
�
_ �
Signature (Owner/ Legal Representative*) Dat
* 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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Application Date: � � � " � ' � � ���+5� ���� �� Tax Map: � �s
Amount Paid: __y�_r / �t ������ Parcel#c ( 73
Receipt #: �� � �
JE:�rn-s-an-an+•*,•,�*�aanflian.� ���j�,s.]�d�n.
� Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
� i SG.0�7 �if site visit required j
❑ '�Vell Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
�lication for Services
Services Requested
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
0 Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant In%rmation:
Name• � , �-�+. Z. , Co�S���,�r-� : a� � �nC
Address: ,� s
iD,L�prD � G �%S�
2) Name and ad ess of current own r(if different than applicant):
Name: C �� �o..,
�'.. y�Q u �
Address: 1Z� ��
,r'-,� C Z �S� �-
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Pro�jer�ly:
i J Z �k C7 Tc;,ne i�/1. _ o x1-,r.,
Phone (home): ��? `� �_
(work/cell):
Phnr.e: � lc7' ��-� O
Lc�t #:
O yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems7
❑ yes ❑ 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?
❑}�es ❑ 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
❑ New Single Family Residence Maximum number of bedrooms:
❑ Ex�a_nsion of Existing System If expansion: Cu�rant r: � � ber of bedrooms:
� Repair to :�?atfun�tioning System Will there be a basement? � yes ❑ cio With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Mzx:m�m number of employees:
Total Square footage of Building:
I�ar,imum numbe; o: seats:
�) Water Sup�ly: ❑ New well ❑ Existing Well ❑ Comrnunity Well ❑ Public Water � Spring
Are there any existing wells, springs, or existing waterlines on this property? � yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
� Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, if the site is sub quen ly altered, or the intended use changes, all permits and approvals shall be invalid
r _ / �
Signature (Owner/ egal Representative*) D e
* 3upporting do entation 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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Building Additions/ Mobile Home Replacements
Tax Map #: 35 Parcel#: l7 Address: x�i� �-,���'��
' +��,c� rc z�s'��
Approval Requested for: Mobile Home Replacement
✓ Building Adciition i�oo ��� x�z � t F��Q�
Gq1it�F
Applicant Name: ��. �a�� + "��g� � Cc.a.��f-a � � x 30 '
Address:
Phone #'s: - �'S ^ ?o a 33� -S9? - 2?z o
_,. �si.r� ✓'r��J /�io�S L'uNf�v�✓s
Permit Located: ✓ Yes No
Installation Date: o � Design flow: 3!0 0(gpd)
Current Contract with Certified Operator on file (if required): ��'
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: �efi3'� � (date)
(Applicant's signature if site visit is not required)
• � . � . � i�. � �, ;� . ,�
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.. � �. . ; .. .�,.. _ �. , a .� . '.� _
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Addition/Replacement Approved
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Environm tal e Specialist Date
� i�I���Z
�k9� ���5 .
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www..personcount .y net
�.
Amount paid �U���O �� � �j��
� Receipt !� ' �� �
, .�
�-� � - a n�r,iCATI(�N FnR ;
Improvements Permit.(Fstablished/Recorded Lot)
Imp.covements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permi[ (Addition)
/- ).3-99
Date
':., f�A4«C^.4' `�' .�f .f"r�.! '+ca'��.x+x q ��5�+'11�q+�'R��
.equesf ed � , �;�„�.� �� � _.�..� .wf���..,�•� ;,�.,�
Reinspection of fixisting System (Loan Closing)
Repair/Replace existing Septic System
_ Permi[ foc New Well
_ Replace Existing Well
1. Pecmit requested b�
owner/ rosnectT ive ow
Address: � �% �
� - )�(b
�
� Home Phone n: �U�
¢ usiness Phone tt: �
a —
W
¢
z
nt:
- �r�bb� e
7. Dimensions or Pro�osed Structure:
C �Ct.t. t4Vidth: �
Depth: 7 �
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewaae disposal system is intended to serve?
2. Name and addreSs of cucrent owner: 9. Wat�supply t}pe:
.� ohr, �. Ha.r r��5 private . pubIic ❑ community ❑ spring ❑
.3! 9 }EaI�F"a , Are any wells on adJoining property?Yes ❑ No (..'�.
� icborv /UG '7� 3 If so, identify location:
3. Froperty Description: Lot size: _
. Ta;; Map�:_ y' / �
ParceI#: • . Q'�
Township: �.�(n ��ISaCQCe,
. Directions to propercy: State Road #& Road
iames,gtc. �!
�-n �n"fT� �JQ.lC (1rnu�-l�i�ii It1-f-.Zi�n i�hLc✓1'.h ,t�.
'/�
Number of occuoants or neople to be secved:
lU. Type �f structureliaciliry: Proposed�Existing: Li
_ Type of dwelling:
House: �Mobile Home: Q Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: ' Z � �- �
Garbage Disposal? Yes ❑ No,�
Basement? Yes ❑ No�If so, # of basement fixtur�s:
CLEARLY STAKE ALL CORI�IERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
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 pcoperty. I agree that the con�ents of this application are true
and represent the maximum facilities to be placed on the propeRy. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand tha[ before an Improvements Permit can be
issued, I must present a survey plat of the propeccy to the Heal[h Dept. I understand that in the event I have not
delivered a survey plat of the propecty to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeiced.
St'�'ncc� Owner or Au(t�orized Agenl
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�" � � PLEASE
, Tax Map #: _
� � Zoning _
. ' APPlicant
� � �oadon:
Subdivision:
PERSON COUNTY ENVIRONMENTAL HEALTH
'ACHED PLAN FOR SOIL AREA AND SYSTEM l
Parcel A I I -�
Townshlp ��('� rj �l�c//�%
SecUon: LoG
Improvement Permit
A buildinq permit cannot be issued with onlv an Improvement Permit
New � Repair Addition Type of Strudure ��, Water Suppiy i7!', d4�
T
# of Occupants # of Bedroom Other
easement? Basement F'ixtures
Projected Daily Flow: 3��g.p.d. Permit Valid For. @'�ive Years ❑ No Expiration
Proposed Wastewater System Type: y� S�. (�h p��wO.��p p__
Pump Required? Yes �No
Proposed Repair : o"�S� �c , c�^a,n �'�C1oJ4�=r�,. ,
PermitConditions:__ ..� ,�� ��J ���y�,�Q,
Owner or Legal Representative
Authorized State
� Date: S-3 I - a �
Date: 5 ' ��(�
The issua�ce of this permit �the Heafth Department in no way guarantees the issuance of other permits. The permit
holder is responsible for chedcing with appropriate goveming bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the inte�ded use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This pertnit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Buildinq Permit
b�'
Type of Wastewater System�V I�JZ Wastewater Flow: .p.d.
Facility Type�d�� ��1 New �epair DExpansio� 0
Basement? 0 Yes Qd-Pia Basement F'ixtures? 0 Yesfl-Pdo
Wastewater System Requirements
Septic Tank Size�a�4�allons Pump Tank Size: gallons
G�.� 2_�
Total Trench Lengttf: feet Maximum Trench Depth: ,� inches Aggregate Depth:LZ.in.
Maximum Soil Cover. �, inches Tre�ch Separation: � Feet on Cente�
Other.
Permit Expiration Date: �--,� (� -(�
Authorized State Agent: Date: '
The type of system pertnitt 0 does 0 do s not differ from the type specified on the application. I accept
the specifications of this permit
OwnedLegal Representative Signature: � pa{�; �.3�—d � �
PCHD, rev.11/18l99
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❑
Application #: �
Tax Map #:
Parcel #: /'7?�
• Perso� County Health Department
� Environmental Health Section
. �.
�
SITE SKETCH
<..Jvva.�,n� C tC�.u�� �
Appiicant's Name Subdivision/Section/Lot#
�-3 0 -�
Authorized State Age Date
Scale: � � � = I� 1
PCHD, �ev.10l12199
w
Person County Health Department
�/�- Environmental Health Section
Tax Map #: .T� c�� Parcel #: / �7 �
Zoning: Township: Ll,��;�.�� P .
Subdivision: Section: Lot:
Applicant: �
Location•
Operation Permit
�
System Type (In Accordance With Table Va): �.�
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
THORIZATION.
"7 � � � �
Authorized State A nt Date
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L-3 = �'S
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c�. = 3�
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Tax Map #: ,� � Parcel #: J��
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Pecti�����
Zoning: Townshi : —
Subdivision:
••. t . �• .�
' � 1
. . �.� � � �� ' � •
Section• Lot•
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements �
B) Distance from system to any welfs Icsd�+
C) Distance from septic tank to foundation rc� �
D) Distance from system to property lines /a'+
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank ✓
B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet _�,�
C) Date of tank manufacture /-19?Aol
D) Tank serial number D�r�S-%� ���Z
E) Liquid capacity of tank ��6i� gallons
3. SUPPLY LINE TO TRENCHES
A) Grade `� (1/8 inch per foot minimum)
B) Material supply line is constructed from '�« SAN �l ��/C,
C) Diameter � "
D) Length 5'
E) Distance from tank to drainfield/distribution device _��
4. DISTRtBUTION DEVICE(S)
A) Type
B) Is Device water tight �
C) Distance from the distribution device(s) to the trenches
D) Is the device on a level foundation
E) Does the device perform according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth(2 �$ �� inches
B) Trench width 3�" inches
C) Distance between trenches `�'' O►� ��
D) Number of trenches � ,,f
E) Length(s) of trenches (.�.��.�
F) Aggregate depth ( �- inches
G) Aggregate material and size , S�
H) Record septic tank outlet elevation � 5' ��
I) Trench grade ✓' (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth �
b. Proper rise over step down ,��
c. Solid pipe used ��
d. Elevations of step downs �(Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
� PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN F�R WELL SITE LAYOUT
Tax Map ik � �� Parr.el # � ��
2onfng Township ��/�/l.•C_�'�"� "`^�
�A Iicant � " "
"
Loeatlon• � Q-� ��m �
Su6diviston• Sec.tion• �
Tvpe of Water Supplv:
Requirements•
Site Approved by
Grouting App ove
Well Log
Well Tag '
Air Vent
Hose Bib
Concrete Slab �
Well Permit
ndividuai Community � Public
► �
.�
,
.. �.
Welt Driller: lrav� (�'t � —
Weli �Approved By.
Date: ��Z�� �
**See Attached Site Sketch**
Welis must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Weils must be at least 25 feet from any buiiding foundation.
Other conditions:
PCHD, rev. 11/29/99
. • P�R5UN COUNTY ENVIRONMENTAL H�ALTH _�
, � � . S�ELL LOG
Date: � ' ��.� � � � ' � � ��1-ng,,� � _ SR# � - � .
— ._ , . . ,�. � ,.
Owne;. _ .
Location/Directions: � � � � .
L�t �E
SUUCi1YiS10T1 Nc'U71C: .�,�.� �11'11 l � �M Sn.� � �' _
Drilling Contractor: ���u���
.�r�Y �r _ r�ONS'i'RU_ CI' 4�
� ' Distancc from Sourc� of
Distancc from Ncarest Properry Linc -
P�llution GpM S�uc Watet Level F�
Total Depxh GO F� Y:eld: . �t. �
Water Bearin8 Zones: �ep F�' - Ft' FG— / Inches
to, -r�' L._.,..Ft• Diamcter'
Casing: Depth: From (',alvanized Steel '� .
: 'I'YPE: Stcel ove: Yes No
� If �Steel, does owner appr Inches
Z'hickness' • Height Above Ground: _
� 1'Veight: • • �
� Thivc Shoe: Ycs N� ' No____..__
Wer� Problems Encounterai in Setting thc Casing? Ycs_ ___
: . . ;, "ycs" givc rca.�on: SandjCement_ Concrete
Gr�ut: Type: Neat — ches
- Annular. S�ace Width_ No._._____
. �Nater in Ar�nular Spacc: Yes_ Poured ��_ �.
Mathod: Pumped �Q � essure______� _
Depth: From_ � ��'
. . a po�tland Ce�ment__ Weight of � bag____...lbs.
Matena]s Used• No. B gs co .
� Tf mixture (sand, grav�l; cuttings) • Ratio: .
Yi� Y'latcs: Ycs '� No ,
,, ., ,, �,,�, v�� ✓ No _ - . . �
I HEREBY CERTIFY THAT THE ABOVE 7NFORMATION IS C REGULA ONS SET
THIS WELL WAS CONS'I'RUCTED IN ACCO DEPARTMENT.
�OR'l�i BY •'THE pERSON COUN'rY HEAL"�H
, .
. _: � �
��Q�=
� Signat>>rc of Conttact � Datc
9