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A36 38Application Date. ., �J i� � Amount Paid: Rec�ipt �• 3� 9 3� J Tax iVlao #• �c 3 � - / y �-� ��� ����� �� ���� �� -�= � � ZCJ1�" � �Y" �a�+�-a,-sa-oa�.�*�•• �o�a.��sa.I1 �'3Zao�.71�ILa � APPLlCATION F�R SERVICES ParcE! #• IF Tl-i� INFO�MAT10R11�11'�9E APPL9C.4T➢ON FOR AN IAAPROi/EMEiVT PE�dNAIT IS 1�9CaRR�CT �a1L59�i�� C�I�►�1GED. OiZ THE SITE IS e4LTEi2ED. TI-oE911 Tb-11E IfVIPROVEMENT PERRA9T AND l�1UTHORI�TlOn9 TO CONSTRUCT SHALL �ECONiE INVALID. • � 1} Pemait requested, by: (Ownerlagent/pr�spective owner): �fl �1 T' s/� << v iv9 � Home Phone: yr� �'�?-'7�,so Address: 1�d � 1_=1.,�, l��� I�✓. I � Business Rhone: 33� � ss- � r S� .i ��r'a h,�f,�,_.,._.� ��o� 2) lVam� and addr�ss of current owner. �� t.� s�-F Tg-.� �s •� o��� d e-e� � s t� . !�O ' i .��n £ :r .�%- �D .�c[ �+ . �x F_ r1 o n n( r/.� �u,c %•4-�*-t ,'% �'- 2�7 7 d/ 3) Prop�oty D�sc�ption: Lot size: Township: ���� �Stabdivision: Lot #� Directions to the property (lncluding road names and numbers): 4) 5) ff�r�p�sed Use an �ertecture Description:,answer each of t e following que$tions: te a) Propased Existing _, Type of Structure: ��-a 1` Width: � Depth: �, b) Number �f Bedrooms: ,3 � �. Number of occupan or people to be served: itrc na�a�c � c) Basement Ye�_, No � Will there be plumbing in the basement? � � d) 6arbage Disposal:. Yes � . No ,_ � iflfater SuppYy.7'ype: Private ✓(new or existin ,. Publ'�c_, CommunityJ Spring _ � Are any weils on adjoining property? Yes�o _, if yes, please indicate approximate location on the 'site pian. � . ' 6) Does your p��serty cantain girevi�u§!y identifi�ai jur��dic$ional wetlarads? Yes_.., No � PLEASE NO'Y'E THE FOLLOWfWG: 9� PL.6�i 0� THE PROPEH�?Y OR SiTE PLAN Ml! sT BE �UBMITTED WITH �-IIS APPLiC�►T10N. 9 PROPERTY LINES AND CORNERS MUST BE CLE�►RLY MARKED. �, ➢ i'H��PR�POSED LOCATION OF ALL STRUCTURES MUST BE ST�►6�D OR FiAGGED. 9 YHE SITE lVlU$T BE RE�►DILY ACCESSiBt.E Ft�R diN EVALUATIOfd BY THE HEALTH DE9�ARTME�IT � STA��: ' ! hereby make application to the Person County Health Department far a site evaluation for the on-siie sewage disposal syst�m for the above-described property. 1 agres that the contents of this appiicatlon are true and represent the maximum facilities to be plac�d on the,.property. t understand ifi the site is altered or the intended use ct�anges, the permii sfiall became invalid. ^ % ,, �- or Legal 6 � 0 a PCyD, rev. 06/27/02 FIAMLER—JENNINGS �� dc ASSOCIATES. PA Paoressioru� �wo suavEvoRs 21T S LAYAR S�REET - PO BO% t288 RO%80R0 NOR'M CAROUH4 17673 (339) 399-B7I2 , un[ss s�cr¢o, u��en ,�w oerco, m�s is e PIiElIYi/iVtY PU1, NOi fdl RECORDAiION, SAlES OR CONVEYN�tES. l' l�/Y N 1 L- 2 t- 7 L- � L• 0 L- 0 L- 7 �- a L- Y �- �o �. „ �- ix L- 1] L- 1� L- 13 �- ie L- 17 l- 1B L- 1Y �- so �- xi �- xt �- x� L- 71 l- IIS BO%BORO COUNTRT CIIR :��e. ae, �. ea �' ��. 0�� DATA TABLEOO(� BEARINO DIS S27•19'1�•E J3.0� 331•3!'41•E 10.11 53{•30'ol•E 16.70' i0� 53)'33'IYE 6t.f0' X f�t'02'73•C D9.l0' 571'31'J3•11 l4.i9' �� 57S'01'�0•11 60.11' s�s•o3��x•■ se.ee� �77•��'�1•■ 53.�2' see•u�o:•� es.��� se�•sv��e•■ ss.ae� seo•�e�ex�x �9.90' S!3•11'SJ•M 5�.1J' uz•a��se•■ +s.v�� N77'J�'O3•E �6.D3' ses•ii�sre s�.s�� 51�•17'SE'E 16.00' S!Y•17'36•E t1.51� 3]2'17'SO'M I3.�0' yp{•}��IJ•11 19.10' ssv�i�zi•e so.oe� su•ie�it•a xo.n� N�o•orore e4.ao� N71•�]'N•E 14.66� 519']�'�1•M �S.lO' RO%BORO COUNTRY CL D.B. �38, P. !0� I J'' / . EITf / �� 13» � i� �3s� VICINITY AfAP �CONtROI COFtNER IF IECEND NF � NA1l FOUNO NS o NAIL SET IF • IRON FWND IS o IRON SE7 O IAATHEYATlCAI POINi .' . /� i� / / �� /� /�IF 'a. �i�°s� •aJ C' ie �s li 2.48 ACRES PIAT CAB _'�FIANCE�_ FillD IN PERSON/EOU�1rr �o�srcn o s a+ T� .._. DAy,pF ,r�"�". 30..- � 'CIOG( .Jr. f11L0 . MAS011 [wn� M[ �.y :: , �n.bw 11 1010 �110�7'�I ��..`�.� p �ui�noa v t��m[ii ccisr n a or u dtic l� FNa�(ae M�0�qIn•�1; , JI'I��I�Y����'�IIII��Y��WIII���.GCA lNff " iwcawon,�reo 0.8. 227. P. i{ IS' ■nstee�ttn� PUYP LINf EASE�ENt 2 1.77 ACRES -3� PIAT OF SURVEY JAMES A. LONG HEIRS WOODSDALE TWP., PERSON COUNTY, N.C. FEBRUARY 2009, HAMLETT—JENNINGS 8 ASSOCIATES 212 S. LAA�AR STREEi, ROX80R0, N.C. NEAI C. HAMLET7 L-2465 M . � % M 110 �110 � � � � __ .. _.- -J 9M iR.W11 Ina� • 6G /f. ot�� � =,t 3�5•�� is ee.�� +ts�e �s � . 5o,5C .���• i \ d . s � 'i �0 —' ! �°�ti� '. ,� ,, SR 1337 + ^M1ti IS 4� ,,,� \N= 60 � f\�11 IS + � ``\ tR18L1C ROADI �' �or a i wutw�e�o 1 `�\+s ior � j � ,,\ ORAIWIElO ry IS � +:.o�o so.rr. � � Ng . � 73.06 1 �. '�� `\ t % `� 00'11 �g � y`�r \ ?� r!5 � � ,�, � NY i� ,`\ IS ,`\ p �J, `'\ 3 ���`F . 3.50 � .\N� ''J ACRES � �' �.C�`.��� C`�'[� j �a � � ''� � 1 � _,- , NS � `, \. � \ Q �V � /, r' ,i--' ��os� ws ,^ `\'\`� � � : o � :�—� g fl3 ., � __.__- 5,�.,�.1�� ...---���� �� �� � 3 ,(, --- � ._- � R d ,+4� ��,�. (,7 „ f,.--�� 1,,.�+�,� -��. ��f� �1,�'��'GL ,J� "�._„ �w 576'p4'S '/' ,�.- �Y. .�' ��� ,1�1(,#.,(�,'� ' .—�'_ �, N9 .�-R�W �w�'° � ,�- ,�z. .� � v�.�� r IS -� S�a,06'S� '�,r�'Q�-I o 1 NORfN CAROLINA 7ER50N COWtY �} /.1� -/ • V���� .� N9 �/' � �C7 � 1. ."'��l.C�_H�4L�iT'"""' CERIIFY TIUt iMlS U $ .�1'�� �/' �. SURYEY CREA7E5 A SUBDIVI510N OF 1�h9 I1:TNIN a 575 SR P�4K__ camrr. r�r��[ss wr �wq u+o su� nrts � ns .��� _l�o�r ar JE@95��@7_. 20_99_. . ^�,. ./, Ng ��~ . '�o % �0 � l-4`'� `-- t9 � ' . / - ppOfE5310NAL IANU SUHV�� —""' \� NS �/� � / . �'� �1 NS � � . �e o� xs �, �. __N€Df_S__r��4Eti__, certT�rr nur tx�s �S /�' ANAACN.LL�SURVE7 WDEyIk+DER YVtSUPENY $IOM � M� IDEEO OESCAIVIION RECdtUCO IN BOON _.___. , PAOE �_...� [TC./IOTIERI: TN.1T THE UWNOMIE4 /�, •. NOT SURVEtEO ARE CIEARLT IMDI[ATED Ai UR�eN fROY I1lORYATION �MAA IN BOOK ._!__, �AGE CA(�Q�'' L__: TIUT THC FAi10 OF PFECISION �9 C�L- StATC OF fMW7N CMOtlw1 ;• tiN „����' CUlAiEO 15 1:.JRiRRQ!__: iNAT 1NI5 PLA1 NAS �'' COLMY OF PERSON .' Q' •••••• • '%L�' IR[P�REO IN ACCOHO�NCE �fTll C.S. 17J0 �5 (� j0'•E�'$$/0••,7 � D IiNE55 YY OrtlOINAL SIONATVRE t. r?r_�,�_._-��!=l� . REVIEII WFICER a vcrtson oawrr, �ERi FY TNAT iNE YM DR VLAT TO 11HICH iMI3 CERifFIC�TE !3 Af/IXEO YEEi4 ALL SiANiptT REWIRE�ENTS /OR /IECORDINO. s- Y e4_ �v EI � �ICER � D�TE'�" ' 1 HEREBY CERTIFT T/UT i{E SUB0IYISION PLAT AS OEPICTLD NFflEON NAS BECN ORANTEO fiNAL �PVROVAL MIRSUMIf TO TNE PEASCN C0. SI�OIYl410N REOULAifON3. �a.�.tc.__���__. ?^t49 o�re �uM�rro wu zonuw ADYIN[SiRATOR � t 4 � �' i y t�L-2483�j F `t,�'�1SUiN��.� .,F'�� •�.��,6,r /5 7u� AMEWE ■ R(p�$TRAiION NWBER J1K1 SEA[ TNIS �$_ D/Y or .[caeuear_, �.D.. 70_4@_. suaveron _.la1�S,�xi.. �^--s----""---^ =='= Rf015TRAT10N NUM9ER """."4"?463._��_� PLAT BooN 1S P�ge 909 Application Date: I �— � 3-v � Amount Paid: a DO D . Receipt#: <} q 0� `� 3 ,..��� S� �I��:� �� _ -' - - � � ���� 7Gsa� a ar� aa:�raam aa�.m 11 IE� mm71 �7Lv. Application for Services (Sentic Svstems and Wells) � Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobite Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Tax Map: Parcel #: � C'_a.l � �.1 e,' I�I �,� i e� , �,�i- �e�'r� ��o � N� ° ❑ Construction Authorization (Fee is dependent on the type of sys 0 Permit Revision $75.00 �. Repair of Ezisting Septic System No Char�e Important: If the information in the application for an Improverner�t Per�nit is incorrect, fa/sified, or the site is altered, then the Improvement Per�nit and tlieAuthorization to Construct shaU become invalid 1) Services Requested by: Name: IJF�� G. 1�P.N►�-r Phone #(home): Address: Po Ba x 1�,lo(o (work/cell): 33(A- 59�- S?4Z � 2a �c �eo 2o i 1J G Z� SZ 3 2) Name and address of current owner (if different than applicant): Name: JA, r.��s A� . l.r�►� Address: li � 3 EtJ G� E woo � A�l E DC7 2�-l-I�M } r.1 L Z']'1 d I 3) Property Description: Lot Size: 2• S Z�c�..Subdivision: �, .b. . 1.01•�G Lot #: �_ Address and/or directions to Property: C1-1Ut3 1.A�1�E �00'� ROh� — sE'E A'i'T'A�+{E4 G:IS 4) Proposed Use and Type of Structure: Residential X Business/Type: Other Number of bedrooms 3- 4- / Number of people served (seats/employees): Basement: Yes No X (with plumbing: Yes No X� Garbage disposal: Yes � No S7 Water Supply: Private Well _� (Proposed Existing _) _ _ __ _-__ Community�N_ell. Public Water System: - -..---- - •e ere on tlie adjoining properties? No x Yes (please show location on site plan). Note: A comnleted apnlication must also include: .� ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated I am submiriing this application to request services from the Person County Health Departmen� The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representative): I�1Q� G. —1� , Date : v�� 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � �� � �. � � � ��� � T�x Map � Farcel # • � �� � � [ � Su,bd.ivision i � � . � . � � � , . � � � , t , I , Phase Sect�ion Lot # Improvement Permit Permit Valid for Five Ye rs No Expiration � Type of Facility: New ✓Addition # of Occupants # of Bedroo s Projected Dail Flow Proposed Wastewater System: 0 7 Proposed Repair: Water Supply ..� rr g.p.d. Type: / Type:1� Permit Conditions: airr�►n a�� Se�ci�l� - Owner or Legal Representative Authorized State Agent: � Date: Date: 2-1�f —Qy The issuance of tlus pernat by the Health Department in does not guarantee the issuance of other pernuts. 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 `Laws and Rz�les %r Sewa.ge Treatment and Disvosal 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. Authorization to Consiruct Wasiewater System (�2equi�ed for �uilding Permit) * See site plan and additional attachments (_�. Propose astewater System: AC��i� Dume(EZ,�aw orC�ian,be�/ Type 1� Wastewater Flow "�l��_g.p.d. New Repair Expansi r Soil LTA 3 g.p.d./ ft 2 Type of Facility: �ri v� �e��a�e►�c2 Basement _ Yes _ No �Vastewater System Requirements Tank Size: Septic Tank: Ooo gal Pump Tank: Oo gal Grease Trap: '----gal Drainfield: 'Total Area: 90o sq ft '�otal Length � ft 1Vdaximum Trench Depth 22 in o_c, Trench Width 3 ft Minimum Soil Cover: _� in Minimum Trench Separation: q ft Distribution: Distribution Box Specifications: Authorized State Agent: �� Permit Expiration Serial Distribution ;i,i,� � The type of system permitted is Conventional *� Accepted permit. Owner/Legal I2epresentative: �Pressure Manifold Date: � l'�—D� Alternative. I accept the specifications of the Date: PCHD rev. 11/10/0� � '����,�� �1����� L� � � ,%� ,�p �"'��'' �}� �• 4/ �✓ �../ .1. V � .Il. ]��-m-�iy-�,.,,,,,a„ ��.�.�.11 IHL��� � �i'I']E �I�TCgi : Na�tne _�, S Tag Map # � � � � Pat.�el # 3 � Subd'sri 'on � . � Sectian/Lo�# �_ 7-��-�9 � � . Authorized Sta.te Agent . � ]Date . Sys�re�ra cdmponen�s re, present a�pr�narimate �cv:storars o9�ly: 7'he con�tmctor sr:�est, fl'ag the system prior t� ; Ssg�aans�sg th� irrstallutinn to i�sure that pnv.perg�ad� is mrr�s�tained _ L�0 0 � � 1b 1. ,� �3 � 0 � ;� � � ���:.., �, � � � : �. �;� � � � � V �� � � � _, ,,,--' ,, ,-'' - cs �, I ... � _.•",�.� > > L � in � r' , �%� � � � • - .�' ° u� cn �� ; c, �-' / Q � � �r, � � cC� c� (�i 4 � � �'� �-F-� �Cl 6' ��s` � f, 4, v1 '�. Q� t . �� tf I U .- � � � �' `'C .._I ~' `) . _ . 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(!.! 7 �' ^ t1� O) . � C' ,�' � (O �' " � .,.. J � � c0 `j' Ur r� � `T V ^ C�J ,�. ' - .t,i` � ��� �LI �v `� v� � lfi � t � �n D �n O � � O � r � " . `Y � V, ,� 4r ;�, s_ ^ rr- � cn ,.�• r� o r: � J: a-; ;.�. c..' �V C� � N i� ` '�,/ N G) G' O r Cli �' Ir. O � q.� V- r; I" l; � � �� cf� ,-� ' -. ' � ? �i- : _ � .-. .. - , _.: :� Cv . rh ,,. � �= Qy. ;�..._ . � � , ?1� "�.? • �; � ; �, „ ° `'OiV � n co O ci> �... (/i �--������ ����1' �� . �. � J �� � � ���� ��ca�na�ss��rn.ar�rm�a�.�a�n.�. �'��m��� IdEMA A�C Simples Contzol Panel • , . � ("t �" X �4" Presstu� Tzaated Post � • Slopad Ta Shed Water 12° Seg�ration ' El�etrieal Condui� • ' • •, .: , • ' ••' � • • • . •: . • . � i �" Cover• Acc�asCoren • . , � • , . � � • , � � ' � �• � � '" ' ! ' ► : r �' ..: • , �' ' � �, �,. Opnning iilled Wit� . �ti Siphon Hola' � It�et �'mm Septic Tanlc poi1� �ement Cno��t (Down Hill) q" SCH 40 PVC Pipa � � ' ' C�� • Va1�T'@ H�gh Watax �laxx►t Lavel . (6" Separation� . f: v.,, iIigh Levml- Yusnp Ox . ' . ' ,: rQaporLock . � � * Ho1e . . . � �Dr� �Up Fi�l). • � � • Law Ler�al -I'ump OfT � �� • . . �.• ti ' Precatt Coxisxetq Tanlc ,' x sxe � " � ` I�fatesial5tza h>330q PSI • '��;.. .' . � ; •, � ' • . : .� • � — ��ilx ����`i��) � ' ��I'Cf3� � • S�i�hcl�ivis-i�on � � F1����5�c�:'Scct�ior�'Lot # Duct SealHotk Concreie R�ser ' Ez�ds Of The Coz�uit ' -'� 24" Muiitxann � " '' ' - -- �6" Segaxaiion '�;hx��ded Gate Yalve ; Usticn . , • : ' �r;.J'G�' . �„ ;_'.r.rPoxtlaztd Coxicxafe Gsaut � . _ . ;: Maa4ic . • - : , Zip Cvnd.a � . . � OpeaingFillad With Tie� snPplY �• • Portland Cament Gnntt • Lin9 � • " . Outkt To Distnbution r u�„„ 2" SCH40P�C Pipa T..) ��. � �Dp� ' Float Wu�a . � � .. • .� �7cats +.�.' � • �.. � �itamovabla ��. E1oat Trao , , ' �. Pump . .� . : �. 4" Coaurete - ,• . Hlock � i •,a; ' � ��� �����ti, ;� � o o G�.L{�I� gI�IP TA� � � . � . . . . � �:.�. � u,�vyo 1r n-i'� _ —I �� ��a� � Zq -���f-�f' �� h �a. � � i�" i 5 2s�i�n�a� on ` . y .4 ���, � I�J�I�.S�� �-������ ,/ .I� :na-s-vn-�caTM*����exa�E:a]L IHL�e�.tA�+EI�. pwner: s �O� J� Tak lYIap: � 3�� � Parcel #: 3 Date: 2`Z y�-oq Lirne �ap '�ap (5c�a) Ta� F➢ow Liaae ���gt� &'➢ow / foot # �iaa�u�e$er(in) ( m) (ft) � �(2: � 2 • 3 • 4 � � 5 6 . 7 � 3 - � 9° . 10 3 �O ft of line x 65 gai. per 100 ft= ;' 100 =_�gal 75% x gal =�_ g� per dose �+�_ gal per minute (gpm) = k'iow fl3ate Fz-iciion k�ead - _ . � r �[,ass: • 2 ft per 100 ft of supply line x_��_ ft of.supply line =100 = �° ft . ft x l.2 =� ft of friction head .� IYIanifold Size: 3-�' " Force 1l�iain Size: Z" PVC � � 'Tmtal iDynaanac �ead ="'Z� f.t of Elevation head +_�ft of Pressure head +�_ft af Friction Head = '�- 2q TDH � , .� � �'ump Requiremen#: �� . GPM @ Z.Q . ft of Head. . De�awdown: i1�� 1 per dose ,-` 2] gal per inch =�^ inch drawdown per dose � � � �r _.;, �. �, : � � :�, �. �s: , , � - - � �..,�. . . • Y .., � _\�'�����'S ,. ; � ,. � • :`o, � : � � ���)I�00�0 �I 1�1 �) �1 -_ , iiiiaiiiiiNi�iiiiiiiiii�iiiiii -.... .... ..< . s �N!!!!!��!!!!�!!!!Nl��!!�!�!� 1 I I I 1' - :, Y' � ", � � '�� -� q�� �_s . 4" b" Max l�To. Taps oi� oue siQe ,uce b 31z for tap ' L+ both si t3 S a/�» �ps li► � 4 � 9 9 3 I S a� ��( a�, es%�w�a� 4D+ 21 � 1� I " " �1ow per Tap �- 3i.z 1Llatzrial F'ioti�� ir��I ,:•, Sciierl �4U �.S �i •� Sc}ied �i) i•1 ?; " Sci:ed 80 � �. i ., �ched s0 1=•= � : ���� 1' �� j ����..1� ��� ; �1 Y ' ' - ^-., �/ `�J� � � � � i�.n.-���:��.�-����.�.11 IL--�L «�..11��. �i�1 �-�+ I�L �'��+ �1�/�II'T (P��eva� ✓ �3��saaa-� ��� r���: ,A3 � ������: 3 � �aa�di��s�oa�: �,at: A�pfl�c�n�'� a1��ae: �u,.< .�./ l���i�g Ad���s�: ���ne 1'��aami�e�-s: �.,����:mn ������e�: _ ? ��' I�+ a ��� ��rrnit �oaadaii�n�: 1) See attached site plan for pYoposed well location. 2� All appdicc�ble State and County Yegulatians governing construction and setbacks a�ply. 3) �ermits expire S years from the date of issue. ���er �'�nd��aon�/�'��antents: �2� W� �� v�tf" n� Ooar �n�rz:� d�t1 -. ��r�aa� as�a�es� �y• �Da�k�: Z-2y�=e�' ���'�'�+���'�'� ��'+ �'1�1��..�'�'��� 1��� �I�� ���p���iuo�n: EHS/Date Location: Grouting: Well Log: tiVell Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: `��� �a�qller: Pump Installer: �n�e� ����������a: EHS/Date Installer: Depth: Grout: �e� ��a��do�n�e�a�: EHS/Date �ompleted: NIethad/Material(s): _ ��s�n�e #: License#: ���9 �ppr���d �y: ����: Date Sam�p?e Coilected: P�:son Counry Environmental �?ealt�'� 3�� S. YlorQan St.. Suite C Rc�;boro, NC 275 i 3 Date Results l�lailed: rhone: 3�6-�97-1^,90 ra�: �30-�97-7808 8IlIOU