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A36 39��� �f�y��� w �'-1 �.� . GJ.��a-r ,���,���/� ���� �ffl9 � ,� � ��, . /f���u.P� /'�t"!'f,,�`" :,� �,�'r'"z�,�`' �,�� �-� , � � ,�- 4_ �^ ,� =.,,� e�, � . i` �' (�� /2J � O �a f � ��►'�^ J • �f�ri/�,ps4n �tG� �9G (� tN/n.�fT�d l �'CGl tar> � Ra � ( � �/ � /L / // �,// s/f / / . / / � dl��n Gv� � ur✓��/O,r (i� � C�Art�!%�i� `�" 7h �° �'1ldd � G��o/ sa1(.S P � P `� Gtt�eQS �r �E ,3 1°�S ��s �� ��c�- �-�� ��.��) � Apalicatian Data: (o `� �'� � � Tax Mao #: /-t 3�'" 1 �f Amount Paid: , O � Recai�t�: � �3 �-�� � ParcQl�: � � •�����__'�� ���� �� �! 4•ZG - __ � � �U"1�T � �Y" �su�^3rams�.-----^ .osa��.I1 �—�o�.IL�I�a APPLICATION FOR SERVICES IF'i�-1� INFOR9�i�Ti�N IN THE APPL9C.4T➢O6d F�R �►Pd l�fiPR�VEMEi�T PE�iflAIT IS fP9GaRi2�CT. F�1LS9FiE33, C�iA1VGEif C3R THE S1TE IS �►L?�i��D, THE9V T�-ilE 1MPROVE�E�IT_P�RI�i9T AND AIJTHORI�►'i'108�9 YO COh�STiaUC7' SNALL �ECO�flE IMV�►LlD. � '1) Penvait reqvest�d �y: (Ownerlagera#lpraspec#ive owner): `� R �= s/�. << r� ivy Home Phone: 9� v ���-�� 5 o Address: //v � �- ;�5,� d I� ✓. I Business Rhone: _�-; �. .s-�; s- �; S 3 .i •1 FC {� � N r� c 2��o; 2) Nam� and ad�9e�ss ofi es�rreni oweeer. �-1�.'� s�z-� ��-,N zs i� L � N y� d � e� u s t� ' C ;.� �n i s.� �� .a c^ . // 0 �, ��! v l> c.� ,; n cfT � .✓7 �_. ,e. Lt.-r•�-t , '% � 2 ? 1 d / 3) Prop�ety Descr��tion: Lot size: Township: :��s� �Subdivision: Lot # v Directions to th� property (lncluding road names and numbers): 'Tn �.�s r c ?ie-�c � �� 4� L,a.� �d � '�6 �. ctic � = oo .7 4) Propos�d �3se and �t�aac'tvr� Descr�piian:.answer each of the foilowing questions: _ a) Proposed ✓. Existing , Type of Structure: sC�� Width: Depth: �. b) Number of Bedrooms: 3� �. N�mber of oc�up nts or people to be served: u� �o�..��c � c) .. Basement Ye� , No �, . Will there be plumbing in the basement? - • d) �arbage Disposal:_Yes �� � . No _ - 5} if;Ja�er �upply. Ti ype: Private �(new �r existing�, Pubiic , Community� Spring _ Ar� any wells o� adjoining property? Yes�,/No _ If yes, please ind'�cate approximate locatiori on the 'site plan. � . � 6) Does your progaerfij cantaire gireviau§!y identified jur��dic�i�nal wetlar�ds? Yes_.., No `� PL�SE IVOi'E THE F�LL0INIMG: 9� PL,A i OF 'THE PROPEi�TI OFd Sii'E PLAR{ Ml9Si BE �UBI4A1Tf�D �1UITN 'rl-iIS �PPL9CAT60�f. 9 PROPE�ZTY L1NE� AMD CORNERS MUST BE CL�►RLY MAR4CED. -, ➢ iHE PR�POS�D LaCATIOfd OF ALL �TRUC'TURES iViUST BE ST�►6CED OR FLAGG�D. � THE S9TE IViUST SE R�►DILY ACC�SSiBL� FOR d1N EVALUATIOId BY THE HEALTH DE�,�RT11iE�1T STAF�: � I here5y make application to the Person County Health Department for a site evaluation for the on-site sewage disposai syst�m for the above-described property. 1 agres that the cante�ts of this applicatlon are true and represent the ma%cimum faciiiiies to be plac�d on thi%pr6g�rty: l understand ifi the site is aitered or the intended use changes, the permit shall became invalid. � � i Legal � -��`U Date PC: iD, rev. �6�27�02 Application Date: � �`� � 3`�U � Ta.x Map: Amount Paid: � b6 , 0� Parcel #: . Receipt#: �- q o a q 3 ���.ss" �I�I����T - = � � � ���� T�_ �rn.w n u-ca nassaa �� �ca �.r_n, ll 1�-� a�.cn.Il 1£. �I�. Application for Services ' (Sentic Svstems and Wells) Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement) $225,00/$125.00 ❑ Construction Authorization (Fee is dependent on the type of sy; 0 Permit Revision $75.00 ❑. Repair of Existing Septic System No Char�e Important: If the information in the app[ication for an Improvement Permit is incorrect, falsified, or the site is altered, then the Imnrovement Permit and the Authorization to Construct shall become invalid 1) Services Requested by: Name: 1-1 �EPt t_ L.-%�a n� ��rr Address: P D Bo�C I Z G� � o?� BbR.o , fJ C_ �--t 57 3 Phone # (home): (work/cell): 33� - 5 �i9 - aZ � Z 2)Name and address of current owner (if different than applicant): „ Name: Sp�MES A . �►J4 Address: � l p 3 E �.14 � E ul�o v/.Lv E D U Ra-t P�M ti 1U L. 2. Z� n 1 3) Property Description: Lot Size: 1� 1��4Subdivision: S/�. (ro IJ G Lot #: 2- Address and/or directions to Property: C(-lU B t�.I�E (� o� RoP� u 5��' /�?T�C�I� GT S 4) Proposed Use and Type of Structure: Residential �_ Business/Type: Other Number of bedrooms 3—¢ / Number of people served (seats/employees): Basement: Yes No � (with plumbing: Yes No � Garbage disposal: Yes _ � No 5) Water Supply: Private Well �c _ (Proposed Existing _) Community Well: Public Water System: _ ---- re ere on the adjoining properties? No es (please show location on site plan) Note: A comvleted anplication 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 ver�ing that the property is ready to be evaluated I am submitting this application to request services from the Person County Health Department. 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): , Date : o � 200 06/U7 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) / �. i� .' �. .' .' .� .' .' 46 .52� �2 � 9S. N � .P .P O i � 37.54 2.52 ACRES± 167.16 MELTON & DAVIS t�5.60� 1 .77 ACRES± p� a '/_ _� .�, ,�, ,. ,�,_ ,�' _/-_ o _�' 46a•� �- '�� v ,�. , ,�- ,�, ,�" ,i' M � '' -� _'-� I' i' �/� �/ -�� ��� -�� �- �/' �/� '/• 216'$ -i ' � i' ,/�I ,�'��' /�' ,�"��' /.- '�,,i_ / �52,� , / ' /" //' �� /' /-o � ; � ^ti� /' ' �� �' � � ! 100 � . � � / i ,, ; _�� �.� ���� �1/� ��tt �lnp 1�36 p� � 3 � �� * �� ������ ryl,��,��,�,J(�,�,�,� � l `_.7La'tY717r" <CD 7T"Il.Il7�71 <C�� 7L��.2.A.J1 1L Jl c� �iLl1 �� lrW�°IA�l:31CaJl3l5lSU � 0 �' � Permit Valid for Y Fi Type of Facility: Pr;�� # of Occupants rv�ux G Proposed Wastewater S} Proposed Repair: �� Improvement Per it e Years No Expiration ,�L��,�;dQn�� _ New Addition_ # of Bedrooms _� Projected Daily Flow 3(eD Permit Conditions: �air►-�g� Q �% S�b��s Owner or Legal Representative Authorized State Agent: � Water Supply �%I f .p.d. I Type: ��� Type: Date: Date: 2 - z 3 -a�j The issuance of this pernut 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 a�id Rules for Sewage Treatment and Disnosa! 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. Authori�ation to Construct Wastewater Sysiem (Required for �uilding Permit) * See site plan and additional attachments (_). Proposed astewater System: n�c J� nM�vt EZ i"loW er �n�M���YI�e �.tl��. � Wa�ewater Flow 3�6 g.p.d. New � Repair Ex ansi � Soil LTAK: , 3 g.p.d./ ft 2 Type of Facility: �rl�p� e�j�er,ce. Basement _ Yes }� No Wastewater System Requirements Tank Size: Septic Tank: Od0 gal Pump Tank: Doa gal Grease Trap: `----gal Drainfield: Tota1 Area: � sq ft Total Length �oo _ ft Maaumum Trench Depth 2-Z, in d . C. Trench Width _� ft Minimum Soil Cover: __� in Minimum Trench Separation: �_ ft Distribution: Distribution Box Serial Distribution �/ Pressure Manifold Specifications: Authorized State Permit Expirati The type of system permitted is permit. Owner/Legal Representative: Date: 2- Zi�-09 Date: Z-2�{-/�F ✓ w%Pu"� Conventional Accepted Alternative. I accept the specifications of the Date: PCHD rev. 11/10/OS -�� ?,.��► 1�'�J�.��L� � � ����� ]�E��y-��,'.r„ ��.�.11 ]HC��.11� - ��'7',� ��'TC�x : Natne � 1� Ta� Map #� 3�� Pas:�e1 # 3 I Subdivision _ � Section/Lot# � . � 2-z..-o9 . . Authorized Sta.te Agent . � Date . sy�r�m �o�po�� ��r��� app��� ����ou� � y: The con�ctor snrrst fla� the systerra prior to . begirsnirsg t�ie installu�ion to i�s�re that pm�ierg�ade is m�i�tained , ' --.--. - .. . __ -� __ _ _ - -- -- . _ - _ -�- _ _ �����` J --_ � ' �s�- ; ___ `�: ; . ; - _ ; ". „ �, i�—, ���=:_;- -,,, J�a ",'vrv,•tir`'f, �r _. �`C`,1�: ` /'r+ \}`� ^� �Cfi; ^ L� � C i�r ,- , r , �o �\� J ��� � �� � �SKP�( �ine. Qnc� cirain-�;'e[d ?liSetv►evri' rvluSi' �� r►'�c�rl�d �('1' � -{a in�i'a��cr�'1on• I °r �.;�5`� `C2�'� �'��.oC T^.7A:. JS v.-, �a � 6�'.=4� — --- --_�//- � -� __ Q�, T -�5 ° �. . f•��r�_• � �� i � �\T•. i � 6 .� _ , � ,� � �,tia� •n ' c� � �S L:� v .� � %� � � �/� �� �` �' �' P� ( t �' ` I`� �ff _ ^ '�iS�;�Tl1.��;.. V�� � µ`, h�_�, � ,; 75 �� _, . I �� J8e`G�.�»` � a' J I r I� �. . ^ �I L� 0 1�' 1 J � / �(�/��y`. �?iJihill' J k � ----------�i / Jp � � roi,`: �� % � _ F �w �(�� _�: � 1` _ �t; I� `�, a` � � -� , `-r ,I� �`_. � S % o��a'� - �� ��ifia �s�er� �. F �, � �`j _ 3 p ,�.- / 3 be �� � r, 9•� � . k � 3ao� ���� W( �um� � � � �� r � ���+ en -�:�-- -- -- -- �- �. � i c^ :J4.. ,' � �_ -- �_ .... li�` .� ' ..I ._J���' %�: .. ���c'`'E �il il�', SCAC.�� 1''= �D�_ _ - - - C Ltcd �J n" v'� �� ( ou-�� � �Qe � - - - - d ° r -� o raP� .�- - -%- - --� -- /1���. � �� �-d vA ✓_ - - �—;: „ . � .--z �.. L-��♦ :`L�1�`:�'. a � ����, �� I�1�I�.��� �----�� ������ �o�� �t :Rns-,�a-•�,,.n,.,.,..��,e:�.0 ���.�,�. Owner: 2 . TaX Map: ��� � Parcel #: ��_ Dat Z" 2f� OQ Lirne '�'ai� '�ap (5c�) Ta� �'9o�w Liaae �,es�gt� �'fodv ! �oo$ # �iaa�ete�(ian) ( m) (ft) 1 2 � . D On �07 � 2 � 3 � • 4 � � 5 b � 7 s � � 9° � �0 � .�_ ft of line x 65 al. per 100 ft= ' 100 =� gal 75% x� gal =� gai �er dose gal per minute (gpm) _�9ow R�a�e PVCf�o ;7slw Frictaoa �e�d - � � � C T,�ss: , Z� ft per 100 ft of supply line x^' 2-� ft of supply line =100 =�' J ft , ft x l.2 =� ft of frictiorr head . NIanifold SA�e: �"� " Force t1�Iain Size: _�" PVC � 'I'btal IDyn�aac Head =�� f.t of Elevation head +_�ft of Pressure head +�ft of ' Friction F�iead = .�_TDH - , ' fl�urnp IBee�uar�s�aent: �_ GPM @ �� • ft of Head. �� 5 I3rawdmwn: --��gal Per dose ,—` 2l gal per inch =�_ inch drawdown per dose �� es�mA� �e�edssieduPVCTas 11m�-��p� NSE-PW 91 � . .,, , i►; :.:., u,, ; „ „ . ;,, ,. ,,, , , � � �-- ' o � : � '.' '�� ��c�)i�0000 ����i���1�Ns��**�������������� �N+��������� N�i��N�►�������� J Y' PLANVlEVJ �' 2Yps � jiVCSII Vohe] i Afmil�is+. � Iad/mc�eQ - - i4ianifold Siz�! # Ta anifold IYfax No• Taps off oue sic g� {Re�uce b•%2 for tap ' bot! �4» ta s 3���� tavs 1 2" 4 � 3» 0 5 �p+ 21 � �� I " F1ow per T�� - ' Sizz iYlare�-ial Flow G? �� ,.,, Sc:ted �4U �.� i ;; " Sc3�ed -ill �-1 ?, " Sched 30 r�.1 � ?; •• �clted 10 1=•= ; �►y-sa s� -�� , 2t , �� ,�1�w���z ' � � . ��a, � ��}`I`�i� �4Q : . . � . :�' ' • 1 ' . ' . • , . ;• z • • . ' � ' � :'�� •� . 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' y ' ' ,�� ' 1. , • • J• � t ' • � . ; • � Y � ; ' , , . •zabo� staaay . . seaoa n 4 � 4 ►�,• �• ,.• �' . . ' —� ;?�°a IQ�°�I3 uci}axtd9S pZi xs}e1Yl Ya'IS °1. Pad'IS . � L' �;sod pa}easy �znssasd ��$ X ��� T�d t°zlu°� saTdsznS �i� VY�I�Ii .`�[�'�[.���-� �-��-¢at�r�-¢ac��c�..�.v�� � � �.b.. JL � � �� �` '' - �.y''�'�g. r T � a, �-�'1 �� ���� �� ���. '_ `��,;.���� ; ��.��� � �� � ; � � ���� i�.a-�.��:o��-����=<�.11 ]E-�iL�.�]i��. ��I��� ���1�/1L�T (Pa1e� �/ ���aar� '�'�:� I�ap: � 3 � ��nbdiv�.saoa�: A��flaea�a�'s i�d���: Pa���i�ing Ads���s5: _ ��n�ne i'�ua�iue�s: �,����:on �� � � �► _ � �����a: 3 . /1 I I � �. (..o d�211 L°4' �� ` V�L� I.AKP d- � on �u� LAk{�_ �% ���pnit �ondaiion.�: 1,1 See attached site plan for proposed well location. 2� All appdicable State and �oainty Yegulations governing construction and setbacks apply. 3) Permits ex�ire .5 years from the date of issue. �f3�3�er ��nda�iara�/�'a��aaaazents: �_� w.� ai,L�' Oaod �Oaara,c� / � -- �a��a� as�a�es� by. ����• 2—Zc� —09 ����'�'���'�'� ��' �Ffll���+ �'��� I��� '�J��& I�n�����noanc EHS/Date Location: Grouting: Well Log: tiVell Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: `�Y�� ��ll�r: Pump Installer: '�I�1� t�ppr���d �w: Date Sam�le Coilected: Pe:son County Environmenial �?ealth 32:; S. Vlorgan St., Suite C R�aboro, NC 27573 �.,n�e� ��a�g������a: EHS/Date Installer: I)epth: Grout: �e� ��aa��onffie�a�: EHSll�ate Completed: IvIetl3cd/Material(s}: �,as�sa�e #: License#: ���e: Date Results Vlailed: rhone: 336-�97-1'90 rat: :30-�97-%808 8I1 /O U