The URL can be used to link to this page

A37 28Application Date: � 0 � �� Amount Paid: � y _ Receipt #: � i��,°° �--,��, � �� 8'ZZ.�� " � � �.7I�T�f°� � J'1 )I'',an�viin-cp�m�rana:-�rn�:�eall �HIQ-tn.�lQ:ll-n _ _� JU _ _ Application for Services Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Home Reolacement or Buildinf $150.00 (if site visit required) Well Permit (New/Replacement/Re $30Q.00/$200.00/$75.00 ition Services Re uested Construction Authorization (Fee is de endent on the e of Permit Revision Tax Map: � 3 � Parcel#: 02 $ a�--i-=�"a--_ CM �O�GMU.r Repair o Existing Septic System Applic tion: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: � �► � s�— Address: ' �Jc `��S �ti�U �� S�Y 2) Name and address o cuf rren�wner (if different than applicant): Name: ��'r''IC Address: 3) Phone (home): (work/cell): �� Z O S � � Phone: I Property Description: Lot Size: �� Subdivision: Lot #: Address and/or directions to Property: �� t 5-� Cl:� d SE. �7 �`iZ.�• C� T" � yes � no Does the site contain any jurisdictional wetlands? -�-yes CJ no Does the site contain any existing wastewater systems? C] yes �o Is any wastewater going to be generated on the site other than domestic sewage? CJ yes �no Is the site subject to approval by any other public agency? p yes � o 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: / Occupants: � Expansion of Existing System If expansion: Current number of bedrooms: � Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no 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 � Existing Well ❑ Community Well O Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no Please note any known ground water restricrions or sources of cantamination: '` 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 above is complete and correct. 1 also understand that if the information provided is inaccurate, th it ' ubse u ntly altered, or the intended use changes, allpermits and approvals shall b invalid. r� � l � S gnature (Owner/ Legal Representative*) Date * 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) _��, s� ��.� �� .___. .. � � �..� � � � lC��a�-��.� ��.IL IL—��.Il�I� Applicant: -� Address/Location: Improvement Permit Permit Valid for: Five Y ars ✓ Non-expiring Type of Facility: DU�i�C New _ Addition _ Number of: Bedrooms �/ Occupants / Employees / Sea • Proposed Wastewater System: Proposed Repair: Permit Conditions: Authorized State Agent: (X) Owner or Legal Re Tax Map: ��Z Parcel:� Subdivision Phase/Section/Lot # Water Supply: Projected Daily Fiow: Type: Type: Date: Date: gallons/day The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applicanUproperty owner to insure 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 is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the Piorth Carotina'Laws n�rd Rules for Sewape T�eatment and Disnosa! Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Nealth Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (�. Proposed Wastewater System: �,��,/�r�.� (*)Type � Design Flow ,� gal./day New Repair Z( xpansion T Soil LTAR: ��j' gal./day/ft2 Type of Facility: �s.=. Basement: _ Yes f/No IV. and V, � the Person County Health Wastewater System Requirements �/`,�, f y�,�� ,��!rl.tl�•t/!�� (iSTi � � -�b .7`%OLt1 G� � �/f��I'��/''' Tank Size: Septic Tank � gal. Pump Tank gal. Grease Trap gal. %��``� • Drainfield: Total Area �� sq. ft. Total Length � ft. Max. Trench Depth �� inl �� Trench Width � ft. Distribution: Distribution Box Specifications: Min.Soil Cover in. Min.Trench Separation�� ft. / Serial Distribution TC / Pressure Manifold Authorized State Agent: Issue Date: /� Permit Expiration Date: � The system permitted is: Conventional /Accepted ?C / Alternative / Innovative . I accept the conditions and specifications of this permit. (X) Owner or Legal Representative: Date: � 6 07� �� Person Countv Environmental Health, 325 S. MorQan St, Suite C, Roxboro, NC 27573/ ph: 336-597-1790 (rev 5/ 121 t, ��„ J I � �JS.LI �4��+4 ` � � � � �V y V �� IE�.�s��•e�¢�.]L' IE-3i��•Il�7la SITE PLAN Name Tax Map # '�,�azcel #� Subdivision ` �, '�,�. Secrioa/Lot# Aut6 tize S Ageut Date System compoaents represent approximate contours only. The conmctormust flag t6e system priat ro beginnirtg the iasra!latian ro insure r6arpmpe�gradeismaintained. , ZK N��' � � W � � �/�'t��l� i'r �- � � / �� x^'�� T�� / �',,—� �t.�i'o��. �J�� ,a �ia��J� � / _ `j � � ��, �, �Q � .�.�.�yS-tnA 0 �u /N � �. �7 J O _ .� � ��C%✓!'�J� ' � �� i s ��E6: • Fuc.L �j,J �//L�t/`C �t�.G .��J .��i5�'iN/�' ��t��! ,do � /�rJSyD . , � � �so' a�' .v� ��r�� e�N �.✓� ��os��. o L//�/f� 6�� LI"� 7'!'d'�ilG hfl�it� �EG,a .�rs �� R�P��p /�2�02 7� �y�r�.w ��hriyu�s�,/. T � %QGT�G�� aoTTD�� k�': �" DECp . � . �.. -� - } �y �vEsrlo�l� ��r-��T �'��f� � ��--o��z� :�- � �� E ��rA-L.'L ��. ss ��.� �� I��.�na-��.�-�.-n ��.Il IE��.Il�11� Applicant Location: Tax Map �7 Parcel # � Subdivision Phase/Section/Lot # # of Bedrooms z Operation Permit System Type (From Table Va): i� Type V& VI Expiration Date: Product (IIIg): gy� �� Type V& VI Renewal Date: 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 Authorization. (Authorized A ent �GLDir.to� (Licensed Contractor) , �•t° 7�� J� l � r.\ .. � � � �� Scale i1 'i � PCFID, rev. 12/14/12 o e^ (Date D � (Date ., �� g,�� \ � _ � � :� � �-o pJG �G �s�•sy �fA� � F L-r� i a�� Line / Z Total 0 Tax Map: � Parcel #: � Septic Tank System Checklist (Type II-I� System Type: � Notes• Pump System Checklist Pum Tank InitiaUDate State ID & Date: Ca acity: Riser (6" min.) NEMA 4X Box Model: Piggy back lug Hard wired Alarm functioning Mounted on ost Above grade (12") Conduit sealed Pressure Manifold Number of ta s: 5ize and sch: Contracted Certified Operator (Type IV Systems): Tank Com onents InitiaUDate Pump model: Block (4") Nylon retrieval rope Float tree and attachments On/OfF float swing: in. Alarm float (6" se aration) Anti-si hon hole Check valve Threaded union Gate valve Conduit sealed Outlet sealed A proved and secured riser Su 1 Line Size and material: in. sch. Length: ft.