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A38 1AThe District Health Department Orange, Person, Caswell, Chatham, Lee Counlies SEPTIC TANK PERMIT Date �' ��' �� Name of owner: ��''f �' ��,l��. o �'! Name of contractor: Address and Directions �,'�� X�/2�/� Person or firm doing installation: ��'✓?�� S Address -� �(1, No. of persons to be servec�� r- Bedrooms 1,� 3, 4. Additional appliances to be used: Disposal, dishwasher, washing machine Recommended• Septic ta � � Nitrification line: �,lL_.7; / Above recommendation based on information received and observed soil condition. Septic tank and nitrification line must be inspected and approved by a member of �he Dislric! Health Depaztment siaff before any portion of the installation is covered. Date Approved: �-12^ �. Countersigned Sanitarian O. David Gazvin, M.D., M.P.H. District Health Officer (Over) NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on adjacent property, etc. Write in measurements in order that installations may be located at later date. . SUGGESTED INSTALLATION (Date ) � , c... p (Aoad or Street) FINAL INSTAI�i.ATION (Date ) (Road or 6treet) Application Date • i5 'a � � Ta�c Map: �� 3� Amount Paid: � 36a C�� , 3� ` Parcel #: �_�,� Receipt#: 5� �la� ��d . a"�� - l-2 ,�� `��.5� �� ' �-�-- C� � � � � � �i�ca^cv-nzr.-�aa�� ac ua�,�u.� �'�.c�,an...Ild�ia Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 if> 600 d (Fee is de endent on the e of s stem ermitted) 0 Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired $75.00 ❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) 5ervices Requested by: --� Name: /%'l i(<� �/ ' 1/��, �tz .n► Phone #(home): �3(e - 227-' R 7 7 2- Address: �^ � G � �i � ►� �� . �E i � . (worWcell): 33�0 - 24 0 - -� �q c�_ ! 1 � � �--'�, ' � � �= 9�7� �.� 2)Name and address of current owner (if different than applicant): Name: .� �-�� L� Address: 3) Property Description: Lot Size: Subdivision: Lot #: Address and/or directions to Property: �Ai � I� a�.J E'�'� K f-ri /�h�? 4) Proposed Use and Type of Structure: , Residential Business/Type: _��Cc �'�9��t a�(i ,—, �, �„ Other Number of bedrooms / Number of people served (sea / mes ployees): Basement: Yes No (with plumbing: Yes No _, Garbage disposal: Yes No ��E�� ,,,�,� �C�ti�P f�� eCl f S %�T�, .y 5) Water Supply: Private Well (Proposed Existing � Community Well: Eublic Water System: Are there wells on the adjoining properties? No J�es '`� p,�,�. �� -/T�.s (please show location on site plan) Note: A comnleted avvlication must a[so 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 sub�itting this ;.pplicaticn tc request services from the Perso� County Health Departruent. I undersiand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. ,/ � %; � ` '� / '/ � . �% Signature (Owner/Legal Representative): `'� � (,•1� ��% Date . ' � � 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) I•� I �� I•� � \// - . T�x M�p � � P�rcel # : � ��) � � � � Su��bd��ivision I I , , . � , � , � , , , . � , I I I � I � I , Fh�se Sect�ion Lot # Permit Valid for Type of Facility: _ # of Occupants _ Proposed Wastew Proposed Repair: Permit Conditions: Owner or Legal l Authorized State � Improvement Permit ✓ Five Years No Expiration �C�e.�,2�rnolr,uPpS)�- (n_ ('Am�o�,ii?S New_Addition Water Supply L��PII _ # o B drooms _ N/A Projected Daily Flow �� g.p.d. �%r7.'�� Type: Type: Date: � ' � 6 " 1 � Date: /- Z 3 -/ Z The issuance of this pernut by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the applicantJproperty owner to in sure that all Person County Planning and Zoning and Building Inspecrions 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 Rules for SewaQe Treatment and Disposal 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 Construct Wastewater System (Required for Building Permit) * See site plan and additional attachments ( �• ). � Proposed stewater System:�� 2S% �.��u � n,, Type �� Wastewater Flow �l o g.p.d. New _,��Repair Expansioi _ Soil LTA�: •.3 g.p.d./ ft 2 Type of Facility: � ;ce -►- (� (�A wtp5► �S _ Basement _ Yes _ No Wastewater Syst m Re uirements - �,��d Tank Size: Septic Tank:1� gal Pump Tank: DOD gal Grease Trap: � gal , ( s� Drainfield: Total Area: Ja Zo sq ft Total Length 3 D ft Maximum Trench Depth �_ in Trench Width �� ft Minimum Soil Cover: �_ in Mini m Trench Separation: 9 ft Distribution: V Distribution Box Serial Distribution Y Pressure Manifold �r� /J�e�� Authorized State Ag Permit The type of system permitted is ventional ✓ Accepted permit. ��' Owner/Legal Representative: /v� �v Date: J- 2�-/Z Altemative. I accept the specifications of the Date: a, -16 - I 2 PCHD rev. 11/10/OS • .�� JS.. ��.D. y .. �-' • . _~ V� `�/ l V �L. JL IE��u-�,.T,.-."��.11 ]E-3I��fl� .. . ; SiTE ��TCH � Name �1 �.e _ �� So N Taz Map #��.Pa�ce1 #�� Sub ' ' ion _ � Section /I�nt# ( - ��.�'/2 ' Autho�ized State Agent . � Date . System cdmpo�rents nepresent u�iproa�imate�contours only: The confrac�tor must, fTag the systemlDrior to ; beginning the instacllation to irisure that propergmde rs maintained 2d928 � : i193i�� / .�-. ,�- . ,� G � �n � yroP --\--__ c� ��nK fi \ �� - �� 0 �— � �� DO�� o , ' _ �o:,� ' _ o' _ ` . ` S� S�Zr�1 , �n� ��) fe-if � a on ��ee�►n lhah��• .L h � - �� ,s-� l � - r��C W 2 en�t (c ee5 � ' y ln • ,c� i� Ca 5��5 + �h e ' � `( g � '� � � 3�D� � �� /t � �.�s; � S��oU�� be CbVere� W - �$ fre�lc� �a�r�5 I �e�c��es � So,� �o�, �s��. �;- � _ � S � : , ,� :10o i��t_ � � � � � Suifa��e ��.ss ��.�� r � � �� I��.��,.-n-T ��.�,Il I�IL��.IL�I� Applicant: � � Y�F, (.,� ) � ��o n Location: Tax Map � Farcel # � Subdivision Phase/Section/Lot # ##�f�l�taems ' e Sr�S Operation Permit System Type (From Table Va): Product (IIIg): �Z 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. �-- 9 - //��Z J � ( uthorized Agent) (Date) � � (Li e sed Contractor �— �-/►'/2 (Date) �i Scale: iso ��t��i w S� , 'o ;�K -�r� �o� i�-�� Line Length � 2 `l D 0 $D �0 Total 3�%p Tax Map: � Parcel #: � Septic Tank System Checklist (Type II-I� Notes• System Type: � Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes• NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP e-mail Date: ._.,�� S f ��.�� ' � � � �� I��n��D��.��.11 I�3C ��.Il�I� Applican Location: T�x M�� : F�.rcel # � Subdivi�sion Ph�se Sect,ion Lot # Improvement Permit Permit Valid for Five Years _ No Expiration Type of Facility: � ,-ou �,� New Addition # of Occupants �� of B�drooms �----' Projected Daily Flow � Proposed Wastewate System: e' le Proposed Repair: u Permit Conditions: fer„n i�de�l Ynf _24� �e,r%(�a��r►� (�o ��n�SYn� ' r� q Owner or Legal l Authorized State Exis�+n� Water Supply _��[� j� g.p.d. - ��1� � -�-i�c�J Type: a Type: Date: Date: � 0 The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. 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 Rules for Sewa�e 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. Authorization to Construct Wastewater System (Required for Building Permit) * See site plan and a'dditional attachments (_J. �F�°'� ua�'u'�� e�� Wastewater Flow 5 d. Proposed astewater System: ��o � w u YP Q � �—g•p• New � Repair Expansion _ Soil LTAR: � Z� g.p.d./ ft 2 L-7 �uA �� Z� Type of Facility: � �u r� _ Basement _ Yes _ o -��.�i �� Wastewater System Requirements Tank Size: Septic Tank: �eZ�'�gal Pump Tank: 1e3�2ga1 Grease Trap: �-gal Drainfield: Total Area: � sq ft Total Length 53 ft Maximum Trench Depth %� in Trench Width �_ ft Minimum Soil Cover: �_ in Mini um Trench Separation: � � � ft Distribution: Distribution Box Serial Distribution ✓ Pressure Manifold Specifications: y ,Q.M � � I 3b' ' % .P.c�� j � � �� --�M -� � l0 3 � Authorized State A� Permit The type of system permitted is permit. Owner/Legal Representative: Date: 2- �! -/D Date: Z- y- /� � w� u ►� Conventional � Accepted Alternative. I accept the specifcations of the Date: PCHD rev. 11/10/OS 0 • .�� ~ ' � � �lJ 1�J �L .11. ]��-��.m,�,,,...,, �m.�.11 IE3C�� SITE S�TCH Na�me �j ��j i �Snr� ., Subdivisio A thorized State Agent � Tag Ma.p # 3 �S � Par�e1 �,� Section/Lot# _� I-- Z�-�n � Date Syatem cbmpo�ren�ts s�epresent approarimate �contours o�ly: The contmctor naust fXag the system prior to . beginnirag the snstall,a�ion to i�sure that propergrade is mesir�tained , � � r��c, � �l/ s�w� . - � �s g,P��. C��(�Z�� -��W� — Z.A� C��+) c.a►�rer s f�� ojla � Pu rn� 5 3 Gon ve��-�i � W i � ,E�,�, � 13�' �. ^ � � ,� �e�c�� ho�-bu� 5 �'.�t,v�a�� Il D� � Place 3'` a��1�=� i ona � � �.�.�z. ' 103' �vver over s ys-�rv► /� Pu�M ia�K �33s �,��, \ � � ��,. i� � S� -� C � a n K�Ce Z� �� i►�, `�. � . � � �{'' in5�'a��ui� on �MeQ�i�i i'��of�'� / SC�LE � l " = zoo' , so� � e PVCf�e Velw Ao�BQe� �� S�- I�l��.�� -- = � � � � ��°�� ,�/�'/ '�I/ JE;.. �cn-v-ii n-aD �=•0�ca�E.aJC ]HL.�.�.1L,�. Owner: IV 111�2 W 1�Sa h . Ta� Mag: g� � Parcel #: ^ Date: 2-y-/o '�'�p (Scia) � Ta�a• �mw � Line �e�gt� 0 y �ow / �oot 1�5� 3 � �� ft of line x� gal. per 100 ft= �Z� ;' 100 =�_''�al 75% x gal =� g� �er dose c"2. gal per minute (gpm) _�ow fl$aie F'�ic�o �ead _ � � � � . g.�ss: �� ft per 100 ft of supply line x'� 1 SO ft of.supply line =100 =�, 8 7 ft �l� ,$�7 ft x l.2 = g ft of friction head � . � IVianifold Se��: 3 " Force 14�I�n Siz�: � 2� „ PVC.. .. 'I'dtafl i)yn�ac �$ead =�_f.t of Elevation head + 2 ft�of Pressure head +.`�_ft of Friction I3ead = 2�} TDH � . �um� IBeq�nir�atnent: 53 . GPM @ 2�� ft of Head. . �eawdow�: 35j gal per dose ,-` 21 gal per inch =�_ inch drawdown per dose se�dnteaorvcTas 'I�g��p NS�4W - :I�� 'i:::i:�. .1� '.11' 1; � .1'1: , t9:.1.,.�. . � � - �,. � � �- �t��}��0�� i��*N* � �� *�� :� � � � �� N��.�� .�� J Y" �� .. , i � � �� ) �� • �- , , ' .._.. �,_ - 9�� -�� s . a 53 GPi�1 � � 2.� � a-F �i�Ad 14ianifold 9'rze / � Ta s ufold Max No. Taps off oae side � {i%duca b Ih for hap � both si li4" t3 s 3/a" taPs l�a � 2» 4 � 3„ � 5 3 16 y ' �0+ Z1 l2 .. " F1o� per Tap - SL:2 1��gjRQ1 �' 01V 1T�1�' �l. ,• SCt1CCl �i� �.J • ;! " Sched �U i•1 �, °� Sched 80 � �.1 � ?; • ,ichecf ?0 1=•= � r � � �; �� ' �� 61- �i � � � i ; .�... �' ,� ; r� �..J � �� .�-�.:��,� �.:n;�.<��.�:il ��--�i�:�.�.11�:J� � �ua��a�� gt��a�l I`�I��ce ��u�a� fl��ne�n�� Tax Map #:�_ Approval Requested for: Applicant � Address: Phone #'s: Parcel#: � 1Vlobile Home Replacement —� Building Addition Perrut Located: Yes V No Installation Date: —� Design flow: _ �� (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: j�–? ��lY�' (date) (Applicant's signature if sit� visit is not required) A� Il'�A��9I��l��fl�fl�L�fl� ��Dfi,m��e� //— �� Enviro entalI-�ealth pecialist Date 11/15/�5 Application Date: 1 1 t q� Amount Paid: aUp .0 Receipt#: ��q�, c+�°.�a7Z0 Tax Map: ,�. O 3 � Parcel #: O o ! A ��; � �� - �� i� 1C.� ga -ar �i u^- �ca u-n �rnn <cr 3ra -�L-..zn �1 1� "�Y <c".zn. �� ti�a. Application for Services (Septic Systems and Wells) • Services Re uested mprovement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if > 600 d) (Fee is de endent on the e of system ermitted) ❑ Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired) $75.00 � Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 No CharQe 1) Services Requested by: Name: /1'�! kc �v �� Se � Address: � (� 6 � ryi /.,1�¢ � PE�° ; �, "�� ; �y.%��a,T Phone # (home): ; 3li .Z .Z 74'Z? 2� (work/cell): ��4 2(ec �79(� �e �� 2)Name and address of current owner (if different than applicant): I�Tame: Address: 3) Property Description: Lot Size: Subdivision: Lot #: Address and/or directions to�Property: �Io S ��ac/r ��p �.��., �Za� 4) Proposed Usc and Type of Structure: Residential Business/Type: Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No � Garbage disposal: Yes No 5) Water Supply: Private Well (Proposed Existing _� Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) 1Vote: A completed application musf also include: ➢. A plat/site p[an of tlte property that sliows property dimensions and the size and location of all proposed structures. ➢ A sig�ted copy of the `Lot Preparation' form verifying tliat the properry is ready to be evaluaied. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. . Signature (Owner/Legal Representative): Date : 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � �� sk�Ow�2.�, 2. �-�t.�. �,�, S � l�d 0 '�t��a.�c �'1 'oTM-, �.�d '��ja,G ��r. p , � �....�- � � vn�.�. �-� v,�. �-1 F��s��- Zo io � o��./�2- � V � �.a ac.� Tr.2iv�. ,. t�� -�-� o -� `�D�� r � �� , j �,,� �� ' � � � �� 1� •-g71"Q�'717L"QD7i11.7Ti�i1�f,.'.�I11Ld�L� ��i1.J1'(�� Building Additions/ Mobile Home Replacements Tax Map #: � 3� Parcel#:� � Address: 9�0� 1�G✓LLDG•'G �/1��.1 !�� Approval Requested for: Mobile Home Replacement t/ Building Addition Applicant Name: �iills /��/C•h�r� Address: �r�� a�i�tii��G Phone #'s: Permit Located: �/ Yes No Installation Date: Design flow: (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: (Applicant's signature if site visit is not required) (date) Addition/Replacement Approved Enviro nta He Specialist /D Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcoun .net .0 � � —.� —�._� . „��,y � � NS � � ' � _ ._ � _ I . � � . . `� � qR 396�86� � - — ' — — _._. _ _ � i . . . . . �` k�NG F� PJ � -- _'�---___� { � �� c —' I . . . . . . . \ \ \ \ `�C iq �� PJ p,! `1 . . . . . . . . . . � `\ `\ � '� � � I �.�.�.�.�.�.�.�.�.�.�. .� � � �� \ �� \- \- i � i . . . STAGE PARKING. . . \ . �` ` - � � � � � � � . . . . AREA . . . . . . � � �# � �. .. ........ ......i:� \\\�\\ i� __--;. r � �.+ "'� �" / / � / � i 1 SMH SOLQM ON 415 . . . . NS . . • �W�%D A� . I�` . . . . . . . � - ' '� .�E CE A�'' � � STAGE AREA � �}\` PJ I ____--__ �� a)� r — --_�` `� �\\��\� �� . � � ��/��. � �• \ A'0✓� � � � 4�Q' X �0' PQRTAB�E ��•`'/ / `�' '�� / � O lyno� � � � S't�GE \ \ \ �¢ / / a �. � �� .� \ \ �^, � � ��, ��. �' � ticF � � .�\ . \.�\ \ � �/ /� 6�. �tti/ � / \ � \ � � � �, '�pg�F�N� � � 4 //�/ # `� \ NP��,c�P ��/� G4NCESS10N AREA .� �. � � ,.,� I �� # � p� �� :/ � OFFICE BUILDING � � P��'' �� 12'X12' WOOD STRUCTURE N84'33,'22':i�y QQ% � .-'" �""f� NO BATHR�OM �� /� -' 406.88' i � --9 1 SM H �.-J SHOP CLYDE A. SOLOMON D.B. 242/91 .z 0 rn � � � C , 4 Person County Environmental Heatth 325 S: Morgan Str�eet Suite C Roxboro, NC 27573 �� //�� O '---------_ 495.62,---_._.` N W J I� FUTURF PGAi��nir