Loading...
A40 156Person County Health Department Existing Sewage System Report For: Mobile Hom� RA Aep �ac� m�.e�nt � ✓Addition ` C�Tbv,'��cU � � Requestee: Cha�l�s ��S _ Home Phone# �Z�" � � �, (� � ��� Business# �_ "/�� � �� 'Pax Map# `�� I�� Location/Uirections: t -l�� f �T + � �� ��V ►S �-c� Original Permit Located Septic System Uesigned For: kesidential _� Business Other (specify} # Bedrooms � # Employees Other _ llate lnstalled G' ` Water supply �1 v�'�C� 'Pype of System Wn��n1 ►��I _ Nitrification Line I I�� X3 � Tank Size Certified Operator Required On site wasL-ewater disposal system showes no visually apparent malfunction on Yermission is g According to the attached site plan. Comments: , �'` =-�r� �, , Application Date: � �23 =�� S� ��q ���� Tax Map: �� Amount Paid: 1 6 -U� .r..: �' � � � ��,�.� Parcel#: � Receipt #: � C� IE.�cav*na-cDTM*+*�*ao�a�aa.l� I���e,s..1L •d�la. A Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $ I 50.00 (if site visit required) � Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 for Services ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Infor �tip n• Name: �/Y'� ��� Address: / y ,r��,� n� , � �zsz� 2) Name and address of current owner (if different than applicant): Name: 43C1�5 �.�� � Address: 55 �,w.�n, ��cu�� _ L� � ��,� �c - �;�� � Phone (home): (work/cell): — ..�� Phone: 3) Property Description: Lot Size: Subdivision: Lot #: Address and/or directions to Property: �A �—'-7 1Joa1, �aV►'� �. __--7 CouH� ���;(�e L�, ❑ yes ❑ no Does the site contain any jurisdictional wetlands? � yes ❑ no Does the site contain any existing wastewater systems? ❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes 0 no Is the site subject to approval by any other public agency? ❑ yes ❑ no Are there any easements or right of ways on this property7 (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 of bedrooms: � ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes f�no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: �� JC Z� � Maximum number of seats: 5) Water Supply.: ❑ New well l,�J 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 0 Alternative ❑ Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccur , or f'the site is subs en altered, or the intended use changes, all permits and approvals shall be invalid. � � J�A - .___ � �� Signature wne egal Representative*) Date * Supporting.d umentation required. • Permits are valid for either 60 months or are non-expiring when accompaaied 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) 1 �/1 � v ��al cS Gt.v�S I' ow,���p m /J"p Dp �• /,G'G t�''s ,�� y ��� �j C' 7� ��oo) �'e �sfutes � �u� '/ � >�I #� �o- /.s6 _ � ,�i,z e ; / 3.� �'r�s T� �l� ���I �—� ., ��v. �� j ,, �, s /e " � � a �� i , Amount pai Receipt .�� � H O � � � w U � a d ��6, da ' � '� 3 . � 3 �'¢ �� � Improvements Permit.(Established/Recorded Lot) ImpFovements Permit (Unrecorded Lot) Improvements Permit (Mobile Home Replace) Improvements Permit (Addition) � i�-�� Date Reinspection of Exis[ing System (Loan Closing) RepaidReplace existing Sepiic System Permit for New Well _, Replace Existing Well z 1. Permit requested by: . 0�- �,� ��. 7., Dimensions or Proposed Structure: I ome Phone #: usiness Phone #: � - and 3. Property D 4. Tax Map#: Parcel#: _ i Township:, 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility . that this sewage disposal system is intended to serve? ner: � no 9. Water supply type: �' ���� � private � . public ❑ community ❑ spring ❑ Z" Are any wells on adjoining property?Yes ❑ No �. �, � 'S If so, identify location: ion: Lot size: t� 33 A-� � � Directions to property: State Road #�,& Road mac vtr '� // // 10. Type of structure/facility: Proposed: �Existing: Q I Type of dwellin • House: obile Home: L7 Business: ❑ Type of business: Number of Employees: Number of bedrooms: � Garbage Disposal? Yes ❑ No� Basement? Yes ❑ No��so, # of basement fixtures: L Number of occupants or people to be served• �� � CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the Pet'SOn COuntY I3Calth Depal'tment for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of [he property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evalua[ion of the site by the Health Dept., this application shall become void and all fees paid forfeited. Owner or Authori�ed Agent Permit Issued ❑ Signature Date ' � Permit Denied ❑ Plat Observed ❑ ;:; a = . . ,..t. < s::FXCi'ORS-STiEEVALUA'f10?t, y : ` � � ..:; „i?�RF?�:�. r a pjtF�2 � f:<.'ARFA3, f.� ARFa4 s. . »t , ...:. , , , ... ,.,, I. SLOPE (%) S S S S PS PS PS PS U U U U 2. SOILI'IX71JRE(12•361N.) S S S S (SANDY, LOAMY. CLAYEY. NOTE 2:1 CLAI� PS PS PS PS U U U U 3. SOiL S77tUCil1RE (I2•361N.) S S S S (MYEY S01LS) PS PS PS PS U U U U S S S 5 3. SOILDEP7}1(IN.) PS PS pg PS U U U U 3. RESTRICi1VEH0RIZONS(iN.) S S S S (UiPERVIOUS SiRATA, ROCK) PS PS PS PS U U U U 6. SOILDRAINAGFJGROUNDVVATER 5 S S S (E7C7II2NAL A INTERNAL) PS PS PS PS U U U U 7. SOiLPERMFABiI.iiY S S S S (PFRCOLAA770N RA'[E) PS PS PS PS U U U U E. AVAILABLE SPACE S S S S PS PS PS PS U U U U 9. SI'CECLAS5IFICATION(SEEBELOW) SOiL SERIES S-SIJITADLE PSPROVISIONALLYStJITA6LE U-UNSURABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �I1 areas, wells, water bodies, slope patterns� CtC.� C:�AMfPRO�DOCN+PPSEC.S�IFINANCE.PC r � a W � a �I� B 2285 PERSON COUNTY HEALTH DEPARTMENT ' WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. T� Map # -t\y � Parcel # � Zoning Township � Owner/Contractor Location/Address Subdivision Name iir L . C����.iT���Lt� S.R.# � Lot# g SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area I, 33,4-c Size of Tank /(5Q0 �CI�- SFD � Mobile Home Size of Pump Tank Business # of Bedrooms � Nitrification Line ��` X 3� Max Depth Trenches �? 4 " Permits may be voided if site Well and Septic ayout by Comments: � .c�-�n� Date /�-/,� 97 ell Permit Paid �'� WELL or #ntendec�,use changed. �� d I �.�, �� ,� a� �a �� SPECIFICATIONS dividual �/ Semi-Public Required Slab '�— iblic Replacement Air Vent �'" te Approved Required Well Log �/ ell Head Approved � Well Tag f �outing Approved � Comments: Date C►o Installed by Approved by This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmeotal health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditio�s on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. 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. c:\amipro\permit.sam O1/95 rev.l.l Person County Health Department J� I.� Environmental Health Section Tax Map #: l`1 - I v Parcei #: ��� Zoning: Township: t� c�s �i �O� �� Subdivision: �C�7c�c17�� �� Section: Lot: u Applicant: �� �J� �''P � � A U �� ..s 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 THORIZATI . , �� .� �s�9 Authorized State Agent Date Tax Map #: J I�� Parcel #: ��� PCHD, rev. 10/12/99 Person County Hea{th Department Environmental Health Section Zoning: Township: _��� Subdivision: ��!\��('����e _ �� Section: Lot: $_ Applicant: _�a r/P� jpo� dr S Location: Operation Permit 1. LOCA710N AND SEPARATION DISTANCES � A) System meets .1950 setback requirement� B) Distance from system to any wells � C) Distance from septic tank to foundation D) Distance from system to property lines —%� 2. SEPTIC TANK �� A) Visually inspect the exterior walls and top of the tank B) Visually inspect the interior walls�affle, tee, filter, riser, lids, air vent, bottom, and water tight outlet 9 C) Date of tank manufacture _� D) Tank serial number 57 /3 1H�— E) Liquid capacity of tank 1 n0 D gallons 3. SUPPLY LINE TO TRENCHES A) Grade �u.. �a� (1/8 inch per foot minimum) B) Material supply line is constructed from 5�.�► �(D PI%� C) Diameter y � D) Length E) Distance from tank to drainfield/distribution device � 4. DISTRIBUTION DEVICE(S) A) Type � f�/ B) Is Device water tight (X C) Distance from the distribution device(s) to the trenches I � 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 �_ inches B) Trench width 3(e' inches C) Distance between trenches � �2e D) Number of trenches E) Length(s) of trenches � � � �f /� � F) Aggregate depth �_ inches G) Aggregate material and size , �'".S % H) Record septic tank outlet elevation I) Trench grade Su ���„�; ..-� (< 1/4" per 10') J) Step downs ✓ a. Minimum of 2' of undisturbed ea�r b b. Proper rise over step d9wn c. Solid pipe used ✓ r�,,�� � d. Elevations of step downs ��d{Record elevations and show on as built) See "as built" plan on attached sheet. PCHD, rev. 10/12/99 � � �� � i � . �..��= ► 4 :, . � � �.d. V �� �.J � �;srn�nar��nan�n►,a��rntE�.�. �c��.�¢� Suilding Additions/ Mobile Home Replacements Tax Map #:�Q_ Parcel#: j5c� Address: SS � u„�'rv r.Ke. Ln� .ax�ir IU�'_ Z�5'11% Approval Requested for: Applicant Address: Phone #'s: Mobile Home Replacement ��uilding Addition . Permit Located: V Yes No Installation Date: 2- —� Design flow: 3L� d(gpd) Current Contract with Certified Operator on file (if required): Water Supply: V Well Public or Community Wastewater system skaws no visual evidence of failure on: �' Z9 "�� (date) (Applicant's signature if site visit is not required) Addition/Replacement Approved � Enviro ental Health Specialist �-�' /�' Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net ���,sf �1��.��� �= � � ���� I���a-�����¢�.Il IL--3I��.Il�II� SITE PLAN Name I(1 Tax Map #� Parcel #�� Subd' 'si n " Section/Lot# y- Z -� uthorized State Agent Date System components represent approximate contours only. The contractor must Jlag the system prior to beginning the installation to insure that proper grade is maintained ,p � O� �� ��(� (Y`Qin�atn � i�r� o� s �� sws��, � � Person County Health Depattment Environmental Health Section Tax Map #• � - � Parcef #• _ ��� Zoning: Township: �� ��� r� Subdivision: �Ou /1 *tv (� �57� Section: Lo�: � Applicant: (�h�� fP� �Q �1 i � _ Location: �peration Permit System Type (In Accordance With Table Va}: e•��'O� THIS SYSTEM HAS BEEN INSTALLED IN COMPLiANCE W1TH APPUCAB[.E NORTH CAROLINA GENERAL STATUTES, RULES F�JR SEWAGE TREATMENT AND DlSPOSAL, AND ALL C�NDITIONS QF THE IMPROVEMENT PERMIT AND CONSTRUCTION THORIZAT! . � � -� 15-9 Authariaed State Agent Date y4 �� �� 4 �h y � .�� •{ �.t , ; t� � ,. , a . ai , ��,1a �� . , V�0 ZL � �. � ���� � ',�, 1 �' 11. r �� �-� - S� Taa MaP #: �y� Parcel �f: �S� S�Pf'�� �a►� � t n�'D -1-9� 9 ��s ���� s7� r�a PCHD, rev. 10/12/99 Date: z � ��, ' Owner. � C`� Location/Directions: Subdivision Nvne: Drilling Contracior: PERSON COUNTY ENVIitONMEHTAL HEALTH � T WELL LOG SR# Lo[ # WELL CONSTRUCI'ION ` --" Distance from Nearest Properry Line � C� Distance from Source of Pollution_ ( . � ' Total Dep.th:—�2 �'� Ft. Yield:_��___ GPM Static Water L,evel 2�r� Water Bearing Zones: Depth �__rt._(� � Ft_ '7C� Ft� � r��t, Casing: Dept}i: From�t���Ft. Diameter:_ ', /t Inch�s TYPE: Steel � Galvanized S[eel .�" If Steel, does owner app:ove: Yes No � Weight: Thic};ness:� H�ight Above Ground: l� Inches Drive Shoe: Yes -/ No Were Problems Encountere.d in Setting the Casing? Yes No _-�' If "ycs" give r�ason: Grout: Type: Neat Sand/Cement Coricrete Aruzular Space Width Inches Water in Aruiular Space: Yes No - -. Me.thod: Pumped � - Pressure � Poured �-. � � �. . Depth: From � to 2� Ft. . . Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs. If' mixture (sand, grave]; cuttings) - Ratio: to �ID Plates: Yes � No � � �� � 4 x 4 slab Yes �o � I HEREBY CERTIFY THAT THE ABOVE INFORMr1TION IS CORRECT AND TH AT THIS WELL WAS CONS�'RUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH $Y�THE PERS0�1 C�'vi�ITY HEALTH DEPARTMENT. )---- ignaturc of Contractor Datc �..