A40 173—
The District Heolth Department�
CASWELL - CFiitTHAM;ILEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IM, RQV NT$ pERMIT No.
Pexrriit VOtD � 3 ear .., ^ r��—..�
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Owner: _��
Location•
; _> ,. o < <,-�,,;�� � ,
Contractor: "�� a�� �'►'� o v� T�
Wafes Supplps Private � public
,
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Sewage D ities: No. bedrooms ���-'bishwasher, D���
washing machine, other sutomatic appliances
Size of tank: _,��r,`,��.R� NitriRcation line: _E j���
C%V
Other disposal facility: _
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANl' PORTION OF THE INS� LLATION IS COV-
ERED AND PUT INTO USE. �
� � ��i � �r P ~
Date approved: Signe - � /�' :+r� ~.
Well: �� 1
Sewage Disposal: I Counter-
aigned � �L, r
BY� (Owner or his representati �ei
Cert�esie oi Completion �
Date Approved: �^� � J � By: n
Samtarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
MAF�.'-2015 06:15 PM STEPOfAITH 3365992855 P.02
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Appllcation D�te: „��'i
Aamount P�id: =-7,��
Rtceipt #:
Iwprovem:nt Permit (��ta �W:
$200.QO/5300.00 (i�> bQ4
Mnbile Home Repl�ce�mcnt or
$1SO.W {if site vieit requit+
'WaU Perneit (New/�epluceme�
$30d.{}OI$Zb0.00/SyS.00
....�
�.,`"`�,. , f ������ Ta�c Map: �
.�., • (� � ��'�,,� P�rcel#; �,_,,,,, 13
J�asrr:a*oxAra�nx.E�sl ���i�s
�O�'
COnstraenon
i) Appllcant rmat�an: .
Nam�e: +
Addresa: i
�1
x) Na�ne �nd address of cwrre�ut owner (� di�erent tha�t appuc�nt):
N�me:
Addreae�
3) Property UesCrlption: Lot Sizc: ,,� R� Subdivision:
�lddre,gs and/or dircc�ons ta Proper�y►: .��
of
ing Septic Syetem
No Chargd �A 5150.D0 or $3b0.00
a�al►e, MAr�l�ll " so�1- y32B
Phoae (ll,ome):
(worfdt;clt): '�5` lo ~ ' ,
�hone:_. ,
#:
0 yes Doee the site cantain any jurisdictionsl'wetlQnd�?
0 yes Does the site car►tain any exigtin8 wastrvv�atar s�yst�ma?
C] yea o Is an� westevvster going #o be gonerate� on tbe sites other than domestic sewage7
Cl yes O r� Is th� sit�s subject to aPl�� bY �' ��li° ��1°Y?
f� yea l�fio Aro tl�ere any cadements nr righc of way� on thie prapemly?
(if `y�' is checked, pleaat �+rovide supp�t�g daoumentatio�)
>
a) raposed Use and 'I�pe of Stract�e: ;. ,
d �
Cl Now Single �'amily Residcnce Iv�axi�rnim numbar of bedrooms:
�io�t of Existing System If expension: C�ront number of bedroom�:
to Malfunctioning System Will the�e bo a basement7 � yes C3 no With plumbxng fixturee? C] yte ❑ no
dl+Ian»�,�id�atfsl
Type of business� - -- T4�I SgWlYC f00tdgC P�HLit�dln$: �
Maximum number of empioyees: --- Max'tmum munber of seats: _.. �..
a� Water Supp�': C7 New well K��an� wcly o commu�t� wea� ��ub�� w'a�r Q SpriY►g
Are there aqy e�dsting walls, ap�ing�, or existing �uvaterlin� an this propeciy? � yea no
b) If aPP$'ing far `�utborizalion to Coa�hvct', pleeae �di�ate preferr�cd system t�ype(s):
❑ C�nveutional Q Accept�d G Innavative � Alternarive � Othar �] Any
1 cerl� th�i the information provided above is cantplete cr�d eorreet I also understcr�uf that if the informvttan provided is
In at , nr if the site is subsequ ntly altered, or the intended use chcut�'es, all p8rntits cmd approv sh !t be invalid.
Slgrl�tu (Own L,e epresen 've*) te ,.
* Sup�Orting dooum 'an required.
• Fermits arr vatid for eltber 60 month� or ar+e non-ezpirin� whan aecompa�led by an approved p�ati
• A completcd `Lo[ Pxparadon' form mnst accom�any any application requiring s aite e�valuat�tan.
(iQ/i l) Person Coun�ty Environment�l, iie�lth„ 325 S. Morgaa Sk, Suite C, Rwrbam, NC 27573 (33b-597-179Q)
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Applicant:
Address/Lc
Tax Map: � Parcel: % �'3
Subdivision ��J�
Phase/Section/Lot # N !r
Improvement Permit
Permit Valid for: Fi Years Non-expiring
Type of Facility: New _ Addition _
Number of• Bedrooms / Occ ts / Employees / Seats:
Proposed Wastewater System:
Proposed Repair: _ __ �
Permit Conditions:
Authorized State Agent: �
(X) Owner or Legal Representative:
a��
Water Supply:
Projected Dai
gallons/day
Type:
Type:
Date:
The issuance of this permit by the Healfh Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met This
lmprovement 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 Piort6 Carolina °Laws
anrl Rules for SewaQe Treatment and Disaosal Svsiems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will cantinue to function satisfactorily in the futare, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Pro osed Wastewater stem: �u1 P � � ��o ��U�a�*�I`y gn � gal./day
p y r� �, ('�hQ,,,� �,r pe � Desi Flow
New Repair � Expansion Soil LTAR: gal./daylftz
Type of Facility: ` Basement: Yes No
(*) System Tjpes Illb, IIILg, IV, and V, require psriodic system inspections by the Person Counry Health Depariment.
Wastewater System Requirements
L��Sfi��j
Tank Size: Septic Tank 000 �J gal.
Drainfield: Total Arza / Z�OU sq. ft.
Trench Width ,� ft.
Pump Tank -- gal.
�I'otal Length DD ft.
�d�1in.Soi1 Cover� in.
�rrease Trap--'-- gal.
Max. Trench Depth g in.
p,c,
Min.Trench Separation 7` 9 ft.
/�,
Distribution: Distribution Box / Serial Distribution� Pressure Manifold
S eciiications: 1, � s,' � S�e S�� St� t�b)
n , .
c' v a — �, �soi�.
I �,�
Au�horized State Agent: Issue Date: �-_�o-!S
Permit Expiration Date: 3-30 - 20
Tlie system permitted is: Conv nt onal v /Accepte / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: ` Date: �v --'� '� s�
Person County Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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SITE PLAN
Name�_ Cu Ta�c Map # ��Dp�cel # ��3
Subd' ' ion Section/Lot#
- 3-30 -/
thorized State Agent Date
System components represent approximate contours only. The contractor mustJlag the system prior to beginning the
installation to insure that propergrade is maintained
. __ _
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Applicant:
Location:
Operation Perrnit
�
System Type (From Table Va):
Type V& VI Expiration Date:
Tax Map �� Parcel # 173
Subdivision nl�ldr
Phase/Section/Lot #
# of Bedrooms ��
Product (IIIg): ���f � e m��,�
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. �
(� - Z9 /�
(Authorized Agent) (Date)
r�Prob Co���'� 1�-29-15�
(Licensed Contractor) (Date)
Scale NoNE
PCHD, rev. 12/14/12
pG�,s a ��e
�Eri� �iP%cj�l�" �'s �
6�1 �J
�ic�rn%tr�
Jr`l� f:i t" 4� %! )1 t` $ ��
dl c�- �"?a� e C� �ar�5
5� S�em �c+� ia SfG� f ou-�
c� ee� %ecau� o� �'� e cy ���j
� ex�sfi � ��K� L�'ne5
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Tax Map: � Parcel #: (i
Septic Tank System Checklist (Type II-I�
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Notes: � �i,,.� i�,�� . �� ,� �. �)�� .��,
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System Type: �_i � - C!
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Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes:
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