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The District 1-lealfh Deportmenf
Oraage, Person, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
DaY�n ���� Dat -- —
Name of owner: �
Name of contractor: ���(� n r� �' � � � n C{
Address and Directions ��� b�'� � }�t� • G �)
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Person or firm doing installation:
Address
No. of persons to be serve� Bedrooms 1�3, 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine
,Recommended• 5eptic tanl�—.0 ����
Nitrification line: � ^�' � —/
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line musf be inspected and
approved by a member of the Dis3rict Health Department staff before
any portion of the installation is covered.
Date Approved: g � ��$
- �
Couatersigned
Signe�
Sanitarian
O. David Garvin, M.D., M.P.H.
District Aealth Officer
.�
(Over)
`fVOTE: •Make sketch of installation showing location of house, se�tic tanks, privies, water supplies on
; adjacent property, etc. Write in measurements in order that installations may be located at later
. ,
date.
SUGGESTED INSTALLATION (Date ) � FINAL INSTALLATION (Date ' ' )
(Road or Street)' 4 (xoad or Street) '' .
I I I I I I I E-�I I I I I I I I�-I-1� I I I I I I I I I
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Amoun t paid � �� •
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Improvements Petmit. (Established/Recorded I.at)
Impravements Permit (Unrecordcd Lot)
Improvements Permit (Mobilc Home Replace)
Improvements Permit (Addition)
_ Rei
�`��'�'�
Date
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tion of Existing System (Loan Closing)
Repair/Replace existing Septic System
_ Pecmit for New WeII
_ Replace Existing Well
l. Permit requested by: . 1 7. Dimensions or Proposed Structu e:
owner/prospective owner/a�ent:
i..�t,1('2V1 �\ Width: 3� � �'Z.vhi �r �a��� /Vlas�y
Address: • 3 LQ 'S (� . Depth: a�'� �' ���^, �`'�'' ��"�
O. cro G_ riS %� g, What type (if any, additions, expansions, or
� repIacement is anticipated to the structure or facility
w that this se�va;e disposal system is intended to serve?
� Home Phone �: 33(� -Sq� �306
a
usiness Phone n: 5`t�i- .��UO
x
z
2. Name and address of,current owne:: �-�- 9. Water supply t}•pe:
� private �j . public ❑ conmunity ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�
If so, identify location:
3. Propecty Description: Lot size: ao 76 aL
. Tax Magn: 0�'7 10. Type of structure/facility: Proposed: �Existing: Q
Parcel�: Type of dwelling:
Township: 4`�v� ��i House: ❑ Mobile Home: Q Business: ❑
5. Directions to property: State Road n& Road Tyge of business:
ames,ytc. Number of Emp(oyees:
S% 1� o Lo `S � Number of bedrooms: �
�.;,�� Q�_ Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No,�If so, # of basement fixtures:
6. I�Iumber of occupancs or people to be served: �
CLEARLY STAiiE ALL CORNERS OF THE PROPERTY AI�ID THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOr1 COunty Health Department for a site evaluation for [he on-site
sewage disposal system for the above described property. I agree that tl�e conteats of this application are true
and represen[ the maximum facilities to be placed on the propecty. I understand if the site is altered or the
intended use changes, the permit shall become invaIid. I understand that before an Impcovements Permit can be
issued, I must present a sucvey plat of the pcoperty eo the Health Dept. I understand that in the event I have not
delivered a survey plat of the pcoperty to the Health Dept. within 60 D�YS after the date oE the evaluation of
the site by the Hcalth Dept., this application shall become void and all fees paid focfeited.
Signecj Owner or Autiiorized Agent
�
Person County Health Department
Existing Sewage System Report For:
Requestee:
Location/Uirections:
�lI
0
Mobile Home Replacemettt
t/Addition
Home Phone# l� [ –��p
eusiness# 5"/`� � !�
'Pax Map# ��� "l`7
_ � _. _
0
Original Permit Located �—
Septic System Uesigned For: ^
Kesidential 13usiness Other (speciFyl _
# Bedrooms � # Employees Other _
Uate "1'nstalled � � `��o Water supply �('��i GL�
'Pype of System U !Ti / " C,C � cc� wi � �v� �
Nitrification Line � + 1 �� ) –
Tank 5ize
Certified Operator Required
��
On site wasL-ewater disposal system showes no visually apparent
malfunction on " l_��� %
Yermission is granted to:
According to the attached site plan.
Comments:
Environmental Health ��C..
DATE
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* HOUSEIS SERVICED
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Application Date: �" � 3� � 2- `�� �("' ���� (��T Tax Map: 2-
Amount Paid: .._,. .�•� J �-'�d' v Parcel#:
Receipt #: � �� � � ����
TE�' �ra�nn-an:IIn_rr.xa�:an.daaIl 7Hlais.11��:I�.
tion for Services
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
0 Mobile Home Replacement or Building Addition
$150.00 (if site visit requiredj
0 Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant In i•mation:
Name: l �f Phone (home):�3��U�3� D �
Address: �� � .�--r (work/cell): 3G 3 G � � �
�—U � 0.2 7 S �
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: a�%���..�'stibdivision:
Address and/or directions to Property:
Phone;
Lot #: -- -_--
❑ yes �}-r[o Does the site contain any jurisdictional wetlands?
❑ yes �I-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 ❑ no Is the site subject to approval by any other public agency?
� yes ❑ no 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:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System �Vill there be a basement? ❑ yes ❑ no With plumning fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum r.umbe: of seats:
5) Water Supply: L7 New well C1 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):
O Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
1 cert� that the information provided above is complete and correct. I also understand tlzat if the information provided is
inacc ate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
. �
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Signature (Owner/ Legal Representative*) Da e
* Supporting documentation required.
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A compieted `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)
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Tax Map: � Parcel:�,_
Subdivision
Phase/Section/Lot #
/ Improvement Permit
r/
Permit Valid for: Five Years Non-expiring _
Type of Facility: �,r;va�_ �, P,tnC� .� New
Number of: Bedrooms 2/ Occupants `f / Employees
Proposed Wastewater System:
Proposed Repair: �CCe 2 �% � ur,iio_h_
Permit Conditions:
Authorized State Age
(X) Owner or Legal
Addition
i Seats:
Water Supply: C� � e/ �
Projected Daily Flow: gallons/day
Type:
Type: �
Date: �—/ �-�2
Date:
The issuance of this permit by the Heafth 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
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 North Carolina `Laws
ai:d Ru1es for SewaQe Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Pleither Person County nor the Environmental
Health 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 S stem: CC S o �,,� (*)TYPe� � Desi n Flow Z�%d gal./day
New Re air �Ex nsio Soil LTAR:� �� gal./day/ftz
T'ype of Facility: �/� �`���i�,P Basement: _ Yes No
(*) System Types Illb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department.
_— --- Wastewater System Requirements
Tank �ize: Septic Taiik OnO �iil. Pump Tank gal. Grease Trap—gai.
Drainfield: Total Area rQ (�� sq. ft. Total Length 00 ft. Max. Trench Depth �(� in.
p • C.
Trench Width .3 ft. Min.Soil Cover in. Min.Trench Separation � ft.
' 1 Di tribution /►� Pressure Manifold
Distribution: Distr►buhon Box / Seria s
Specifications:
Authorized State
Issue Date: (v —/3 LZ
Permit Expiration Date: —/�—/ 7
The system permitted is: Conventional /Accepted 1/ / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: �'��—� Date: 6 aJ� 2
)
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Subdivisi n
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Authorized State 1'�gent
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Ta.g Ma # �' �-� Pa�ce1 # �
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Date
System cumponen�ts represent approxima�te �contours only. The contractor r►aust, flag tlae syste9ra prior to
beginning the irrstadlation to ansus-e thaipr�npergmd.� i.r rrraintained ., � �
ata � �
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Applicant
Location:
Tax Map � Parcel # �z
Subdivision
Phase/Section/Lot #
# of Bedrooms Z
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. �
�
(A thorized Agent)
�J � .}f�^�
(Licensed Contra�tor)
,�
r�- l� -12
(Date)
to —l�{—( 2 __
(D'atZ)
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Scale: � �Cp ��Q,
Taz Map: 21 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:
_ , � _D� �
AQQlication� Oate: , . . . . Tax fNa :�k
amountPaid: - .. . . : � )]�
i��CE1G��: ' � . . �3rC8��� `�/ 1
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� APP1JC.ecT10N FOR� SERI�IC�S
�� I /
1) Permlt requested by: (Owne�lage�lprospeclive ownerr �- � �'�'j
Home Phone: ��i'9 — 3'�� Address: ` 5
Business Phone: �9 B--S8�9 3
2) Name and address of cs�rrent owner:
3) Property Description: Lot size:
Diredions to the property (Indud
Township:
names and
Loi #:
,.-. - ��._a.�,����+ �l�� ��� �l�,��ur�� ��ai�tlo€�: �i1�LUBf e�s�'1 Dithe f�!l�Itil�g (���t'i���� : -- -- -- - - .-- . :- - -. _ _ -- _
aj Proposed _, Existing V Type of Strudure: Width: Depth:
b) Number of Bedrooms: Number af ocxupants ar people to be served:
� c) Basement Yes _, No-��1 there be plumbing in the basement?
d) Garbage Dispasa� Yes _, No ,� .
� 5� Water Supp[y Type: Privafie new or isting , ublic_, Communify � Spring _
Are any weUs on adjoining � s,_ No _ Ifyes, please indicate approximabe location an the site plan.
6) Does the prope�ty contain previausly identifled jurlsdicttonal wetlands� Yes _ No �,�_
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OE hiE PROPE�2TY OR SITE PLAN MUST HE SUBMCiTED 1NITH THIS APPLICAiION.
➢ PROPERTY L1NES ANO CORNEi2S MUST BE CLEARLY INARI�.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. �
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DE3��F.iVT STA�.
1• hereby make appl'ication to the Person County Health Department foc a site evaluatiort for the on-site sewage disposal
system for the above-described property. I agree that the contents of this applic�tion are true and represer�t the maximum
iacilitles to be placed on the property. I understand if the siie is aftered or the intended use changes, the pe�rnit shail
become invalid.
.�
Owner or Legal Representative
Datie
PCHD, rev.101'17101
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Applican
Location:
Ta�x M��� �. P�rcel #
s��n����,s��o�,
Fh��s�e SecMt�ion Lot �
Improvement Permit
Permit Valid for _ Five Years _ No Expiration
Type of Facility:
# of Occupants # of Bedrooms
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
New
Projected Daily�]
Water Supply
g.p.d.
Type:
Type:
Owner or Legal Representat' Signature: Date:
Authorized State Agent: Date:
The issuance of this ermit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty wner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement PerinIt Is subject to revocation tf the site plan, plat or the Intended use changes. The Improvement Permit Is not affected
by a change in ownerahip of the property. This permit was Issued in compllance with the provisions of the North Csrolina 'Laws and
Rules for Sewage Treatment and Disposa[ Svstems' (15A NCAC 18A .1900).
' Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�
Proposed Wastewater System: �� Q.(��-a`� � Type � Wastewater Flow z�.g.p.d.
New . Repair ✓Expansion _ Soil LTAR: o�5 g.p.d./ ft 2
Type of Facility: o? ��, ��._ Basement _ Yes ✓No
Wastewater System Requirements
Tank Size: Septic Tank: ��� al Pump Tank: � gal Grease Trap: �� gal
q� �
Drainfield: Total Area: /� sq ft Total Length �C7 ft Mazimum Trench Depth �� in
Trench Width � ft Minimum Soil Cover: �_ in Minimum Trench Separation: ft
Distribution:
Specifications�
Distribution Box
�erial Distribution
� �1n�„�-
Authorized State Agent: � !
Permit Expira ' n Date: � 7— 6 —
The type of system permitted is l�Conventional _
the permit.
Owner/Legal Representative:
Pressure Manifold
� ��
Date: � �� �
Innovative Alternative. I accept the specifications of
Operation Permit
Date:
System Type (in accordance with Table Va) �G� •
The system has been installed in compliance with applicable North Carolina General Statute, Laws and Rules for Sewage Treatment and
Disposal, and all conditions of the Improvement Permit and Construction Authorization. Issuance of this permit does not guarantee that the
wastewater system will function properly for iven period of time.
Authorized State Agent: _ � ate: ,�-�,3-���
PCHD rev. O1/23/02
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� HOUSE IS SERVICED
BY UNDERGROUNO
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Applican
Location
T��x M�p � P�rc�el �
S�ubd�ivis�ioi�
Fh�s�e Sec�t�io�� Lot #
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
A HORIZATION.
� _.
- ��l �Y � ���,�- �3
Authorized State Ag t Date
. - ` � J /� �� _
Installed By: � ; / Date: ��
� T� J��
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� S�3��AC iAIVK INSi�E�TiON C9iE+�9�Cl..IS�' (i'ype il - IV)
v
Tax Map # Parce! # System Type (Table Va) �C(L
Owner/Appiicant Subdivision
Address/Location ` � � Sec/Phase Lot #
sepucianK
State ID/date
Capacity.
Tee and Filter
Baffle
Sealant
Riser (if applicable)
Tank Outfet.Seal
Permanent Maricer
Pump Tank
Width
Trench Length
Trench Grade
Trench Spacing
Rock Depth and
Dams/Stepdowns etc.
Pressure Laterals
Hole Spacinq
� IV�f.r VIL�i�
Pipe Sleeve
Waterproof /Sealant Tum-upslProtectors
Riser Required Setbacks
Water Tight From Welis �.
Pump From Property lines
::.._ -_ Check:Valve/Gate Vaive -_- -: -.- Strvctures[Bas
�.- Anti-sip on o e . iic es rain�
� Floats/Switches : .- � ...: : :. : -. :, :�. : Surface Water:
Alarm visable and audible) Public Water S
Eiectrical Components Verticai Cuts =
Rate gpm Water Lines
Approved Pump Model Vehicle Traffic
Block Under Pump
Pump Removal Rope/Chain
Distribution System
Serial Distribution '
Low Pressure Pipe •
Appr. Pipe Material and Grade
ft.
it�.
f�.
1
1•1lC�`
��LT���
r
Easements/Right of W<
Other
Easements Recorded .
Tri-Partate
Comments�
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pchd rev. 3/13/01
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: � I Parcel # V� Township � I � � e— � � � �
Applicant:
1� � e�n �Q.�
Subdivision• t I
�
T�e of Water Suvulv:
Rec�uirements•
Section• Lot•
ndividual Community Public
Site Approved by 3F� �'a4-oa
Grouting Ap roved bp ✓��% �-c�
Well Log �i-o1� �oa'
Well Tag
Air Vent
Hose Bib '
Concrete Slab
Well Driller.
Well Approved B� Date:
`�A '�.
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ZS 25k
'�°�See Attached Site Sketch**
Wells must be 10 feet from property lines. (�
Wells must be 100 feet from septic systems. ��' ^��� �- I`'
Wells must be at least 25 feet from any building foundation.
Other conditions:
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PC�ID, rev. 09/07/01
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Owner: s(
Location: �
Subdivision:
Well Log �j_
Tax Map /� ^7 Parcel # ���i
Lot #
Well Construction
Distance From nearest Properly Line (Minimum 10 feet) `d
Distance from Septic System (Minimum 60 feet) �„ �S
Total Depth: ��O ft Yield: _�_ GPM Static Water Level: o�C� ft
Water Bearing Zones: Depth J/ o ftaa� ft ft ft
Casing:
Depth: From �_ to �� ft. Diameter: Co in
Type: Galvanized Steel ✓
Weight: Thiclrness: -/ 8� Height above Ground: �� in
Drive Shoe: _�'Yes No Any problems encountered while setting casing? =Yes � No
If "yes" give reason:
Grout:
Neat: Sand/Cement Concrete GraveUCement �
Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured � Depth C� to � F�
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: /Yes No 4 x 4 slab J Yes No
Drilling Log
Location Drawing
From To Formation
6
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I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person County Health Department.
Signature of Contr ctor � ID# o? �l�( g Date %-�3 �