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Person County Health Department �
Sewage System Improvements Permi
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Date: -�'J- `�� i� ermit Vo'id After 5 Years � �
Owner: '� `' SR# �T
Location/Directions: � /",� ,, , � � �' r «,�
Subdivision N :���1(,{���flZ:��1��1� f 4. � Lot #T���
Lot Size: ''9 Type of Dwelling:
Water Supply: rivate: �� `� Public: —� '
Bedrooms: � Garbage Disposal �,�i- �~�� t ss ,
Basement '� ,— Basement Fixtures�T
INFORMATIOI�.CERTII�'�'I�D, BY - . _ �i� �� . ;; /�'� �:� . � �
$�7litailall: ' � 1,� �.yE ! ;1 '% �- ` --� - ;oM1�ner or representative ! /
REPAIR: ' ��' `� " REE�AI.L7ATION: �
Size of Septic Tank• �gallons Size of Pump Tank:
.-�L���C�^ — � — — — — — — —
Nitrificauon Line: z _ _
Depth of Stone: 12 inches ' ��
Max Dep[h of Trenches:
Altemadve System: Conv. Pump LPP Pump
Remazks:
------- — ---------------
Date Well Appmved: � � Well should be 100 f� from any sewer system
BY Sanitarian���
Date Sewa tem A
BY � Sanitarian
R IFICATE OF COMPLETION
Contractor. , o �,�,!
------------------------- �
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained .��-
by owner in such manner as not to create a public health hazard. Septic tank and'd
nitrif'ication line must be inspected and approved by a member of the Person Counry �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemut is subject to revocation.
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
% supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date: Note location of water supplies on adjacent lots.
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�'erson County Health Department �
Well Permit �
Date: � Q }� P�ermit Void Afte,r�`Years
Owner �'D � c.r-t-t� - —
LoCation/Directions: _ _
Subdivision Name:.
Drilling Contractor:
v��% �
SR# S%N
I
Lot # z_
WELL CONSTRUCI'ION ►d
Distance from Nearest Properry Line Distance from Source of �'
Pollution ;n,
Total Depth: FG Yeld: �GPM Static Water Level FG �
Water Bearing Zones: Dept� �� FG FG _��G
Casing: Depth: From _�_ to Ft Diar�r. ��_ Inches
TYPE: Steel Galvanized Steel
If Steel, does owner approve: No
Weigh� Thiclrness: Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No
ff �,yes" give reason• � d
GrouG Type: Neat S ement Concrete ;4
Annular Space Width Inches
Watet in Annular Space: Yes No
_ Method: Pumped Press Poured ��
Depth: Fmm � to FG
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
if mixture (sand. gr ve , cuttings) - Ratio: to
ID Plates: Yes No
4 z 4 slab Yes �— No �
I HEREBY CERT'IFY THAT THE ABOVE INFORMATION IS C
THIS WELL WAS CONSTRUCfED IN R ANQE WITH
FORTH BY THE PERSON COUNTY HE L� QR'I�N'I'
Sanitarians Signature
Sketch well location on reverse side.
t EC'T AND THAT
; ULATIONS SET
Dat
c� �
Date Issue
Date Completed
a NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
,� at later date. Note location of water supplies on adjacent lots.
(1)
�'�� G�-;,�'P ,� y�v`�
(2)
�= a=���tioa �a±e: � 1
Amount Paid: l 0. a
Receipt #: 1 q 3� I �
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�...,: ►• � �. � ����'. Parcel#: ��
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�lication for Services
Services Requested
0 Improvement Permit (Site Evaluatlon) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d Fee is de endent on the ty e of s stem ermitted)
obile Home Replacement or Building Addition ❑ Permit Revision
$150.00 if site visit re uired $75.00
❑ Well Permit (New/Replacement/Repair) 0 Repair of Existing Septic System
$300.00/$200.00/�75.00 Appiication; No Charge/ CA $150.00 or $300.00
1) Applicant Information: �
Name: � us a� w� �� Phone (home): ��33 G- S zc{- � Q y�
Address: / b-G Z.% w �/��� c.-' j'r- (work/cel l):
2) Name and address of current owner (if different than applicant):
Name: �tir,� �- ir���s� ?��1���- Phone: / 33G --S-o�/--l��G S
Address: /� G rk K�a-e- � r
� �LS
3) Property Description: Lot Size: � Subdivision: �G�l�' �/� Lot #: ��
Address and/or directions to Property: S� 7 �Y�i� L� C h��-�%� ��
❑y� 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 ❑ 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: :
ORrsidential �
O t+'�:w Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: Current aumber of bedrooms:
0 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 ❑ Exisring Well � Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
��6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional O Accepted � Innovative ❑ Alternative ❑ Other C7 Any
1 certify th the information provided above is complete and correct. I also understand that if the information provided is
inaccur t, the s' e ubsequently altered, or the intended use changes, all permits and approvals shall be invalid.
� °L =/`-" �3�/� l �'
Signature (Owner/ Legal Representative*)
'� Supporting documentation required.
Date
Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
A com�leted `LotPreparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N��27573 (336-�597-1790)
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Building Additions/ Mobile Home Replacements
Tax Map #:",��_ Pazcel#:� Address: /!�I G��fit/'i ��/�-
Approval Requested for: Mobile Home Replacement
. X Building Addition y�X Z� � G'/1�Ja��
Applicant Name: ��,�'„�,�
Address:
Phone #'s• ' �pc� 7� �,�'�
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Permit Located: ✓ Yes No
Installation Date: �-� Design flow: s�� (gpd)
Current Contract with Certified Operator on file (if required): �
Water Supply: ✓ Well Public or Corrununity
� Wastewater system shows no visual evidence of failure on: /S �� (date)
(Applicant's signature if site visit is not required)
n�
Addition/Replacement Approved
Enviranme al Healt pecialist
����
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
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Applicant:
Address/Location:
Taz 1`.Zag: _"t-�� Parcel: (oY�
S Kbdi•�isior. �
Phase/Section/Lot # l
Improvement Permit
Permit Valid for: Five Years Non-expiring
Type of Facility: � New _ Addition _
Number of Bedrooms / Occupants / Employees / Seats:
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Authorized State Ageni:
(X) Owner or Legal Re
W
r Supply:
ected Daily Flow: gallons/day
Type:
_ Type:
llate:
Date:
The issuance of this per ' y the Health Department does not guarantee the issuance �f other required permits. It is th:, responsibilin� of
the applicandproperty er to insure that all Person County PIanning and Zoning and Building Inspections requirements are met. This
improvement Per it is subject tu revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in � aership of the property. This permit was issued in compliance with tt�e provisions of the l�torth Carolina `Laws
and Ru[es for SewaQe Treatment and Disposa! Svstems'(15A NCAC 18A .1900}. Neither Persoa Couaty nor the Environmental
Health Specialist warrants tha+ the septic system wiil continue to function satisfacto::ty in thc future, or that the water suppiy will
remain �table.
� Authori�ation to Construct Wastewater Sys#em
�'ee site plan and additional attachments (� j.
Pro osed Wastewater S stem: �r`',���G?� (*)Type ��c Desi�n Flow �cd gal./day
n � Soil LTAR: v-��l` gal./day/ftz
New Repair � Expansion _
Type of Facility: �,�C '3 f��' f-���'d.-v%� Basement: _ Yes �l�do
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(`') System Types I�Ib, Ilibg, IY, c�nd V, require periodic systsm inspertions by the Person Corsnty Health Department.
Wastewater System Requirements
Z�Ci r� ��i
Tank Size: Septic Tank gal. Pump Tank '`" gal. Grease i rap '–' gal.
Drainfield: "Total Area �l-'�_ sq. ft. Total Lengtl� !��_ ft. Max. "french Depth 2�, in.
Trench �Nidth _� i�. Min.Soil Cover _(� in. Min.T'rench Separatian "' � ft.
Distribution: Distribution Box / Serial Distribution �/ Pressure Manifold _�_ w
Specifications:
�
[ssue Date: ;� f�/!Y�
Authorized State Agent: - --�— �
Permi� Expiration Date: �`���,,�7_''�.�
The system permitted is: Conventional /Accepted 7C 1 Alternati�e / Innovat;ve . I accept the conditions
and specifications of this permit.
(k) Owner or Legal Representative: Date:
�:;
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-17�Q (rev 5/12)
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Name: �f,�,r.�,o- adaress: i�
Subdivison.: ���t/_/i�_/ i� Lot:��
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System Type: �
Septic Tank: /Dp/� �Ilons
Pump Tank: gallons
Total Linear Feet: _���
Max.Trench Depth: � "
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Tax Map: �22
Parcel: �,�
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EHS: �
Date: � �
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Scale:��
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Health with any qujstions (336) 597-1790.
Additional Comm�nts: C�l.GlG ��hf?�9 ��1�1%/7DGt%/VS � /U5%!� �ff.�b
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