A28 13Per:son County Health Department �
Sewage System Improvements Permit
D�: '-���2 This Permit Void After S�Years � Pennit #�H� 8?4
lO.ocation/D�recaons: arc� ��r��f' _sR# _1LS� •
•�, - - „
r � . v � J•
Subdivision Name: a )x c� Lot #'� �_
Lot Size: �, 7. �. p� Type og �elling.
Water Supply: Private: �_ public: Community:
Bed�oms: ��ge ���
Basement Basement Fij tures
1NFORMA BY
S�I11f8I18i1: owner representative
�'�� VALUATION:
Size of Sepric Tank: ----�ons Size of Pump Tank; ---
Nitrificadon Line: f �/ •
Depth of Stone: 12 inches
Max Ikpth of Trenches:
Altemative System: Conv. Pump� I,pp p�mP
Remarks ����Y-p -1�, ,."c P�.�r�a�—.flL�, a ..�
,. __.,„ '�"°
—"_---- ._---- u �
Date Well Approved:��=/ ���Well shaild be 100 ft from any sewer system
BY Sanitarian
Date S, ge s rov
BY � sanitarian
� CATE OF COMPLETION y
Contractor. '
-------------------------- �
�
Sewage System location, installation, and protection must meet state and locai �
regulations. Sep6c tanlc should be pumped out every 3 to 5 years and shall be maintained
by owner in such martner as not to create a public health hazard. Septic tank and �,
nitrificatian line must be inspected and approved by a member of the Person County
Health Depaztment before any portion of the installation is covered and put into use. If
the site plans ar intended use change this peimit is subject to revocation. ��
(G.S. 130 A-335F)
i
Location of sewage disposal sewage system sketched on back. �
S
�
(OVER)
� Application Date• 3 3 �
Amount Paid: �
Receipt #:
A�
Improvement Permit (Site Evaluation)
�200_00/$300.00 (if> 600 endl
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
��� S� ������T Tax Map:
�: ► • � � �� Parcel#:
� cC��J�T��Y
IE��aa-o����a¢�.11 IC-33[m�.Il�l�
tion for Services
Services Requested
�Construction Authorizatioa
(Fee is denendent on the type of
Permit Revision
$75.00
Repair of Exisiing Septic System
Application: No Charge/ CA $150.Q0 or $300.00
1) Applicant Info ation:
Name: C Phone (home). �� -�-„�'7 9`�' ���G�
Address: ( (work/ e 1 . � 3C� - . �','�'i � -S,� 3[�
2) Name and address of current owner (if different than appGcant):
Name: rn � Phone:
Address: s f0� n �U /�� f� 9(]
�S%3
3) Property Description: Lot Size: Subdi ision:
Address and/or ��ctions to Property: ��
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#:
�D,�k' o k � v✓i � -� n r� /� - — .�c����-�' �
❑ es o Does the site contain any jurisdictional wetlands?
�s ❑ no Does the site contain any existing wastewater systems?
❑ yes CL�� I any wastewater going to be generated on the site other than domestic sewage?
❑ yes Is the site subject to approval by any other public agency?
es ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
��`�>
���/��`�
�ok
4) Proposed Use and Type of Structure:.
�dential
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ 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 xisting 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 ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ �y
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�/
ignature (Owner/ Legal Representative*) Date
* Supporting documentation required.
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
�1 n/� 51 Per��n (:rnmtv Rnvir�nmental Health. 325 �. Mor�an St__ Suite C. Roxboro_ NC 27573 (336-597-17901
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April 12, 2016
Rebecca Morrow
P.O. Box 3091
Roxboro, NC 27573
Re: Septic System Repair Application/ Tax Map: A28-13
Dear Ms. Monow:
On March 31, 2016, you submitted a request to the Person County Health Department for a septic system
repair permit. On April 4, 2010, an initial site visit was made to evaluate the existing system and explore
possible repair options. The evaluation was done in accordance with the laws and rules governing
wastewater systems in North Caxol:na (GS 130A-333, NCAC T 15A: 18A .1900). At the time of the visit
the existing system was failing and discharging wastewater to the ground surface at the lower end of the
drain field. An evaluation of the portion of th� parc�l in the vicinity �f the homs determined that the soils
were unsuitable for a system repair.
The soiUsite would be classified as Unsuitable for the following reasons:
Rule .1941: Mixed Mineralogy
Rule .1942: Soil Wefiess
Rule .1945: Available Space
A second visit was made to the property on Apri18, 2016, to investigate repair options on the entire parcel
(A28-13) and on the adjacent parcel (A28-130). No repair options were identified on parcel A28-13. A
provisionally suitable area on the adjacent parcel (A28-130) was identified and the perimeter flagged. If
you would like to use this area for the septic system repai:, the area must bz surveyed and conveyed to the
parcel with the house (A28-13). Once this has been done, the Health Department will issue a repair permit.
You have the option of hiring a soil scientist to review our decision. A soil scientist may propose a system
in the evaluated area that meets the requirements of Rule 1948(d), or they may identify another portion of
the property that could serve as a suitable off-site system area.
You also have the right to request an Informal Review of this decision by the State Regional Soil Scientist.
A request for informal review must be made in writing (forms available) to the local health department. An
informal review is conducted at no cost to you.
In addition, you have a right to pursue a jormal appeal of our determination. To pursue a formal appeal,
you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, NC 27699-6714. To get a copy of a petition form, you may write the Office of
Administrative Hearings or call the office at (919) 431-3000 or download it from the OAH web site at
http://www.ncoah.com/forms.html . The petition for a contested case hearing must be filed in accordance
with the provision of North Carolina General Statutes 130A-24 and 150B-23 and all other applicable
provisions of Chapter 150B. N.C. General Statute 130A-335 (g) provides that your hearing would be held
in the county where your property is located.
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
t'
If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative
Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The date of this letter is April 12,
2016. Meeting the 30 day deadline is critical to your formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are
required by law (N.C. General Statute 150B-23) to serve a copy of your petition on the Office of General
Counsel, N.C. Department of Health and Human Services, 2001 Mail Service Center, Raleigh, N.C. 27699-
2001.
(Note: Do not serve the petition to your lccal h2alth department. Sending a copy of your petiti�n to the local health
department will not satisfy the legal requirement of NCGS 150B-23).
Please feel free to contact our office if you have any questions or need any additional information.
Sincerely,
��
Harold Kelly
Environmental Health Supervisor
Person County Health Department
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A�stslication Da4e: �
Amount Faid: �
R�r.eitst #• I
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APPLICATION F�R SEiZVIC�S
Tax lAap #- Z
�aroai #: � .�,�
IF THE� IP(FORMATION 1M THE APPLICATION F�R AN iMPROVEMENT PERiViIT IS INCORRECT. FALSIFiED,
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AAID AUTH�RIZATION TO
CONSTRUCT SHAL� BECOME tMVALfD. . - '
1) Permit requested by: (Own ge p pective owner): S ��, �o�o�i �.
Home Phone: � � Address: Z Z 2.0
Business Phon��Z- 3/. j� Y-�- �/ 7S"��
2) i�ame and address of.current awner. ��'f'lLf�- CY •!� �G�.� r"'h—�._
3) Property Description: Lot size: .�,7 Z Tawnship: ����Q �rI Subdivision: Lat #�
Directions to the property (Including r�ad name� and number�): - �,, _ � '
4)
5)
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a d '� y� <w �'� `i s� � � �
Proposec! Use and Structure D� crfp on: answer each of the following questio s:
a) Proposed _, Existing �r/ Type of Structure: /�Dou�,,g-,� JL%i� � Width: �� � Depth:�
b) Number of Bedrooms: ,��� Number of occupants or people�to be served: .
c) Basement Yes . No _ Will ther�e plumbing in the basement?
d) Garbage Disposai: Yes _,, No ✓ �
Wat�r Su 1'� : Private new or existin Y, Public Commun' S rin _ ,
AP Y.YI� .� t — 9—i �/ � P 9
� Are any wells on adjoining property? Yes No _ If yes, please indicate approximate location on the
- site plan. � _
�) Does your property contain previmusly identfiec� jurisdictional wetiands? Y�s_ ldo_
PLEASE PIO'TE THE FOLLOWIiVG:
➢ A PLAT OF THE PR�PERTY OR SiTE PI..�1A1 MUST BE SUBMITTED WtTH TH1S APPl.ICAilON.
➢� PROPERTY LINES AfdD CORNERS MUST BE CLEARLY M�►Ri�D.
➢'Y'HE PROP�SED LOCATION OF ALL STRUCTURES MUST BE_ ST�►!�D OR FLAGGED.
� T�iE S1TE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF. �
I hereby make application to the Person County Health Department for a site evaivation for the on-site sewage disposai
system for. the above-described property. f agree that the contents'of this application are true and represent the maximum
facilities to be placed on the property. I understand ifi the site is altered or the intendeci use changes, #fie permit shali
har�nma invaliri .. �
Owner or
/
Date
PCND, rev. 06l27102
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Tax Map #�� Parcel # � 3
Existing Sewage System Report For. y Mobile Home Replacement
Addition Type•
Requester. �uS ��� b��"' Home Phone#
c� 1 F�an k C.u.S ��TZ oad � Business #�J�4- ra � 1
I imbtrlaKc. , I�G a �S'� � .
Location: ��.5 � ,P�a (Oc.IC (.,% � r� �.o�d (� Qox � 3�'�' �
Original Permit Located: N �
Water Supply: f �u�t- W c- � �
Septic System Designed For: V Residential Business
# Bedrooms� # Employees Other
Other
System Type: C��1vet1�1�0�1�-� 'Tank Size:_� Nitrification Line: ^'��0� X3�
Date Installed: ? Certified Operator Required: N� �
On-site wastewater disposal system shows no visual signs of malfunction on ��� �
Permission is granted to: �`�-b�<i d n«a ti o►��
r rr� � �1�, c e,0/l
�-c- C�� 0� -��.t, n i�rl Fc'c�-6'on C, �`� c S►
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Environmental Health Specialist Date: Vr� ���3
Application Date: �� � 6 � �!'� 6l � r y Taz Map: ���
Amount Paid: � �O� `����� ������
,. � � ���,,� Parcel#: _
Receipt #: (, 77�6 `
3 �, �� lEffi���r����.�,ll lE1[�,�ll�
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Aonlication for Services
❑ Improvement Permit (Site Evaluation)
�200.00/$300.00 (if> 600 �nndl
0 Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
Services Re uested
❑ ConstructionAuthorization
ee is de endent on the ty e of system ermitted
❑ Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: h cc
Address: O
ho 3
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size:
Address and/or directions to
��� �/✓
Subdivision:
Phone (home): �3CP —�99—�j5%,3
(work/cell): , ��� --5'�� —S��'3 d
Phone:
#:
/ U I� /Y � // -T J �/ �!
❑ yes C�-rr� Does the site contam any j's ictional wetlands?
� ❑ no Does the site contain any existing wastewater systems?
❑ yes �,ua�" Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes �-��Is the site subject to approval by any other public agency?
C�J-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: �� / Occupants: —3
❑ Expansion of Existing System If expansion: Current number of bedrooms:
epair to Malfunctioning System Will there be a basement? � yes �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 � sting 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 ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
' � /� //�
S�g ture (Owner/ Legal Representative*) Date
* Supporting documentation required.
• Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15} Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applicant:
Permit Valid for: Five Years
Type of Facility: �
Number of: Bedrooms / Occupants
Proposed Wastewater System:
Proposed Repair:
Permit Conditians:
Authcrized State Agent:
(X) Owner �r Legal Representative:
Tag Map: r�� Parcel• /�✓
Subdivision
Phase/Section/Lot #
��p�ovemer� Per�it
Non-exniring
New Addition _ V4'ater Supply:
/ Employees / Seats: Projected D�i
Type:
Type:
Date:
Date:
gallons/day
%s
The issuance of this permit by the Health D ent does not guazantee the issuance of other required permits. It is the responsibility of
the applica�nt/property owner to insure all Person County Planning and Zoning and Building Inspections requirements aze met. This
Improvement Permit is subject revocation if the site plan, plat or the intended use changes. The Im rovement is not affected
a c ange m owners ip e proper . �s permrt was �ssued in compliance with the provisions of the North Carolina °Luws
mid Rules or .�ewa � eatment and Du osal stems'(15A NCAC l8A .t9U0). Neither Person County nor the Environmental
Health Specialist rrants that :he septic system will c�ntinue to fanciion satisfactorily in the future, or ihat t�e water supply witl
remair notable.
Authorization to Cons#ruct Wast�water�ystem
Se� site plan and additiortul attaehnrenis � i�.
�
�a-1el
Proposed Wastewater Svstem: �,,,��, Q��_p��A �x„—p/(*)Type� Design Flow ?�_ gal./day
Nev,r Repair � Expansion _ �_`� Soil LTf�R: `� .��-� gal./day/ft2
Type of racifir,�: �,�,,� ?j -�D��,�.� Bssement: _�'es �/'I�o
(*) System Types Illh, Illbg, IY, and V, requireperiodic system inspectians by the Ferson County Health Department.
Was±ewater Sy�te� ltPq�ire�en±s
Tank Size: Szptic Tar�k��(i� gal. Pump Tank p�a gal. Grease Trap ""' gal.
Urainfield: Totai Area �D sq. ft. Total Length �_d ft. Max. Trench Dzpth i�3 in.
Trench Width � ft. iVliri.Soil Cover�_ in. Min.Trench Separation q ft.
Distribu�ion� Distributi�n Box / Seriai Distrihution__ / Pressure Manifold )C ,�v,,��p T��
Specifications: �2� -«/�r,�l�o,,/' ��n�,_v�,✓o�y� lsi�,�.r�� ��'97 ,(�46�. �v�� �<�t/�i
C�Z'�
Auth�rizad State Ageiii:
�ssue �ate: i �d ! �
Pe.�nit Exgiration Date: / ;
T'he system permitted is: Conventional /Acezpted i� / Alternative / Inno�ative . I accept the conditions
and specifications of this permit. '!I- � �
{X) Owner �r Legai ite�resen�ative: ..�'►�C�(� � Date: / o�LP � �
Person County Environmental Health, 325 S. Morgan S"t, Suite G; Roxboro, NC 27573/ph: 336-597-179U (rev 5/12)
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Sloped To Shed Water
b" Cotrer •.
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I�let Fmm Septic Taak
4" SCH �0 PVC Pipe '
NEMA 4X Simplex Contml Panel
4" X 4" Pressnre Treated
12° Sep�,ration
Electrical Cox�nit =
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�• ��` Access Co.ver• � ,• • ' e� ' .1 . � i
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Clieck
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Higk Water Alaxrn Lev�el
, (6° Sepazatien�
;:�� �. Higlt Letrel- Pump Ox -��,..��
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T�x M�E� � • P�rccl #
Suhcllivision
Ph���s�e Sect�ion Lat #
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Ex�d� Of The Co�duit
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Thxeaded Gate Valve
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Zip Co;
Tips
;. Precast Coziczete Tank 4" Conaete
:•; (Mate:ial Strength }3500 PSIj gyo��
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Con�eie Riser
6" Sepaxation
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;r,�...�-Poxtland Concreta Gsout
_ . _, Mastic � - - •
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�pply . . , . � Openiag Fs11ed i�iiith
,� � � ; Portland Ce:a.exd Gmut
4utlet To Distnbuti,on
2" SCH40Pi�C Pine
1e F7cat Wires .� �
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F1oat Tree '•
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/00� GAI.LalY FU�IP TANx
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Pump Mu t ge Rated 7o Detiver
GalLoas P�= Hinute,
AgasRst �`�Feet QE iota.l
Dyea�ase Head (IDN) .
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1[ �a.n-vnn-aauannn��raiE.za1L 7EHL�e+an.11�EJla pwner. G(%
Tak Map: � Parcel #: Date: �
�ine �'ap Tap (Sch) Tap F'low Line I,ength �'lova /%ot
# Diameter(in) ( m) (ft)
1 � � � a 7! �
2 � z v ,i '
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4 '
5
6
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�,� ft of line x 65 gal. per 100 ft = ;' ] 00 =�gal
75% x�t gal =� gal per dose ," gal per minute (gpm) = Flow ltate
Friction �-Iead - ��
I.oss: � Z;7 .ft per 100 ft of supply line x� ft of supply line = 100 = Ol.�• � ft
fJ,�� ft x 1.2 =/,� ft of friction head
Ntanifold Size: �_" Force Main Size: �" PVC��
Total Dynamic �Iead =�ft of Elevation head +_�ft of Pressure head + f�_ft of
Friction Head = 3 ( TDH '
�'ump Requirement: iY GPM @ '3/ . ft of Head.
Drawdo�vn: /!00 gal per dose = 2l gal per inch = ��� inch drawdown per dose
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11�ianifold Size / # Ta s
uifold Maz No. Taps off one side
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� - Tax Map ��� Parcel # , f_�
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PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �F$�.cC,� MoR'�W
Address �9 �`��-+4 W t� fJ� i(L.Y �D County P�.so�
Collected By ���.R.lC.1L 1{ . Si'� ��
Date Collected S' a9 i3 Time Collected 9: 351}t'�
Source: � Well ❑ Spring ❑ Other
Location: ❑ House Tap ❑ Well Tap '�Other �,�S�A� SP«��T�
0 No Charge � Charge
........................................................................�
****************************************�*******************************
Results
Present Absent �
Total Coliform ❑ � �
FecaUE. Coli ❑ .�
Reported By���,.� d9-� .�r� "� _
Date Reported S� 30 -- ��