A28 156Application Date: � `JJ �
tAmount Paid: . 00
Receipt #: 7 I � `l �
e,�-� ��SG A
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$3�6.00/$200.00/$75.00
��';,) f �����1 V
������
] �Gsawna-o�a�xa��¢�n.11 I�3I3I�m.11�l�
tion for Services
Tax Map: �'C � � Q�
Parcel#: �� a�
Services Re uested
Construction Authorization
(Fee is de endent on the e of s stem ermitted)
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
Y) Applicant Information:
Name: Mbt'fc7 W J�-f.��'��� LLL
Address: _/J�q4 i 1,�_���'-f �� •
_Re�l�brc�� i� �,�76''7 �l
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): � .3�i� .�� � � � �5
(work/cell): ?�3L� -Sq o� - aSJ 9
Phone:
3) Property Description: Lot Size: ��. Subdivision: Lot #:
Address and/or directions to Property: i R'73 �]�1�r u, �a 1� �
�bX.��O 1�c ��� `�l �1
❑ 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 �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 Will there be a basement? ❑ yes � no With plumbing fixtures? ❑ yes �1 no
�1on-Residential M �
Type of business: /� i g �41n"I'" �'`l3�°J � I�I Total Square footage of Building: q� ,
Maximum number of emp oyees: f� Maximum number of seats:
5) Wate Supply: ❑ New well � Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? f� yes ❑ no
) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other � Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, o� if the site is subsequently altered or the intended use changes, all permits and approvals shall be invalid.
S ature (Owner/ Legal Representative*)
* Supporting documentation required.
3l S�Z�t�
Date
• 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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
�
ConnectGIS Feature Report
Page 1 of 1
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NOTICE Recently, v�e have had several users report�biowse� com��atlbilit� i wes e�,hrn tr,ing to access our GIS website Typically the problem stems from users who hav
recently upgraded to the Windows 8 operating system or a new version of Internet Explorer. We were able to resolve this issue by directing users to the Intemet Explore
Compatibility View tool. This link is to Mkrosoft's "How To" for the tool: http://windows.microsoft.com/en-US/intemet-explorer/products/ie-9/features/compatibility vie�
f this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGlS has bee
prepared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system ar
notified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 3ll ConnectGl
assume no leqal responsibiliry for the information in this system. Grid is based on the NC state plane coordlnate system, 1983 NAD.
http://gis.personcounty.net/ConnectGIS_v6/DownloadFile.ashx?i=_ags_map5197b667a6e5... 3/5/20l 5
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Taz Map: ��8 Parcel: ��
Subdivision
Phase/Section/Lot #
Applicant: l`Ra��w� t-�'�MS l.`.`
Address/Location: ACsat�c�.=-�.�-� '�'O � �$`l� _b��-oc.�t. '���'� 1� _�_--
Improvernent Permii
Permit Valid for: Five Years x_ Non-expiring
Type of Facility: 3-iiP.. ��s'� New � Addition _
Number of• Bedrooms '3 / Occupants� Employees / Seats:
Proposed Wastewater System: `��he i�► , w�5"� �r
Proposed Repair: 1`�ia�(� A�-�L.l� w aS"�o�
Water Supply: �.�s�►�b �; �.u..
Projected Daily Flow: 3�_ ga[lons/day
Type: �3�
Type: '� +3 b
Permit Conditions: 1"��a�h�-s� �r� � 5���. �J►sa-`cR�Sr���. : �-�o«� �. ��1,t�c����l'A
U'� �-►-n�S
Autherized State Agent: '�J�.ckC. A. �hR't� _ Date: �a1-►S
(X) �Owncr or Legal Representative: Date: _
The issuance of this permit by the Healt�� Department does not g�:arantee the issuance of other required permits. It is the responsibiliry of
the applic�ndproperty 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 Improvemeni is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina �Luws
nnd Rules for Sewa�� Treatment and Dunnsa! Svstems'(15A NCAC l8A .i9U(1). N�ither Person County nor the Environmental
Health Specialist warrants that �he segtic system will c�ntinue to f�nciivn satisfattorily in the future, or ihat t�e water supply wiil
remair potabfe. _ _ — __ —
Authorization to Construct VVastc��vater System
See site plan and additioszal attachmet:ts (_).
Proposed Wastewater System: 1�M@ �� w���'�3`� (*1Type "�CCA� Design Flow 3�00 _ gal./day
Nev� 7C Repair _ Expansion _ Soil L'Cl�R: O.�.� gal./day/ftz
Type of Facilit-,�: 3-�R. i�►a11,S� Bssement: _ Yes 7C No
(*) System Types Illb, Illbg, !Y, and V; require periodic system inspections by thz Ferson County Health Department.
Wastewater System Requirements
Tank Size: S�ptic Tank 150�p gal. Pump Tanh 1� gal. Grease Trap —"" gal.
Urainfield: Total Area 148Q sq. ft. Total Length 3\0�0 _ ft. Max. Trench Dzpth 1$ in.
Trench Width 3 ft. iVlit�.Soil Cuver � in. Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution__ / Pressure Manifold %�
Specifications: _ � ���5 �. �30�
Lt� �f �xASC �� �+�►c��
M
S
—1 �1
A�rthoriz.,d State Agent: '1%:4,+c.�s�, A. Sr.� Issue Date: '�l -� �5'
Permit Expiration Date: '-1-�.� - �O
�u��
7'he system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the cot�ditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 32.i S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
Morrow Farms LLC (1873 Blalock Dairy Rd)
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1 inch = 100 fe�t
� v Septic System Lines
-- Roads
� Proposed Building Envelope
%� Drainfeld Repair Area
Parcels ����� �� ���� ��
43.539479
150 079482
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SITE PI.AN
.,. �oR345
223.830886 N�`'- ����` ���� `�' Tax Map # �`� Parcel # �
__ Subdivision Secnon/Lot#
1�`�w. L�i, �l- SY�tTNa `{ - -1S 189.827899
Authorized State Agent Date
5ysrem components teptesent appmximate conmuts only. The contractor must flag the sysrem priot to begznning the instsllat�on ro
insure ehar propergrade is mainrained.
0 �0 �V 00 200 300 Feefi N
0
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Tax Map: A aB Parcel #: �� Date: `� - a\ - t�
Line Tap Tap (�c�n) Tap �opv Line Length �oe� / foot
# i)iarmeter(vn) ( �) �:• (ft)
1 �'} � SO �0.1 �30 .`�s�
2 ��
3 v
4
5 ��' 1� �
6
'1 �. 3� 3b� .
S
9
14 �
3b'� ft of line x 65 gal, per 100 ft=��`��`t �3�}��t = I00 =�' _ gal
75°lo x�3`1 gal = i'1�, gai per dose �� gal per minute (gpm) = Flow I�ate
Friction �ead
Loss: ���I� ft per I00 ft of supply line x'� ft of snpply.line =100 = 5�� ft
S'�^ft x 1.2 =�•'� ft of friction head �.
Ii�lani€old Size: �" Forc� Main �ixe: � " PVC
�otal Dynaar�ic �ead =,� ft of Elevation head +�- ft of Pressure head �- � ft of
Fricrion Head = �+ TDH
Pump Reqaaire�emt: 3�- GPM @�� � ft of Head
Drawdowia; �'1b gal per dose ;a2�T ga1 per inch = tn inch drawdown per dose
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