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A28 200, �� o y. �`' �° s The District Health Department CASWELL - CH�THA"n�LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPAOVEMENTS PERMIT No. �Gt$Q �J Date �^ � ? - �' � Owner: —Tj— r� � e Location: �� , I I �n � Contractor: � � �J/ � Water Supplp: Private �*�'r Public Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal� washing machine, other sutomatic appliances Size of tank: r Nitriflcation ��np� �J ( b b �C�' ' 1� ti �� /C v n( itif,1,�P 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- PROVEI} BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. � Date approved: Well: Sewage Disposal: - By � l % t J Signe Sanitarian Counter-� � ' signed (Owner or ' represeritative) Certificate of Completion Date Approved: `—I � �? �, By � anitarian (OVER) Location of well and sewage disposal facilities sketched on back. Application Date: � Amount Paid: I �0 , 00 Receipt#: 6�t�03 ��?.S� �� raar.vnv��aa��++a�,�rn.�..,an.� g"'��.tn...11.�.�n Ta�c Map: ''4 � � Parcel #: � o v Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if> 600 d) (Fee is de endent on the e of system ermitted) Mobile Home Replacement or Building Addition 0 Permit Revision $150.00 if site visit re uired) $75.00 � Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Services Requested by: c,` Name: -=T�}So N �. I-��-(� R I S Phone #(home): 3 3(, 5 9�-� o� 9�r�, Address: � � 5 C�a� ( i e C'arr R (work/cell): S 7- 6► 7 (c� �4 - 48oS _��cro � �JC 2757� 2)Name and address of current owner (if different than applicant): Name: Address: { %d0,� � c��i — 3) Property Description: Lot Size: �. �s Subdivision: Address and/or directions to Property: 27 S G/�j4�'LI.iC C.�� R� I S� W `�` �, l e 5 � - � (.��-- � iT�.� �s-�,� ,�d yy � ,^-- ,.-- 4) Proposed Use and Type of Structure: Residential �/ Business/Type: Other Number of bedrooms �_ / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No � Garbage disposal: Yes No 5) Water Supply: Private Well -..�(Proposed Existing � Community Well: Public Water System: Are there wells on the adjoining properties? No �� Yes ao�az Lot #: �a��0 ,�1 c 2 7 r 7`f .n ri9h'f'tM C�Ar��e �`r�� ST � �^^n�- `"` �� (please show location on site plan) Note: A comnleted application must also include: ➢ A plat/site plan of the properly that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the properry is ready to be evaluated. I am sub�itting thi� �pglicaticn tc request services froir. the Ders�� County He�lth Department. I ur,dersiand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvats shall become invatid. Signature (Owner/Legal Representative): Date : � "�`�( - � 1 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) Application Date: �� 3 r� �� S f�� Taz Map: A� 8 Amount Paid: �..,•�' � Parcel#: �O 0 Receipt #: , � � �� ]C�� .11 ]E-1C��.A;� � Improvement Permit (Site $200.00/$300.00 if> 600 Mobile Home Replacement or $150.00 (if site visit requir� ❑ Well Permit (New/Replacemer $300.00/$200.00/$75.00 for Services Services Re uested ❑ Construction Authorization ee is de endent on the e of system ermitted) Addition ❑ Permit Revision $75.00 � ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: �"�d�) 2 � �Z�-� S _ Address: �7 S C C.I L C /: �c� cR� � N� 2� s � y . 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Phone (home): �36 �� (' ^ �g (work/cell): 3 3 6 3ay ' 'Yf�S` Phone: Lot #: ❑ 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? I ❑ yes ❑ no Are there any easements or right ofways on this property? �PP�' . ��c,L(� q4� (if `yes' is checked, please provide supporting documentation) 'LG x ya' ✓ 4) Proposed Use and Type of Structure: ❑Residential � ❑ 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? O yes ❑ no With plumbing fixtures7 0 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 ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property7 ❑ 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): ❑ Conventiona! ❑ Accepted ❑ Innovative 0 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 bse e ly altered, or the intended use changes, allpermits and approvals shall be invalid. � 2 Z� � Signafure ner/ Lega Representative*) D te * Supportin 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) I•� I �� I � � (,) \ T�x Ma� � % P�rcel # � � � ��) � � � � Su�bdlivi�sion � . , \ � � , � � , � , � � � � � , � � � , Ph�se Sect�ion Lot # Permit Valid for Type of Facility: . # of Occupants �r Proposed Wastew Proposed Repair: Permit Conditions: Owner or Legal Authorized State # Improvement Permit No Expiration �kiS�rn ��.e New Addition Water Supply —G� ooms Projected Dail Flow g.p.d. ' Zs o Type: Type: Date: Date: —/7 // The issuance of this permit by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspecrions requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina Zaws and Rules for Sewa,�e Treatment and Ddsposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water suppiy will remain potable. Authorization to Construct Wastewater System (Required for Building Permit) * See site plan and additional attachments (_). ' l �� Proposed Wastewater System:�CCC�t� ��Z-r�n,,,� �'►arv,�� TYPe (�[ 1 Wastewater Flow 3C� b g.p.d. New Repair Expan ion Soil LTA'�:�� 3�_ g.p.d./ ft 2 Type of Facility: �� 5 i�i�� Basement _ Yes v' No Wastewater System Requirements EKi s� n� Tank Size: Septic Tank: (d0� gal Pump Tank: ' gal Grease Trap: — gal Drainfield: Total Area: ��D sq ft Total Length �_ ft Maacimum Trench Depth Z�1 in p,C� Trench Width .3 ft Minimum Soil Cover: � in Minimum Trench Separation: �_ ft Distribution: Distribution Box �Serial Distribution Pressure Manifold Authorized State Agent��u�� Date: / 7�/� Permit Exnirati6n Date: S't = l7 — The type of system permitted is Conventional Accepted Alternative. I accept the speciiications of the permit. Owner/Legal Representative: � - Date: Z� PCHD" rev. 11/ 10/OS ' �\�� J.�� JY. 11L1 �� \J .� t ^1 �9 '�" � � � 1�,��u-�,r,,,r,,.,,.�„�.��.11 � ]F-3I�.�,.11 �I'I'E ��'�I�I ; Name �JRSo �� ,�a r� r i� Ta,g Ma.p # Z� Patcel #�0 Subdivisi Secrion/Lot# — � - /7-�l uthorized Sta.te Agent Date System cdrnponents ne�iresent ia}�iproxisfaate�contours only. The contractor rraust, fZcsg tlae ,rystem pygor to begi�ning the installntion to ansure that prn�bergmde is y�intained — A'��n�ev, �in� �foses�f fo h��5�; �p' -�d� c��,-f'i�� u � �a��, � �P� r�� a�re � w1 ' �1 ea,, f, So i � �►� �c � � � — lip,� �A��, ``- �S' �o` a`� �in� �osf oI� I G�' �� cK CS�' �- SI�e. S�e¢�h ) � �5' —��' �C� �� Zy ��n�, 1a��-�m _. �� --r �� - I �1 � ,� 1 � _ s�,�, ExiS-hh�� ihr. �� w �. ' f � ►� �, � ��ck � ;hS j=c�I I � -�yor,�� 1 C i�i S� � J�vrn��wnrY� I3'�� '��° �u�� uN ✓a�ve � � � 7'� e� 1btJ Avt.1 �j q�'�' r �� d 6� � �'�oX U�, J 1��'Pd � �-�, a �l . ��. �lace� �.�15�r� , �� ?` )� �� IE�.�a-��.,,-„-„ ��.Il IF7Im�.II�I�a. Tax Map � Parcel # ,dd Subdivision Phase/Section/Lot # # of Bedrooms � �� Operation Permit i�. 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. � (Authorized Agent � _ � (Lice d Contractor/� � Q`L _ _ _, � �, �� ► P{�e ,-,�� ► Scale: �,_ �=z3-�! (Date) �—Z3 �/ (Date) � ., S'�� • . :/ Tax Map: � Parcel #: � Septic Tank System Checklist (Type II-I� System Type: _�IA - J -- Pump System Checklist Contracted Cert�ed Operator (Type IV +Systems): Notes: NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP e-mail Date: � j � �� . �: . ,�' � �� b 1 d� � � � � Ji li 1�:�.�-�.�<��.�;�.«�.�.�.11 �.��:.�.I1��. � �u�Il��Il�a� �da�a�n�aa�/ PVg��ce �� fl��n��an��n$� Tax Map #: �� Approval ReqLested for: Parcel#: ZOv Nlobile Home Replacement � Building Adriition Applicant Name: �.JRS I S Address: ` �6 �.-� N� 2��7y Phone #'s: �� —`,�D$� S�� (�1 �2 Permit Located: � Yes No Instaiiation Date: q'-11 �4 Design flow: J?�� (gpd) Current Contract with Ceriified Operator on file (if required): Water �upply: _� Well Public or Community Wastewater system shows no visual evidence of failure on: �- ��—��_ (date) (Applicant's signature if sits visit is not required) Comments: C � Y �Z ' �.� A��fl�ao� ' ��p1a��aa�� a°�� g- lg- I I Envir nmental Hea Specialist Date 11/15/OS a /) ��` !) �' 1 ' , .1� /1 � � �,� l \ � � �- � ��,., I I---I �-� ,:� I � I � Building Additions/ Mobile Home Reulacements T� Map #:� Parcel#:� Address: a2.7� C�-r�rli e�'r � � i�oKbo�-o _ t�1�� a27�� Approval Requested for: obile Home Replacement Building Addition Applicant Name: �l �o r.J �arr � S Address: 7 Cha�rl i e Car�r- I° oX�Q� N �- �Z�T�f Phone #'s: Permit Located: ✓ Yes Installation Date: No Design flow: 3(e0 (gpd) Current Contract with Certified Operator on file (if required): Water Supply: �Well Public or Community Wastewater system shows no visual evidence of failure on: 2- Z3—! (date) (Applicant's signature if site visit is not required) Comments: Addition/Replacement Approved � � Enviro ental Health Specialist 2-23 t� Date Persan County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcounty.net