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A28 31Applicallon Date: �d F� Amount Paid: vZ . DD Receipt #: 63 �J l:.J* 3 • _.-- Im (Site � , � s.� I��I��T ! � �' a� �� '' �/��.° .�'' c��TI��°� # l�uac -a-�,•,,,•••nrc�.�a4:.m.Jl 7L-3r¢iai,n -d,�1a. � �r5 Application for Services Services ReQuested 600_gpd) t or Building Addition $150.00 (if site visit required) Permit (l�iew/Replacement/Repair) $300.00/$200.00/$75.00 0 Construction Authorization (Fee is dependent on the type of ❑ Permit Revision $75.00 Tax Map: � a g Parcel#: � ❑ Repair of Existing Septic System Applicatioa: No Chazge/ CA $ I50.00 or $300.00 1) Applicant Infqrmation: � / Name: —. • S'. u h�r �n/ Address: S . �07 2) Name and address of current owner (if different than applicant): Name: � Address: 3) Property Description: Lot Size: � Su.b �}'visio : Address and/or directions to Pronertv: 7'� �� .2� r.i // �!/•C. Phone e): Ci/�%�p��% 35 5� (wor ce 1 • Phone: Lot #: �� ❑ y�s G�'no Does the site contain any juris�ctional wetlands? �/ 0 yes ❑ no Does the site contain any existing wastewater systems7 ❑ yes � Is any wastewater going to be generated on the site other than domestic sewage? ❑�s � B"no Is the site subject to approval by any other public agency? � 0"yes ❑ no Ate 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: O sidential //Z ,� ./> New Single Family Residence Maximum number of bedrooms: �� ❑ Expansion of Existing System If expansion: Cutrent number of bedrooms: � Repair to Malfunctioning System Wil) there be a basement? ❑ yes �no With plumbing fixtures? ❑ yes�no ❑Non-Residential Type of business: Total Square footage of Building: Maximum number of employees: Maximum number of seats: 5) Water Supply: ❑ New well �Existing Well ❑ Community Weil O Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on � is property? �yes O no � 6) I��lying 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 correcd. I also understand that if the information provided is inaccurate,�.o,r if�he � te�is subsequently alt�r the intended use changes, all permits and approvals shall be invalid. �nature (Owner/ Legal R�pfesec Supporting documentation required. �D-� � Date Permits are valid for either 60 months or are non-expiring when accompanied by au approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. 110/111 Pers�n (',�untv F,nvir�nmental Health. 325 S. Mor�an St.. Suite C. R�xhnrn NC: �757� �'�'i�_S4�_t �om M � . �'�� 3�0i �J�i . U 5�� c-�, I 12j �—��, ; ,�f �� .�� ?Ce �-Yn �- � ��.11 IE-� � �, ll �I� Applicant: �: 5 , �.'�.i.1Y�PZU� Address/Location: Hw� yg s. � Z ��o nQ.�.��..,,��c oe, � �a� � � Improvement Permit Permit Valid for: Five Years � Non-expirina Type of Facility: �A¢� ��„� New � Addition _ Number of: Bedrooms a/ Occupants4�''',X/ Employees / Seats: Proposed Wastewater System: - Proposed Repair: f�t,�.c,4�� w ��"�c ��►yc,-rio PermitConditions: �ovw� S� Y� p� �,o wi a��.�a� c�b'� ��- Authcrized State Agent: ��,�c�. A _ (X) Owner or Legal Representativ f Tax Map: �� Parcel: 3� Subdivision _ _ Phase/Section/Lot # •� V4'ater Supply: ��r� '^l'�v.. Projected Daily Flow: o1�}b gallons/day Type: 1 fL Type: 1ii6 1r��uc S� � S�i�` '�Si1�,tlx1(�C�� C.�cl�.. Date: -1 Date• •o / _ The issuan�e of this permit by the HealLh Department does not guarantee the issuance of other required permits. It is the responsibility of the applic�ndpr�perty owner to insure that all Person County Planning and Zoni.zg 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 aild Rules for SewaF� Treatment and Disnnsa! Svstems'(15A NCAC 18A .i9Ut)). Naither Person County nor the Environmental Health SpKcialist zv�rrants that �he septie sy�stem will c�ntinue to fanciioR satisfa�torily in the future, or that t�e water supply wi�l remair poia5le. Authorization to Construct Wast�water �ystem See site plan and additional attachments (_). � Proposed Wastewater System: (;oJ,��l-ha� (*)Type ��, Design Flow �'�O _ gal./day New � Repair _ Expansion _ Soi( LTfiR: O• � gal./day/ft2 Type of Facilit-�: �•j3�, �� '�� Bssement: _ Yes � No ('k) SystF� Typs IIIb, Illbg, IY, and V, require periodic system inspections by th_e Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank (o�� gal. Pump Tank '� gal. Grease Trap � gal. Urainfield: Total Area 91oo sq. ft. 'fotal Length 3�� _ ft. Max. Trench Depth �_ in. Trench Width 3 ft. iVIin.Soil Cover _� in. Min.Trench Separation � ft. Distri6ution: Distribution Box� / Seriai Distribution__ / Pressure Manifold Specifications: � �►� �'as�-yC� . Authoriz.,d State Agent: l'��ttS�►cal i� .�irN � Issue Date: Ie�-9- 1`� Permit Expiration Date: 10-9 -- Iq T'he system permitted is: Conventional i� /Ac pted ` rnati e / Innavative . I aecept the co�iditions and specifications of this permit. (X) Owner or Legal Represent,�hve: l Date: /l �d � �l � Person Counry Environmental Health, 32� S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) . 9, � �,`j' 5�� • I = �� ,� 5 � � D , � ��, �� .� �� -- cC � �T1�T'IC�Y � av asoanaaa�0�m�m�.� ��.��Ila SITE PLAN Name �� S- `�►�'►FNa Tax Map #� Pazcel #.�� Su division Secrion/Lot# ��C\< . S't,� IO- 9 -1 Authorized State Agent /; Date System compoaents represent appmxrmate c niours on� . The ntractarmust flag t6e sysrem pdor to beginning the insrallaaon ro insure rhatpmper�mdeismaintained.� � � / ��r```- \ � � � / � Qn � � ILG''i f�1Uro 5�s1�, � �� . � ��: � � � �� 4 � � s�S-�M - �yo 6�A �ac�,flc��l - 33�1 ►-a. i-Y, - O . �5 �.�R. - i g" t,,t�,c, -�,�r�c� h�.� �E O:1 1�t .a,Sz�v.. wtYEl� w�. ,-,� �` � -�E Ca,�.�cx 4t�'0 w� �a�srv�S 1.��15q�- ��►�ro . �. 4�e� � C-�'�-Z, oa`.`t � � � __ __ ��a�,ac� T c,� I ��-��° , � �� .s� ��.�� I��.�a��,�-,t-,� ��.71 IF��.IL�I� Operation Perrnit � �t System Type (From Table Va): Type V& VI Expiration Date: Tax Map Z-� Parcel # �_ Subdivision N%4 Phase/Section/Lot # 1� # of Bedrooms 2 Product (IIIg): EZ Type V& VI Renewal Date: �'�_ 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. � uthorized Agent) �� 'S� i n S� �(Licensed Contractor) Scale � PCHD, rev. 12/14/12 r / � U � �� ,�ti .�.b. 1�D�T � � 2 /- j�p (Date) �S�,a��ed (��l �z�� sr�Dbox Line Length I 20' v Total ?�JQ � Tax Map: � Parcel #: � Septic Tank System Checklist (Type II-I� System Type: 'I� — _ J Se tic Tank InitiaUDate Nitrification Lines InitiaUDate State ID & Date: S-�Z �_�- Trench Width: 3 ft. ►�SS - Z- - Trench De th: in. �/ Ca acity: 5- Total Length: Zc�p ft. Tee and filter Minimum spacing: ft. Baffle Rock de th/ uality N,c} Vent Dams/ste downs Riser Grade (< .25" in 10') Outlet boot Cover (6" minimum) Perm. Marker Setbacks Distribution From wells 5_ 2f-/ � D-box (levels set) 7'S -Z( - Pro erty lines Serial Foundations/basements Pressure Manifold SurfaceWater LPP Other: Notes: Pump System Checklist Pum Tank InitiaUDate State ID & Date: Ca a y: Riser (6 in.) NEMA 4X Bo Model: Piggy back lug Hard wired Alarm functioning Mounted on post Above grade (12") Conduit sealed Pressure Manifold Number of ta s: Size and sch: � Contracted Certified Operator (Type IV Systems): Notes: �d i a� lo �c� � :.., �Le �-wi"� il-J4-R� a - Improvements Permit (Established/Recorded Lot) I_ Reinspection of Existing System (Loan Closing) Permit (Unrecorded Lot) Permit (Mobile Home Replace) Permit (Addition) � O �..a ' Bacteria 1 it requested by: owne spective n� �ress�: / � / b� �P�i �a �vr a w � a � ome Phone #:_ usiness Phone #: _ Chemical � Repair/Replace existing Septic System Permit for New Well Replace Existing Well _ Petroleum � _ Pesticide � _ Lead �%9 qis�y-� . Dimensions or Proposed Structure: M� �idth: � � o� �'�.! r� S e. � �,v b 0.�-1� �voM � enth: i 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewa� disposal system is intended to serve? Na and addre s of curre t owner: 9. Water supply type: .� �, �J , � . �S �c . �n� • private ❑ public � community ❑ spring � j� ts-�„ � C ►� —/ �� C - Are any wells on adjoining property?Yes� No ❑ If so, identify location: : Lot size: Tax Map#: Parcel#: _ . Directions to property: State Road #& Road .� - .- . � .�'_ � .� � � �� . �a� ,� � .- • . �. • , � � �'�-e � .�,e , , � ...r neonle to be served: _ 10. Type of structure/facility: Proposed: �Existing: ❑ Type of dwelling: House: ❑ Mobile Home: ❑ Business: C��^� Type of business: �A-�m . 5�' Number of Employees: Number of bedrooms: � Garbage Disposal? Yes ❑ No f� Basement? Yes ❑ No�f so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PersOn COunty Health Depai'tment for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shal�become void and all fees paid forfeited. Owner or Aut�ed Agent Permit I�e�n� Permit Denied ❑ Plat Observed L�3� � � S ignature Date l�• � � � r fi r _ _ _ _ _ _ _ PACfORS-Sl'IE EVALlJAT1bN . ARPA 1 ' AREA 2: AREA 3 AREA a:: _ _ _ _ l. SCOPE (96) S ,.�J� S S S S O/ {% PS PS PS J�a U U U 2. SOII. 7'E?CTIJRE (1236 iN.) / ///�� S S S (SAKDY. LOAMY, CLAYEY. NOTE 2:1 CLAI� . PS `�� PS PS PS � U U U ;. SOQ. STRUCIURE (12-36 W.) S S S S (Q.AYEY SOILS) PS PS PS U U U 4. SOiL DEPITi (INJ S S S S S � Q PS PS PS U U U i, RESTRIC77VEHORIZONS(IN.) S S S (IINPERVIOUS STRATA. ROCK) PS �� PS PS PS U U U 6. SOiL DRAINAG&GROUNDWATER S S S S (EXTIItNAL & IN7ERNAL) S A r PS PS PS /U U U U 7. SOII. PERAIEABILI7'Y S S S S (PERCOLOATION RA7E) S 7/Y1�I PS PS PS � J/'1�'� u u o 8. AVAQ,ABLESPACE S O� S S � S PS PS PS U U U 9. STIECLASS(FICAT[ON(SEEBELOW) SOIL SERIES S-SUiTABLE PS-PRO�'ISIONALLY SUITABLE U•UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.) C:WNiPRO�DOCSIAPPSEC.SM FINANCE.PC f � � � � -- � V V � � � , PERSON COUNTY HEALTH DEPARTMENT _' �; • 1 WELL AND SEWAGE SITE, LOCATION �% OVEMENT PERMIT � � Tax Map # � � � Parcel # Zoning Township �fi!/P � i /� Owner/Contractor Date �,�L 9<� Location/Address /`�� n�,�...,d. �� ,..� ��.�—,�F�F S.R.# _lI�CI Subdivision N Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is altered te e se c nged. Well and Septic Layout by Comments: ell ` W Installed . _,. _ . C 3ividual �/ Semi-Pu �bl ic Re te Approved ell Hea proved _ Comments: Installed by, � .��V l `J' Approved by_ C�o� �/��/� � SYSTEM SPECIFICATIONS Required Slab t Air Vent Require Log _ � e 1 Tag Approved by, a�� This repoR is based in paii�on information provided t�ie homeowner or his/her representative in the application submitted for this pertnit i�i'e environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic tank system will continue ro function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permitsam O1/95 rev.1.0 Person County Health Department /� Environmentai Health Section Tax Map #: /'f � Parcel #: � Zoning: Township: �Q�� Subdivision: Section: Lot: Applicant• ,,r71�� /��i�� Location: � � t° � �, �j� �� U 1�4�1 v� � , ��% � �� ,�Gi C��I�G �2�N -� �-�� . Operat�on 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 AUTHORIZATION. . � L ?-�I-OD A horized State Agent Date Tax Map #: �' Z� Parcel #: ,"l� ,, „ �5'�/'/a-„ PCHD, rev. 10/12/99 Person County Health Department Environmental Health Section Zoning: Township: Subdivision• Section• Lot: Applicant: � t� Location• � �1 r �� y��Y �� . `� !� I��" � 9 er �ion Permit 1. LOCATION AND SEPARATION DISTANCES A) System meets .1950 setback requirements,��_ B) Distance from system to any wells �l QD � C) Distance from septic tank to foundation 2 2► ► D) Distance from system to property lines �10' 2. SEPTIC TANK ✓ A) Visually inspect the exterior walis and top of the tank B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent, bottom, and water tight outiet ,/ C) Date of tank manufacture "7-�i-(� D) Tank seriai number ' '� �2-- E) Liquid capacity of tank �Q,(�_ 9aflons 3. SUPPLY LiNE TO T ENCHES A) Grad � 1/8 inch per foot minimum B) Material sup i�r line ' constructed from �G C) Diameter D) Length ' � E) Distance from tank to drainfield/distribution device �_ 4. DISTRIBUTION DEVICE(S) A) Type � B) is Device water tight NI� C) Distance from the distribution device(s) to the trenches � D) Is the device on a leve{ foundation E) ❑oes the device pertorm according to its design specifications F) Record the inlet and outlet elevations 5. NITRIFICATION FIELD A) Trench depth �P inches B) Trench width ,�i�inches C) Distance between trenches Z� D) Number of trenches E} Length(s) of trenches F) Aggregate depth _ j� inches C � G) Aggregate material and size � H) Record septic tank o tlet elevation � I) Trench grade (< 1/4" per 1' . J) Step downs � a. Minimum of 2' of undisturbed earth b. Proper rise over step cy�wn �- c. Solid pipe used v d. Elevations of step downs (Record elevations and show on as built) � See "as bui � p an, attached sheet. 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"C[1[S Wl:t,1, 1�YAS COt��S'I'Itt1C� I'1-;l�) 11�1 Ac-'C:Oltl:)�1Ni:l; 1'Vl"I'I I ItI:c;IJI..A"i'IO1�15 SL•"1' I'OK'1'll 13Y'1'111: 1'l:l�`;Oi! ('c`�lJ�'1'}' t11;�11:('!1 l�l:l'��It'I'h-if:t�J�l'. �,��,�5� ,�i�;ii,i�iitu c,l� �'c,i�ir�ic:t�,r �.��y�`6U. (��i:: � // / / / •( � �� /Ny^V � / / �� ;: / � � : �� ` _.� : �-�� .. ;. �. ��,�,u,` _ ; > > � � . .� � r�.�� ` �.��' sr�� '�� > .��- �f►�� r_ .. , _ _ �..,� . . . , �� . . _ � � _ __ . f n�, �rK�� -r ,� � �, � � / �: a �� y, � �r�r?�,-n`� � � k .. "l 2�+,� y� x'Y#1�� `fi�� i J . l ?. - { �y� A /bl�f2�`S� '� �� r�►��6h� �/ ! '� � e:.�,,�� ""' ��- � � �,c,� �t � � � �3�.W�� L �' � � � vt, � �� " y�� t �� if� �;; % S F ; :.. ' r � t � �� . ��f:�� i �� x ' , � -�*�-� '��, � . _ �a� r�,hit�tGt�� -�`` '�?� _ =:� ;ns�-�lf�r ��tz� �%��` �� 3 �� ' ' � j _-� .n,.,�..;r,'-=: �'�� :� " s `, �� Y� :. _ ,- � �: i� � � a � � � . � ��. ,��