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A28 50The District Health Deportment CASWELL - CHATHA�iI - LEE'- PERSON COUNTIES Y � Water Supply and Sewage Disposal IMPROVEMENTS PE IT � Date • � � ' �� x Owner: ^ � �,s � pq . Location: � I �� r � p, Contractor:n � � � /- , �- Water Supplp: ivate -fC_ blic � . Sewage Disposal Facililies: No. bedrooms � Dishwasher. Disposal, washin chin other auto tic appliances r�� / Size of tank: d � �� Nitrification line: �`r 0 1' 3 ' Other � disposal facility: ' z�'+�►�= �� 7� 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 an3 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- PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. Date anproved:�� Well: � Sew e Disposal• � By: r � Signed .��-1�D►'}�I %3' ht•f��' Sanitarian �*� Counter- (Owner or his representative) Ceriificate of CompleYion < Date Approved: 7 (3_ (� S n tarian (OVER) Location of well and sewage disposal facilities sketched on back. 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 Application Date: ��l3�1� Amount Paid: /I�G _ Receipt#: ��?,��! �� anvn�-acaga*r++�++.cyaa�,en.� �F'��+ m.Il d�ia Tax Map: 2 S Parcel #: 5D � Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) 0 Construction Authorization $200.00/$300.00 if> 600 d Fee is de endent on the ty e of s: ❑ Mobile Home Re lacement or Buildin Addition ❑ Permit Revision $150.00 (if site visit re uired) $75.00 0 Well Permit (New/Replacement/Repair) Repair of Existing Septic System $300.00/$200.00/$75.00 No Chazee �(1) Services equested by: Name: � onliv � � {� h � ( �; Phone # (home): syy— � y 7 % Address: gZ I CS ( A� I c� c k D�9i �� c�, (�/cell): S � 3-- a S[� � � ok I� o�- o IVC• �7 S'7 �- 2) Name and address of current owner (if different than applicant): ��r�—+ N c� i N Name: `�%� Address: ��"�� Ivr� �J�eA'�ib s� � 3) Property Description: Lot Size: 2� � Ac. Subdivision: Address and/or directions to Property: 4) Proposed Use and Type of Structure: Residential ✓ Business/Type: Other Number of bedrooms �_ / Number of people served (seats/employees): Basement: Yes 1� No (with plumbing: Yes No V) Garbage disposal: Yes No _l� �Jk(CI e. — 5) Water Supply:/ Private Well r/ (Proposed Existing _� Community Well: Public Water System: Are there wells on the adjoining properties? No _S� Yes Lot #: Ci,�v�-!� CeU� �34' ,50'-�''-� �5� CwoYK) 591 �33 l (please show location on site plan) Note: A completed apnlication must also include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): , Date : 3 /(, 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� S.f� ��$.�� . , ,_,� � � �� IE��u�«D��«: ��.�.Il IE�3C �.�.11�1� T�x M�� ; P�rcel # � Subd'ivision Ph�s�e Sect�ion Lot # Improvement Permit Permit Valid for Five Years No Expiration Type of Facility: New Addition _ Water Supply # of Occupants # of Bedrooms Projected Daily Flow g.p.d. _— ---�..� Proposed Wastewate/rI System: Type: : ProposedRepair: �t �'.�„�r.�� ntan�d /� �FZ-�(oc� or C/�rn�� Type: 11 Permit Conditions: Owner or Legal Representative Signature: Date: Authorized State Agent: Date: The issuance of this pernut by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the applicandproperty owner to in sure 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 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 'Laws and Rules for Sewa�e Treatment and Disposal 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 supply will remain potable. Authorization to Construct Wastewater System (Required for Building Permit) * See site plan and additional attachments (_�. 1 / � Proposed Wastewater Sy,stem: �r�en�� , f/ �urnCl FZ-F/cw or��ait�r YPe � � Wastewater Flow 31�0 g.p.d. New Repair �/ Expansio�k _ Soil LTAR. � Z25 g.p.dJ ft 2 Type of Facility: rri� ,s� v►�CP, Basement _ es _ No Wastewater System Requirements ��s-H� Tank Size: Septic Tank: cv� -�al P�mp Tank:' 000^gal Grease Trap: �gal Drainfield: Total Area: '��_ sq ft Total Length 'l.� DD ft Maximum Trench Depth �� in Trench Width 3 ft Minimum Soil Cover: �_ in Minimum Trench Separation: q ft Distribution: Distribution Box Specifications: Serial Distribution �Pressure Manifold Authorized State Agent: Permit Exp: `7—Z1-1a The type of system permitted is Conventional �/ Accepted�I��Alternative. I accept the specifications of the permit. � --7 Owner/Legal Representative: Date: G — ��- � � PCHD rev. 11/10/OS .�� S, f� ��.� �� . , (� � �� ' �n-wna^ccDnn.n�xncc;�n.��n.� �"""�¢:�a�.11��n Applicant: Location: Permit Valid for _ Five Years Type of Facility: Improvement Permit _ No Expiration New Addition _ Water Supply Projected Daily Flow g.p.d. — Type: -�- a rv� �, er _ _ Type: T�x M�� 1 : P�rcei # � Subci'ivi�sion Pha�se Sect�ion Lot # � # of Occupants # of Bedrooms Proposed Wastewater Sy tem: Proposed Repair: Cc Z Permit Conditions: Owner or Legal Representative Signature: Authorized State Agent: llate: Date: The issuance of this pernut by the Health Department in does not guarantee the issuance of other pernvts. It is the responsibility of the applicandproperty owner to in sure 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 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 `Laws and Rules for Sewa�e Treatment and Disposal 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 supply will remain potable. Authorization to Construct Wastewater System (Required for Building Permit) * See site plan and additional attachments (_). Proposed Wastewater S tem: e.n�e� (� Z-�%oW o r C/ia w,1 er) Type� Wastewater Flow 3� 0 g.p.d. New Repair�Expansio _� Soil LT _ g.p.d./ ft 2 Type of Facility: ��; ��e �:e.s��e�ce, Basement _ Yes _ No Wastewater System Requirements L �v sfi Tank Size: Septic Tank: 1 �DD�aI Pump Tank: gal Grease Trap: J gal Drainfield: Total Area: 3�� Y�sq ft Total Length �� - I So ft Maximum Trench Depth �_ in a,c� Trench Width � ft Minimum Soil Cover: �_ in Minimum Trench Separation: �_ ft Distribution: Distribution Box �Serial Distribution Specifications: Pressure Manifold Authorized State Agent: � Permit Expiration Date: %—Z��/d The type of system permitted is Conventional v Accepted Alternative. I accept the specifcations of the permit. /� _ Owner/Legal Representative: � l' --� Date: �% � Z7 —�� PCHD rev. 11/10/OS i �� . �� y �--' . �-ti �C � ��'1C9�Y �r'-•lCb'a�]t'��rn�rn-n�Ba71�1II.1L �iL.�LL� Si'TE ��"I'C�3 Name � �� ti�� . I' �� n 5 Ta� Map # U� � Pa�cel #�� Subdi � ion - Sectian/Lot# -��— � -� � 7 ; I - �� Autho�ized State Agent Date System cdmponents represent approximate�contours only. The contractor »aust, fdag the syste»a prior tn beginning the installatcion to insure thatpmpergsrtde is maintaaned d,, -I-� c r� �--- -� I� e s�� p r-h o,� Z — �--- — f�,�e ,�,� I�t — I��S�"a�� u�� {"A�� OO�q� S{�rk�fee i��i'Shauk( gu�� un �a�v� � ,, � ; . a�o�e dr, �e �� , �. — pu� fi� S� 1 ne� excee�� '� a� _ Ru�. sGl� �0 2 al� �. ex�sf� � I � puwt ��^^-�C��l S�oul� l� worKed o� _ 5� �' �i�w c�ra�rr�iel� �'�� — �� C�� W � I � -b A; = ��c�ei � � � %IG�ocK �ai��f 1<<� , � �x�� 1�,�� C�i� — I u ` ! � ,'�,, � _ � �� _ � � � . �� _ i � � 'R� # _ �� ' � .,.� � �, �`"��5 �� w .' � - � � � .� ,� :.� � � '�� .wT � - � M; ; �r � � �� ..: ' "i.. s' *'s _ � ,._`.�*. s . ''�. z � � �:_ � ��.. ��: u � � � . � . � �� . ir' g ' . . ' '� ''�. ,. . . � ,. ' _ p�, , a g mt;: _ � S � F: � . .� � . . ,,y� ,� , - 1:=�' i�' ` � _ `�-.. '�•� _ ��'` "' ' y � � �- _ �'ty y�a, � �, r � �;§ ��Il ��. � •`" _ "'x : �" .N �y Yr �j � - - �� r i �"� �� . - �' +c ��'. iy �r � �� '� ;r ,��, � �1:.. �'�� g 'Cm �.: �� - � �}��r.� �~�� ;$i. � :mv,__'�^"aa...�a!' _�, ' � ��. � � �� ..- '� �t` : � SCjjL� ,. ; ` �� ,� — � � ,� (� � � a� : �. � '� � � � •. �:.�� " _ _ �� —, � x � � A � ^M i 'C #' = � i 1 y`�.-�'^�.a,� �,�� .. - ' - `� r � :,� _�- � � � .� � � , ,� � �� >� x. � �s�= _ F � t� � '� �� Ja��- _ -. � �` * � �` � � t'' I � � : ��;:, � �� ,• S� j �.. y _ , ;�. � � �� `� , `�'�' �'�- ' ,.�„� `� � �� ; �� h �r� � ,, �e , �,�'' ; � W �� , z � � �:� �n�,,"�.-'�� a Y� � . h ��. � k... � �� y� �".. � � ��`{ � � �� . _. # �' � _ .rL R j(_'.'� _ . . �Gs �� ;.�`'�, G �3 �y �� k R. 'f� V 'iy ` ( PR- Uj � �C�. ��, �-�� ,.,� :'�r�. + �� - '� ,�1�Y1� � I k �.;; ' ,t—$, �� . ' / , 5�[ 'i„9 � -�', 4. •� . � @" � � , . - " � 5, � "E y{� ,� ,> � lrrt:'.s -� ' . f "�r,`�� " i ¢ , f � �tr�- .v_ �, � �. ' . . _ E`' � -3� _ � L : " _. ,�.� �4p�- �o�,� _ � � � I �, � ��``�: �� FiLALOGK D,41R i � � �; : �. � � �.� < � '�, ' � .�.� �'v:; *t - `` � � �� Y Y _ , � n �. 4 __.�^`—^-,=+, ,_;_'�:� �� «a�. �~� , , � � ?`� �.::. ��.ss ��..�� IE��aa-��,•-„-„ ��.Il I�3L��.Il-�11� Applicant: Location: Ilr � , Operation Permit Tax Map � Parcel # S-U Subdivision Phase/Section/Lot # # of Bedrooms 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. ( thorized Agent) ( censed trac or) !1`'' ' ,�a� r� 0 � 4� �� a � Sca1e: o�' � �Q, �'30'/D (Date) �-30 -�v (Date) � 1 ti�� b� W,°� �°' �� O � � ��2 � � � R�� y �!� ' � (�` �i � ��`�,` t,' g _, i �� . -� � . i� Tax Map: � Parcel #: � Septic Tank System Checklist (Type II-I� System Type: � Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes• NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP e-mail Date: