A28 62,
� Site �valuation Application
Fee Collected YES
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Date: � '023 - � S .
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APPLICATTOId FOR IMPROVF�iENTS PIItHIT
1. Permit requested by: owner/�rospective owner: �
agent:
Address: �.3 d� �1( L � /���x/ /7�/;
Home Phone ��: %�/ % 7� 35��1 Business Phone ��:
2. Name and address of current owner: ,//y��j :a�
3. Property Description: Lot size: .�� �� ��
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4. Tax map ��: � Z� Township: � � \ V � �V �\ � �
Subdivision Name: �QP.��� ,/�l7��/L� Lot ��:
S. Directions to property: State Road �� & Road Names, etc.
6. Permit requested fors New Installation: � Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
8. Dimensions of Proposed Structure: Width: �� Depth: J�i
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10. Water supply private? k public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? If so, identify location:
11,
Type of structure or facility: Proposed: Existing:
Type of dwelling: House: i< Mobile Home: Business: _
Type of business: Number of � loyees:
Number of bedrooms: � Garbage Disposal? Yes No
Basement? Yes Ir'o x If so, number of basement fixtures:
12. Clearly stake all corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system 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.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A-335(F)
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Si ed Own r or thorize� Agent
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Permit Issued �
Permit Deni`ed ��
Plat Observed �
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I�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARFA 3 AREA 4
S S S
1. SLOPE (�) PS ��p a7� US �S PS
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2. SGIi. TEXTURE (i2-36 in.)
(Sandy, Ioamy; clayey,
Note 2:1 clay)
�3. SOIL STRUCTIJRE (12-36 in.
(Glayey soils)
4 . SOIL DEPTFi (in. )
5. RESTRICTIVE HORIZONS (in.)
(Iu�ervious Strata, rock)
. SOIL DRAIIIAGE/GROUNDWATER
(bcternal & Internal)
. SOIL P�RMEABILITY
(Percolation Rate)
g. OTHER (speci£y)
PS '' (` �
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Ps 7 3���
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Ps 7�1fl
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9. SITE CLASSZFICATION �
(See below) �
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOt�4fENDAT IONS / COMMII�TS :
S:�_TE CLASSIFICATZON DTAGRAH (Include: Soil areas, property lines, roads, streams, gulZies,
Wet areas. fill �reas, crells, c�ater bodies, sZope patterns, ete.)
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PERSON COUNTY HEALTH DEP A ��� 5
' . . . � ARTMENT .
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT pERNIIT � `
Tax Map # � Paxcel #
Zoning Township �'v� i !/
Owner/Contractor r r; i �� „-�, ; �; R � Date_ _�-r` _ � � _ ��
Location/Address I� �'sr �_ ��l- C1.. � _i �. _ . �,., .
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Subdivision Name
Lot#
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Pernuf Void after 60 months.
Permits may be voided if site i
Well and Septic Layout by
Comments:
Date
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�-ermit v oia it not in compliance with zoning regulations.
s alte,�r irhtenc�ed us� changed. ,
lnstalled by �;
.
Approved by
SYSTEM SPECIFICATIONS
�' � � Individual � Semi-Public
� �,� Public Replacement
�' � � G� a Site Approved_
� �C�� Well Head Approved
�r ' Grouting Approved �
Comments:
i / ii /` � r�. � � n
Date - � Installed by
Required Slab l�-
Air Vent _ ��
Required Well Lo� //
Well Tag 1/
c� Approved
This repoR is based in part on information provided the homeowner or his/her representative in the applicati no submitted for ihis /
envirorimental health specialist is not responsible for false or misleading information contained in the applicatioa The environmen�tal healU► specialist
is also not responsible for concealed conditions on the property or for statements in tivs report that may have resulted &om false or misleading
s[atements provided to him in the application. Neither Person Courrty nor the envuonmental health specialis[ wazrants that the septic tan:c system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�ami o
pr �permit.sam O1/95 rev.1.0
ORIGINAL
Applicadon Date: �'� %.�a/� ��� f� ������ Tax Map: ��
Amount Paid: 0 .� U �,.; ►• � � � ��,�� Parcel#c � �
Receipt #: l�f o2 I a
l�uawaa-��*�*c�3a.�Yei.lL 1«a��,.11 •d�.
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 d)
obile Home Replacement or Building Addition
$ I50.00 (if site visit required)
❑ Well Permit (NewJReplacement/Repair)
$300.00/$200.00/$75.00 _ ___
ilication for Services
Services Re uested
❑ Construction Authorization
(Fee is de endent on the ty e of
� Permit Revision
C�1
1) Applicant Inform tion: '/
Name: a�tih Lc�LJTdr`
Address: 7 � a c c; � �2
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2) Name aad address of current owner (if different than applicant):
Name: S a� C�Z�ci t,Ja� t�:
Address: iZ ; aa
o � �
of Existing Septic
fication: No Charee
Phone (home): 33�",�a `f � ? �3�%'
(worklcel l): 3 3 G•- �'o y� ? 5��
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Phone: 3� 6��D y- fl `� �f S
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3) Property Description: Lot Size: �%• �t Subdivision: f o�'�w r�3r<� c+� Lot #: I
Address and/or directions to Property: N� 15 � w c5T
❑ yes no Does the site contain any jurisdictional wetlands?
C�1"yes ❑ no Does the site contain any existing wastewater systems?
❑ yes L�no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes Q�no Is the site subject to approvat by any other public agency?
❑ yes �no Ate there any easements or right of ways on this property?
(if `yes' is checked, please provide supportuig documentation)
4) Proposed Use and Type of Structure:
OResidential �
❑ New Single Family Residence Maximum number of bedrooms:
RiExpansion of Existing System [f expansion: Current number of be ooms: �
� Repair to Malfunctioning System Will there be a basement? ❑ yes �no With plumbing fixtures? ❑ yes ❑ no
ONon-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well �Existing WeU ❑ Community Weli ❑ Public Water ❑ Spring �
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes �7 no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
� Conventional ❑ Accepted ❑ Innovative ❑ Altemative � Other ❑ Any
I cert� that the infor ation rovided above is complete and correct. l also understand that if the information provided is
inaccuraj�, of if the �e is �sequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Legal Representative*)
�` Supporting docamentation required.
���vl6,��1y
DatT—
Permits are valid for eit6er 60 moaths or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
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Applicant: NA��1R�1 �►�'�a1
Address/Location: Hw�t 15$ w -'�
Improvement Permit
Permit Valid for: Five Years X Non-expiring
Type of Facility: � i�.O�ql�. 4�iy New Addition i�
Number of: Bedrooms / Occupants $�i' Employees / Seats:
Proposed Wastewater System: C,ora����ti.
Proposed Repair: �avE��iE�,
Tax Map: �8 Parcel: �
Subdivision ��A�Z QRwac�►
Phase/Section/Lot #
Water Supply: QR�►v�'rc W�r,v... �fx�s�►�bl
Projected Daily Ftow:� gallons/day
Type: �_
Type: 1T �
Permit Conditions: M'�*km�� 5'ct� 'L1�sa�� •'U�vr� M�., �'a�5�. w� Aw��
�oc� 5�ls�t� AcR��•
Authorized State Agent: 'qE4.R1UL j�c. Sntr� Date: '7 �3► y
(X) Owner or Legal Representative: Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicant/property 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 Improvement 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
nnrl Rules for Sewage Treatment and Disposal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply wili
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: �E�,,� (*)Type �_ Design Flow y� gaL/day
New Repair _ Expansion _ Soil LTAR: 0.34 gal./day/ftz
Type of Facility: 3�'o y(�.CR�M �.QRt,S���, Basement: _ Yes � No
(*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person County Health Depa�tment.
Wastewater System Requirements
Tank Size: Septic Tank �USra� gal.
Drainfield: Total Area 4'45 sq. ft.
Trench Width 3� ft.
Distribution: Distribution Box
Specifications: • �144 135�
Pump Tank —"
Total Length ��
gal.
ft.
Min.Soil Cover � in.
Grease Trap "'—' gal.
Max. Trench Depth 2L _ in.
Min.Trench Separation g ft.
/ Serial Distribution� / Pressure Manifold
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�1ao' P ��E -t �� � �c:,��r.Moa+Pc�
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Authorized State Agent: UF�cJ�. l�c. 5MCr1�, Issue Date: 7 v1 ly
Permit Expiration Date:
The system permitted is: Conventional �/Accepted / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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SITE PLAN
Name ��w'��N Tax Map #' S Parcel #�
Subdivisio �A� Section/L t#
'iJr.R�UI . 7 a.�t
.4uthorized S�►te Agent ate
System components reprueat appraadmate cantouts oaly. The contracmrmustf/ag the systempcor to begianing theinsta!l�tion to
insure thstpmpergrade is maintained.
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WELL LOG ,•
� � � , C.,�R,�? c�?�t�.raC-�. C,� ��T��, .
Date:_��L�.S � � :
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C.�wner: _ L � ��Q�'t � � SR# .
L,ocation%Directions: _
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Q,.h.��vio��i�n T�Tmm�• . • a..v� rr
I�rilling �ontractor: 11 � �•
WELT. CONSTRUCTION
: I�1ist�ncc fr�m Ncarest Properry Linc Distancc froin Sourcc of
Pollution :"
'I`otal Depth: Fc. Yield: 2 GPM Static Water Level . Ft.
V✓atcr Bea.ring "Lones: Depth F F� F�, �t.
Casing: I�epth:. From Q to Ft. I�iameter: / Inches
TYPE: $teel � Galvaruzed�Stee1 ✓ �
If Stcel, does owner approve: Yes No
Weight: Thickness: • Height Above Ground: Inches
I�rive Shoe: Yes No .
Were Problems Encountcrcd in Setting the Casing? Yes No
If "y�s" aivc : c�son:
Grout: Type: Neat Sand/Cement ✓ Concrete
Annular Space Width � Inches
Water in Annular Space: Yes No
Mezhod: Pumped Fressure Foure3 ✓ .
�e�th: From � to Ft. � �
IYlaterials Used: No. Bags Portland Cement Weight of .1 bag______lbs.
If mixture (sand, gravel, cuttings) - Ratio: to
�D Plates: Yes ✓ No � �
4 x 4 slab Ycs ✓ No
z HEREB� CERTIFY THAT THE ABOVE 1NFORMATION IS CORRECT AND THAT
'�HIS WF.�,L WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
�ORTH ���THE'PERSON COUNTY HEALTH DEPARTMENT.
. ��� � , :� 16 31 Q 5.
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Signatt�re of Contra --%� Datc
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