A28 86Application Date:
Amount Paid:
Receipt #:
�-9-I�
__� / /�'
0 Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
� Mobi!e Home Replacem�nt or B�ilding Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
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1C�!:�rnv-a�u-�cn,•T,•n,� �ta=n.�d.s..fl 7r���o.�.11d��,
tion for Services
Services
❑ Construction Authorization
(Fee is dependent on the type of
❑ Perr.�it Revision
Tax Map: �� �
Parcel#: ��
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C� � O� �1l/�
pair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
/1) Applicant Inforg� tion: ,
Name: /� �' S
Address: � /,�,�D IG lZ c
f?ox �o �" a h/� . 2 7 5'7 3
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): ��r-��%��
(work/cell): �'9�'- �33 �
Phone:
3) Property D�scrip�ion: Lot Size: L� Subdivision: Lot .#:
Address and/or directions to Property:
❑yes �'no Does the site contain any jurisdictional wetlands?
[P(yes ❑ �o 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 f�7'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 Malfi,�nc:ioning S�stem Will there be a basement? 0 y�s � r.o ��J:.h p:um�ing fixhares? ❑ yes rJ no
❑Aion-Residentiai
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well �1 Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes �no
� 6) If applying for `Authorization to Construct', please indicate preferred system iype(s):
^I� Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or ifthe site is subsequentiv altered, or the intended use chanQes, all permits and anprovals shall be invalid.
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Signature (C�wner/ Legal Representative*)
�` Supporting documentation required.
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)
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Applicant: U0� Notr� �
Location: „ , , _ __
T�x M�p r � P�xcel # % -
Subd!ivision
Ph�se- Sect�ion Lot #
Improvement Permit
Permit Valid for Five Years No Expiration
Type of Facility: r i in IQes�P hGe _ New _ Addition _ Water Supply la i l' I I
# of Occupants max (n # of Bedrooms �_ Projected Daily Flow _� lo b g.p.d.
Proposed Wastewater System: Type:
Proposed Repair: r Gt�P S�% Type:
Permit Conditions:
Owner or Legal Representative
Authorized State Agent: �
Date:
Date: - � 2
The issuar.ce of this �ermit by the Healt�'� Depzrtment in does not guarantee the issuance of other permits. It is �he responsibility of the
applicant/property 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 SewaQe 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 System: CC ZS uC ) Type Wastewater Flow ��g.p.d.
New Re a'r Ex an ion Soil L� , g.p.d./ ft 2
P ✓ P
Type of Facility: r, v p41 �n c.e Basement Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: LX 15-i�►�al Pump Tank: ---gal Grease Trap: �` - gal
Drainfield: Total Area: � DD sq ft Total Length �OD ft Maximum Trench Depth � in
p.G,
Trench Width � ft Minimum Soil Cover: (Q in Minimum Trench Separation: _� ft
Distribution: �istribution Box
Authorized State A�
Permit
Serial Distribution
.
� ` n
Date: �1-i0-
Pressure Manifold
Date: - Q- Z
The type of system permitted is Conventional Accepted Alternative. I accept the speciiications of the
permit. (��'r/ " ,
�wner/Legal Representative: Date: %2 �02-
CHD rev. 11/10/OS
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SITE S�TCH
Nam.e �bb .%V orris Tag Map # Z� � Pa�cel # g�
Subdivisi _ � Section/Lot#
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� . Autho�ized Sta.te Agent . � Date .
System cdmponents r+epresent a�iproximate�eontours only: The contrac�tor must, flag the system prior to ;
-- �-- begin�ing the i�rstallation to i�sure that propergmde is maintairled
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Tax Map.� Parcel # �
Subdivision
Phase/Section/Lot #
# of Bedrooms -3
Applicant: I�ab Nar�iS _
Location:
1�1� P�ja ��� (�1,
� � Operation Permit
System Type (From Table Va): Product (IIIg): �✓� �
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.
- � � �. -
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(Au orized Agent)
l i� �6(Ow�nn
(Licensed Contractor)
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Scale:
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y-Ig-12
(Date)
�{- IX-12
(Date)
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�` �1ew
I h �rt�
Line Length
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Total 230'
Tax Map: � Parcel #: $_ (Q
Septic Tank System Checklist (Type II-I� System Type:�
Notes• F%(��x `�' bu(( rrdh �/a���
Pump System Checklist
Contracted Certified.Operator (Type IV +Systems): �
Notes• �
NOTIFIED BLTILDING INSPECTIONS: Copy of OP e-mail Date:
(Revised 12/09 BH)
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c�' � . _ �'he� Distrrct�- Health Department �
+ Ql� � `��� "'�""^"CASWELL - CHATHAM.:- LEE - PERSON COUNTIES , '
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� M�'�" VV�ater Su1�1� I� and Sewa[� e Disnosal ►,
�'� ����'�� "' IMPROV.ENIENTS,-;PERMITallo r �
= Date _� – !n =' �'�" �
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�����`� Writer Supplp <Picivate:<v-• " .��''� �Public � `
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Seviiage Disposal Facilities:, No: bedrooms �— Dishwasher� .Dispo�al.. �
._......_: ...:....;, . ....._ ...:--._.. .. : ._ .. . . . � .
� washing machine, othei sutomatic ,appliances ' �
Size o.f tank: - F`� Nifiification line:= ��'� jX =� �
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- .„ . .
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� Other disposal .facihty :: • • '
. _ .. _ +. . . ; . i
Wa�ter_.supply.aiid:sewag'e.disposal:.facilities�location,.installation'.and .
protection. must meet state'and local regulations.. �
Sept'ic tank-should be-pumpednut•every.3•to-5.years:and.shall.�.be main-. �'
tained by owner in such a manner as not to create a public health hazardr .
. Septic tank__and nitrification:,line.;'MUST=BE.'INSPECTED AND_:AP- •
PRCIVED BY A MEMBER OFrTHE DISTRiCT;HEALTii DEPARTMENT' ��;
STA�'F BEF�RF ANY. PORTION':;OF THE' TNSTALLATION IS_�CO�-
ERF,D AN]3 PUT INTO: USE. . ... . __._ _. . .
Date approved:_ � � Signe � _
. • .: Sanrtari - -
We11:
O
Sewage Disposa�: - f .Counter �� . �'
� By, signecL_� � :
_.. " � (Owner or his rep esentative)
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}; �,e„
-� Certifica2e of Cumpletion 1 �• . . _
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Date Approved: � � By: � " •
� anitarian
(OVER)
Location of well and sewage disposal faci:ities sketched on back.