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A29 127
ad ,. Pm�rnt paid o�.-���a Receiat l� ' 6� ''j ( . , . — . � ���� � � O � � w v � a W ¢ z ?ers;,r� �ourny hvait� C�r� � p � � 325 5. �iofc�an Stre�i �, s�oxcoro, N.C. 2�5?.� � ��' ,�� � I U— I�— 9 9 �� q�trier'�?2 �3-15 � 7 1 l D a t e Improvements Permit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing) Impxovements Permit (Unrecorded Lot) Repair/Replace existing Septic System improvements Permit (Mobile Home Replace) _ Permit for New Well Improvements Permit (Addition) _ Replace Existing Well Y 4 ! 'A ry �L. � W. M \ 9i T � � '. f � \�. . � �. a � �.. 'L Nw � Y.o°i Lsb _ �' S K E � � .vEY . _ 'FSS'w. 7 �. � �ti ,s �� � 4 n . �� S ��`i^iiF.. 3 E s .`r 4 yx �_ "S l ,.; . g �Y cc.d`,T 7� �+.4..'i s r,t x ��+ �x �. � v� f ..� � ;� a= ''°� >" �� �x.�:<,�>..<�. <�y�z,�,:���;wWaterSample to�,be�Collected < �.��=:>Yw.��<.�.�.�t ��..,�: ,�d.�: �.� x_.<<.�.<, ...,�.�._: >�..�.�:..,... _ . ^..� , Bacteria �� Chemical ! , Petroleum Pesticide _ Lead 1. Permit requested by: . 7. Dimensions or Proposed Structure: owner/prospective ownedagent:. .��me� F���� ' ' Wrdth: .�� � _ Address: P c> i3aX � �� � y Depth: 30 � v r N: e- a: � s. What type'(if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? Home Phone #: y �I - 8(o c� 8 �� usiness Phone #: �l�! � ��6 � 2. Name and address of current ownec: t-9. Water supply type: �- private � public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No Q. ' If so, identify location: n I<now n - 3. Property Description: Lot size: . Tax Map#: A. -.a q 10. Type of structure/facility: Proposed: �Existing: Q Parcel#: 1 a� Type of dwelljng: Townshlp: OL �.v�. .{ 1�.1 �_ House: ��Mobile Home: C� Business: ❑ 5. Directions to property: State Road #& Road Tyge of business: ames,�tc. Number of Employees: G � �� � .� n Number of bedrooms: .__�___ Garbage Disposal? Yes, _❑,,, �o � � Basemenf? Yes ❑ Nol.ad'if so, # of basement fixtures: lc. � 6. Number of occupants or people to be served: ..-.�nn nt'? A T T CLEARLY STAKE ALL CORI�IERS OF THr: YKUYI�K�1�Y ��,.,.tvli tnr. �.vxu��.j� �y- �----- PROPOSED STRUCTURES. I hereby make application to the PeI'SOn COunty Health Department for a site evaluation for the on-site sewage disposal system for the above deseribed 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 sha11 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 deIivered a survey plat of the property to the Health Dept. within 60 DAYS after the date oE the evaluation of [he site by the Health Dept., this application shall become void and all fees paid forfei[ed. � Signcc� Owner or Authorized Agent - -,----r_„ __ . PLEASE SEE ATTACHED PLAN FOR SC?IL AREA AND SYSTEM LAYOUT Tax Map #: rT' 2�% Parcel # �Z? Zoning Township OL%�/E ���L Applicant: ���ES %��� LocaUon: S/� �16� Subdivision: /��E��� � ����5ection: Lot: � Improver�ent Permit A buiidinq permit cannot be issued with onlv an improvement Permit New t�Repair _ Addition _ Type of Structurek6Us�Water Supply��U�� �" # of OccupantsbM�X # of Bedrooms -3 Other . Basement? � Basement Fixtures? � Projected Daily Flow: c�� g.p.d. Permit Valid For: �Five Years ❑ No Expiration Proposed Wastewater System Type: [��vE�O"�'��- � G� Pump Required? Yes (/�Vo Permit Conditions: ���%� OJV GONTI>/�lR �i�X//�'1G!/yl T�?�7U�H /� �!°Tf/ 2-0 ��- S�� S/TL� SKC—TCN /� Owner or Legal Representative Signature. Date: �� Z� Authorized State Agent: Date: �� �� The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This site is subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. nT Type of Wastewater System`�IUCi, Facility Type: �u s r Basement? 0 Yes o Wastewater Flow: � g.p.d. New � Repair DExpansion ❑ Basement Fixtures? 0 Yes C�� Wastewater Svstem Requirements Septic Tank Size:� gallons Pump Tank Size: N� gallons Total Trench Length: �0 feet Maximum Trench Depth: � inches Aggregate Depth:�Z in. M�Diimum Soil Cover: �' inches Trench Separation: ( Feet on Center Other: ���� aN �N��iR • Permit Expiration Date: �� l� "'t Authorized State Agent: Y�> Date: �� The type of system pe mitted q�,does Q�es ot differ from the type specified on the application. 1 accept the specifications of this permit. q „„ Owner/Legal Representative Signatu � ��`'�f' _ Date: ��— �Z �"!� PCHD, rev/ 10/12l99 t�\��` ' ��S.Q1�. �� V � ' '`r��iLl�� ^ • � V i�� �" �.iCai�aa�am,r,,,r,�.@� .�mIl. ��m�.-+r.:Ca. � �i S �. .T�1 �.�• • . I� �any �� I�� Tao �#�a� P�� � la � , S n o St � �([ c- 2i d c � .� Se�tion/Lot# 1� ' �-30-03 � Aut�orize� Sta-t�� Ageut - . � Date . • .5'�rst�s�t raarrs�one�t �ses� � �r�rt�ssrs �r. �''qae �r �st,�ag �3�e yst�s�eoa- �. begivas�ng �ae a��n � ssrsasa� ��i��ergsE�de �r srs�ed : � ' ��T��` Tni�iul Systcr►, ' � (,�i �l bc, in Ori �,I �nat Soi IS . �'� - 0.rc� •Pcrr�r�t� by !►�ikc N� - . ZR9.t�� r! _ I b0� Scal� I E}ddi {�on�l (CcPtcri A-r� �c.a£cd bY T �/�ac, �o ac-c�oM�da fc. 1'►'tov�'nq hoksc. 1"t.t�,rwuld d =�`-� .. . � n I � -��.1✓--�--- � � �, ��u;t �oa . Q� KnnD•,�,���L p`v� � -.-- z �o' � , I o 2a. � �%0�.�'/ ,� . PK �'�=c. � �Zo , � a,�� Q �( ��1 . �`cF h`��'�` �►�o�+n� o M n �l Fr9 W���' ' . r 0 � 0 ���3, re� fl9 J�I41 ���.�� �'��.��1� -- � � ��-���- ����� � ���.� ���.�.�� ����� ���E SEE A'�'�'AC�i) P�l.l�T ��It WE�L SIT� L��OiJ'I' '�ax �iap #: I' �i �'arc.t�1 # %'� � 'I'o�Q � �� �. �r%. �/: 511�7t�1ViS10E1: 1.t9C�11�1I: '�y�e of Wat�r ����vv: �es��ffi�m�. � s � • • Site Approved bp Grouting Appsoved bp s H- 1 Z-�i -� �e11Log ✓SH 12- � 03 �ell T C5" � �;r v�t � aa -o� Hose Bib Conc7ete Slab I/ � wen ��: ����►.s S�1'dOII: �AL' / 1 • �� ff � � F � � (�'�'� C.fSI`'��'�C'(,O � �j V'G�''�( c�.xQQ , —�� � Evr�,� r� : c�Q �a rr-e�vz �l ,�.u. � . wtsLO • ' • . r�i .,-. � •� . - ��� - �: ., ,. : , , - ,. ,� . _ -� / -- - , - . - . a �� -- Wells must be 10 feet from propertp liaes. Wells must be 100 feet from septic systems. � Wells must be at least 25 feet from any biuZding founda�ion• Other conditions: - — � � �� rv�.�. 4- �en�`'�'� `'(j �,i � P�` � c��'r� PCf-ID, rev. 09/07/01 ' ��� S � 1� � � `- .� �.� `��.��� `_' ' - �`�.�— t� cCj ZU ��C �C' "�i,_ �.u�n�r�in-�ca st�.�i7�:n.�v- u.u, �L..:�w lt. �.��.�•c.:fw1� �l':i1:n. � wncr: .,ocation: >ubdivision: i.J,. �.t.J .� �}��%._ -.�' �,. _.::�P�� W�+�IUt�U �Vl1 r� C ��lc /' �'.l'tic ! 0' � ' ' DGi�O(iC'�.�°) J � - �! - o `'s i� (;�. �0 b ���:L1 i��l:lj) �� l�:ll'CC� ir �� �Y�� l�'!c!1 Coustx'ucciou )istar.cc Froin ncarc�i 1'rupc:rty Linc {Nfiniii���:n lt; �te;c;t} �`� ____.__.._.... )isiancc 6roni Scplic Systc:ul (Ivliiiiinum GO icct) � 'otal Dcptt�: � Ct Yiclu: „�¢__, GPM Sl'alic W:itcr L�vcl: �L,Z.__... [t Yater Dcarinb Zonc:�: Dcpciz �� I�t l�t _:'t _ f�t ::�sizzb: � cp ch: Prom ____��.` 'ype: Galvatiizcd Stce;! to ��,� il. llianictcr: (2�� iri V — L Wcight: �� ":'hiekness: � I-iei�;l�t al�ovc Grou�lcl: _._/ >�-- i!1 ►rivc Stioc:: � Yes No �\jly pi•ob[cm� c►zc�u►�lcrcci wl�ilc: 5c:liil��; c;isiu;;'? __ Y�� '�No ."`j�CS" biVC CCaS0i1: __. ---•------ �rout: Neac: S:u1dlCemci�t ✓� Cos�crcic Gravc:l/Cctncnt �'�tu�ular Sp�c� Widt!i `�_ II�CI)l:S V��:IICI' li2 .M11U�1i• Space: Ycs '—" No Mctliod of Grout: Pumpcd Pressure; '� 1'ourcd � Dc:pth �• ta rt. �atcrisIs Y1scd: No. f3a,r,s Portla.cid ccnic:n[ Wc:i�;iic ui' 1 L':i;; _�_____ f'uuiul; It mixtlu�e (sai�cl, ��ravcl� Cl1IC1IlE;J� ��Z:lIIU �� �O i ID platcs: �Yc� No �E x 1F �lab �.'c:s w-- No .Urilliiid l.ob l,c�c:itio�i lli':�wiit�; 'nereby certify that cllc abovc iitXon�.�atiotl i� conecc ai�d tiiat ttiis wcl? w�s e:vnsc�uc�cd :n uccordancc with rc�ulations ct fotth Uy thc Pcrsou Coun�y 1•l�alcli Dc:l�artm�nc. �:.r.,.,+,,,-� nF t''nnfr�rtnr �� �� �L� _ ��) i� �i�t.a�__ 1�:ttC � ,� ) 4�0\� . ,. ,,,,. � �� � ���� �� �ti* a�� �,r � � ���� 7���.s-�-,� ,�,�,. ��.�.]1. IE IL��,71�. Applicat�. ��X fv1��,� `.�;, P���r�c�el r . S'lFh C��i :' Ir5�1:011 • • Ph:�,se �Sec�t�i.aii �Lat = . . �-��ration: P�rr-�it . � • . System Type (fn Accordance With Table Va): �Gz � ' THIS SYSTEM 9-1�►S BEEN INSTALLED IN COMPL.i�►NCE VNITH APPLIC�►�i..E NORTIi '. � CAROLlPIA GEPIEF�AL STATU'�ES,. RULES .�Ol� SEWAGE ��T�t�AA�'AAENT A►iVD� �DISP�S�►!., AND A►i.L COIVDITiOidS � OF THE INIPROVEMENT � PERIIflIT .�►1VD CONS�RUCTiON 1�U'4HORIZ�TION... . . . . . - . . � _ .. .. . . . .. . . . . . .� .. . . . _.....�. ..��a�.-c��( ' ` � .. � � � Autho ' d State enfi • � .� � - � : � : �Date � - � .. re.iy'" ..�s�es�� . � _ � . : � . .. . . . ' . . . . � � . . . . . � � -----M`s�ajfe�!-gya ;.,.-r.-�,, ��.;.; 5 Date: a� a3=�y � . � . � • • . ,� � , . � . . _. • � -. �.. •. .. � . �. . ' _ . �IiY' '' '. .. : :. .. .. S// � 11S � • ' ' � ��- �n� : . i '.�,�i � . .' ._. . . _ _ . _ :... .. __-::_: . : ' •: .... ... —.� � . . .. � � . . . ��� � ' '• ' •— • . . . . . 115 ' S// . � s i I. . I. I 5. , s,�� . 1 a'$' • s'�► 12? s�� 5��� �,� � � ��y' . 5,, ' S'�1 s�, ' - � _S'/� 5 � �• 11^�S-o3 `� 1� - I�oO s-r�3-►�ta - � rC�iD, rev. G7/29/02 S�3�9C� T�AIK d�I����ON C�iE�9C1.1�'� �7'�pe li - IV� . Ta: MaQ #'�� Parce� # 1�7 System Type (Tabie Va) ��z OwmeflApQlicant �-.QS �►� Subdivision `��1t� �¢ AddresslLocafion � Ser,lPhase L�t # ►� St�te IDldate g�1�la � 1 � Capaciiy.��-� � . gal. Tee and Fi�er Baffle Sealarrt Riser (if applicable�__ Tank Ou�et: Seai Permanerit Marker � � : Pta�tp Tank tate e � Capacity . gai. Wateroroof /Sealarrt � Riser . � Water Tight .. Pu�np � �heck Vatve/Gate Vaive . � � -siphon o e � .• �ioatsl�witches � � � � � � � . A(arm fvisable and audibiel �� i9Pm) Approved Pump Model � Blodc Under Pump Pump Removaf RopelChain �Disiribution System Seriai Distribution '� ressure an' o Low Pressure Pipe • Appr. Pipe Materiai and Grads Vaives �� � Tr�nch Wid�h ft, c �-a= �� Trenct�. De th tn. �-�. Tnench.Length ' fii.. Trench Grade Trench S acing Rodc De th and Qualiiy � DamslSte downs etc. � � � Pressure Laterals � Hole Spacing . � o. e. ize .. . . . � _ . . Pipe Sieeve . � � - � � � � � Tum-u sfProtectors • � � � ��qupred Se�aac�s - � From 1Nells •. � � � �3 � From Property lines � � . : .Structures/Basemer�ts.:: � �.� . � � rt es - raina � e ays � - . . . _ : . �SurFace` Watets . . . _ . . . _ . . .. Pubiic Waier Su lies Verticai Cuis �>Z f�. . � Watef Lines ✓� Vehide Traffic i Easeme�s/Right of 11U� �he� Easemer�fs Recorded . I . Corni�eoa�s' 0 pcf�d rev. 311 ?J01 0 JAN-06-2011 03:31PM FRO�- Am.ount Paid: I-13 - � � Receipt#: 3 � �# q �-3 T-755 P.003/004 F-209 Parcel #: ���, S� ���� �� � -� ����i��' 7G �s�a�r n a- �m aa, �s-xxa•titi 3ra. ti:.zn. IL IE�t .ce .�o- ll �aka Application for Serviees (Septic Systems and Wetls) Scrvices Yle uested Impravement Permit (Site Evaluation) ❑ Consi�uction Authorization $200.00/$300.00 (if> 600 d (�ee is de endenc on the e of s stem ermined) � Mobile Home Raplacement or Building Addition ❑ Pcrmit Revision $150.00 (if site visit re uired $75.00 L7 Well Permit (New/ReplacementlRepair) ❑ Repair of Existing Septic System $300.00/�200,00/$75_00 Application; No Charge/ CA $ I 50.00 qr $300.00 1) serv;ces Requested by: ,A M y� uc% y Name: �15' S(�l,Y► �00 �S Phone #(home): �I'1� - g51-q70b - DC Z3 7 Address: 5� I-h � (work/cell): G 2)Name and address of current owner (if different than app)t�ant): Name: B�Ca.rjl -� K.j Address: I�u c�x�,�na.,�n l� . '�.6�bcNt� � tJC, a,-15-1�4 3) PropeMy Des¢ription: Lot Size: Subdivision: Address and/or direetions to property_ �-jq �—� ��, {-}p� a) Proposed i)se 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 Suppi : Private WeII � (Proposed Existing � Communiry VVetl: Publie Water System: Are there welfs on ihe adjoining properties? No Yes (please show location on site plan) Nnte: A corrrnleted applicatian must also inctude: ➢ A plat/site plan vf the property thut shows properfy dimensions atzd ihe size arad location of all proposed structures. ➢ A signed copy of the `Lot PrepaYat�on' forin ver[fytflg that the prvperty �s ready to be evaluated. I am submitting this application to request services from the Person County Healtt� Department. I understand that if the information provided is incorrect or if the site is subsequentl� altered, or if the intended �1se changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representative): _�� Date : 1 I � —� 10/08 Person County Lnvironmental Health, 325 S. N�or�an St., Suire C, Roxboro, NC 27573 (336-597-1 i90) �. �-- � � � ���. , ��, , . � ,j ; , , �� � � � ���� �:�.�v-�i.�{cD:�.m.rn.��s.B.x�.�.�. l��.�a..,�c�.�n. � �ann���a�� �de�a�no�a�l Pvlt���flce �t��ae fl��������n+e�n�� Tax Map #: A Zq Approval Requested for: Parcel#:�, 2� �,C 1Vlobile Home Replacement �1 Building Addition (Si,�Jirn rv► (� Po a l) � Applicant Name: i n Address: � � � Z� Phone #'s: � 1q - 551- 9 �o� Permit Located: 'V Yes No Installation Date: 2.� Z3'� Design flow: `j (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: ��/� �/� (date) (Applicant's signaiure if sit� visit is not required) ��fl�o ���a����a��� ��5������ -, � /$"�/ Envi onmental Health Specialist Date 11/15/OS . ���,� / �11L(� �l.�J \J ��� . t ��_' � � � ��� 1����• �,r„ ,r,,.,, ��¢�.11 If-3[�.�.11� � Si'I'E S�TC�-i Name � �u�� � �, i�,� � Ta.g Map #� Pa:tcel #/ Z% Subdi 'on � �� �� ' Section/Lot# / 7 �, � � � � � j_���_fj Autho�ized Sta.te Agent Date System componeri�ts nepresent approximcste �contours only. The contractor must, flag the system�rior to beginning the installation to ansure thutprolbergrade as maintained ���I c, i���-�cz 1 i� ���� ��� n� ��' / i � � �-Y �r,� �%l< .�,r..�.._�,. ...� ,,�: �.�,..� .._.,._<,� �A �.�,.. �, T ,. ,�.�. ��..,.�__._ _�.— _m _ _... _ - -- - ����'��� � �� "�� � M� �. ' ; .. , � �' �h ,! i','�5'> :'�i _ 3, <�f `3��..Y ?r��"�n� 7� �° �/;: f , ��� ``�� \ ���� E� . , ���:S::rr..� . . 4 , t � \� M 1� �� ��. f�' �'•��/ r�5� . . ���My� � � �. �� . �� Y'NI 6`�5 � d : x� ; ` �� �� �e ��, , � s �F � �`'"y y, ,. � k�,. :: � ,y�, ; , q . � .3 � `�•���i�'�: . /. ; . _ � X�, �.� - „ ,. . �/y ; �� � // �. / N� � C� �. � / i; i ^' M i/ � � ��� � � x� ...� �j�i� <, / � / �' / � � � ���� `�` � � � � k`�r%" ,, ;, � � �„ � �''`+- �'""'�,.;,� d`� � .:,.,.,�:� ,�. K> . �,;:� � ��,� ��'` _ . � W�.�, i , '•. .. #_::' f; I�n, �f . �.:'. . .