A29 129�ersor� Courrty haaitn C��:;:
` Amount paid oC�O�o� �;JS.�viofg2nStre�t
�, R e c e i p t �� ',� 6 Roxboro, N.Cr. 2�5? iw � i) '��' 9 q
• � �QllflEt'��?2-?�-is ,� D a t e
� CJY�.�-b��' ( APPT.TC'ATInNF(�R SFRVICES
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Improvements Permit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closin
Imp.Fovements Permit (Unrecorded Lot) RepaidReplace existing Septic System
lmprovements Permit (Mobile Home Replace) _ Pecmit for New Well
Improvements Permit (Addition) _ Replace Existing Well
�, a. w .t � i. � h ..� �;. � �- � n p . s,. [ s k t - n ✓ � L &a,�,..,-.v ,C ss ...;`•, a K �` : o „� y"��
y� ar �'�' �eK f >".s k ii f s� R t ! t.: » lb�.u,2' i t .k. e� X�t n+, �. t,� �^£�.
l� 3Sk � � '� � �i SaC =W C -. .i �s}E. i dz .�_..fl� YkWater.Sample to be Colleciec� $ d,y^�. { K �� �� „r-
fw.. f,...e:�....f <...�:>:...:r.»�.....s:...a.,<. �.. ....°'+,.wr;. <s z .,�...�..W.._.,.re..<c -.... .:,...-..�.�-„�....,.,w............,, . ... 'x. >v'..�.'� .,�.� *.`. .r3..' sv;e,r s..;w..,..a�.;�As•zh
_ Bacteria _ Chemical _ Petroleum _ Pesticide _ Lead
1: Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospectiveowner/agent: .�Me� ��1��, " ` Wrdth: �� � —
Address: P c> .�o� � �(� 1`1 Depth: 30 �
,
v r N:. c_ a- ' g. '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 �l ' S(� �� �
usiness Phone #: �I � I–�� � 8
2: Name and addre�s of current owner: r 9. Water supply type:�
-{- private � public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No j�.
' If so, identify location: ) n I<now n –
3. Property Description: Lot size:
. Tax Map#: A. -.a 9 10. Type of structure/facility: Proposed: �Existing: Q
Parcel#: 1 a�( Type of dwell�ng:
Townshlp: OL �.v�. 1��.i, House: Cl Mobile Home: C� Business: ❑
5. Directions to propercy: State Road #& Road Type of business:
ames,�tc. Number of Employees:
G � �� _ ..� n Number of bedrooms: �_
Garbage Disposal? Yes, �❑� o [�
� Basement? Yes ❑ Nolad'If so, # of basement fixtures:
le. �
6. Number of occupants or people to be served:
i r T
CLEARLY STAKE ALL CORNERS OF THE PROPEKTY Al�lll '1CtiL: I:VKi��.t� vr ni..1
PROPOSED STRUCTURES.
I hereby make application to the Pet'Son COUIIty Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the con[ents 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 [o 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 shall become void and all fees paid forfeited.
t ,'
.
Signcc� Owner or Authorized Agent
�
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: f? � z9 Parcel # l2 -/
Zoning Township �G�L� ���
Applicant: V�i'�/�S /���
Location: sK //62
Subdivision: ��'f�VI�E �`f���Section: Lot: �_
Improver�nent Permit
A buildinq permit cannot be issued with oniv an Improvement Permit
New �Repair_ Addition _ Type of Structure��Water Supply�ZlV�'I� W�L�—
# of Occupants 6%� # of Bedrooms � Other •
Basement? �Q Basement Fixtures? �
Projected Daily Flow: �'+� g.p.d. Permit Valid For: Five Years ❑ No Expiration
Proposed Wastewater Sys m Type: / G!/%�� / ONl�CNI �0/�%f L �'��
Pump Required? es No
Permit Conditions: �1�14�-1- oIJ GaN�R �fi-xlVUIuM i��NGM DEPrI�I 2L" ,
Owner or Lega! Representative
Authorized State
�e sl�ls'�i�► v�s/�
T'/on! �2FP/9-iJ?
Date:
Date: // �19
The issuance of thi permit by the Health eD partment 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. Thls 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.
Authorization To Const�uct Wastewater Svsiem (Required for Buildinq Permit)
Type of Wastewater System � 1I 0{� Wastewater Flow: v� g.p.d.
—b
Faciliry Type: {"�D(�-S� New L4�epair OExpansion ❑
Basement? O Yes o Basement Fixtures? O Yes �o
Wastewater Svstem Reauirements
Septic Tank Size: 1� gallons Pump Tank Size: �� �O gallons
Total Trench Length: y8� feet Maximum Trench Depth: ZZ inches Aggregate Depth:iz in.
M�mum Soil Cover: �7 inches Trench Separation: � Feet on Center
Other:I��LI. Dh� ��p�ITDU�. Z.SrO� �� uCT7o/J ��/�j�.' _
Permit Expiration Date: �� �� � �
Authorized State Agent: �Date: �� �
The type of system permitted f�does does not differ from the type specified on the application. I accept
the specifications of this permit.
< <�"'Z"��
Owner/Legal Representative Signature� Date:
PCHD, rev110/12/99
x
.
Application #: �DBs�
Tax Map #: � �29
Parcel #: / Z9
Person County Health Department
Environmental Health Section
SITE SKETCH
JA�MEs f�i� �Pos�vir� �e�o�� �r i�
Applicant's Name Subdivision/Section/Lot#
' � �- ,�s �� �
Aut ori e tate Agent Date
System components represerrt approximate contours only. T/ie contractor nzustflag tlie systent
to be�inning the installation to insure tliat proper grade is maintatner�
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�,, �80- o, /
�,� " . . �
:�' V�� Ll. �� 2v'xzyo' _
� �o�
$b� I bo'm��, �1w�1 jRr�KS•
,y
Fiflini�. 3t.8jo�s � � z",�'�Y `q.�`F
� '��'` � 'r' 307.5`/
3z`�,n� ���fa �_ � .
��n � // �"' f v /T,f•
Scale: � �/ - ��� /
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/
PCHD, rev. 10/12/99
AQplication Date: I'� � ��
Amount Paid: 6
Recaipt #:
• �
������� ���.� ��
— --_ c� � �7"1�'IL� �Y
�sa�aa-amaa,--�--�• ��.��.71 7F-�Lm.�.I1.�7��
APPLICATiON FOR SERVIC�S
i'ax 9Aaa #•�1- —2 /
Parcai �t: � � /
IF THE IIVFORMATIOIV IN THE APPLlCATION FOR APl IMPROVEMEiVT PEFtMIT IS INCORRECT FALSIFAED
CiiANGED OR THE SITE IS ALTERED TFiEN TFiE 1MPROVEWiEA1T PE�flflIT �ND AUZHORIZAA�IOfV TO
COfVSTRUCT SHALL BECOME INVALID. �
1) Permit requested by: (Owner/agent/prospective owner): Jarn� s�����
Home Phone: a ZZ Address:
Business Phone: 2 7�72
2) . Nlame and address of current owner: J'
O S
Z
3) Property Description: Lot size: Township: Subdivision:
Directions to the property (Includi�g road,,�ames_and n}�mbgrs): �, D��.;�
Lot #�
4) �roposed Use and Structure Description: answer e ch of the foliowing questions:
a) Proposed ✓, Existing , Type of Structure: �� uSP Width: 3 � Depth: ��
b) Number of Bedrooms: �_ Number of occupants or peopie to be served:
c) Basement Yes . No � Will there be plumbing in the basement?
d) 6arbage Disposal: Yes . No �
5) VNater Supply Type: Private �(new ✓ or existing�, Pu lic� Community� , Spring _
Are any wells on adjoining property? Yes_ No �If yes, please indicate approximate location on the
"�, �site plan.
6) Does your property contain previousf}/ identified jurisdictional wetlands? Yes_ Wo �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE �ROPEtZTY OR S1TE P.LAPI MUST BIE SUBMITTEfl WITH THIS APPLICATIOM.
➢ PROPERTY L1NES AfVD CORNERS MUST BE CLEARLY NIARKED.
9 THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAaCED OR FLAGGED.
9 T}iE SIT� MUST BE i2EADILY ACCESSIBLE FOR AN E1/ALUATIOIV B`l THE HEALTH DEPARTME�IT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposal
system for the above-described property. I agree that the contents of this appiication are true and represent the maximum
facilities to be plac�d on the property. I understand ifi the siie is altered or the intended use changes, the permii shall
become invaiid. , �
Owner or Legal Representative
1 2q ��
ate
PCND, rev. 06127l02
���i 7�.i� ������
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1���-aa-���. ����.Il. g-3I��.Il�I�
•
T��x M�� � P�,rc�l #
► � � �
S�uibdivi�s�ion � � � �
Ph��s�e Section'Lot # �
' �� .� I � �
� . •� ,
rG�L'�-.�'� ' ' �;r ' �,��ni�l►�L1�_/���'�' � . �,. .
Permit Valid for
Type of Facility: _
# of Occupants�
Proposed Wastew
Proposed Repair:
� Five Y
�.#of
ystem:
Improve�ent Permit
No Ezpiration
New � Addition Water Supply ��f
s Projected Daily Flow _��� g.p.d. �
L<7�4w�2 '1'ype� A'
Y4:il'Q Type: �C�
Permit Conditions: �� �jly;� �Q � "
Owner or Legal Represe
Authorized State Agent:
Date: ' J� ��
Date:
The issuance of this peimit by the Health Department in does not guarantee the issuance of other petmits. It is the 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 Sewage Treatmeni and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
5pecialist warrants that the septic tank system. will continue to function satisfactorily in the future or that the water supply will remain
potable.
Authorization to Const�uet Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_).
Proposed Wastewater System: �;til�l�Qvi �7,t�ts�, � �%f�lU'Q' Typ�� Wastewater Flow �� g.p.d.
New � Repair Expansion Soil LTAR: •�� g.p.d./ ft 2
Type of Facility: ��, Basement Yes i� No
Wastewater System Requirements
Tank Size: Septic Tank: �0 � gal Pu�p Tank: gal Grease Trap: gal
Drainfield: Total Area: �(9a .sq ft Total Length � ft Mazimum Trench I)epth �_ in
Trench Width ?� ft Minimum Soi1 Cover: _� in Minimum Trench Separation: (� ft�` �
Distribution: `�'� Distribution Box Serial Distribution Pressure Manifold
Specifications• � �� � ����
Authorized State Agent: ll����
Permit Exp' on Date:
Date: 'JJ��s
The type of system permitted is � Gonventional Innovative Alternative. I accept the specifications of
the pernut. , I/�.
�wner/I.,egal Representative: � '%� �i��'�� Date: %— 5= O�
PCHD 1/17/2003
__. :�..:.;.:s:
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7E��a-��m,�,�,.����.lL IEyI��.Il�11�
SITE SK�TCH �
�Cj�'►�11%S ����`�� Tax Ma #_� Parcel #_/.c �
Name _ _ . _ P
Sub '� ion o,sg� �� Section/Lot# �
Nl v�l'�/ —a
Authorized State Agent Date
System components represent approximate �contours only. The contractor must, flag the system prior to
beginning the installation to insure that propergrade is maintained
�� � ���� ��
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I��:��.a-��.,.-,��, ����:]L IF3L��.7L�.I�a;. .
WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �
Applicant: _
Subdivision:
Location:
Parcel # _ /,� Township:
Type of Water Supply: � Individual _ Community
Requirements:
Site Approved By: �
Grouting Approved Byt
Well Log: � �
Pump Tag:
Well Tag:
Air Vent: /�
k
�l
�
Lot #
Public
Liner:
Installed by:
Depth set: _
Grouted:
Date:
Hose Bib: � Water Sample:
Casing Height:
Concrete Slab:
Well Driller: N �rn �/�(�� � _
Well Approved by: Date:
****See Attached Site Sketch****
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
�-�l�e-s��
PCHD rev O1/27/04
..--`�'`r: �. s�.� .��.�.� ��� � � � ��.�
. .^ (� T �y�
�..�.v-�y �"� � �'�..J �''�' � �:�°�^'w�l' � �l_�� �,'1 c •.......�.,? t.!!
�a�a�..as,ra.�..s.Il �'�L�.ea.Il��a � (�pp� �
'' ---4 S
��,: � Well Lo�
'�c� , �� �-�.11
i,r�carion: �,� f �G� �. _ „-�--- Tax 1V�ap .� Parcel #� I �
Sub�3i�i�iur.; ,� -���-c' `3 -r�'�...�'_ _`
�� � � � ��i.�_' _ Lot # r
W�!! C�n�trnction
Uistance From ne�t Property Line (IvYuiimum 10 feet) �% ?'
bist�nac fro� �op��c System (Miztianum b�! fcet) .���
TotaI d)efpth: �� p} Yicld: �� GpM Static Wate�x LeveI: _��� g
Wat�r Htarin� �anes: De�st� /y �' � �} �
----�- ft __ R
C��aif�t�. //,� `]
Gep�b: Fr�i �m �..�____._ � ...L�� ft. Biameter• � % �
Typ�: Galv�ed St++�eei • ---�..
"WeiBht. � 'Thickness: Height above Gmund j�_ �
brive Shoe: Yes No A,ny proi�lems� aru�uniercd w�ils �ettia�g c:a�ing? Yes No
If `�ye�►' �v� re�son: „� ____
Grout:
:v��at: Saad/Cemeut Cuncrete GravcUCemcat
An,nulur �p�uce Widtlz inches Water ia t�unular Space .r.
'Vl�th�od of Grout: Pwape� .___.! Presgure Poured Dtpth
'.tiintea�aals Uscds -
No. Bags� Port3and ceme�t Weight of 1 Hag �� Pouads
If mixtvre {saad., gtavel, cunings} — Ratia �___ to
ID plat�s: � Yq � No 4:� 4 slab Ycs No
Fro�
'1Co
Iiril9�at� Gng
Yes _ Tr'o
to fi�
Loc�t[ota Drawlag
�� s.�; �. �
f�'�
1��eby cerci�y th�t t.�e above infarmu�ian ia carreci a2sd that this w�cll was constrircted in accorciarice writh regulations
�ct forth by ri7c Person Cou�ty H th Deparrtrncnt. �
�I�s�ture �f ('ontr�act6�_�/�Ci-�' -� �/ i "f � YD # .�l7� D�te �,` _G ✓ � �
PCHD rev 01/16:0«
���s i , �� ���� ��
��.e �� � � ����
��a��i.�-��.s���.��.�. g��.�n.��7�n.
Applicani
Location:
�x Map � � P�rcef # '
Subciivision ;. � ; .
Ph�se Section:'Lot # �
# of Bed�rooms
�, ,
�1 ;� � � �� � � � ''.
�: _ `
System Type (In Accordance With Table Va): �
THIS SYSTEIVI HAS BEEN IfVSTALLED liV COIVIPLIANCE WITH APPLICABLE NORTH
GAROLINA GEidER,4L STATUTES, RULES FOR SEWAGE TREATNlENT AND DISPOSAL,
AldD ALL CONDITIONS OF THE IIUiPROVEMENT PER[VIIT AfVD CONSTRL7CTION
AUTHOR TION. �
. ' . � � -
Authorized State Agent Date
�
/29/04
�
<.,;,
� :..`,,•, ; �. . � ' �E�3'1C °1'AN&� 1Pl�P��`���P� ��E��(L9�i (Type 16 � I {�
Tax'Map #�Z� Parce! # Z Sysitem Type abie Va)
Owner/Applicant ,JQ� j� Subdivision osevi /
Address/Location Sec/Phase L #
Septic T�nEr ' ..' , . net'a91�a�� ' • • iira �cat ora anes � � . . , � e�itaa �te
State�ID/date -.32 � -�- S� - rench Width �� 3 ft. �% 7' 9�7
Ca aci S- a. � T'rench De th ' in.
Tee and Filter � T'rench Lenath ��.�ft.
Baff1e
Sealant .
Riser (ifi applicable)
Tank Outlet Seal
Permanent Marker
Puma 'iank
�,�
Waterproof /Sealant
Riser
Water Tiqht
Putrr�p
Check Valve/Gate Valve
Alarm
Electr
� Rate I
A ra
Blocfc
and audib
�onents
Under Pu
Removal
. ��Distr�but�on.5ystem
Serial Distribution
ressure ani o
Low Pressure Pipe
Appr. Pipe Materiai and Grade
Valves
�
Trench Grade � �
Trench Spacing
Rock Depth and Quali
DamslStepdowns etc.
Pressure Laterals
Hole Saacin4 �
Pipe. Sieeve . � �
Turn-u s/P.rotectors
Requir�d� Setbacics ,
From Welis ' � ' ` ` ' '
From Propertv lines /
Surface Waters
Public Water Supplies
Vertical Cuts (>2 ft.)
Water Lines
Vehicle �Traffic �
Cora�aments
�/Right of V�
Other
� Recorded
pcf�d rev. 3/13/0�1