A29 1300�
Amount paid ���.
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�ers,^,r� CouRty t,�sit� C�;::
3�z� S. ivtorg�n Stre�t
Roxboro, N.C. 2�5T.�
�: �t�rier �?2.?3-15 �°
I(1-1�-99
Date
Improvements Permit.(Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot) Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Weli
Improvements Permit (Addition) _ Replace Existing Well
y� y�� ,�, i t�t �3.e,�.�� „y „�FE r S i.,Ma.� 4ti,,, r'r. -. �,s>� ;f'� t�. �_�, ^.r� Q'� �r",z,X r t�s�i�r�.d� sK<z t,rr�,���.. ,�y'��._.S.�,j�:
tE.,,,�, : X r, .... ��-�x �t� �,�� ��x ,.,<, ��n��Water Sample to be Collectec� ���-�.w x.=.�K:�.,.�'�.��-..<5:, .< � : ,�,....�.�,:.e�.><-
E.s�..f°.av....�� h.wK: Na':C, eAt..E....3i.P.>., e. w- .[ �.w� ' �S '0.2 . ��.J. .nw.r.�4..uHr.....
. . . . .. -.I.. _ .. . . . v.f .
_ Bacteria _ Chemical _ Petroleum _ Pesticide _ Lead
l. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospective owner/agent: .�Me,� N��� ' Wrdth: �� � —
Address: i� c> . (�o �l � I (� 1 �I Depth: .3� � ,
��' ' c= a= ' 8. '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 - 81� � 8 ��
usiness Phone #: �I � ! - �3�6 8
2. Name and address of current ownec: + 9. Water sugply t}•pe:
.}- private � public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�_
' If so, identify location: ) n I<now n -
3. Property Description: Lot size:
. Tax Map#: A. -.a q 10. Type of structure/facility: Proposed: ClExisting: Q
Parcel#: 1�3 D Type of dwell4ng:
Townsh�p: OL �.�� .�i �.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 [�
� Basement? Yes ❑ Nolad'If so, # of basement fixtures:
1 e. �
6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'Sor1 COunty Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the concents 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 to the Health Dept. I understand that in the event I have not
deIivered a survey pla[ of the property to the Health Dept. within 60 DAYS after the date oE the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfei[ed.
Signce� Owner or Authorized Agent
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: fT�2 / Parcei # ���
Zoning
Applicant: ���5 ���
Locatlon: �R !�� Z
Subdlvision: /'� �FV��E ��d�� SecUon:
Township ��✓�� �/�
Lot: _ ��
Improverr�ent Permit
A buildinq permit cannot be issued with onlv an Improvement Permit
New ✓Repair _ Addition _ Type of Structur�S�Water Supply p/�IV/}�E(A/ELL
# of Occupants 6�� # of Bedrooms 3 Other .
Basement? � Basement Fixtures? /l��
Projected Daily Flow: � g.p.d. Permit Valid For: [[�Five Years ❑ No Expiration
Proposed Wastewater System Type: (°h�C'`J1'%ra4l ��—� J
Pump Required? Yes ✓No
Permit Conditions: //i5%f�GL O/✓ �-�N10U�2 !!�i'4�Xi/yI u/"� T%1L7V�'fl ,l� �!3� Z�l �
SFG ,.S! � Z / � Et/C..,�I/.
Owner or Legal Representafive Signature: y� � Date: l/�1 z��l (
Authorized State Agent: Date: / //
The issuance of this permit by the Health epartmen 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.
T�
Type of Wastewater Systeml ��� 1
Facility Type: �us�
Basement? 0 Yes C�t o
Wastewater Svstem Requirements
Septic Tank Size: �_ gallons
�tewater Svstem (Required for
��^� Wastewater Flow: ✓� g.p.d.
New Repair DExpansion ❑
Basement Fiutures? 0 Yes Cs7-t4o
Pump Tank Size: �� gallons
Total Trench Length: � feet Maximum Trench Depth: � inches Aggregate Depth:� in.
M�bilmum Soil Cover: � inches Trench Separation: ,� Feet on Center
other:ll���"� d IJ C.�N�U� • _
Per►nit Expiration Date: �� �� �`l
Authorized State Agent: -� Date: �� ��
The type of system permitted �does does t differ from the type specified on the application. I accept
the specifications of this permit.
Owner/Legal Representative Signatur • ��� Da�: r�r 1 Z—�1 �
PCND, rev/ 10/12/99
,� .
�
< ,,;
Application #: 208S'7
Tax Map #: A '29
Parcel #: /�30
Person County Health Department
Environmental Health Section
SITE SKETCH
�f�M�s Nlt� �EV��cE �lia6� ��-z�
Applicant's Name Subdivision/Section/Lot#
)I
Autho e ta ge a e
System components represent approximate contours only. Tlie contractor n:ustflag tlae system
to be�inninQ the installation to insure tftat proper graae �.s macntainea.
b ►
Scale: � = (DO
_ — ^ Gu" _ '
J
PCHD, rev. 10/12/99
���.sf ���.���
�.,- � � ����
�.aa�n�c^��rnnxn��n.��n.� ����.���ia
Tax M�� i � P�rcel #
Stihciivi�s�ioia � Ir . ' � ���' •
Ph��se Sect�ion Lot � -
� � Improvement Permit
Permit Valid for �/ Five Years _ No Expiration
Type of Facility: ��Q - New ��ddition _ Water Supply ,
# of Occupants �_ # of Bedrooms �. Projected Daily Flow �Q g.p.d.
rror�sel Wastewater System: P� n'��' o� Type:
Proposed Repair: _ �,� �/�p�l•`�-i or14',( Type: �
Permit Conditions:
Owner or Legal Represe ' e Signature: �
Authorized State Agent:
Date: % / z 7 /Uf
Date: /-- d�S
The issuance of this permit by the trealth Departrnent in does not guarantee the issuance of other permits. 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 Carollna Zaws and
Rules for Sew�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 functlon 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: C�jf1 vQ�`�"'�'1.C� TYpe �_ Wastewater Flow ��Qg.p.d.
New � Repair E�ansion Soil LTAR: ., 0?75 g•p•d./ ft 2
Type of Facility: � , Basement _ Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: � gal Pump Tank: � gal Grease Trap: �_ gal
Drainfield: Total Area: ��v sq ft Total Length "*`c� ft Maximum Trench Depth �_ in
Trench Width ,� ft Minimum Soil Cover: �_ in Minimum Trench Separation: � ft
Distribution: Distribution Box �-�Serial Distribution
Specifications:
Authorized State Ag
Permit
Date: 1—IQ -
Pressure Manifold
Date: �'� � �_�
The type of system permitted is ✓Conventional I ovative Alternative. I accept the specifications of
the permit. � /
Owner/Leeal Reoresentative: i` ��//''"`'� Date: � Z`� °�
.'.:.`':``"�:`':::�'��.:�. :.''::.� .'..'.�' ::�.� ;. ... :��:,:�'. ..> :..:.:.:::..'..� ..�::.:.:.�.` ;...� . .
��� � ;�� ���� ��
. .
�.'�'''.,.::�:.;;.;,..,::...,;..;:�:::::(�:`�,���:��'� .
........:.:.:::.�::...:.::.::.::::.:..:.,....:.:� .: :,...,.::. .:.. . .
�.�a;�u:.�r�a?4:aca�:�ar�::aa��:�►:71��;: �;:�C' �,rn,�:�71�;� .
WELL PERMIT
PLEASE 5EE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �_
Applicant: Tc
Subdivision��
Location: � 9. S 1
Parcel # (3� Township: � �: v e.�-: `�
Type of Water�Supply: � ndividual _ Community Public
Itequirements:
Site Approved By: :l } `i����
Grouting Approved B: l� � 7
Well Log: 1� � �
Pump Tag: ✓ �
Well Tag: �
Air Vent• ✓ � '3'S �'31 �wr
Hose Bib: r �
Casing Height: ✓ �
Concrete Slab: �/ /I/" �, .
Well Driller:
Well
****See Attached Site Sketch****
Liner:
�Installed by:
Depth set: _
Grouted• _
Date:
Water Sample:
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:
Date: �� l -1 ! �
PCHD rev O1/27/04
`"'�.�, i , �� � � � � `l1� �
�_.- � � � ����
���a���.a�����.11 �ZL��.II.�I�n.n.
Applicani
Location:
�
0
�x M�p , � P�rcel # /
Subcilivision �. � � ; . �
Phase Section Lot # /♦
# of Bed�rooms
���tl�� �r 1�
. �
System Type (In Accordance With Table Va): -�-Gt
THIS SYSTEflA HAS BEEM INSTALLED IIV COIVIPLIANCE WITH APPLICABLE NORTH
GAROL'INA GENER�►L STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDIT10iVS F T E_ IMPROVEMENT PERMIT AND CONSTRUCTIOM
AUT,t�jORIZAT�OI�)��� � -- �
0
Installed By:
r
�.� '�" ..
}_,ITa
0
0
.��/�/�.� -
Date
Date: ��.3/%�
�2— 9 7
`2-/03
L3'loo
L�f - lO(�
LS' C¢
�f 70 `
PCHD, rev. 07/29/04
�
�E��'1C TAN� BA��P���'i�R! G�dE��C�9Si Ciype 16 - IV�
Tax Map # A�q Parce! #�/ 30 Sysiem Type (Tabie Va) .,�a
Owner/Applicant �� I.�/,��/��� Subdivision ��vr/ ,,�' � -
Address/Location Sec/Phase Lo .�
State�ID/date :��''�;—���2/`
Capacity ,,��; --/��.� gal.
Tee and Fiiter
Baffie �
Sealant
Riser {ifi applicable)
Tank Outlet Seal
Permanent Marker
Pump i'ank
.,..p.......,� y...�.
Waterproof /Sealant
Riser
Water Tight
� � Pump
Check Valve/Gate Valve
Alarm visable and audible)
Electrical Com onents
� Rate m �
A roved Pum 1Vlodel
Blocic Under Pum
Pum Removal Ro e/Chain
. � Distribution. System
� Serial Distribution
ressure ani o
Low Pressure Pi e
A r. Pi e I�lateriai and Grade
Valves
►�i�r�ticat�on �a,
Trench �dth �� ;
Trench Grade �
Trench Spacing
Rock Depth and Qua(i
Dams/Stepdowns etc.
Pressure Laterals �
Hole Spacing �
o e ize
Pipe. Sleeve
Setbacks
From Wells
From Propertv lines
Surface Waters
Public VNater Supplies
Vertical Cuts (>2 ft.)
Wa#er Lines
Vehicle Traffic �
Easernents/Right of 1�
Other
Easements Recorded
e ie pera or oi
Tri-Partate Aareemen
Corraments
ft.
in,
�ft.
�
.
pcf�d rev. 3/'13/0�1
l\
;�
. �...
��--,`�� �s- �� I�I�II�.� ��
�.ti -•�:
��vas= �� � �J� ��
A ��
:; �
Owner: _____�L.
Location: s'
Subdivision: -�-
C� OD �
� � �� ���� ,�r.//� �. _
� �� _ � - lo � trS`�
,.
Grout Log �
Ta�t Map �qpazcel # ��d
. Lot # �,
i
' ' Well Construction
Distance Fror,z.ne�rest Property I,inc (Minimum 10 fcet) �
Distance fron S fic Systcm (Minimum 60 feet) `/
Total Dtpth ��� �} yield: ,� D GpM' Static Water Lev e L• � S g
W a t e r B e a r i n f; Zo� e s: D e p t h �"$ �} ft ft
--.—
Casing:
Depth: From !� to� �, Diamctcr: �
Type: Galvani�ed � � .
Weight�_� ���a5; /� Height above Ground: �� �
Drive Shoe: � es No Any problcros encounteted wtule setting easing7 �YeS _L-2�o
'�if "yts" giv� ra�so�:
t.,
Grout: �
rfeat: Sand/Cement ✓ Concrete GraveUCement
. p,nnj�lar Space Width �_ inches Watet in Annuler Spacc Ycs
�Yet�od of Grout: P�unped Pressure r/poured
Materlsis Usc:�l: : Dcpth d to �:Ft.
Mo. $ags PortIend cement ^_ W�ght �f 1 Bag �� Pounds
It miXture (sand, vel, cuttings) - Ratio _� tv-�_�
�l�_p�ates: ` cs _ No 4 a 4 slab ✓ y�s No �
Liner: —
��'eP�'' Date Installcd: Grout• Installed bY: .
DriWng Log
FormAdon
��c�
Locition DrawIn �;
�il����t���_�� . �l �
. —
� � -
�
I hereby cectifj�� tha� the above information is correct and that this well was c�nstructed in accordance witli rcgulations set forth
by thc Pcrson C�wnty Health Dopartmon�
`� �
Slgnature of C'ontractor
# � b 3 DAte ��% d �S�
Pump Installment
Pump Installati�n Contractor. State Re
pump jkp�; 8istration Number _
ft Static Water Levei: g
PurapMRke �.Afodel: Pump Sru utd Rating: f
--. � -`_. 8Fra
I hereby certify t'�at this pu�p was instalied and the well head campleted according to the Person County W�II Rules in effect
on this date and(ihat a copy of this record hns been provided to thc wcll owncr. .
ipi ""' ��i�'a�a � lia;� s"'"��
11+7�N I�:MwL����e] 'ay w����d w .
Nr ti:oi rooliQiiio:
PERSON COUNTY HEALTH DEPA1tTN1ENT
355� SOUTH NIADISON BLVD.
ROYBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAtY1PLEANALYSIS
Name of Owner or Tenant ��f �o �k�
Address .;,1- Z� �s�� �C ��n County �e�s a�
Collected By CSx�/ ����-�-
Date Collected �(-'ta -��
Time Collected (c�: �s
Source: �] Well ❑ Spring ❑ Other
Location: ❑ House Tap �Well Tap ❑ Other
`�No Charge �1Charge
� �� w j r,-� �c � �.....J1—
�*�***��****�***��**�����**��*��***��**��*�**�*�***�**�***���*************�**:�
�**��*��***�**�**�**����**�****�***�*�**�***�*�***�*�**�***��**��**********�.**
Results
�s�S� �1��
Present Abse t , -� �L1 �('�„�'��'
Total Coliform ❑ � %1� ..�,,, --� '��
V--' �` ���
FecaVE. Coli
Reported By
bactreport
�
4�.�' `����
�
�Y1T
Application Date: i zi �, Tax Map:
Amount Paid: Parcel #: .
Receipt#:
��--•�_ � �I��� ��
������
��ravna aDaa�•-+Y+• ac-�ga�.mll � �<c3an.Il�.�ia
Application for Services (Septic Systems and Wells)
Services Re uested
0 Improvement Permit (Site Evaluation) Construction Authorization (issued with Improvement Permit)
$200.00/$300.00 if> 600 d (Fee is de endent on the e of s stem ermitted)
❑ Mobile Home Replacement or Building Addition 0 Permit Revision
$150.00 if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No fee for Application
�� Services Requested by:
� Name: � o µ
Address:
Phone #(home): 33�-59 �- l �� �
(work/cell): 334- S`I z- - OG 7�
2)Name and address of curr nt owner (if different than applicant):
Name: a2�+ /' ��-
Address: fi _ ��Z
,t:'vk�c<£� izG 175��/
3) Property Description: Lot Size:
i0
r//L
e f G
���i//z '�E/` Z Lot #:
G S GZ
4) Proposed Use and Type of Structure: //� �
Residential Business/Type: Other Z,�iz 7U�h<LG'"��%
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No _�
Garbage disposal: Yes No
5) Water Supply:
Private Well �Proposed Existing _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No _
Yes �please show location on site plan)
Note: A completed application 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 eva[uated.
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):
: /` z�' /o
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
�� $
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� 1 /
''�.►� Y b '� �� � � � � � �
.AL:d�]!,�"]I.Ir'�7�1LIi31CI1.�'i7171¢•aSLJI .1L 1L ,tG�'ia�.Jl���
�uilding Additions/ 1dIobile �ome l�eplacement�
Tax Map #: ,Q-2q Pazcel#: / �D
Approval Requested for: Mobile Home Replacement ,
- �� Building Addition /2 ic ��Z �i�.e.j�� �r�D.,��
Applicant Name: ''��3�4,.i
Address: "
� Phone #'s:�"g9� /060 _�92— Dlo ?S�
,i �
� Pernut Located: . '� Yes No
Installation Date: 'Loo S Design'flow: (gpd)
Current Contract with Certified Operator on file (if required): �i''"
Water Supply: �/ Well � Public or Community
Wastewater system shows no visual evidence of failure on: y. i o__ (date)
(Applicant's signature if site visit is not required)
Addition/lteplacem�nt Approved
Environmental ea1 Specialist
11/15/OS
d
Date
i
��
.f
�y s 1
�, � �. � � �J �. �7 � �
���7��]L��-7��7mt��.� ��:eS1.11'��
Building Additians/ Mobile Home Replacements
Tax Map #:�� Parcel#� � �� Address: ___i?9 �1 ��,/�� /�,./ .
�ppro��al Requested for: Mobile Home Replacement
_� Building Addition �� 6✓�2 �jlih��� ��i�
Applicant Name: � � � ''.
Address: � �'��/�-j-�%��
Phone #'s: ��or.�� � 37?�0
Permit Located: � Yes No
Installatian Date: 7� -n s' Design flow: {gpd)
Current Contract with Certified Operator on file (if reqtiired): ill�
��%ater Supply: ✓ Well Public or Community
date
Vv astewater system shows no visual evidence of failure on: { }
(Applicant's signature ii site visit is not required) / �.�—
Comments:_�_o �s- c,Q �'7Ci� �,�r ��c,rG - 1�1�0 �/o� y�/�.oa�i�
4 . l �
Addition/Repiacement �pproved
'_ � --
Environment 1 lth Specialist
ia/3%�
Date
Person Countti� Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 33b-�97-1790.� Fax: 336-597-7808 www nersoncountv.net