A29 41i`
Apptication L�te• �'f' 13 7 \3���� '1t��1���1 V
Amount Paid: 0
Recefpt #: � 3� ���
C��{� V� --�-�.�so��C�¢�.Il IE-iLmm.Il�lk�
A lication for Services
- Services Re uested
Improvement Permit (Site EvaIuation) ❑ ConstrucHon Authorization
$200.00/$300.00 if> 600 d ee is d endtat on the e of
❑ Mobile Home Replacement or Buildiag Addition ❑ Permit Revision
$150.00 (if site visit reQuired) $75.00
❑ Well Permit (New/Replacem
$3 00.00/$200.00/$75.00
� tU Ck�
v � �- o �
� Repair of Ezisting Septic System
Applica6on: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: K�vih � �YDok� �T1�Dek 1-
Address: 22 QX1-h- Rd -
�axborro, NC 2�� 4
2) Name and address of current owner (if different than applicant):
Name• Couroii ne W( Ide
Address: 4� (.�S 1-4�Ard i e M i I I S 13� •
RoxboYo. NL 2"15�14
3) Property Description: Lot Size: � G�Gr�S Subdivision:
Address and/or directions to Property: `��
Phone (home): � I q-�43' 2�� Ca
(work/cell): �,�,(o - 504 - 33rd�
Phone: 33b- sqq - 50-7'Z
#:
0 yes no Does the site contain any jurisdictional wetlands?
O 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 sewage7
O yes j8( no Is the site subject to approval by any other public agency7
❑ yes J�'no Are there any easements or right of ways on this property7
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
OResidential
�New Single Family Residence Maximum number of bedrooms: �' / Occupants: �
❑ Expansion of Existing System If expansion: C�urent numbe of bedrooms:
� Repair to Malfunctioning System Will there be a basement? �yes 0 no With plumbing fixt�ues? �yes ❑ no
❑Non-Residentlal
Type of business: Total Square footage of Building:
Maximum number of employees: Maximum number of seats:
5) Water Supply: � New well � Existing Well � Community Well � Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property7 ❑ yes � no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please iadicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative 0 Altemative ❑ Other � Any
I certify that the information provided above is complete and correct. l also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
* Supporting documentation required.
4� I
Date
• 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.
i��i�v� n----- r'---'-`--r'---:--------�_� Tt__�.t �nc c� •r--•---- n. c�__,�_ n T__'1'___ 1T/'� �1�7L�1'1 i�+�t en�f t�nm
�� 1
�..�`��. �
� • �� � � ����
]f-''>.rz�v-;�nro��:,r1���r-n�c..f�-n.��zn,1� ��`.���e;�zn.111t;.:�n.
May 9, 2017
nsuring o hcalthy en�ironment
Re: Application for Improvement Permit: Tax Map/Parcel: A29; Parce141
Dear Mr. Tippett:
The Person County Health Department, Environmental Health Division on S/5/2017
evaluated a portion of the above referenced property at the site designated on the plat/site
plan that accompanied your improvement permit application. According to your
application the site is to serve a 4 bedroom residence with a design wastewater flow of
480 gallons per day. The evaluation was done in accordance with the laws and rules
governing wastewater systems in North Carolina General Statute 130A-333 including
related statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative
Code, Rule .1900 and related rules.
Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina
Administrative Code, Rule .1940 through .1948, the evaluation indicated that the site is
UNSUITABLE for a sanitary system of sewage treatment and disposal. Therefore, we
must deny your request for an improvement permit. A copy of the site evaluation is
enclosed. The site is unsuitable based on the following:
X Unsuitable soil characteristics (structure or clay mineralogy) (Rule .1941)
X Unsuitable soil wetness condition (Rule .1942)
X Unsuitable soil depth (Rule .1943)
X Insufficient space for septic system and repair area (Rule .1945)
These severe soil or site limitations could cause premature system failure, leading to the
discharge of untreated sewage on the ground surface, into surface waters, directly to
ground water or inside your structure.
The site evaluation included consideration of possible site modifications, as well as use of
modif ed, innovative, or alternative systems. However, the Health Department has
determined that none of the above options will overcome the severe conditions on this
site. A possible option might be a system designed to dispose of sewage to another area
of suitable soil or off-site to additional property.
For the reasons set out above, the property is currently classifed UNSUITABLE, and no
improvement permit shall be issued for this site in accordance with Rule .1948(c).
Note that a site classified as LJNSUITABLE may be classified as PROVISIONALLY
SUITABLE if written documentation is provided that meets the requirements of Rule
phonc 336.597.1790
fax 336.597J80R
325 South Morgan Strcct, Suite C, Roxboro, NC 27573
.1948(d). A copy of this rule is enclosed. You may hire a consultant to assist you if you
wish to try to develop a plan under which your site could be reclassified as
PROVISIONALLY SUITABLE.
You have a right to an information review of this decision. You may request an informal
review by the soil scientist or environmental health supervisor at the local health
department. You may also request an information review by the North Carolina
Department of Health and Human Services regional soil scientist. A request for informal
review must be made in writing to the local health department.
You also have a right to a formal appeal of this decision. To pursue a formal appeal, you
must file a petition for a contested case hearing with the Office of Administrative
Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714. To get a copy of a
petition form, you may write the Office of Administrative Hearings or call the office at
(919) 431-3000 or download it from the OAH web site at
htfp://www.ncoah.com/forms.html . The petition for a contested case hearing must be
filed in accordance with the provision of North Carolina General Statutes 130A-24 and
150B-23 and all other applicable provisions of Chapter 150B. N.C. General Statute
130A-335 (g) provides that your hearing would be held in the county where your
property is located.
Please note: If you wish to pursue a formal appeal, you must file the petition form with
the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS
LETTER. The date of this letter is May 9, 2017. Meeting the 30 day deadline is critical
to your formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative
Hearings, you are required by law (N.C. General Statute 150B-23) to serve a copy of
your petition on the Office of General Counsel, N.C. Department of Health and Human
Services, 2001 Mail Service Center, Raleigh, N.C. 27699-2001.
Do not serve the petition on your local health department. Sending a copy of your
petition to the local health department will not satisfy the legal requirement in N.C.
General Statute 150B-23 that you send a copy to the Office of General Counsel, N. C.
Department of Health and Human Services.
Please contact our. office if you have any questions or need any additional information.
Sin erely,
�r � �Y��
Adam Sarver, REHS
Environmental Health Program Specialist
Person County Health Department
Enclosures: (Copy of site evaluation); (Copy of Rule .1948(d)); Soil Consultant List
The Districf I�ealth Dep4rfinent
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
Dat� � �
r
Name of owner:
Name of contractor:
Address and Directions � .��'`"'���
No. of persons to be serve� � Bedrooms 1, 2, �4.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Recommended• Septic ta
Nitrification line:
Above recommendation based on ififormation r�ceived ana observea
soil condition. Septic tank and nitrification line musi be inspecied and
approved by a memi�er of the Disirict Heaith Deparfinenf sfaff before
any portion of the installation is covered.
��
Date Approved: �7 3� l9
,/ Signe�
�� Sanitarian
By: -
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date.
SUGGESTED INSTALLATION (Date ) FINAL INSTAId,ATION (Date
(Road or 6treet) (Road or Street) �
������-�---�����rr�r�����■���.���.�.
■■■.■■■.■.r■■■■■■■■ .■■.■■■
■■■■�■■■.■■■■■■■■■■ ■■■...■
■■■■■`��■■■�■■■■■r ■■■■...■■
■■■-� .(/����■■1,■■■■■■ ....■..■■
■��..�''�1►�����1�■������.���������
�� ���e�a �IAr�/�r���■�■�����■
f�li�������C�����■��������■����
■����■���i���■���■��■������■
■����■��■���■���e����■����■
■���■��������■������������■
■■������0�����■ ■■ ■■�■���■
■���■��■■■�e��■ �� ■����■■
Ao���•n�: �l -oZo2-6� . ,... . . . . . r�.�a� �02 9 .
� ' . ._ . . . . �=`�-- .
. � �� - � ` � a�.
1 D � �j •�..�`�� � ������ . . . � �
� . - � _ ` '� ���� . . W���' a�,,;��
� � � . -r�-- q..:-..�-�a.,_,..�.�.�.� �� �
. � � • . � ' . IJJ�"� 10 (ty`
.�t_� �h• _�\ ` ' �
i , � �
..i - ��` � ��� ..� i / /a / / •
� r _ i _ i .�
� _ i � .,.
. _ � '. �, �
r, ,. , �: �. i� �- J
� ,)
.� � r
! L •
0
3i �l��Y ��on: Lat stzec � aw�hip: s�n: • Lat�t
Dii�ae �o th8 P�P�hI ���8 roadrtamee e[1d rlumbers): _ � o �P R e c T� /' � � �-7��st.. ��,
4) Propa�rd Up and �ds�lttr+s �asc�o� an�wec esch d;�e �� -
� a) �P� _ _ �S � Z'YPs crES�ttcbur� ' � � 1A1�. t�
b) i�hirr�er ot 8ed�notrt� . Nurnb� of ocapanis or pecpie m he �rver� ' ,
c) Ba�men� Yes _, No _VI�1 thers be �g tn ihe �? � ..
� ��Y���_ . .
� YlFmir suppLy'iyp�s: Psi+reme �nsw `�cr aode�ng �, P�c._, Catn�t�NiY i. �_ .
Ate-eay u�s on a�g pt�? Ysa __„ I�lo _ tt ye�a. pi�+se lndh�6e a�s lo�ion en ��a �n.
� Dow ths prop�rty � priewb�siy t�d jur�i �� Yss _ No ✓ .
PI.EJ►9ENOTET�iEFOLLOWW�'�: . . � � , . •' , .
'�➢ A PLAT OR'iI� PR,�CPi�irY' 01� S�fE PL�1N l�l9T HE � lAR'i'E� Ttll9 APPLLC�►TiON:
D P�OP6�71r LINE9 AND � It19T � f�.BARLY YARl�. .
➢. T1�IE L�OP09� LOCAT�ON OF ALL 9TRUCi!]RE9 !t]8T 8E �TAl� OR FiAGt�. • .
D THE SRE HNST HE READILY A�1BLE �OR A%1 E1/ALUATtON BY THE t�ALTH D�l1�81�1'f �1'AF�r.
1• hs� n� a�on tc ihe Pe�rson Caunty ri�ittt 0� fbr a�a �va�ton Ror ihe a[aeite ae�e +�sPos�i
sY�n for the abave-descttbed properiy. 1 agree iitat the cmt�ts' af ti�is ap�on � ttt�e a�td r�r� the t�cwm
� ba be piacad on th� praperty. 1 und�and ii the s� is aiiesed at the � usa ct�anges, the ge� �ll
� ��- . (J . _ 1 ° A
��_ sa�i�i.�
C•�'�*T' • -. _
- PCc1D, n� 10tt71Q't
0
_ ���,;;�� ������
' � � �.J l�! ��
�' �m�a-o�* �+eaa�m.]� ��mIl�
Si'I'E. S��TCH
N �arc�l�in (.�i �e
� �
Su �on �l�
Authorized Sta.te Agent
Tax lY1ap # ' + a� Parcel #�
� Section/Lot#� � ! �}
� 4 a�-o.�
� Date . �
Sysrem componen�s repr,esent upproximate �contours only. The cotltrador »sust, flag the system j�rior to
beginning the irutallation to insure that propergrade is maintained
Application Date: — � � 2
Amount Paid: C�
Receipt #: 7—� � Z- /
� `� �
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ MoSile Home Replacement or �Suilding Addition
$ I 50.00 (if site visit required)
0 Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
`�� SS ���� �� Tax Map: Z
,_..,,, � • - Parcel#:
^'� � � �T�T�`�
�"�.��cav-na-rcnn.nmrn.�=nd.s�.� u���,si.]���.a.
tion for Services
Services
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
�75.00
pair of Existing Septic System
Application: No Charge/ CA $ I50.00 or $300.00
1) Applicant Information:
Name: �
Address: �. ,
0 o C, 2Z
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): J�q q �.� 0� �L.
(work/cell):
Phone:
3) Property Description: Lot Size: 3 a� � Subdivision: Lot #:
Address and/or directions to Property: �
� . '�e �
❑ �s Lf no Does the site contain any jurisdictional wetlands?
C3Yyes ❑go Does the site contain any existing wastewater systems?
O yes L' f Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes �_� 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:
❑ Fxpansion of Existing System If expansion: Current number of bedrooms: y�
C�Repair to Mal.fi.�nctioning Syste:n Will there be a baser:ient? L� yes ❑ nc V4'ith plumbir.g fixtures? ❑ yes 0 no
❑Non-Residentia!
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well L�t'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 type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative � Other ❑ Any
I cert� that the information provided above is complete and correct. 1 also understand that if the information provided is
inaccurate, or ifthe site is subsequentiv altered, or the intended use changes, all permits and anprovals shall be invali�i
� � �
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
��19-/�
Date
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)
���J��- .����� V ��('�'
�+ ' ^� � V � 11 JL
�lCb'�17['��rn�emm„La7LR.¢�.� ��L.ffi.��r�rn
Name � ti � �- �r' �r ►1'�, ����e
Subdi � ' n
Autho�ized State Agent
0
�I'I'E ��'I'C�-I
Tag Map #�� �' Pa�cel #�_
Section/Lot#. _ -_ - -- . _ � _. _ ---------
�-� z /7
Date
System cdmponents represent approxirnate�contours only. The cvniractor »aust, flag the systemlbt�or to
beginning the instadla�ion to ansure thatpmpergs�ade is rr�aintained s�vV' �% �� -� �?X
--��� ° ( (�'` �,-�e h � �, d e�,
��-, ��i
°m.-�„_,.. ^R'" `E �Cf" d I � 3 � - . . �' .. , ,..� . .... �, �.:I
��>..' +- ='� �� y 1 �, '�`� � �i = � a � � a.�� � ,�"" ���h�. �
�� � �y�.� .�e ` �
� �� x`� � i
3 f � r�i � 4t� y ��
� ,y� ' �� ,�,'... ' F ��� °�,: � . - �f � .
�, ,� �' ' � � � � � � � _��
� > �
� : -n ' . ,� s ^�
�$ +`� i, � �'ps � � g�� x . � i- �. �� � � �� _r \ � �
�� �
�
>
.. .
a- ..
�. �� � �� � � � ' ���: V �I
� �
{�� � >= � �� °� �. � � � ° � � � : ��� .
�
�� ` ��'�� I I
� �. � �� � s ' i
� '� � ~ �'� � � ��.' � *�`" �";�k�`" � ,� �� . F �+� a`� r
.�,��ss ;.� . � �' � ,� ,� � � � �" � �' a . � z�:�r ay � ,:
( n � � � �'"��^� �: ��� � � +� � �' �,
< �
� � �� �"� � �' ��� �"� � ��� �� � �3�
� � � � ��€ �..�" �*�� � � ��� 5� � � tc�. .,a � ': t�.�'i � `^ ,��':�y �e .. . � �'a" ; � I
A �
; �#.
A �
F � : � p ' '.r� ' .�, i� ' "$ � #. �"�;�' � .
�,
3� . 9 `�. ft�..' . ,1 _ � r. "£ ' ..
1�`$�mt �" �2 $ . � . � � +,sJ� 4 �,� � .S4!t.,
t �i '�S � � i� '�''^� 4k� � � f '� �. � I
�� N L � � � u "�}...:� Y "A" � �2 � 'y �eF
�� r�y� 1 �,�,�. . . . . �`� '�'t�,� �:' 7 � `^0 .'Yd:Y� .F
o � � �` xp fl i'q � �Y
���� � �_�� . .. � . .. � �
` �� ��� � � .
� '� ,� u �' J �,� � i� �
� �� . . � � ,/ � �: ^���
�^ R
II ��� ��. .', s` � . . . ..
; � � �
.
.�,. �, , � q., f��'���^�`�._ II
+� � /
I�� � ����� � �� � �
s � �c ; � �` ��
,� �� � .�
�� ��� `� �-SC5£ �� � � ��� �
� � � �h u � , a� � � e ,i
� �s � /'� ^.� ,.7-�� `� �t, g� � ��'d sj� ��'"�� i
/".t�.'�' x,� .. 'i
I ... �a '�.�� t .<< d i /� �' �:"'. . rw�*.�=... a ,.. ��
��� S;f� ���$.���
�� ~ � � � ����
I���u��D��«����.]1 I�3L Q,�,..11¢I�
Applican
Location:
T�x M�p : � P�rcel �
Subdivision
Fh�se Sect�ion Lot #
Improvement Permit
Permit Valid for Five Years No Expiration
Type of Facility: �r, �a ��?N� � New Addition Water Supply �Iel (
# of Occupants # of Bedrooms �_ Projected Daily Flow �� g.p.d.
Proposed Wastewa r System:
Proposed Repair: (',��v� '� rn. e r se
Type:
Type:
Permit Conditions:
� Gt l�i ��Gi. �i' S
Owner or Legal Representative ' ature: � �� Date: — l�— l�
Authorized State Agent: Date: — - Z
The issuance of this pemut by the Health Department in does not guarantee the issuance of other pernuts. 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 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 Sy tem���� Type Wastewater Flow ��g.p.d.
New Rep 'r �Exp sion Soil L �. Z�7 g.p.d./ ft 2
Type of Facility: � V � Basement _ Yes v1Qo
Wastewater System Requirements
Tank Size: Septic Tank: � is r al Pump Tank: — gal Grease Trap: ---- gal
Drainfield: Total Area: sq ft Total Length 00 ft Maximum Trench Depth �l� in
D��•
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: � ft
Distribution: ��istribution Box Serial Distribution
Authorized State A�
Permit
Pressure Manifold
�''/7-/z
The type of system permitted is � Conventional dr ✓Accepted Alternative. I accept the specifications of the
permit. , � ��
Owner/Legal Representative: ���,tia`c�-� Date: � �— � a�-
PCHD rev. 11/10/OS
���.ss ���.���
� � ����
I���a-���.-� ����,.Il I�ILm�.IL�I�
Applicant
Location:
Tax Map,� Parcel # �
Subdivision
Phase/Section/Lot #
# of Bedrooms , 3
Operation Permit
System Type (From Table Va): Product (IIIg): �z
This system has been installed in compliance with applicable North Carolina General5tatutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authnri�atinn_
9�
�
�
J�
�
�.Soi � i 5 PS i rt -�-i r�f
.�,'e►�ti an�l gef r be�;'cr �
t n Z��- .3 C, 3 ��R)
QP °�,�L�
;
Scale: �����
1�-S�Ys �{e.��
5 3—�Z
(Date)
S 3 —l�
(Datej
�
� �AA
� J �
� ���
� ,�.
\ CpnL(Bfe
�' d -�o�
' � ���
. �,.
),
,,n
._
,:
��
I'��� �
Tax Map: � Parcel #• �t �
Septic Tank System Checklist (Type II-I�
Notes •
System Type:
Pump System Checklist
Contracted Certified Operator (Type IV +Systems):
Notes•
NOTIFIED BUILDING INSPECTIONS:
(Revised 12/09 BH)
Tank Com onents InitiaUDate
Pump model:
Block (4")
Nylon retrieval rope
Float tree and attachments
On/Off float swing: in.
Alarm float �6" se aration
Anti-siphon hole
Check valve
Threaded union
Crate valve
Conduit sealed
Outlet sealed
Approved and secured riser
Su 1 Line
Size and material: in. sch.
L�?na h' ft.
Copy of OP e-mail Date:
PERSON C�UiVTY E�IVIRONMENTAL HEALTH
PLEAS� SE� Ai"TACHED PLAiV FOR WELL StTE LAYOUT
Tax AAsP #: �� 1 Parcel # 1 I
Zonlog Township V f I � C. C'1 1('
Applfcant
Cc�, ra � i nc, lrJ i��� �
�tio�: `T�S � I�l� Stc.rs ��r� 12 d� L: �x o�0 1
' i�/A
Subdlvision• Sectlom Lo�
TYpe of Water SupplY:
Reauirements•
Well Permit
�Individual Community Public
Site Approved by ' � "��
Grouting App oved by �iC- - ��-
Well Log — 7 `oJ—
Well Tag
Air Vent
Hose Bib
Concrete Slab
Weil Drilier•
Well Approved By: � Date•
**See Attached Site Sketch**
Welis 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:
� j�' pFFdr��c..
�e,,cQ c� c I � � n F�D�,� ya �d >
�;etW �t( (p D � �ro M �1bmc,
P .
� s ( � �ar K� �� � :Bl u.c i� �a�.s
r Wt[�
PCHD, rev. 11/29/99