The URL can be used to link to this page

A30 6�il ��,��'� ��ly � r ' PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVIP LOVEMENT PERNIIT Tax Map # /� 3U Parcel # Zoning Township %3vs �/ �� Owner/Contractor SarQ o%� ex �� Date -/S-S�4 Location/Address W;/l�a� l�',cc /�ousc l� ss�� l-�or�a� S.R.# Subdivision Name Lot# A 1468 I _ _ SE�AGE SYS�M SPECIF,�CATIONS /� n I # Permit Void after 60 months. Permit Permits may be voided if site is alt e Well and �. � Comments: Size Size / IN�x Depth'I�ryEhes � 'oid if not in compliance with zoning regulations. or intended use changed. Date Installed by Approved by. WELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Slab Public . Replacement� Air Vent Site Approved Required Well Lo� Well Head Approved Well Tag Crrouting Approved qq Comments: Date Installed by ��O�hQ� ��i� � Approved by This report is based in pazt on information provided the homeowner or his/her representative in the application submitted for this per[rrit The environmental health specialist is not responsibte for false or misleading infocmation contained in the application. The environmental health specialist is also not responsible for concealed conditions on the propeRy or for statements in this report that may have resulted &om false or misleading statements provided to him in the application 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. c:lamipro�pennit.sam O 1/95 rev.1.0 ORIGINAL � ��:r,:;c,r, c��v��•�' I{NVI.IZON�;::N•rni, iu:ni,l��i . . IJP:I,I. I,U(� 1�ate: __�-,/�'�--11 . Owner: �., �_e.l �x`�-� r-- L,ocation/Dircctions: -----. .... �,; ,::;... -:,;•. � ::.7 . . . ._ _.__.- --- R#� .__ --- _.. . . ��b.'!vi 'i li ------ . .. s o Nan�i c: ----- . Dr�llin� Contracto.r:._..��/_ . . _ _� ---- ot # , . ._. � �1 /1 � -- � 1 � . - �. T., 1�_ n-- 1�1�;1_.I (�:(_)NS"t'Itl b---- -- . Distance from Nc• � - �- - JCIi'(nfv . . ; arest 1 ro��crty I_,inc ./S�/us V llis�;�ncc;lrom Source of ' Po�lution d ,�S Total.Dep.th: .�— Ft. �'icicl: � > � -.-� �....__ C�� M Sta�ic Water Level 'Ft: Water B�earin -- � g rLones: Depth. , t�t. .. � � li � Casin � ----- -_.__... �. ._..—_.__�"t. _____�___-�t. g: Deptl�: From___-��_____io---- -�-c� --I'�- Di�imc�cr: � � Inches TXPE: Steel � CJalv;u�i�c;d Stcc1 v � Z.f Stecl, docs owJlcr app�-ov�:: �'�;; No , � Weight:�_'['}lickncss: ' --' :.: ��C�_' .I-Ic�ght Abovc Ground:__�_`_Y =rnches . .. Drive Shoe: �'es____ N�� .. Were Pzoblems Elicot�r�tcrcc( in ScttinZ; �Ic C,,sin�`I Xes �� o Xf "ycs" �;ive rcasoii: — ---__�; Grout: .Type: Neat -------.__-�---...._ _.---------- �,-�:�.: S:�,icJ/ ' , . . . . �'� •;�_;<. C�;II1C,IlL ✓ Concre[e ^'s':�'� .., � .,.. ular.�Spacc Wieit�� ,3 - <,;:,;,.. __. Trichcs .,,. Watcr in Anni�laz- Spacc: �`�.:; . __ --- �� ✓ . • Methocl:� I'tun��c:c�+�---- 1'rc�::::ur�� —_ ._-- -----_ _...__. 1 'c, �.irc�cl c.� � : ; . . ,,. . , - .. cpt��: From ---- --Q-�------- ►��_._ _�v-- �'�- . . . Materials Uscd: No.1�3.i�;s ,('occl:uid Cciric t - :�: ZFmi;.turc (sand, gravcl, cuctin��ti) _ �f• n—_.. — Wc.lbht of.l�bag��lbs:�. ll ��(1`�C�. _� �('� k4�•'!tt' .�D Pl;�tes: Ycs ci -- •, ::;:� — -- - No . � . . .. ;;: � 4 x �� slab Xcs �/_ No _ . ... _ ..._ •. . . '.�,;:. _.._.___ _ ... �; �i--------._____..---..._.----I)I�II.I.INCT 1`CXT _ � , . ._-- . Fram -� 'ro � _,____ 1_'cirrna[ion Descr�p --; — - ----.�5_�� -rl � _ .._.___.._. �..._--- ----�-- Z HEREBX CERTIFX T�1AT `1'I-IE ,�,�3(�� N�:UKM1�'�'�ON ZS COR T�S WELL WAS CONS 1'RUCI'CD �N �,�CORllA,NCE V�r,[TI-� REGULr �D � FORTH gY�TH�� PERSON Cn[1N�'Y (�Il;l�1,TI-I DLP�I:TMEN"I'. ATZON .._ _. �-_��.��---� jr�-<<� �IUJI.IIII['C i)i COIlIi,iC(C�i' � �i .�/'v.% f '/ ` t ; Datc T5 :; .� �,� g a G 1 7 3 13 I ( p. � 30 Application Date: � I � 1 � �O �0 � ��`Sr`. �� Taz Ma Amount Paid: �,�,;� r .._. • Parcel#: �_ Recei t #: � " / �-- 1 Fl— 3 8 " � �: � �� P � �':aa�fiacmr+�*�TM*�aa�mll ��im.l�iE�ln. Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) 0 Mobile Home Replacement or Building $150.00 (if site visit required) ❑ Well Permit (l�Tew/Replacement/Repair; $3 00.00/$200.00/$75.00 for Services ❑ Construction Autharization (Fee is dependent on the type of ❑ Permit Revision pair of Existing Septic System ` Application: No Chazge/ CA $150.00 or $300.00 1) Applicant Inform tion: � � Name: L' c� o� o v� Address: ohe s 5 ��e � �a _C. 7' � 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home): 3 3G -S9 �f-, 336 � (work/cell): 33 - SO - Phone: 3) Property Description: Lot Size: Subdivision: Lot #� Address and/or directions to Property: �a 3 0� a Sse I 1 0 � a v` ❑ yes o Does the site contain any jurisdictional wetiands? p yes � Does the site contain any existing wastewater systems? ❑ yes B'� Is any wastewater going to be generated on the site other than domestic sewage? O yes �� Is the site subject to approval by any other public agency? ❑ yes io 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: / Occupants: � Expansion of Existing System If expansion: Current number of bedrooms: �_ ❑ Repair to Malfunctioning System Will there be a basement? 0 yes G]-nS With plumbing fixtures7 O yes ❑ no ONon-Residentiat Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Suppty: ❑ New well xisting Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? es ❑ no Please note any known ground .water resfictions or sources of contamination: 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I certify that the information provided above is complete and correct. I also understand that:f the information provided is inaccu te, the site is subseq ly altered, or the intended use changes, all permits and approvals shall be invalid. - ' £7 —�S ��% Signature (Own / L 1 Representative*) Date * Supporting documentation required. • Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��, ; � �� - - . � � �� JF-�e a�.vwn a- � �,.-,,,,, � �a.��.:1 �-� � �. � ��la. Taz Map: � � Parcel:�_ Subdivision Phase/Section/Lot # Applicant: U✓1�R ��e+� Address/Location: —�_ ---__._.___--__----_---- 2? 3��sse!_�,._� � Permit Valid for: Five Years Type of Facility: � , Number of: Bedrooms � / Proposed Wastewat Systemj _ Proposed Repair: �� 'e Improvement Permit Non-expiring New _ Ad3ition _ Sl/ Emnlovees / Seats: Permit Conditions: `�?-e� S�`� l��4�e Water Supp;y: �i<� � 9 Projected Daily Flow:�fo gallons/day Type: �'q Type: � Auth�rized State Ageni: �'"� Date: 'S 3�l (X) Owner or Legal Representative: � Date: 3� 13 - The issuance of this permit by the Health Department does not guazantee the issuance �f other required permits. It is th:, responsibility of the applicandproperty owner to insure that all Person County Planning and Zoning and Buildina Inspections requirements are met. This improvement Permit is subject tu revocation if the site plan, plat or the intended use changes. The Improvement 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 rui�[ Rules for Sewage Treatmene and I)i.cnosal Svstems'(15A NCAC 18A .1900). Neitber Persoo County nor the Environmental Health Specialist warrants t:►a� t�e septic system wiil cantinu� to function satisfacto: �ly in thc future, or that the water supply wiil remain potable. � Authorization to Construct Wastewater System ��ee site plan and additional attachments (�. x Proposed Wastewater System: l�vivv-fk �i 0 �c� � New � Repair _ EYpansion /' Type of Faci(ity: i"�1�i'��P s- (*jType �`% Design Flow �� gal./day Soil LTAR: . ��'S gal./day/ftz Basement: _ Yes � No ('`) System Types I�'Ib, Ilibg, II ; crnd V, requireperiodic systQm inspections by the Person County Health Department. ss�s�� i�'a Wastewater System Requirements Tank Size: Septic Tank c d 0 � gal. Drainfield: 'Total Area �� sq. ft. Trench tNidth � $. Pump Tank `� gal Totat Lengtl� S� _ ft. Min.Soil Cover � in. Grease � rap "� Max. "french Depth _ gal. 2o in. Min.T7ench Separation � ft. Distribution: Distrihution Box� / Serial Distribution / Pressure Manifold _____ Specifications: ��- Sl�� /J Za"� __T_ Authorized State Agent: �"` '"`�`e� tssue Date: 3'-3 `( Permi� Expiration Date: 3�-3� 2i The system permitted is: Conventiona! �/Accepted ! Alternatire / Imiovative . I accept the con�iti�ns and specifications of this permit. � 3� ) 3� �,7 (X) Owner or Legal Representative: Date: Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) �`,?,J f ��11��1 V � � �� lE��sm�ffi��.Il ]E-3[e�.Il� . `.• ;�",f ;�',f''�,%: ,^ Name: � Subdivison: System Type: %�'u�'`P''�fi�u` Septic Tank: �� gallons Pump Tank: � gallons Total Linear Feet: 5� Max.Trench Depth: Zo " Site Plan �Address: GG Lot: �;, r� �,i �� Tax Map: � � Parcel: � , EHS: �y�tX�� -�- � �, � Date: 3�3 "�% }�,SSF.f ��' -i�?' � �"�'��F'f7� - �`�%Pqi r �Y2 � � Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation. 2) Contact Person Co nty Environmental Health wiih any questions (330) 597-1790. / r Additi�nal Comments: s [ ZG� �► �es y,�I �r' f ,,,�;; ;: . jl��;fl J�'�� / //'. % / •' ,`lf / i• `/f �/��'��f��% fl �! ,u f f•' % % f' ' . , - , .� f' /;' ! �'`, • ` �` %,: / .' flfF:'-ri;�:�, i� : ;�' i,� , .�`; , _�: �•: :-�: '�:; , ��` ) f �� .�� ]Fys��a-��.-,Y„ ��.�.;t I�-��.Il�7� Taz Map: � Parcel: �P Subdivisi�n Phase/Section/Lot # Applicant: �%u �� 'D1�� Address/Location: `_ --�__�__��__� ZZ 3 o SSet� o,. '�r+� _�---i- � Permit Valid for: Five Years Type of Facility: � Number of: Bedrooms Proposed Wastewater Syste • Proposed Repair: Permit Conditions: Authorized State Ageni: (X) Owner or Legal Rc Improvement Permit Non-expiring New Addition Water Occupants / Employees / Seats: � �• Daily Flow: gallons/day Type: Type: Date: Date: The issuance of this pe �t by the Health Depaitment does not guarantee the issuance �f other u�red permits. It is th:, responsibility of the applicant/prop owner ±o insure that all Person County Planning and Zoning and Building In ctions requirements are met. This improvemen ermit is subject tu revocation if the site plan, plat or the intended use changes. The Improvement is not affected by a cha in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws rurd es or Sewa e Treatment and II�s osal S stems'(15A NCAC 18A .1900). Neitber Person Couaty nor the Environmental Health S�ecialist warrants tha� t�e septic system tiviil continu., to function satisfacto::iy in thc future, or that the water sugpiy wif! remain potable. Authorization to Construct Wastewater �ys#ern See site plan and additional attachments (�. x Yroposed Wastewater System: �r � � New � Repair _ EYpansion _ Type of Facility: dl � °l (*}Type �a_ Design Flow — _ gal./day Soil LTAK: `— gal./day/ftz Basement: _ Yes _ Pdo (``) System Types Iilb, Ilibg, IV, r;nd i�, require periodic system inspections by the Person County Health Department. Wastewater System Requirements - Tank Size: Septic Tank "— gal. Pump Tank l 0 D �gal. Grease Trap ' gal. Drainfield: 'Total Area --- sq. ft. Total Length �--_ ft. Max. Trench Depth ��P in. Trench iNidth -- t�. Min.Soil Cover � in. Min.T'rench Separation '— ft. Distribution: Distrihution Box / Serial Distribution / Pressure Manifold �__ S iv ►� u Cp� �-..�a�:er. rp9'�.cl�r-e �r ��urr� Authorized State Agent: tssue Date: 3� 3^�, �� j' Permit Expiration Date: 3-3"Z'Z � �r�� The system permitted is:•Conventionai /Accepted / Alternati�-e / Innovative . I ac�ept the conditions and specifications of this permit. (k) Owner or Legal Representative: Date: Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) �'�,��- pr;� � �� s�-- IE�I�II�..��T `=...' �c � ��°� ��s�� n� �m�al¢]�. ..... _.. . . ! � SITE PLAN � Name �� v� Tax Map# �� Parcel#�_ Subdivis Section/Lot# Authorized State Agent Date Syslem components represent apprarimate contours only. The contraclor must ffag the system prior to beginning the installation to insure rhal propergrade is maintained Note: An Accepted system may @e used in place nja convenlional rystem wit.hou[ pe: mit auth.orizafion or modiftca�ion. ��°'�_ II � �-�� s1�. � l b-e �,1,� }- � �s�e-� �--�s�+-, � �'e.0�r 11Att �{" C��vidc��" r �� lo�� a�. �u�,P �� s f r-e-� C� s�- Co �. G+re; �. �� 1�,, + '�:� ��?, ) f �� - �--�' C� � tL��T � � I��aa-��•-„-r ��.Il �3LL��.Il�II� Applicant: Gi� �a� Location: ZZ 3o SSQ� V Operation Pern�it System Type (From Table Va): � Type V& VI Expiration Date: _#�� Tax Map �° ParGel # �_ Subdivision Phase/Section/Lot # # of Bedrooms Product (IIIg): t� � Type V& VI Renewal Date: �� 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. Y�t � (�'�'� ( uthorized Agent) t�� S (Licensed Contractor) Scale � PCiiD, rev. �m��.� l� (Date) (D �- s-t (Date) Tax Map: �3 a Parc�l #: � ��,✓, Septic Tank System Checklist (Type II-Ii� System Type: �� Se tic Tank InitiaUDate State ID & Date: �—; — � (� � 5r i �2 ✓ Capacity: (�`f S� p 0 0 Tee and filter Baffle � Vent Riser +/� Outlet boot Perm. Marker �/ Distribution D-box levels set) Seria1 Pressure Manifold LPP Notes• Pump System Checklist Pum Tank InitiaUDate State ID & Date: Ca acity: Riser (6" min.) NEMA 4X Box ModeL• Piggy back plug Hard wired Alarm functioning Mounted on post Above grade (12") Conduit sealed Pressure Mani%Id Number of taps: Size and sch: Contracted Certified Operator (Type IV Systems): Notes• Tank Com onents InitiaUDate Pump model: Block (4") Nylon retrieval ro e Float tree �nd attachments On/Off float swing: in. Alarm float (6" se aration) Anti-si hon hole Check valve Threaded union Gate valve Conduit sealed Outlet sealed A proved and secured riser Su 1 Line Size ancl material: in. sch. Length: ft.