A30 80The DistriEf Health Depcartmenf
Orange, Person, Chatham, Lee Counties
SEPTIC TANK PER1vlIT
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Name of own , , � y
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Address and Directions ��, .
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Person or firm doing installation: �. C• F�i �
Address / ( � �C'aojt o
No. of persons to be served bedrooms 1, 2, 3, 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Minimum Requirements: Septic tank �� �A �-
Nitrification line: �T Q � � �� / �
Septic tank and nitrification line must be inspected and approved by
a member of the Hea12h Departmeni staff before any portion of the
installation is covered.
Date Approved:
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$ •
By• anit
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
I`3OTE: 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.
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Application Date: 7`� �� �
" Amount Paid: ' ��b
Receipt#: � �� �
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APPLICATION FOR SERVICES
Tax Maq #: � `"� �
Parcel #: �
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested b:(Owner/agent/prospective owner): _��LNnv �!-�t,JK ��wn���
Home Phone: 336 0! Address: 205 To�., �ll�r Q�Q•
Business Phone: �X bo r � C'- z7S73
2) Name and address of current owner: � h �. �.I�i.,��
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K br. /�j . l�- `• �7S].3
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3) Property Description: Lot size: Township: 8. �`� � Subdivision: Lot # _
Directions to the property (Including road names and numbers :
a� o v e 0. Ir�S S
4) Proposed Use and Structure Description: answer e�h of �he followin qu�stions: � �
a) Proposed �� , Existing _, Type of Structure: 0.��-� �- V��i �� � v Width:�2= Depth: I�
b) Number of Bedrooms: ' Number of occupants or people to be serve :
c) Basement: Yes_, No � Will there be plumbing in the basement? �10
d) Garbage Disposal: Yes , No _
5) Water Supply Type: Private �✓(new or existing�, Public_, Community_, Spring _
Are any wells on adjoining property? Yes_ No ✓f yes, please indicate approximate location on the
site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No �✓
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described 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 shall
become invalid.
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Owner or Legal Representative
7-/9-oZ
Date
PCHD, rev. O6/27/02
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Tax Map #_� Parcel # �
Existing Sewage System Report For. �obile Home Replacement
Addition Type: �-�irLOn� Li� 1�.
Requester. �n,� � 8 rr�,� Home Phone# �� �� g��
�� �c7iirl ��(C,fl KOacl Business #
Original Permit Located: �
Septic System Designed For: �Residential
Water Supply: Or� V�t� 1.�: C, ( �
Busitiess Other
# Bedrooms ? # Employees Other
System Type: l..0/1 U�I�On�I Tank Size: �� ��� Nitrification Line: ����x3 �
Date Installed: // SJ Certified Operator Required: ��
On-site wastewater disposal system shows no visual signs of malfunction on GJ�O'� .
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Pertnission is granted to
Q��l�) p�? (..� 1 r�G-�/v� /�r1 �i'n G C.,� �-��, �G
�J r�. t b F-(� c. �i � m c. ��` X I(o ` Ci.c�d r`-�i on i.,� i' l � Ci !(o W F�r
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a-��on -f� u.� c.,x�bfi�g c..sc/� � a cS�p/us �c�4�a.-Ei'�
�-f��� st�-Eic.� L�O l�c� � EXC�4U/�TE f��fi C�(,ir -�o f�d� o�
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Environmental Health Specialist Date: �� y�
3/��/,�
Application Date: 3-� � � 7 �,� � 0 ���.� f��4 ����
Amount Paid: 1 �—>. � � ��� �
Receipt #: � g� J�r`��aa-,manaxa,0�n.�mA. IHIc�.e�.Jl4Jla
�—
� 110
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
for Services
Services Re uested
Construction Authorization
ee is de endent on the e of
Permit Revision
Tax Map: �
Parcel#: �
pair of E�isting Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: � �1�0 W � � .
Address: O � �'o it
ro �
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
Phone (home): 3 3�o -S 9 7' �DO �
(work/cell): 3 3 � - So - 839 �
Phone:
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
0 yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
Q yes ❑ no Are there any easements or right of ways on this properiy?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential '
❑ New Single Family Residence Maximum number of bedrooms: 3 / Occupants: �
� Expansion of Existing System If expansion: Current number of bedrooms:
� Repair to Malfunctioning System Will there be a basement? ❑ yes O no With plumbing fixtures? ❑ yes ❑ no
�Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
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 properiy? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional 0 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, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
,C',�,�� D.,,,,� 3 �a /7
Signature (Owner/ Legal Representative*) Date
* Supporting documentation required.
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.
(10/15) Person Count.y Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applicant: _�
Address/Location:
Permit Valid for: Five Years
Type of Facility: �
Number of: Bedrooms / Occupants,
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Authorized State Ageni:
(X) Owner or Legal R�
Taz Map: � Parcel: $��
Subdivision
Phase/Section/Lot #
Improvement Permit
Non-expiring
New Ad�ition Water Su '
/ Employees / Seats: P' ed Daily Flow:
Type:
Type:
Date:
Date:
gallons/day
The issuance of this perrnit b•� e Health Department does not guarantee the issuance of other required permits. It is th:, resFonsibility of
the applicant/property o r to insure that all Person County Planning and Zoning and Buildina Inspections requirements are met. This
[mprovement Perm' s subject tu revocation if the site plan, Qlat or the intended use changes. The Improvement is not affected
by a change in o ership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws
aird Rules or ewa e Treatment and I�ic osal stems'(15A I�iCAC 18A .1900). Neitber Persoo Couaty nor the Environmeatal
Health S�ecialist warrants tha� the septic system wiil continu.. to function satisfacto: iiy in thc fature, or that the water suppfy wiil
remain potable.
Authorization to Construct Wastewater Sys#em
See site plan and additional attachments (�.
x
Yroposed Wastewater System:
New Repair _ EYpansion _
Type of Facility:
(*)Type ___ Design Flow _ gal./day
Soil LTESk: gal./day/ftz
Ba.sement: _ Yes _ No
(`") Sysiem Types Iilb, Ilibg,l V, ��nd V, requireperiodic system inspertions by the Person County Health Department.
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- Wastewater System Requirements f'�„ /� ��D '
ff�� w�
Tank Size: Septic Tank D/ DD gal. Pump Tank gal. Grease Trap gal.
Drainfield: "Total Area sq. ft. Total Lengtl� _ ft. Max. Trench pth in.
Trench iNidth ft. Min.Soil C er in. Niin.T'renc eparation ft.
Distribution: Distrihution Box / Serial Distribution / Pressure Manifold �__
�!'7 -�i O
Authorized State Agent: issue Date:
Permit Expiration Date: Z �-
The system permitted is: Conventional /Accepted I Alternati�e / Innovative . I accept the conditions
and specifications of this permit. /�
(k) Owner or Legal Representative: �} �, Date: 3'� y���
Person County Environmental Health, 325 S. Morgan 5t, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
Tag Map 1� 3� Pa�cel #�
�,��tsf ������ ,�- Subdivision
-. � � �� � -� Phase/Section/Lot #
I��.�.s�������.Il IE���.Il�.
# of Bedrooms
Applicant:
Location:
�iLY' \
�uerat�on Permit
System Type (From Table Va): ��� � Product (IIIg): �a"� �ti
Type V& VI Expiration Date: Type V 8c VI Renewal Date:
This system has been installed in campliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
n� � �-r�✓�,�
( uthorizEd Agent) .
I� 1.�.��'S
(Licensed ConUractor)
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Scale �_
PCFiD, rev. 12/14/12
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(Date)
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(Date)
Tax Map: Parcel #: _
Septic Tank System Checklist (Type II I� System Type: �C�
l�ot��:
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
1Votes: