The URL can be used to link to this page

A31 126Site Evaluation Application Date: Fee Collected YE5 � t70 � � �� ;�� APPLICATION FOR IMPROVE2:L•'NTS PFRIiIT J �b � ,� 1. Permit requested by: owner/prospective owner: � , agent: Address: � _- Home Phone �r: ,_g'-� 9- .,.., =4��9 Busin ss Phone �'�: 2. Name and address of current oianer: 3. Property Description: Lot size: �•� f�� 4. Ta� map ��: �„�� Townshi : Subdivision Narne: � c/s Lot ��: S. Directians to property: State Road �� & Road Names, etc. �_ '�4 . i i i � /1 .G a �. � _' ., � .,--..� ._ �?r 6. Permit requested for: New Installation: �/� Repair: t�dditional Renovation re-using present system: �-/v-9a' .�, �,. � , � ', . �� 7. Number of o�cupants ar peogle to be served : ��-�- i��u e W a1 . �so � � � ��._� ti. Dimensions of Proposed Structure: Width: No{-�,'t�cr.�►� Depth: ,�jp,L ,(',veu,)a( �] 10. i? , z � iahat type (if any) additions, expansions, or replacement is anticipated to the struc- � ture or facility that this sewage dispos3l system is intended to serve? � �� - w � — � ; - � / w Water supply private?. y_/ public? community? spring? ..� � Other source? (Sp�cify): '� Are there any wells on adjoining property! y- If so, identify location: � / . -� l i)rl �l�t� � • �.-� � � l .:sL-1.. LL� __v_�_� __ 'Type of structure or facilzty: Proposed: s� Existing: 'Tyge of dwelling: House: _� Mobile Eiome: Business: Type of business: Number of Employees: Number of Uedroams: 'N..�f ,t/acJ Garbage Disposal? Yes PIo Basement? i'es No If so, nurnber of bas�ement �ixtures: 12. Cleasly stake ail corners of the property and the corners of all proposed structures. I hereby make application to the Person County Health Department for a site evaluation or existing system evaluatic�n for the on-site sewa�e disposal system for the above descrit�ed property. I agree that the contents of this application are true and represent the naximum facilities to be placed on the property. I understan� if the site is altered or the intended use changes, the permit shall.become invalid. Permits are valid for 60 months from date of issue. Permission is hereU granted to entel the property for the evaluation. G.S. 13QA-335(F) �. . �GL . Signe Owner r uthorized Agent �.JJ r 0 � � L' ��ermit Issued Permit Denied �lat Observed 0 ��C�aRS - SITE EVAI.UATION a SLOPE (X) o SOiL TEKTtJRE (12-36 in. ) (Sandy, loamy, clayey, Note 2:1 clay) . SOIL STRUC7.'(TR.E (12-36 in. ; (Clayey soils) - -� -- _ _ — . SOIL DEPTH (in.) " � RESTRICTIVE HORIZONS (in.; (Im�ervious Strata� rock) . SOIL nRAIFdAGE/GROUND43ATER (�ternal � Internal) o SOIL PERMF..ABILITY (Percolation Rate) . OTHER (specify) . SITE CLASSIFICATION (See below) AREA 1 PS U S PS U � e'"� S � S � �j (P S � U � u S � S FS U � ? AREA 2 �}-3 A�ZEA �— _,/ �.�-- PS �-� PS u u S S PS o,,,,� � �� S S PS � `�G°"�,� ' u S S ps 3 �' �� S S � �� U U S S P,� S is' S �"�e� u S S PS �� - �'. S S PS PS U U AiZEA cs� ' PS U S � S �' U „ -- � �� U 5cn �t S � U S �- S PS U � S PS t U S- Suitable PS - Provi.sionally Suitable U- Un�u�table ;LCOMMEd�iDATIONS/COMMENTS: C� �,_„ ;+:sE Cf.�►SSIFICATZON DIAGItAM (.2nclude: Soil area�, property line�. raa.ds, �L-reams, �;ull��s s ciet are�s. fill' ;a"reas. �,,' water bodies, slope pattern�, etc.} . Amount paid �'ee �G�,�e� - •: �ecei•pt � ' � � • ��i `�. `'�.t � . � APPLi� H O � � � � c c C � a a � a E- Improvements Permit. (EstablishedlRecorded Lot) Impxovemencs Permit (Unrecorded Lot) Improvements Permi[ (Mobile Home Replace) Improvements Permit (Addition) 1-I1 q�( Date � Reinspection of Existing System (Loan Closing) Repair/Replace existing Septic System ,_ Permit foc New Well _. Replace Existing Well . Permit requested by: ./j1«lh�EL �".4-� ,�icik�.�c.,� 7. Dimensions or Proposed Strueture: owner/prospective owner/a;ent: Width: �✓�` Address: !�ld/ ��rr/�-S _ �d�9�/ Depth: �' L v �il%� L• ��.2 8. What type (if any, additions, expansions, or � replacement is anticipated to the structure or facility i that this sewage disposal system is intended to serve? ? Home Phone #: �� 3d � v`7.2� �%�� ; usiness Phone tt: ,��vE�2. 9/9 �y�y- �,36.5 2. Name and address of current owner: e�� 9. Water supply t}'pe: �' � � � �r�o Er v�- private �public ❑ community ❑ spring ❑ -G�., r2?'6' Are any wells on adjoining property?Yes CZ� No (..�. -z o If so, identify location: /�2i� �i��' �1�- 3. Propercy Description: Lot size: �� ' �b'�eF''� . Tax Map#: �.3l . ype of structurelfaciliry: Proposed: DExisting: Q Parcel#: .Co<' v� Type of dwelling: Township: / u • House� Mobiie Home: C7 Business: ❑ ; 5. Directions to propercy: State Road #& Road Type of business: �� Number of Employees: ? ames,g� � � Number of bedrooms: y� � i Garbage Disposal? Yes ❑ No� ' , Basement? Yes ❑ No� If so, # of basement fixtures: I6. Number of occupants or people to be served: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS OF ALt.. PROPOSED STRUCTURES. I hereby make application to the PerSOn COunty Health Department for a site evaluation for the on-site sewage disposal system for the above deseribed 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. I understand that before an Impcovements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the even[ I have not delivered a survey plat of che property to the Health Dept. wichin 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. < � Signc or Authorized Agent N � � a w � a -_, B 2702 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # A 31 Parcel # /�� Zoning Township �us�� v� �c Owner/Contractor %%i�l, as /../�' S��/�'� Date /- 2�- 99 Location/Address G�Q��'� ��a �� S.R.# l//Z Subdivision Name /,J� /�! .j r��c�� v�'e % s Lot# �' SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area �l. !,'i Ac. Size of Tank /G� SFD h�u�sc Mobile Home Size of Pump Tank /OlX� Business # of Bedrooms�_ Nitrification Line y�D X 3' Max Depth Trenches /8`=ZO�� Permits may be voided if site Well and Septic Layout by �; Comments: S�c co��'� a: be o�� '�s�a//;,�. . ,c �' Dates'(` Installed by intended use Approved by Permit Paid Q' WELL SYSTEM SPECIFICATIONS ividual ,/ Semi-Public Site Approved��j Well Head Approved Grouting ApprovedY Comments: � Required Slab � Air Vent � Required Well Lo Well Tag � 'S Date� (�I �(t'i0 Installed by Approved by This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleadin� information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person Cou�ty 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:\amipro\permit.sam O1/95 rev.l.l �° I � � � ti� � � � - � . � � � � � . , - `�o ��, � . � a c . �2�. , . � �� 1 L24 � . / ' � L 23 � �o°a. . � + 1.?0 OC. I 2 i� ' `� L22 `'� 10' x TO' �� ; Qp I N slqhT trian¢� �. �y Z'j o . Z �t � � L 21 c. �' � \ � �� ,y� I - � � . �� 'S . - ; �� , =� �� , % �� — �,:- � , ' � ia, O ; � e �,ci . , � C,� - � � \ s �',. � `r, .�'•�, � . � � j � '" 'o � ,¢ 0�6 • o, � ,� � - ' � c o. ��, �� 7� Y �� t� � �p^ �p�, �%. � � /� � N D c9 J'� a. �` ?� 2. i 1 a c. �- m o ^ oi � , �` \ ^�F � ,� i �,� ,� ri 'Dp C� 9 av. � �� $�2s-3s-�7-w � `� r----- '4 � � , . � � o °o � �`"� � i� �k ��'L � � = i� � � ;. ,Zg -�'�- I 1 ro � ,��a` � � �r � �' � � � ��' � L 2 � � ' � � ; ��' � �� - . ,� 1 c , ��° � / a �' � '. �v /3� , � - � -+� , � .� . u�� 4 !, ��r � �;' .. �` A t,�, v► N ti/ �Q'�hh7l/!/ �% '�,�Q � � 4 �„ � �� 'F 'c7+ N a' � � / / � �,_� � �' S� � � / j'/ N � / , O �� , m � h � � � �a P i � �,o �,"' a W Lt3 '� I � C . �, ,I �, . -.. , b p Q' �'�. ryti'� "� . �, �,, � ^ ' / �, �. Z / �k,, � ' �6 �a �. t 7 ,� � , ¢2 A e,�,, / r ' � / .,�. (t1 , ; �� _1 � �� / _� ��' r „ f IO�d �i�a t_ t� � • � � ; � �rf .� t .:� ; i .:� �,��,. - j ~ � ,� �% ,, Aiip(OX. �� a � , i�Ci�lr� / �`y.` < 4 �"\ ti�' GC/� / �.I 0� ry� �O ` / '�. � ( 3' � R � ' � �%� C-��'`'`� C� cP �, �6 � ��B :. � \�cP \ti�° — �, / D. L. Whitfieid Chitdren �9-W � �L ( I c�' � ` ( � 1, � \ �. ' ' ,1 L i�'l-� � � ;:�I�,- ��y2 �.�. �t r � � �� / � l , ' - � ��r.�G��<<zi �- i'✓'``ti�"l Ll� � y�o � 5�� C�'��!% Person County Health Department Environmental Health Section ' `�ax'Map #• � �� Parcel #• � - Zoning: Township: ��f ��= Subdivision:,fdll �� l.�,l�()G�1'��i.�5 Section: Applicant: � �.�� ( / ` J�i�i�Ll l Location: �/lG(��1� �(�IG' �� • Lot: � O eration Perm it System Type (In Accordance With Table Va): .� 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. ��1 �i�.�f�� Authorized State Agent (�• � � ��/' f�i� .��-1- �(� Date �� Vl (DDI�'� �(1t � .� � �,` �1...G,1 �ti� ,j Tax Map #: ��I � Parcel #: ! 2� PCHD, rev. 10/12/99 � � Person County Heatth Department Environmental Health Sec 'on � Zoning: Township: Subdivision: 1�111��,�?�� ei�r � ��d5 Section: Lot: Applicant: ,� �� G� Location: � �/l� �C ' �� Operation Permit 1. LOCATION AND SEPARATfON DISTANCES A) System meets .1950 setback requirements �_ B) Distance from system to any wells l�f1 � fi ' C) Distance from septic tank to foundation �S! _._ D) Distance from system to property lines z/1� � 2. SEPTIC TANK A) Visually inspect the exterior walis and top of the tank _� B) Visuaily inspect the interior walls, ba e, tee, filter, riser, lids, air vent, bottom, and water tight outle�_ (p � C) Date of tank manufacture � ——�� A- �}-� D) Tank seriai number % ' S '�2 � i I G�1—Z� Z ��U� r� E) Liquid capaciry of tank�pQQ�,.e��.�allons 3. SUPPLY LINE.TO TRENCHES A) Grade P 1/8 inch per foot minimum G B) Material sup�ly line ' constructed from C) Diameter � D) Length � E) Distance from tank to drainfield/distribution device �� 4. DISTRIBUTION DEVICE(S) A) Type .LG - B) Is Device w ter tight C) Distance from the distribution device(s�the trenches 3� D) Is the device on a level foundation / E) �oes the device perform according to its desi n specifications �% l� F) Record the inlet and outlet elevations �� 5. NITRIFICATION FIELD A) Trench depth 1�� inches B) Trench width � inches C) Distance between trenches� � D"Vl 1°!/%�� _ D) Number of trenches E) Length(s) of trenches 1� �� F) Aggregate depth inches G) Aggregate material and size �5 H) Record septic tank utlet elevation lYYj I) Trench grade (< 1/4" per �0') J) Step downs _ a. Minimum of 2' of undisturbed earth ✓ b. Proper rise over step down ✓ c. Solid pipe used � d. Elevations of step downs �� (Record elevations and show on as built) See "as built�nro�a�attached sheet. PCHD, rev. 90/12/99 Application Date: 7"� �� 3 Amount Paid: 0 • Receipt #: l 7 3� � `�,?, � �� Y.�l V eked� 1- -' � �'�T�T�C� � IE�..�m� a.a-�an_mraa.:.2n.4;.rn.Il 7HIrc�,�.11�:ln. n 0 Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 d) Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement/Itepair) $3 00.00/$200.00/$75.00 �lication for Services Services Re uested ❑ Construction Authorization (Fee is de endent on the e of ❑ Permit Revision $75.00 Tax Map: �3 � Parcel#: I � V � ��e app►'O °` � t� �Ns�°� ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 ./1) Applicant I ormation: Name: .rz Address: � 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): 0 �.—� 'T � � (work/cell): C� — � Phone: Lot #: � ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? ❑ 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? ❑ 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: �dential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Total Square footage of Building: ,3 � x%LS � Maximum number of employees: Maximum number of seats: 5) Water Supply: ❑ New well I��xisting 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 ❑ Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Signatur�(Owne % Legal Representative*) * Support' g documentation required. 9 3 ate 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) !� � �� . , �� , < <�� \ � I � ��.n ��.�.� Building Additions/ Mobile I3ome Replacements Tax Map #:�� Pazcel#: 12� Address: 15� Sfi-a �,i�Qr�c,/ ��,�as Q"� Approval ReCuested for: Mobile Home Replacement �% Building Addition . Applicant Name: �.�1��,f U� Address: 3go(�' I`'tor�Ta c�. �a I�-��,�, n,rP M d 2. I 2 0(� Phone #'s: �( ( 0- z I� -S�Inq �I � h- U�� - ��Zo Permii Locate�: � Yes Installation Date: 5 -1- �D No Desxgr� flow: ( 0 (gpd) Current Contract with Certified aperator on file (if required): Water Supply: v VJell Public or Cornmunity Wastewater system shows no visu�l �vidence of failure on: �- I 0-( 3 (date) (Applicant's signature if site visit is not required) Comments: � A►ddition/RepIacepnent Approv�d � � Enviro ental Health pecialist 7 - � o -�3 Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcount, .v net _ . . . .�` �J�� 1.�./ �� 1 `� 7 �� IE�.�y-�,r,,,,,,.,,��.11 ]E-3I��.H� Nam.e�e ��A Me��e2 Subdivisio � A tho�ized State Agent SiTE S�TCH , Ta.z Map # 3 � � Pa:tcel # � 2 �e Section/Lot# `7- 11�13 Date System components s�e�iresent approxi»urte �contours only: The contractor must flug ihe system1brior to beginning the installation to insure that pmpergmde is maintai�red _.i.,,,� �.f- �n' xz-I o ., : /��n �� I�I:IcSo�J �:uUtJl'1' I:iivll;ulJrll•I�i�ni. ii�.nl.�i�ll I!I•:I,i, I.c��; I ��llc: .--�i�/..�.�,.2.v0� �� , .)wi�er:..��.s:,�_�4e�.._._��---5�'I.�._M.�Ck..--------�- � '' . . ... ..__ _._.__ .... . ....... ... .._.._ S (��1 - -�-�� __._� I..��c�3li��i�/l:)ircc(iun�: C.�1r�t�..l+�. _.�o�n�___..�.�_...._.._._.. _._._.. __..._..------- --..--. ---._--------._ _- ---------._.._. .-- -------------- _ ..--- ---.. ---- ---_ ---. ............-.---_._. ._.._.._..--�----- ---.__ .... _ ......__. . Su�tliviai�.�ii N��ii�i�: V.l.�-- � ,- ' _. _ ` 1 � ..___5�.--�-��►-� --��_�.(�-- ------- - 1:)rillinb �,��niractc�r: _..._.__..--_-- { , �, -------�- [..c�t IE � - ��._��i_ _ � s.l Lo � ----------- wr.�.�=-�-.��Ns�rFZ��c�rr��r1 ---.--------------�—.-----_— l�is�:uicc: li�c�in Nc,►res� 1'Jc��>erty l..in�.--�U t------ l�ist�i�ic� trc�in Source c�f 1'u l l u l io i�i Q.�7-------- ' �l'ut;�l I)cl�ti�:____L(� �----- I'�. �'icici: .1_ (�l'M St��tic Vater I.cvcl Water l3eaiin�; L�n�s: l�c��tl�_� b� I� 1 � -_ `_Ft. , �5r�6�� 't._._._�--}'�. L<<s�ng: DeI>�1�: I=rc�in_ __f___--_tc�---'�L---��'�Ia 1)i�,n�c�er. � � . '('YI'C: Si��l . ----C9�I�_._1ncl�c.s ---------- ----�'alv�i��iz�cl S�ec) v CC St�cl, c1u�, c��vnc:r a��rc�vc: Yc:s ;i N,� �-------------�---- W�i�;li�:---- -. --- I�liick�ic,s: ____.11�iblit tllwv�: �rc�uiici:_ !¢2 _ I�icites L)rive Sl�i��: YcS---- Nc� ✓ W�re Prc�l,lc�i�s Lncount�rccl in S�ttinb �lic Casir��'1 Y�s. ----- -----Tlo � .! . .. . ---�- �- -- ------- --. _. �i yc� b,v� r��s��ii: �irc�ut: �I�YI�: Nc:it.---- ---- Sanc1 C'�ii�c:i►t -------- - � - �— Conc:r�tc A��nular S��icc Wicitl�----_ Z� lncl�c:s ---- �--� ' Watc:r i�i Aniiiilar S��ace: �'�s --------- Nc� � Ivlethocl: 1'uir��x:ci------ 1'rc;ssu�� -- ----Pc�ur�cl u�,�t�,: r<<��.--------� ---- ��> �� -� �� r�- ------ Mal�rials [)sul: i�ic�. I3abs Pc�rtlaricl ('entciit � 1�Vei�;lii c�f 1 l�a�;��_ll�s. If ,r�ix�urc (s.>>>�1, gravel, �:iittii��s) - 7Za�iu: ,._�� tc� � ll-) t'la�cs: i'es '� t`1c� - --�--------- --------- �l x �l slat� Yc:s____ ,_� -- i�1c� ---------- �----------- ----- -------.._- --------------�)R1I.I 1T1�; [.Ck_; --------�-----�--------�--�------ Iac �tl� __L__—.. ------- �- ----- ------------------------�-�----------._..___-�--------------.. Trc;�tt__. . _"I'�, - - - ---.----.--------- Pc�r�n�s�ic�n I��sc�iLic�n � - � - _ ..... .__.._.. -Q-�-:-.. .. ..��: . . _ . . ... . .. .... . . . .. ... _ _ . . . _ . . _. . ...._. --�--a_ _---- ..3b _.._..._ .. sa.ke.ra _(��c.IC . ._.... . . ._.... . .. ....... ... . . . ._ .---- — - .. � -�i�._...____. . �. �. ...._ �fC1V1} ��.__....._ ...-----..._.._..._._.. ......... .. .._. .___ ---�----- �, r ,1 ... . .. _ --""7�-�---- --�.�.�n.S-� - -��_An�_:t-�_.__. _ .---- � -._. . . _._. . T IIl:RE13Y (:l:K"I'll��'"('f1t1"!'"I'fif: A13OVI:II`�I�O1�1�•1r�'I�l(.)i� I� CUIZIZI:(::, '(�I1[S W1:1.1.1'Y�1S C�C)i•!5'I'Rl_1CY1'l:1�) 1Tl Ac~C'O1Z1),�N(,(: 1�Y1"I'1( lt}:c�Uf..A"1'IO�JSISL'•"i' 1��O1Z"1'1113Y"l'l11:1'f;h`�(�iJ�'(>l1N'I'l' fll;�l:l'Il 1)l:l't�fZ"I'h-II:t�J�l'. Si�;ri,i�iir� c,l' C'uiitr�ic:tu�r�'K.�� "'�� . I ��i:: �/jy/��dv �