A31 167Application Date- � 5 ' � �
Amount paid; • N G
Receipt #: � ,�_,_,,,,,_
o....�� � f �Jl.ell�l�'iJ'�� Ta� Map: �J �
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Application for Services
Services Re uested
improvement Pcrmit (Site Evaluation) ConstrucEion Authorization
$200:00/$3Q0.00 if> 600 d) Fee is de endent on the e of s stem ernutted
Mobile Home Replacement or Building Addition Permit Revision
$150.00 if site visit re uired $75.00
Wcll Permit (NewlReplacement/Repair) Repair of Existing Septic System
$300.00/$200.00/$75.00 Application_ No Charge/ CA $150.00 or $300.00
C�ac c� Wk��ri'e1�
1) Applicant Informati�n:
Vame: �r . �t,_�i� n-) 1� ��' ��� �-�CJ
Address: j 1 �Cv '(�f���.L►-C (..,,-,� Gr- ��D
l�tr�,t�- N►� cc.5 ti.t G
==K�z and address of current owner (if different than annlicant):
,
Name: �-�- �.R�W in� (�F-�'� i`�iSZ O
Address: tpt 3 '�Z�t� [�,-a t�L-
(,;+�A�r o rv rv G 2'�-�'Zb
3) Property Description: Lot Size: Subdivision•
Address and/or dizecrions to Properry: �
(�vf��t � ��r s-- . 1-�uS � � 12�
Phone (home):
{wo cel q!�- C��ai -' 1 �i �-3
Phone: C/I`1 " �C',3t � 1��3
" ves � no Does the site contain any iurisdictional weitands? '
❑ yes ❑ no Does the site contain any e7cisting 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 auy other public agency?
❑ yes ❑ no Are tUere any easements oz right of ways on this properry'
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential �
❑ New Single Famity Residence Maximum number of bedrooms: .
C7 F,xpansion of Existing System If expansion: Current number of bedrooms:
� Repair to Malfunctioning System Will there be abasement? ❑ yes ❑ no With plumbing fixtures? ❑ yes O no
❑Non-Residentiai
Type of business: `
Maximum number of employees:
Total Square footage of Buiiding:
Maximum number of seats:
� Water Snpply: O New well ❑ Existing We11 ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes D no
6) If applying for �Authorizafion to Construct', please indicate preferred system type(s):
❑ Conventional � Accepted ❑ Innovative ❑ A.lternative f� Other l� Any
I certify that the information provided above is complete and correct. I also understand that if the infvrmation provided is
inaccurute, of^ if the site is subsequently altered, or the intended use changes, all permits and appravals shall be invalid.
�' L.°'Jt". ^ a� 8�� I �
Signature (Owner/ l�gal Representative*)
* Supporting documentation required.
ate
• Permits are valid for either 60 manths or are non-expiring when accompanied by an approved plat.
• A completed `LotPreparation' 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)
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Applicant:
Address/Lc
Tax Map: �� Parcel:�_
Subdivision � ��
Phase/Section/Lot # !�
Permit Valid for: Five Years
Type of Facility:
Number of: ms / Occupants
Proposed Wastewater em:
Proposed Repair:
Permit Conditions:
Authorized State Agent:
(X) Owner or Legal Re
Improvement Permit
Non-expiring
New Addition _ Water Supply:
/ Employees / Seats: Projected Daily Flow:��gallons/day
Type:
Date:
Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits.l'h�s the responsibility of
the applicandproperty owner to insure 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 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
nnd Rules for Sewage Treatment and Disposal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater S tem: nfCd �25 la e�luG �S�Pin�'�)Type _�_��__ Design Flow �( -� gal./day
New Repair �Expansion � Soil LTAR: J � 3 gal./day/ftz
Type of Facility: �nvn � S; ��� . Basement: _ Yes _ No
(*) System Types Illb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Exi sfi n
Tank Size: Sep�ic Tank OV� gal.
Drainfield: Total Area 900 sq. ft.
Pump Tank gal.
Total Length �Oc� ft.
Trench Width s� ft. Min.Soil Cover � in.
Distribution: Distribution Box / Serial Distribution 1/ / Pressure Manifolc
Specifications: C,{1�2G �,T � �
^
Authorized State
^vrease Trap — gal.
Max. Trench Depth � in.
o . e,
Min.Trench Separation � ft.
__,--y_,._
Issue Date: �-��-��
Permit Expiration Date: � //-/�
The system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions
and specifications of this permit. , ^�
(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)
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DB 239-315
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SITE PLAN
Name �d�Vl� W�I �e�d Tax Map #� Parcel #�
Subdivi ' Section/I,ot#
� �12 -!
Au orized State Agent � i`. � Date
System components represent approximate c ntours on/y. The contractor must,/lag the systemprior to beginning the
installation to insure that propergrade is maintained
—300' �cc - . _ _ _ _
— 3 " -k�eh� �.e�4� .
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— S�r, a( d�s{,� i b�afion
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IE� aa�a. a- o�nx�-n ��a.�a�.Il IE� ��.IL �Iia
Applicant: �//L��� G1%i r`�i�'� t�
Location: s/7�v /�,�'�f i�.✓a ,�a.
Operation Pern�it
�
Tax Map � Parcel # /!v �
Subdivision
Phase/Section/Lot #
# of Bedrooms
System Type (From Table Va): Product (IIIg): �� ;=u, t.�
Type V& VI Expiration Date: 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.
�/ ��
( uthoriz Agent)
�D�O.G�D �
(Licensed Contractor) 7.¢ `
�.5� '�i�i� �
Scale �>�
PCFiD, rev. 12/14/12
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(Date)
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(Date)
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� 13�n1 �'""'e,-.E �- �M'=*''- A
r �_
Line Length
t 1, vo
� go
3 -70
�
Total 300
Tax Map: �/ Parcel #: J 7
Septic Tank System Checklist (Type II-I� System Type: �
Septic Tank InitiaUDate
State ID & Date:
Capacity:
Tee and filter � �
Baffle
Vent
Riser .
Outlet boot
Perm. Marker
Distribution
D-box levels set)
Serial
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 ost
Above grade (12")
Conduit sealed
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes•
Tank Com onents Initial/Date
Pump model:
Block (4")
Nylon retrieva.l rope
Float tree and 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 and material: in. sch.
Length: ft.
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WELL PERNIIT� �
PI.F,ASIE SEE A1'I'ACHED PLAN FOR'WELL SITE LAYOUT
Tax Map #: .�_ Parcel # �� Township
Applican�
Subdivisiori: Section: I.o�
. Location: �
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----Q
Ty,�e of Water Suvulv:
Requirements-
Site Approved by
Grouting Approved bp
Well Log
Well Tag�,
Air Vent �
Hose Bib �
Concxete Slab
Well Driller. �
co���y P,��
Well Approved By: Date:
'�'See Attached Site Sketch'�
Wells must be 10 feet from property lines.
Wells must he 100 feet from septic syst�ms.
Wells must be at least 25 feet from anp building foundation.
Oiiier conditions: ---
PC�ID, =ev. 09/07/01