A31 36The District Health Department
Orange, Person; Caswell, Chatham, Lee Couniies
• _.
Water Suaplv and Sewaqe Disposal
Owner:
Contractor: _
Water Supply:
Sewage Disposal
washing machin
Size of tank: —
Other disposal facility:
� — �� Public
�� Dishwasher, Disposal,
appliances
fitrification line:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Above recommendations based on information received and observed
soil condition. Septic tank and nitrification line MUST BE' INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PARTMENT STAFF before any portion of the inst211ation is covered
and put into use.
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date.
�he; District Health; �DeRartmenf
: .... ._ _ . _ . �
; o:��, p��n. C�wa1L ChafLani. I.� Countie�
� .
: ._ ,SEP'�IC- TAN'-K :PEI�VI�T �
�nat� I — _3! — ��—
Name :of owner: r1� Il/� �r�r ' � -
Name <af contractor: —, � v' n ' r r�"
Address and Directions �'�"��!i�-- �'�'��y�II�� . ,
�r► i��nd+ �nr�i?c�..� j � A
Pe•cson or firm doing installation: ~ , • `
J�CZTESS .
No. of persons to be.serve' :Beclroo 'ms-1,-2,�4•-
,Piciditional :appl,iances to. be used:_:._Disgosal, _cinshwasher,. wasliing
,nac�ine 1� �n r� v . � .. � �
. , ,. . ;
lqecommended• ` � � SePtic. . _ .. _. , . ...; �
+ ___, . .
. ;
Nitrification .line•.
'�/.c1�2� � �.
Above recommendation based on information received;-and- observed-
' soil condition. Sevtic tan� and nitri8cation lirie must be� in'spected.aael �
aFpsoved by a nhea�es �ofthe Dis3rid iiealth`Departmeat;staff before
:' any po'rtion of the iastallation is covered. ' ', ;
,... .:. . . . . ._ .
_ � _ ;_. :.. _ _
Date Approved:, � -- � ;��- b ; ,
,
. . . . __.
. _ . .
_..� . , .
. ' ; ; Si�e� ,
� + Saiutarian •
:+
Bj!' , , �, 14 . . _ ... _
.. ..... , . . _..:_.__.,....`. ; ... .. � .H.
..� �
. , . . : O. David Garvin,, M.D., M.P
'' . : � ` District' Heaith Officer _
- Couatersigned_ � � • .
, .. _, _... (�VVBT�
...,. - { . � ----
_ _ _ _ _.. __ _ .
� �..._...,.�.. __ _...__�
- ��
. � ,� W
F
W . .. ,
� �� �
. �7
,���'��' � _.. _ ..._. _,....__ _ _ �.�___.___..�_.._.._...�_____.�_
..J � '
-
�i .
A �lication Date:2��—� Tax Map #:
Amourit Paid: 0, �,'j =G�G�� � �� ��� � � GL1ll/1��i
Receipt #: 27 _�',Z'7'i `� Parcel #:
��� S� IC-"'I.�II�� ��T
- - _ ������
������.� ��.��.a ��ma��.
APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPI.ICATION 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 by: (Owner/agent/prospective owner): �QU(h �• ���v"R �
Home Phone: ���^- 7l�( Address: 4' /' o�
Business Phone: $'!�'f �132 -�. d�� vu� P l�. , C'• Z 9 S�
2) Name and address of current owner: �Sai'Gtf � �
�
3) Property Description: Lot size: � Township: �� Subdivision: Lot #
Directions to the prope�ty�p�ud�in�/�d name�s d numbers): c,�' a .
f.� ti ��'? �u d�r' w� �-��•��
" � ��� ��i/���
4) Proposed Use and Structure Description: answer eac of t foliowing questions: ,
a) Proposed , Existing . Type of Structure: �i�� ^ Width:�_ Depth: �
b) Number of Bedrooms: ,�_ Number of occupants or people to be served: 1I_
c) Basement: Yes , No c./Wiil there be plumbing in the basement? ciQ
d) Garbage Disposal: Yes J No S�
5) Water Supply Type: Private (new _ or existing�, Public_, Community , Spring �
Are any welis on adjoining property? Yes No _ If 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 LINES 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 place the prope . I understand if the site is altered or the intended use changes, the permit shall
become invatid.
2�2� ��
Owner or Legal Representative Date
PCND, rev. 06127102
��-� , 1 �¢�� ����¢� Date: March 9, 2004
2150 Charlie Long Road
Hurdle Mills, NC 27541
Re: Application for improvement permit for lot located on Whitmore Road.
Person County Health Department - Taac map # A31-36
Dear Mr. Kevin Moore;
The Person County Health Department, Environmental Health Division, on March 1,
2004 au�er borin�s) and March 8 2004 (au�er borin�s — Second ouinionl evaluated the above-
referenced property at the site designated on the plabsite plan that accompanied your
improvement permit application. According to your application, the site is to serve a three-
bedroom residence with a design wastewater flow of 360 alg lons per day. The evaluation was
done in accordance with the laws and rules governing wastewater systems in North Carolina
General Statute 130A-333 and 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, Rules.1940 through .1948, the evaluation indicated that the site is
iTNSUITABLE for a ground absoiption sewage system. Therefore, your request for an
improvement permit is DENIED. A copy of the site evaluation is attached. The site is unsuitable
based on the following:
Unsuitable soil topography and/or landscape position (Rule .1940).
x Unsuitable soil characterisrics (structure or clay mineralogy) (Rule .1941).
�� Unsuitable soil wetness condition (Rule .1942).
C Unsuitable soil depth (Rule .1943).
Presence of restrictive horizon (Rule .1944).
Insufficient space for septic system and repair azea (Rule .1945).
Unsuitable for meeting required setbacks (Rule .1950).
Other (Rule .194�
These severe soil or site limitations could cause premature system failure, leading to the
discharge of untreated sewage on the ground surface, in surface waters, directly into groundwater
or inside your structure.
The site has an existing system in for a two-bedroom single-family residence. We cannot
pernut the addition of a third bedroom, but a house of the two-bedroom caliber may be placed on-
site.
The site evaluation included consideration of possible site modifications, and modified
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.
phone 336.597.1790
fax 336.597.7808
20-B Court Street, Ro�oro, NC 27573
For the reasons set out above, the property is currently classified iJNSUITABLE and an
improvement permit shall not be issued for this site in accordance with Rule .1948(c).
However, a site classified as UNSUITABLE may be reclassified as PROVI5IONALLY
SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d).
A copy of this rule is attached. 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 informal 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 informal review by the N.C. Department of Environmental and Natural
Resources regional soil specialist. 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.perition for a contested case hearing with the Office of Administrative Hearings, 6714
Mail Service Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form, you may write
the Office of Administrative Hearings or call the office at (919) 733-0926. The petition for a
contested case hearing must be filed in accordance with the provisions 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 you're 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 a petition for a
contested case hearing with the Office of Administrative Hearings WITHIN 30 DAYS OF THE
DATE OF TffiS LETTER. The date of this letter is October 7. 2003. Meeting the 30-day
deadline is critical to your right to a formal appeal. Beginning a formal appeal within 30 days
will not interfere with any informal review that you might request. Do not wait for the outcome
of any informal review if you wish to file a 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 send a copy of your petition
to the North Carolina Department of Environment and Natural Resources. You_ must send the
copy to: Office of General Counsel, N.C. Department of Environment and Natural Resources,
1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy of your petition to
your local health department. Sending a copy of your petition to the local health deparhnent will
NOT satisfy the legal requirement in N.C. Gen. Stat. 150B-23 that you send a copy to the Office
of General Counsel, NCDENR.
You may call to Person County Health Department at 336-597-1790 if you need any
additional information or assistance.
Sincerely,
�
, '
Cassandra J. Slagle, S.
Person County Environmental ealth
Attachments (copy of site evaluation and copy of Rule .1948(d))