A31 38The Dis�rict Health Department
Orange, Person, Chatham, Lee Counties
SEPTIC �'ANK PERMIT
Dat ry,.� _ T' _ �>
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of owne��'"" .• � • � ` � • ��'�
and Directions rj� �- j : � k�l r-���i � � � '1� � �, �
Person or firm doing installationc �`' ��—��."` �'-'
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Address ; '+��t"' `'"' s�
No. of persons to be served --�� r bedrooms 1, 2, 3, 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Minimum Requirements: Septic tank �'���'Q� �-�, � 4
% ,+ � , } � a'` r
Nitrification line: � 4•� -•��'
Septic tank and nitrification line must be inspected and approved bp
a member of the Health Department slaff before any portion of the
installation is covered.
Date Approved:
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By: � 1 �'
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
NOTE: 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: Z 11� O R
Amount Paid:
Receint#:
TaY Map: ��
Parcel #:
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1��plic�tion fo�' �e�'w�ces (Septic Systems and Wells�
Sea-dic�s Re uested
❑ improvement Y'ermit (Site �valuation) ❑ Construction Authorization
�200.00/$300.00 (if> 600 d) (Fee is de endent on the e of system ermitted)
❑ Mobile Home Replacement or Buiiding Addition f] Permit Revision
$150.00 (if site visit re uired) $75.00
C 6Ve11 �ermit (Netiv/Replacement/12epair) Repair of Existing Septic System
$300.00/$200.00/$75.00 No Charee
1) Services Requ sted �by: � "
Name: G� Phone # (home): ��L� - %4- � �
Address: � � O D (work/cell): _,� � 4 � j+ � �{-
2)1mTame and acidress of caarrent owner (if differ�nt than applicant):
Name: ��
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Address:
3) �roperty �escriptnon: Lot Size:
Address and/or directions to Property: _
a�-rn Subdivision:
? ot #:
4) Proposed Use and Type of Structwre:
Residential �� Business/Type: Other
Number of bedrooms �_ / Number of people served (seats/employees): �_
Basement: Yes No �_ (with plumbing: Yes � No _�
Garbage disposal: Yes No X
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5) Water Supply:
Private Well �(Proposed Existing _)
Community WeII: Public Water System:
Are there wells on the adjoining properties? No Yes
(please show location on site plan)
1�Iote: A completed ap�lication mus� adso include:
�� plat/site plan of ihe property tliat slzow� pro�erty dimensions and the size a�zd locution af ull
proposed structures. .
9 A signed copy of t/ie `.��ot Preparatiora' foa�m verifyin; that tla� property is ready % be evaluutesl.
� am submitting this ap�lication to request servicas fram the P�rson Couniy �ealth �epaY-tme�at. ��►nderstand that
if the info�mation provided is incorrec# or if #be si#e is subsec�ueaaily alterea, or if the intended use c�a�nges, a�l
permits and approvals shall become invalid. =
Sig��taar� {Owner/Lega1 Representative): , I9��e : �� � —�
10/03 Person County Environmental Health, �25 S. tiior�an St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applicant� �C �� 1 �C bt� •
�prawe���t �ea�mmait �
��a�at ��flad �or ✓I+'��e 3te � t�i'o �apn��aon
Type of Facility: ��.0 New Addition � �late� ��a��sly _ ��
# of Occupants # of erlrooms 3� Proje�ted Daily Flow __�� g.p.d.
Proposed Wastewater System:
Proposed Repair:
Permit �Conditions:
Owner or Legal Representa.tive Signature:
Authorized State�Agen�t: ��
Type:
Type:
Date:
The issuance of this pe�it by the Health Departm�nt in does not guarantes the icenarce of other pe�mits. It is the responsibiliiy of the'
applicantfpropezty owner to in snre that a11 Person County Plaiming and Zoning and Bu�ding Inspections requirements are me� This
3mproveffie�t ��r�it i� s�ject to re�ocaQion if the site plan, plat o� t$ie i�t�ai�� u� chaanges. '17�e I�aprov�e���i Pe�ffiii is not
af%c#e� by � cinange in ovc�erslaap of tlae propertp. This per�i# was i�sne� in c�ffipliancs w�ith the peovisaons nf the North C�lina
`Lssvs �nd Rules �'or Seyvage Tre��e�s� as�d ]9isnmsal Svste�ss' (15A 1�1CAC 1�A .1900). 1V'eithes� I'e�on �m�nty mor th�
En�vir�rarnes►t�l �ealth Specialis$�wasray►ts tt�a�. tlae s�ptic t�nk sys�ema � c�aaiimue ta fianction sa�sa�e#�a�ily in t�� ita�sre ���t�aat
th� wates- supgly wili remaim�potai�le. - __ ._: �.
AaatDio�a�iion �Eo Coassi�oact ��tewate� Sys��� (Ites�reql for ��a1�ag Pe�nana�)
* See site plan arzd additional attachments (_).
Pzoposed Waste�vvater Syst�m: �,?��p,/� %f� � Type �� Was e�vatex• Flow ,�g:p.d.
New R air 'bn _ � S�� I.,�TAR: � g.p.d1 ft 2 �
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Type of Fac�ity: Basement _ Yes �/No � � ,
astew�.��� �y�t�� I2�e�°e��n�s
, ��.i�-�'J �11�`ra�
'T� Siz�: Se�tac '�ank: � �� 'T�c: g� ���e irap: g�il
���ei+d: To�i �e�: _�_ gq � �To#�1 Le�t � �t � l�uia�n� �r�ncla Dep� � �a
T�enc3� RVaalt.�a�J"9 ft lYg'in'a�� 5oa1 C�ees: � in
�istr'sbu�aon: Di§tYibntion �o� ✓ Serial �ista�ii�nti�n
�na� Trenr,9a Se��rr�#iain• fft
Press�re I09C�aaifmid
�'�D�il�iC3$a0Y@S: � N�J' ri4LC.. -l—�L�it "�i�fZC..f T�' �L �' � 9 i iJ .�l� lii 13�fJ C�" —�'�+as� �
-��x#ffiorazea� ��te ���i: __�J
Permit Expiration Date:
Date:
The type of system permitted is Conveational _�Acce�te�. Alternative. I accept tiie specif catians of the
pertnit. � % / �
��+rsa�l.� �al �Ep�es��i��ave: ,, , Date: � D
' PC� rev. 11/10l05
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Applicani
Location:
T�x M��p i P��rc�el # �
Srubd!ivision
Phase Sect�ion Lot #
Operation Permit
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Sysfem 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.
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Auth rize tate Agent Date
Installed By: � /� ,��z�' Date: 2���d ,
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rev. 07/29/02
Tax Map #:
Zoning:
Parcel #:
Township:
Subdivision: Section:
Applicant:
Location:
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements
B) Distance from system to any welis
C) Distance from septic tank to foundation _
D) Distance from system to property lines _
Lot:
2. SEPTIC TANK
A) Visually inspect the exterior walis and top of the tank
B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet
C) Date of tank manufacture
- D) Tank serial number
E) Liquid capacity of tank gallons
3. SUPPLY LINE TO TRENCHES
A) Grade (1/8 inch per foot minimum)
B) Material supply line is constructed from
C) Diameter
D) Length
E) Distance from tank to drainfield/distribution device
4. DISTRIBUTION DEVICE(S)
A) Type
B) Is Device water tight
C) Distance from the distribution device(s) to the trenches
D) Is the device on a level foundation
E) Does the device perform according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth inches
B) Trench width inches
C) Distance between trenches
D) Number of trenches
E) Length(s) of trenches
F) Aggregate depth inches
G) Aggregate material and size
H) Record septic tank outlet elevation
I) Trench grade (< 1/4" per 10')
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" plan on attached sheet.
PCHD, rev. 07/29/02