A32 229di 3 � � °v
Application Date: to � �'� r 0�
Amount Paid: aoa . ��
Receipt#: l �3�\ I
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].��, :ra-.v-uy.: ,r.n sr�,�.rj..,L�..2.en.11 7E�1L�.e�.cn.:Q: a�:lla.
. Application fos- Ser�c�s , �
(Seatic Svstems and Wellsl
G Improvement Permit (�ite Evaluation)
$200.00/$300.00 (if> 600 endl
C Mobile �-Yome I2�placement or �uilding Additian
$150.00 (if site visit required) �
❑ Well Permit (Plew/Replacertnent)
$225.00/$125.00
Tax IViap: /'I c3�
Parcel #: �
Seawic�s 12e uested
G Construction Authorization
(Fee is de endent on the e of s s
❑ Permit Revision
$75.00
_�. � 1Ttepair of Existing Septic System
No Charee
Important: di tfie in, f'ormatian in the application far an Imprnvement Permit is incvrrec2, falsified, or• the site is altered, t/ien the
Improvement Permit and the Authnrization to Cnnstrucl shall.became invalid � �
fl) Services Re ted b�: �
Name: a �'�r�
Address: �/2, C r�s c� p�-
.G /�
Phone # (home):
(woriJcell): � � / % — Q � � / ���
2)1�Fame �nd acidress o� current ovYner (if d'nf�erea�t than applicant):
Name:
Address:
3) P�roperty ]Descriptioa: Lot Size: ���F�'f' Subdivision: �'�'`.S C �� ��iLot #: z l
Address and/or directions.to Prope • ,-� � 1� / � ,f' . �
� � � �e o svu� ` / � � .
f ' O f �r � � o � �o� � � /'r �rv�
4) Prop�sed �Tse a d�'ype of Structur�: � �
Residential � Business/I`ype: � Other .
Number of bedraoms ��_ / Numbei of people served �seats/employees): ,
Basemen� �es � No (with plumliing: Yes 1�� No _� � .
Garbage disposal: Yes �No � . �
5) Water Supply: / • .
Private Well ��(Proposed Existing _)
Community Weil: Public Water System:
Are there on the adjoining praperties? No Yes
(please show Iocation on site plan)
Noie: A cnmpleted application traust also include: �
9 A pla#/site plan of Phe property t&at shows propeYty c�ir�ae�csions and ilae size. and locatron of all
proposed structure�.
➢ A signed copy of the `�vt �'reparation' form ver�ing that the property is ready io be evaluated.
I aua snbanittie�g this a�placatfion io request sea-vices %-o�a the �erson County I�ealtla I�epa�nent. Tl�e
n�for�►ation proviaied is aec�araie. X uncflexstand ih i any sit�, �s altered or tlae antendesd aase ehanges, �il
pers�its ��aal� became anvapid. � �� _
,�ig�a�ua�e (Owner/Legal Representative):
Da#� : ���
06/07 Person County Environmental HeaIth, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-�97-1790)
��* 1 4�� �' �fiLJ �� �-�
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I���au-��.� ��.��.11 IL-���.11�I�
Applicant:
Location:
�
T�x M�� � P�rcei ## _ �
Su�hcl'ivis�ion � . - .
Ph��se Sect+ion Lot # ��
�
Improvement Permit
Permit Valid for � Five Years _ No Expiration
Type of Facility: ���P .�r,;,�u d�el�; � New � Addition Water Supply � i VQ
# of Occupants �'�# of Bedr oms �_ Projected Dai y Flow y$� g.p.d.
Proposed Wastewater System: ry-,v�r,�;�
Proposed Repair:
Permit Conditions: l\� Sii2 ��`�e�ch
Type: !lT'Q
Type:�" b
Owner or Legal Representative Signature: Date: � 3" � 7�
Authorized State Agent: ' Date: /28/�
The issuance of this permit by the Health Depaztment in does not guarantee the issuance of other permits. It is the responsibility of the
applicanbproperty owner to in sure 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 Permit 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 and
Rules for 5ewage Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither Person County 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.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_�
Proposed Wastewater System: �jrl�p�itx�,Q Typ � Wastewater Flow �g.p.d.
New � Repair Expansion Soil LTAR: .3� g.p.d./ ft 2
Type of Facility: �{ a(2 5.�,.L�a �1n.,�' T� ���� _ Basement _ Yes .�i No
Wastewater System Requirements
Tank Size: Septic Tank: 1 a,SU gal Pump Tank: - gal Grease Trap: - gal
Drainfield: Total Area: llo�J sq ft Total Length 533 ft Maximum Trench Depth 22 in
Trench Width 3 ft Minimum Soil Cover: la in Minimum Trench Separation: �_ ft
Distribution Box � Seria1 Distribution Pressure Manifold
'�, Specifications:
Authorized State Agent: ` f �
Permit Expiration Date:
Date: 1t� <%
The type of system permitted is onventiona Innovative Altemative. I accept the specifications of
the pernut. ?
Owner/Legal Representative: Date: " J G
PCHD7/30/2002
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STTE PLAN
Name '�pn Tax Map # fl 3z Pazcel # oZ o1
��vision � Secrion/Lot# . �
xi.'_�, lt�l<I os
Authorized State Agent Date
Sysrem components represent appmximate conmuts on/y. The wntractormustl7ag t6e sysremprior to begianing thelnstallation to
Iasure that pmpergrade is maintained
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+ ta�C�C�'�ns�0.l\ -�e-m on C�rr%,,r .
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applicani:
Locaiicn: -� —
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. S�fsi�m Ty�e (in Ac�ordanca Witl-► Ta4�le Va): �
THtS 5'�PS;'�iif1 ��S �E:..� lN�?.�L�� 9i�! Gi3t�lI�LL�,PlCt ��It i I-3 �P.P�iCA�L.� .iVOR?S-�
GAROLl��i Gci���L STATUTcS, ��ilt.Ej �'C?R �c'�ilAC� Tr'�E�1ThfiEi� i,'�1Vt] D�S�OSAL,
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Authorize� tate Ag�rtt � Caie
installer�. B� � • Date: � �— �OS 92 � � �
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Ot;v�e:-IA�p{icc�i � � S�bd�vi��o� a�rr�s CrPP(�
,�.ddress/Loca�ion Se�fPhas� �- Lcfi � 21 .
State �(D/da�� 5 -I ys'l
Capaci�y j�5 - J2S0�
Tea and Filies �
Baf�e
Seai�nt
Rise� (ifi applicabie)
�=ank Outie# Seal
Perznan�nt iVla�ites-
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Tre�cf� S a�in �
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� Dam�/S# dov�yn� �#c.
Press�re La#�ra�� �
• � Hofe S�ac9na �
�ilarm visat�(e and audible)
�3ec#ricai Com onents
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A roved Purn IVdode6
Bloc� Unsier Pump �
Pum Remava9 �Ro elC�ain
. ��Da��i�su�aor�.: ���r�
� Serial Distnbution
�ressure U6an�rod
Law Pressure Pi e
�,� r. F'ip� Mate�ia� �r�d G�ad�
i/alves �
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Sieave
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From� yVel(s � '
FfOCCI �T'O�EP`t}/ �66'lE',S '
S�LICti,]TeS/� 85 ��T9G'�1i5 . .
4ic, es ! r��nage W.a�+s
Svrfac� 11Vaters
Pubiic 171�at�r �up�lies
Verticai Cuts (�2 �ft.)
V�2�!' L1PI�S
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e �' e perator oi
Tr�-�art�te Aace�en
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Tax Map A3a Parcel # aa9 _ Township:
Applicant: �mh�ral- K Uir, .,-#�w,
Subdivision, y�„�`s � Cr�k Lot #�� �j., Z_ .
Location:
�'yp� off ��tea� S���fly: � Individual _ Community Public
�equiremen�:
Site Approved By: � 0�
Grouting App ved y �
Well Log: � �
Pump Tag:
�11Tell Tag: '
Air Vent: � � �08+
Hose Bib: '
Casing Height: �
Concrete Slab: � �
Well Driller: _�
Well Approved by��
*�**See Attached �ite
�d-Y►
*:: ::�
Liner:
�Installed by: _
Depth set: _
Grouted:
Date:
Wa#er 5ample:
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any buiiding foundation.
Other conditions:
Date:. ,S'— 27-��'
PCHI� rev 01!27/Q4
� ��� s:.� ���.�� ____.
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' .a�..r-a�rc•ozra:m►.s�ora�.o.Il 7�.L�a�.A��a, D� [�� , � - rj �
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�a _.�rn b ��' -�-- K� ✓i �S � a . , ,�� � Vl�ell Log� � stacel #
Tax �� p �
a' �^ S C,re.tl� - I��b _ c�c{ ��v �
Subdivieiur,: 1����'S C4 ��IC ____ I.ot� �I Ph '�' _-'
'V�%elt Con�h�ectian
Distance Frc�� n�xaresi �'ruperty Liae (Muiimum f 0 feetj ___r_� Q�
Dist$nce from �apric System (Miuimum 50 feet) �, A
Totad Dcpti�: �,� ft Yield: PM Static'Watcr I,evel: � 5�, g
Water Hr.aring Zones: Depth l 0�{�ft �� fi fi ft
C'atfa�: g �
I?ept�: Frorn _��� � � � -- - ft. Diamettr: �_ in
Type; G�tv$�iza� Stec!
V4'aght: o i 'I�u'ckac� :s
�.�.... a. ( K Height �bavc Cmound: __ I o� ___ in
Dsive Shoa: _�Yes NU Any probleins r�cc:ounterod while �etti�g casiag? �Y'es _ r�No
��'�`y�s" give re�san•
Grout.
.'Vr,�t: SaucUC�neat Canc�ei� Gravel/Ceaatnt
Anziular S�aca Width ,.,,_ inc��s Water ia Attnular Space -_ Ycs No
'.1ri�od of Groui: Pt�tn�a�il ..�..._ W Pt�.asure _ Poured i3epth to � F�
'.'�xirr�i�tia tJ�tdl:
?v1�. B�g,� Poriiand cement Wcight af" 1 B�g �! Pounds�
If mixture �sand, gcav�l, cutting�} - Ratio to
ID plaus: � Yes No 4� 4 sl�b Yc� No
Drillin� Lc►$ Lc�tion Drawiu�
I bereby certiiy th�t the above informutinn ia corr�cL and that this well was canstructed in accorcfarttce w�ith reguiations
set farth by *.he P�,"rson County Heaith i,epartrn�art.
Si�a�eture nf l'.uatruc4or _�.�..z1TJLy `7^%�G-� IL �k o�0ic� Dste w�y- a g
�` PCHD nv O1/16,'Oh