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A32 249Application Date: g- � g-6 �j Tax Map: 3 Z Amount Paid: a6n . � � � C�� Parcel #: — Z� Receipt#: � 70? 4-$ I Z ZZ 3�3 3��( , �____��'1�?.5.� ������ � �� �---- �-..�- 3ao - —�-- � � TC� c�. � �y� Ii �_� 7LA"S� 711L� KD 1L� 7LTt21 K: , lLa �..GiL �L 1l �L Kw.Zd. l� �1['li Application for Services (Septic Systems and Wells) , Services Re uested Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if > 600 g d) (Fee is de endent on the e of sys � Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired) $75.00 ❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 No CharQe 1) Services Re es� b: . Name: r Phone #(home): 3 6�-� 3 a'Z Address: $ � .'�( � (worWcell): �l� - �2'�-d'6�3 � � , • !.s G �5 / � � Cci 1 � '4�0 �u e��% � i� �Oo�-��bl� 2) Name and address�o`f cu�nt own r(if different than applicant): - Name: l�Cz. N- /�p t'y���3 Address: 5 �¢/`�L l= 3) Property Description: Lot Size: /FL Subdivision: /l/ R Lot #: Address andlor directions to Property: �r,-�-ev�se��'�'aw o-� � t�c, lc/'�,'�� _fii[�� 4) Proposed Use and TSpe of Structure: Residential J� Business/Type: Other Number of bedrooms �/ Number of people served (seats/employees):�— Basement: Yes �� No (with lumbing: Yes No ��R�¢ G Garbage disposal: Yes No � 5� ) Water Supply: Private Well f (Proposed� Existing _) Community Well: Public Water System: _ Are there wells on the adjoining properties? No _ Yes � (please show location on site plan) Note: A completed application must also include: ➢ A plat/site plan of the properry t/zat sliows property dimensions and the size and location oJall proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying tliat t{te property is ready to be evaluated I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. g � g P ) ��`i-����� ���� ` � l 8� � Si nature Owner/Le al Re resentative : �i'��- Date : 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) i�oe "�s ,00� �iis ��a' OO 1001 �SITE VICINITY MAP 4F $ � -N ewK�N ceRauu oertson eawrr �� ..__��%iN_�1._�f,tl�lJNG$____, CER�IFT TMA� THIS $MVET CPEAIES A bUB01VI510N OF LAf9 IIIHIN _ P(y$QN__ �q,Nl'/. IIIINE55 YY NAhO AND SEAL INIS _11_ oar oF _9S4CM9€�_. 2o_Q4_. � __ �{t,_" ' "" "'_""""' PROF ONAI LAM� 51rtv r �� (� .:i0}yy.,j�_�f�+_�IN§�S__. GER�IFT reur mis GLAT IIAS DNAMN I,JAER YY SUPERV(SfON fRON AN ACtUAL SW7YEY WDE UNDER YY SIDEAVISfON /OEEO OESCRIP710N RECORDED IN 8001( __!._, PAGE __C__. ETt.I(O7HFA); THA� iHE BOIWDAHIES NOT RFVEYEO ARE CIEARLY INO(LATEU AS ONANN FROL INFORNA�ION ipkO fN 8001( _ C__, �AGE „... -C--' nur rr� ruTio ov vr+�cisiorr �s c�i- •'N CpRp"� iu�s�eo is �:_±2.000.__; rNer TN�s v��r nns :''t ..<�"••.. VNEVAFiO IN ACCOROANLE �t�N o.s. ��-w es � op�'ESS� "•.f '• AIIENOEO. �fiFE55 W pifClHAI S1GNAll,NE, = =;��4 �ry :' "; kEGlSIF�itON NUYBER AN� SEAI MIS _ll_ U.1Y �� 7r�. ' p� _4ECE48ER_, A.O.. 10_49_. •4 L-3052�t . � • ..' •�4�SUR�": i . yi SVNVE10ft _"'(�' `-�-� '_' ___ .%" '•�•'.......••��,: ,e il:laso _ �\j� �""�..J£�.••" rs[cisra�ttai .Q-- -- 4-�7---- --- PLAT CAB�Af�i"��ER _____ fILED IN PEN i1/ RECI�ra�OF DEEDS ON TNE ---- oer oF -------"• zo-•' � ----' o�t�aK __w. S.�L2S9.►ul,./ _-�Ql�haYl"-"------- xec�srea or oceos � ) fllfo n YtIIiUN C.mly, N[ �n J��ny A�A/N0.10 �ILAIIP/ V Afl A[GISIfN F O(E09 Ooak 15 I aqe 011 III IIIIIUIIIIID IIIIII!lulillll PLAT OF SURVEY DALE E. NORRIS BUSITY FORK TWP., PERSON COUNTY, N.C. HAMLETT—JENNINGS & ASSOCIATES, C-948 212 S. LAMAR STREET, ROXBORO, N.C. DECEMBER 2009, JOHN J. JENNINGS L-3052 � I--I�I � aw szw�i �M� . iw ��. DAIE E. NORRIS . � � RpULO NORFIS O — �� � � v PROPOSEO 50' YR[VATE AttESS EASE4ENI � I � �0 d � `� ��,t, �i �— �� 10 9 � /�ti,�r /�� IJ 72 ` 1 � 50 O � � � �yp0 ^0 `�" � ��1^^^���, 0� /' e `/� J \ � � ,\ ,\ . DAIE E. NORRIS RONALO NORNIS ST�IE OF NORIH CAROLINA cawQ(r� a vcxsor� I 1. ICW� �VrPI!,( pEVIEII OFffCEN OF GEflSQV COLNiY, CEFYIfT fHA� �hE YAP OR PLAI TO M1IGM TNIS CERIIFICAiE IS AFFIMEO YEETS ALL Si�NTORY REOUfREMEXlS FOA RECOROINC. Pfa,,,�_- �iui<c_�j-- lt'JS_'ai REYIEII OFF CER OAIE I MEREBY CERi[f1 �HAi LHE SUBDIV(5(ON VL�i �5 DEPICTED HEREON H�S BEEN GRANTED FIN4L APPROVAL ru+w.wr ro r'c vEason co. wmiv�s�oe� se�uur�eus. "�a+Y1-"�N!k �/_]M�""_"_' �:�Y�XJ OATE YLNYIIHO AND 20NIN0 I w��n�srrurorc 5.02 ACRES �, �;� � �3 DALE E. NOftRIS RqULD NOR1tIS LINE L- 1 L- 2 L- J L- 1 L- S �- a t- 7 l- B L- 9 �- �o L- 11 L- 11 L- 17 L- 11 L- 13 L- 16 DALE E. NOftF1S RONALD NORRIS DATA TABLE BEMINO DIST S{2'lJ'OS•■ 93.95' 581•a]'JO•■ 9I.07• Nl3•]9'34•• 81.83' N�S'09'S0'II 28.58' N30'S6'28•� 3Y.59' N15'12'39'N 30.'!4' N{9'4{'18'i 71.75' NE3'04'S6'■ J8.27' NBO'S8'32'M J8.12' Sal'�8'YO'M S].90' 5�8'30'Il•N tIB.51' 58]'25'JJ'II 39.i6' M9'31'S5•N 38.79' N59'00'S8•N �0.07' N70'13'J1'II Y0.{5' 561'19'JI•I1 23.69' IECEND NF • NAiI FOUND Ns o Nnc� ser [F • IRON FOUND IS O IRON SET o MATIffAIAi[CAL POIN7 UNLESS SICtED, SE�LEa AND OATEO, TNIS [S A VRElIY1NARY GLAT, NOT fOR RECOADA7/ON, SALES OR GONVEYNICES. WUILEii—JENNINGS & ASSOCIATES, PA •�1--• PROFESSIONAL LAND SURVEYORS 212 S lA4AR S�REEf - PO BO% 1286 RO%BORO NORiH GROUNA 27573 (336) 599-87�2 �s ��f/ ' �� � ��� � �� �'y y J ��I � �� � � � �-�.1.�I �� ' ' �a�^i.��o-,.,,,�-,;-, «��.a.�. �"���.��Jia T�N Map �.rc�l : � S u�bd:i vis�i o ia � ha�s�e Sect+ion: Lot � Improvemeat �ermit _ � �'�rmi# Valad �or � �'ive ���s _ �o �i�ation � Type �of Facility: 5• New � Addition �Vate� ��p�plp �( � � of Oceupants �a C_# o Bedrooms � je�ted Daily Flow 3� g.p.d. Proposed Wastewater System � Type: Propos�d Repair: � �� ?� �'rYpe: �Q t /^ -,� � � . Permit �Conditions: �.2,J2 �/' '�'C �� � � Owner br Legal Representative : Authorized State •Agent Date: 3 ! o .� - . — The issuance of this peffiit by. the Health Department in does not guarantes t[ie issuanca of other pe�its. It is the responsi�i7ity of the � applicant/property owner to in szue that all Person County Plannmg and Zqning and Bnilding Inspectioas requizements are met This . Improvemeat Permit is sui�ject to revoca�ion if the site plan, plat or the intended use changes. The Ymprovement lPsrmit is aot affec#ed by a c3�ange in ownership of the property. 7['his. permit was issned in comgliance.wit6 the provisio�s of the North Carolina `Lmvs and Rules for Sewage Tremtment arid �isnosal Svstems' (15A NC?�C 1�A .1900). Neither P�rson �ounty nor the Enviranmeutal �ealt3i Specialist' warrants tb�at. tiie septic tank system w:71 cantinue tn function satisiactorilp in the fu#are or'that the water supQly w�11 remain�potable. - . .. . , . - � -- - A�thoriza#fon #o Constrnc# �Vastewater Sys�em (Reqniresl for Biulding Per�it) � * Ses site plan and additional attachments� (_J• L� o��"� . Propos d Wastewatei System: �( C�G/y �►�T����� Wastewater Flow �:p.d. New � Repair_ Expansion � j � Soil LTAY�: •�S g.p.d1 ft 2 . . Type of Facility: . — - "� /.�PS�, Basement �, Yes _ No ' , . , � �astewa�er Syst�an �.eqiaa�ements � �) �an� Size: Se�tic �ank: O c)� g� pmmp Tank: �d�c� g.�i Ggease'irap: � gal �rai.n�eid• 'Totai Areas I_��D s� i� �Total ]Length O� ft ' 19�a�ffinm Trench I3ept3a � m ��emc3�'�idtH� � ft �'s�u�a Soii Cover. �._ in 1�'iini�nnm Trench Separation: ,� �t �istributaon: �3istribn#ion �oa Serial ' trii�ntion � P�essure 11�Ianifoid S eci$cataons: • � � �1.� ��2��5' ' P }• i � .. Autiaorize� State A.gsnt: iiTO�►''^ �^ permit Expiration Date: 1 ! � Date: The type of system pernlitted is Canventionai �Ac��ted Alternative. I accrpt the spe�ifications of the perniit. � � � . . i�wne�/��gal �8�prese��ve: /? � -y _ Date: Z ' �'� � � PCdD rev. 11/10/OS � ,N� � � 0 9 8 `` 1 . � 1S �� � � ' 'o �� � /�11 w . .. s � . '� � s � � ¢ 3 � - - �\ ' . i S Vl -��✓� C�-� � �SPr�cP,�l `� ��� . ; � � � ; s v� �Paser�,,P,�- �u�,,, b, , �� ���,re . ��� � . . ', d,� 1a�ser�P� � �?ur►, b,� �-�en �,�� �� ca� � ac�l ; �'�,.e�'. . • ,�- j✓I Sd�i t( 5��en.-, o(ur,1� c,Ue�r- -� � J �n�f����.�. '� S � 1 � 'r�'�S�c►--� Ma�t� d-�' � �/�� � �� � 5 ��2 << s�� �° d-�p� � ��� � � ��� � . ;. � � a �( q� �►�`� � ��°a `�� . � .,���� l� S77°23'45'.' 4•�• 6• 5 75 'o C � e_ • a � � _ � ts 137. 17 1S N69°46'41"W 5 1 NORRIS ' �ONA� D NoRR;s . (�����'=l�1dr � ���.�. I�I�I�� ��T . - � � � � ���� I���s�� � ��.�.Il � IE3L��.Il�14�. BTTE PLAN Name (`'e !� rr� � Tas Map #� Parcel #� Sub ' 'si Section/Lot# O Authosized State Agent Date � Bysrem campaaeats teptesear appmaQmare avamurs avly. 23e rnntrremrmustSag tlre apsrem prior m begmnrag tlie inarallsrioa m insvre that amaervrdde is msmraiaed ts ~����1�� ���� �� � `• � � `�J� ���� I� u-��v-ii�r �v �rn��-„-„ �y-a�.tn.� �L � �.�.4���. tdEMA 4X Simplex Control Panei , � �-1 4" X 4" Presstue Treated Post j Sloped To Shed Water 12" Se �u'ation 6" Cover � � .. Inlet �'rom Septu Tank 4" SCH 40 PVC Pipe P � Electrical Conhuit -- • ` Access Cover• .' , ' _ ` � 1 ? . � _ ;, . � e ' `� : • ``• '' • ; �.. Opening Filled With Anti Siphon Ho1e� \ Portland Cement Cmnit (Dwm Hill) A Check ' Valve � Higjt Water Alarm Level ' (6" Separation� High Level- Runp On -,-�� � � �Vapor Lock ,.. ', Hole _ . . : � .�Drawdrnvn �Up Hill) '. Low Level -Pump Ofl' -----`-� ,.; � � . Pzecast Concrete Tank • � ;.; (MaterialStrength>3500 ., , . ` ' • • ' - •`; • ' • • - Tax M�� ,� F�r� e # � llilC�IV151011 P�1��S 'S Ct�1011 tOt � ,O • Duct Seal Both Ends Of The Conduit -- 24" Minimum ;. ., ..., •... . °I'�readed Gaie Valve • Union I `� f-1 . , • � :�.,s�:J�'_`" `�aPo2tlaxtdConcrete Grout • Mutic • - ' . � Opening Filled With Supply ' portland Cement Gtmit Lina •• Outlet To Distx�ution 2"SCH40PVC Pipe Float Wires ' ��� : � �� ;; Floais . � � C p,/� _Removable . , ✓ r � �Float Trne , , : �,, � � ` ,�D {�- 4" Concrete I- �- Block � I " .�. . , • � ;� - , � L - ,, Concrete Riser b" Sepuation Zip Cord Ties + Nylon Rape �fl`� G��,aN �tr.� �� a I.ine # 1 2 3 4 6 7 8 9 10 �`��. � IPI��.��� = � � ���� ( �,�� s 1�.�-�.�����¢�..u.0 ��.�,� O er: Q ``Z Tax Map: Parcel #: Z Date: ( 3(6 Tap � Tap (Sc�) 0 TaQ �'lo� (gPm) `�� S� s Line I.ength � �iodv / �oot v I[+: �t'�a ft of line x 65 gal. per 100 ft=2�a��' ; 100 =��0 � gal 75% x�D � ga1= f a�— gal per dose �o gal per minute (gpm) = k'low itate �riction �ead � Loss: �� 7$ ft per 100 ft of supply line x�� � ft of supply. line =100 =� ft o_ ft x 1.2 =� ft of friction head _ -- _ _ � ___ __ __ _. _-- Z » vn _ _ ___ __ ____ _ _ — - — _ . _ �14�ol�ize,-- " �'e�c�ain�' _ _ . _ _ -�- - - - - - ._ . --- --- - — — — _ _ -- -- - . _ �ofaTDvnamic �$ea� - j�P ft of Elevadon head + ft of Prescure hearl + -ft �f � Pwnp Requirement: �� GPM @ Z �• ft of Head Drawdown: ,...(9 ��al per dose � 21 gal per inc6 =�_ inch dra.wdown per dose a� � n �, �,:� . � � �� �,� � , � hV � _\ �����tO � . � : . . . . . . . , ,• I _- ��,`" , .. �[(�)����00 iiiiiiiiii:iii�ii�iiiiii�i%ii�i ,..:........ II► II I) II/ �f�+�.������'+��������.�:�����►��_� � � � � �. :� .._ : :� : :: �: r�a� �aim� 9m� � ' s SizE Mp � iifold Siz�! � Taps Ma�x Na Taps off oae side lnce b�s :or ta in �oth si� t3 s 3/a» t3p9 i°' � 4 = y g 3 �� 9 � (�+ 4a+ � 2i � ��—J � ' � � ' - • � �1ow er Ta �ue ;y1c�¢riQ1 Flotiv GPLl 1=,• Scl:ed 80 .i.� 1, ^ Sc3ied 10 ?.I s, �• :iched 80 I (1,1 ;, . �`ci�eri 40 1:•? :, ' ���.sf ���.��� �, �� � � ���� I���aa-���• ���.�.11 IE3L��.IL�I� Applicant: ��e N Location: N�,�r1\� ' � � Operation Permit Tax Map 3a Parcel # o?yq Subdivision Phase/Section/Lot # # of Bedrooms 3 System Type (From Table Va): �� Product (IIIg): I- ����vJ 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. ��, a���a F�� (Authorized Agent) ��N�r�v. � � ti�15 (Lic sed Contractor) . '� L o ' ! �-?�I. � c7 `�Z c� z n� z lo g�� 9 z 7 �� � � 8 �O �� 7 � 8z Scale: 4�a��lC� (Date) t�la�l�� (Date) Line Len h I o�� z �� 3 0 �k- y �- Total y Tax Map: A?,�, Parcel #: _ayg Septic Tank System Checklist (Type II-I� System Type: �_ Notes: Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes: NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP _ e-mail Date: `�� )�.)� ���� �� �v �^ � � ���� 7� ��a � � � � � � ¢ ffi.Il IHI � .�..Il �1� WELL PERMIT (New D�Repair� Taz Map: � Z Parcel: 2 9 Subdivision: Applicant's Name: ��� �rr+ � Mailing Address: Phone Numbers: Lot: Locatio �onf Property: v��P r' �� S .—� �'r�k`� f�� FCY� -�i 11t �� i r s v1�Pu� f ��'2 � UdC�(S��,tl��l 112 i✓1 %iYkP� OC� i��'��Q��/ – Permit Conditions: 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply. � 3) Permits expire S years from the date of issue. Other Conditions/Comments: Permit issued by: �. ��� Date• 1 �3 � CERTIFICATE OF COMPLETION New Well Inspection: EHS/Date Location: `� �t(a�l�o Grouting: `� -� la 1 I�o Well Log: ✓3y �la3l�� Well Tag: ,i Pump Tag: ✓ � tl�o Air Vent: ✓ Hose Bib: ,� Casing Height: ✓ Concrete Slab: ✓ I Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ Well Driller: C�(,�� License #: Pump Installer: License#: Well Approved by•. �� �* �� -� Date: �e (� �� Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Date Results Mailed: Phone: 336-597-1790 Fax: 336-597-7808 8/1/08 - Jun 2310 09:55a p.1 . :.``�����`` ��'�:�:�.�:,�� �°�"� � � �� �' �:��:��'�' :�" � � � 1� ��r� -�..�,:����.��. ��.��,.�. ,��� �1�� Gwner: � Locaiian; � Subdivision: iS �rnnt Log . � Tax 14iap � Parccl #�� Lot � —..�.._ Discaz�ce From r�carr,st well Constr�adian i]is�ct fl�om Sepdc Sy� ���um' I O#'eet) {M�aimum 60 ) TntalDq�tj3; i%� Yicld:���M St�t'scWatorLeve�: ' a--- ft �atar Bc�ring �onrs_ Dopfh � S fi.�'�,� ft 17�0 ��� C�sing: . - . �P��. ' FGaI �ed�t�r3 � g- Diatne6a�: � ��� � � ---�--� �eigb� �D+2 Thicla�s: SOQ z: i�Icigl�t above C3round:. .� i�.-. � . Drivc. �hoe: Ycs ,_,�Na AnY P��s encountcred virhr'�c s�tin ' If •'yes" giye reasa� . g��' Yes �./�To GreQt:' . � . / Nca� � � _ _ Sar�lCc�neat ��Comcc�te �_ G�avellCenaent� i4%�+.3�od of�ou���'�"�—' �� Wator in Anm�r�,�c c�y�,�",y Na Material� II�ed: �� --- � �,------ Pov�d ��/�Dcp�,-.�, � � �t. - No. Beg9 Portlaad ce�ent,,,�� 'Sfi'eig}� of 18aB � Potmds Tfmix�ae (����, ���} - Rat€a � t,o � � T�lner: � p�t�s: -- cs „� NQ �4 x 4 a]ab �/Yes `� . �� . , Dat� �qstalEed; . . - . ----^-- Gt°t�-_--..�._._ �ntstatledby; i)rillia�Log - ��� ��� �r�ma To �a........,w__ � • a . ,�.�L �`'`k�Q'uct�"fu,�.c� � �f ccrc(�C� f`Yti (( . I 1�rcbY ca�ify t�at thc above imf�an is carrect aad t�a# tias woI� wes ' bY thc Peiraoa C�umy I�ea�h �� �udtx� ia accor�c� with regulaiioaa aet Pori t . + Stgaatnre o� Co�qd'mctor �� �'1.+�,� . • . • .,.�,. m � �o i4 � Ca _ 7�� _��. � . �� i�t��e � �iF iaatallaiicui Coatcictbr, �; , � . p� �,ti�: ° v�CS . g� g� ��an 0��j ft tic W L�wcl: '� l�f'N°ba': � �. '.s�SZ �p � �� � • --�-�._._ � �' �`�ax��� �_� . Y hsr�bF eertify tbai this pun�p wu unsmllcd aad she well head c�plet�d � on i�s. date and that s coQy of this rccard has been o. �'�8 to the P�rsoa County WeI3 Rutes In afnect � _ Pr �edto fhe we�] owner. Punlp �nst�lear Signs�tup�e . .f �l�i Y/y/� � � .. . f . �., �