A32 258t1�z31��
Applicallon Date: `3 �� � �
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Amount Paid: 0200 , 4 1-1 c��'
Receipt #: � 6� 4 rl � O'-t1
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�red��- � _ _a
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
��� � f �11e���A. � Taz Map:
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)Esav�nn-cDaa�ancaa4:�Il lE-jlc���Iin
_ _ __ _ _ _ __ _ ___ _
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cation for Services
Services
Construction Authorization
(Fee is dependent on the type of
Permit Revision
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) AppGcant Information:
Name: 17U I�$�zc) Phone (home): R 19} 1c�3 -���/q
Address: y!/� �?rn 6e� �fo n e y (work/ ell �/4) �j4�4 � 70�-� cp ✓
1�.�.,-he�,,., ,_../�%C, �'! 7�'f
2) Name and address of cnrrent owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: � 5�L• Subdivision:
Address and/or directions to Property:
❑ yes
❑ yes
❑ yes
❑ yes
� yes
no
�no
�no
Phone:
Lot #:
Does the site contain any jurisdictional wetlands?
Does the site contain any existing wastewater systems?
Is any wastewater going to be generated on the site other than domestic sewage?
Ls the site subject to approval by any other public agency?
Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
J�Residential �
New Single Family Residence Malcimum number of bedrooms:
Expansion of Exisring System If expansion: Current number of bedrooms:
O Repair to Malfunctioning System Will there be a basement? ❑ yes �no With plumbing fixtures? � yes ❑ no
ONon-Residential
Type of business:
Ma�cimum number of employees:
Total Squaze footage of Building:
Maximum number of seats:
5) Water Supply: �New well ❑ E�cisting WeII 0 Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this pmperty? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Convenrional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
ina rate, r if t site is subsequently altered, or the intended use changes, a11 permits and approvals shall be invalid.
�Gv. �.� 3 aa �U � �
Signature wner/ Legal Representative*) Date
* Supporting documentation required.
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' 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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7.C�s�rn.wn�r�zcaa.-naa��n.��.11. ���.�.Il�lla
Appiicant: )c,�
Address/Location:
Permit Valid for: Five Years
Type of Facility:
Number of: Bedroo � / �
Proposed Wastewater System:
Proposed Repair: _��
Permit Conditions:
Improvement Permit
Non-expiring
'n New � Ad�ition _
�Employees / Seats:
n i , � � _, -�
Tax Map: 32 Parcel: �B
Subdivision
Phase/Section/Lot #
Water Supply: 1�Ie I j
Projected Daily Flow: 3(�o gallons/day
Type:
Type:
Authorized State AgE
(X) Owner or Legal
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is 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 1Vorth Carolina `Laws
a�rrl Ru[es for SewaQe Treatment and Disnosal Svsiems'(15A NCAC 18A .1900). Neither Person County nor the Environmeatal
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply �vili
remain potable.
Authorization to Construct Wastewater stem
See site plan and additional attachments (�.
Proposed astewater System: ?�, `c �� (*)Type � Design Flow ���_ gal./4ay
New �Repair Ex ansio Soil LTAR: , Z� gal./day/ft2
Type of Facility: ' Basement: _ Yes _No
(*) System Types Illb, Illbg, IV, and V, require p2riodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank �00 gal. Pump Tank �- gal. ^vrease Trap —gaL
Drainfield: Total Arza f'� sq. ft. Total Length 3�i /7 ft. Max. Trench Depth � in.
a.C.
Trench Width � ft.� Min.Soil Cover �, in. Min.Trench Separation � ft.
Distribution. Distribution Box �/ Serial Distribution ✓/ Pressure Manifold
Au►horiz�d State Agen [ssue Date: � ZS-/(v
Permit Expiration Date: �(- �- Z J
The system permitte� is: Conver�tional /Acce ted ✓/ Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: �. Date: �� 23-! `
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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SITE PLAN
Name Tax Map #� Parcel # 2$�
Subd' 'on ` Section/I,ot# �U� ,
� ZS=(lp
thorized State A ent Date
System components represent approximate contours only. The contractor must Jlag the system prior do beginning the
insta[lation to insure that propergrade is maintained
. .w.._ .r.� ��i o.-� �i vQr Wa�S��ec� �,oi- � � �n ifi`a � SU s�
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Applicant:
Location:
Operation Permit
Tax Map 32 Parcel # 258
Subdivision _�p�
Phase/Section/Lot # /J
# of Bedrooms 3
System Type (From Table Va): Product (IIIg): ��-�.
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.
� -
(A orized Agent)
��,rQ� Leeu i s
(Licensed Contractor)
,�e�
Scale N }�
PCHD, rev. 12/14/12
�SS �
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3 � �z
�u5�e
7�
4'n yz
3 -22-ti
(Date)
3-22-(1
(Date)
N v Pro�,e�� t; �e 5 c(ost
by %+ rh�ea5u �e �
G
Line Len h
I '
Z 22'
3 r 2g `
Total 3c�o '
Tax Map: A� Parce� #: Z_ Sg
Septic Tank System Checklist (Type II-I� System Type: �_
Notes:
ID & Date:
Riser
NEMA 4X Bo�c,
Model:
Piggy back plug
Hard wired
Alarm functionir
Mounted on post
Above grade (12
Conduit sealed
Nitrification Lines InitiaUDate
Trench Width: 3 ft. 3-Zz-t
Trench Depth: �, in. �/
Total Length: ft. ,/
Minimum spacing: ft.
Rock depth/ uality �
Dams/ste downs ,/
Grade (< .25" in 10') ,/
Cover (6" minimum) ✓
Setbacks
From wells ✓ 5 3 -zi-�
Property lines �/
Foundationslbasements ,/
SurfaceWater ,/
Other:
Pump System Checklist
Tank I InitiaUDate
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
Tax Map: 3Z
Subdivision:
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Parcel: �
WELI, PERNIIT
(New�[ Repair_)
Lot:
Applicant's Name: ��
Mailing Address:
2 70
PhoneNumbers: G��q-C�c�q_�Zo4 Cei( q.(9-1:��3��3�1q ��om��
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All appdicable State und County regulatiorrs governing construction and setbacks apply.
3.) Permits expire S years from the date of issue. -•
4.J Issuance of � pErntit do�s not �arantee a potabde w� �er supply
OtherConditions/Comments: �in�r�i� ,�/f Sc'f'L�%��S
Permit issued b��� i�� ,�v'� Date: � Z-��-�lo
Cert'if'icate of Completion
�tew Well: Dii.iner:
EHS/Date EHS/Date
Location: d� 5 3-22-l� Depth:
Grouting: 3/ �c�i� Cer�� �-� e� Grout:
Well Log: �
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
SS
- 2z- t1
Well Driller: 13aw,e
Pump Installer: `
Approved by: -�"
Additional Comm2nts:
Date Sample Collected:
EHS:
Person Caunty Environmental Health
325 5. Morgan St.,Suite C
n....�,...., ni� ��r.o
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: 3 -Z z-(-7
Date Resulis Mailed:
Phone:336-597-1790 Fax:336-597-7808
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Mar081706:53a BarnetteWellDrillinglnc 336-598-9275 p.1
I. Wdl Contr�ctor Infntmxdaa:
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3. Ndl (fu(eheckweII use):
ti'��ter Sappl} 11'dl:
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DlnduscxiaVCammeneial UIieside
❑Aquifrl'Rat7aS'ge
[1AquiferStn� aad R�nvcry
QAquifer�est
QEx�imecual Tahaolu�y
aGeotha�al (£Eosr� I.auP)
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4. Date.A'i11(s) Comp]et�d: 3� L Wd1
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