A32 34Application Date: `�� S(' ������ Tax Map:- ����-
Amount Paid: r,.,.• • � > � � ���,� Parcel#c
Receipt #:
IE:�rna aa-�a*••*�x��nci,en.fl 1C�L�.s.11d,lln.
�
Services
� Improvement Permit (Siie Evaluation)
$200.00/$300.00 (if> 600 gpd)
0 Mobile Home Replacement or Building Additioa
� I SG.00 (if site visit required j
❑ 'I�Vell Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
for Services
� Construction Authorization
(Fee is dependent on the type of
� Permit Revision
pair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
.����' %�2�1�i/
1) Applicant Information: ��- �'X ��� '5��� '`�'��
Name: � Phone (home): ?� - Z
Address: (work/cell): + -'-�-
2) Name and address of current owner (if different than applicant):
Name: Pr.or.e:
Address
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
L�t #:
❑ yes ❑ no Does the site contair� any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
O yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no 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:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Ex�ansion pf Existing System If expansion: Cu�-rznt r►u�be* of bedrooms:
� Repair t� M2lfunct6oning System Will there be a basement? � yes ❑ no With plumbing fixtures? ❑ yes 0 no
❑Non-Residential
Type of business:
M�acimu:n number of employees:
Total Square footage of Building:
t�aximum numba; o: scats:
�) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ 5pring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cef•t� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
b
D e
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.
f 1(1/1 11 Persnn (�`.rnmtv F.nvirnnmPntai NPalth ��5 C Mnraan Ct Cnite (' Rnvh�r.. T�T(' �7G7Z !'2'!�_CO'7 t �nm
���. s� ���.� ��
�r ������
)C�s�znwna���rn.�*-,Y„ �irn��.� ����.Il.�Iln.
�
Applicant: ��
Address/Location:
Tax Map: �� Parcel:�r�
Subdivision
Phase/Section/Lot #
Improvement Permit
Permit Valid for: Five Years ✓ Non-expiring
Type of Facility: �y� New _ Addition _ Water Supply:
Number of: Bedrooms / Occupants / Employees / Seats: Projected Daily Flow: gallons/day
Proposed Wastewater System: Type:
Proposed Repair: Type:
Permit Conditions:
Authorized State Agent: Date:
(X) Owner or Legal Representative: Date:
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 North Carolina �Laws
nnd Ru[es for Sewa�e Treatment and Disnosa[ Svste»rs'(15A NCAC 18A .1900). l�Teither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater Sy tem:
New Repair �Expansion _
Type of Facility:
(*)Type Design Flow gal./day
Soil LTAR: gal./day/ftz
Basement: Yes No
(*) System Types Illb, Illbg, IV, and V, require periodic system inspections by the Pe�son County Health Department.
�� Wastewater System Requirements
NG�►'✓
Tank Size: Septic Tank f100 gal.
Drainfield: Total Area sq. ft.
Trench Width
Distribution: Distribution Box
Pump Tank
Total Length
gal.
ft.
Grease Trap gal.
Max. Trench Depth in.
ft. Min.Soil Cover in. Min.Trench Separation ft.
/ Serial Distribution / Pressure Manifold
� � . .. I //L . �I / 1 .. .i
/ � /11i .
Authorized State Agent:
Issue Date: _�?
Permit Expiratiori
The system permitted is: Conventional /Accepted / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
--�
���`�� ) _� ���� ��
' � � ����
IE��a-��� ��.��.Il IE-3L��.]L�I�
Applicant:
Location:
�peration Permit
System Type (From Table Va): �__ Product (IIIg):
Tax Map ,�Z Parcel # �
Subdivision
Phase/Section/Lot #
# of Bedrooms
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 onzed gent)
------ � I.��.slis ,� �.✓s -
(Lic sed Contractor)
��� i �
(Date)
�}f� %�
(Date)
L� �
C t5"r 1�iy
t rl t=� EL�
� /YVlfs � ����/'�'!�'-�
,�p�"gr�e� �
,���� ��
Scale: �ir5
�.�.p-✓-�1'�- T-��
�� n/�✓�..
���or� �i�V'� ��� cy:�rl��e���i.
�r✓i� ��e��O�,��f��t ��o�-a�C� �r
t��11�j �'�.►:t ►c�
Z'Cv- �''a
��- �GcO
� ►�}Z--
Tax Map: Parcel #•
Septic Tank System Checklist (Type II-I� System Type:
Se tic Tank InitiaUDate
Sta.te ID & Date:
Capacity:
Tee and filter
Baffle
Vent
Riser
Outlet boot
Perm. Marker
Distribution
D-box (Ievels set)
Serial
Pressure Manifold
LPP
Notes•
Pump System Checklist
Pum Tank InitiaVDate
State ID & Date:
Ca aci :
Riser (6" min.)
NEMA 4X Box
Model:
Pi gy back lug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Manifold
Number of ta s:
Size and sch:
Contracted Certified Operator (Type IV +Systems):
Notes•
NOTIFIED BUILDING INSPECTIONS:
(Revised 12/09 BH)
Copy of OP e-mail Date: