A32 38The Distri�f f-I�alth Deporfinent
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC i'ANK PERMIT
� �i _ �
Dat
� ,
Name of owner: �
Name of contractor: � ,��
Address �nd Di�ections
d., . _ r� � _ r
r
Person or firm doing installation:
C,
Address •� [
No. of persons to be serve� . Bedrooms 1, 2, i�� 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Rec` omm nded• Septic tanl�—�� ���� (/
Nitrification line:
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line musi be inspected aad
approved by a member of the Districi Health Departmeni sfaff before
any portion of the installation is covered.
Date Approved: �� �' f� "
By:
Signe�
Sanitarian
O. David Garvin, M.D., M.P.H.
District Heaith Officer
Countersigned
(Over)
v� ��\
NOTE: Make sketch � of installation s owing location of house, septic tanks, privies, water supplies on �
adjacent property, etc. Write ' measurements in order that installations may be located at later �pY�
aate. t ; �,?15
SUGGESTED INSTALLATION (Date ) i FINAL INSTALLATION (Date )
(Road or Btreet). , t (Road or Street) e�"
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The Ds�tr'ict Health C�epartment
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal `
IMPROVEMENTS PERMIT/ Na
Owner: � 1� ' 1/V� 1 ,� � ` `� � ,
Location: —� � �y
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Contractor: � LQ•����
Water Supplp: Private - �, L,-��Public
Sewage Disposal
washing machia
Size of tank: —
Other disposal facility:
No.
: appliances
NitriScation
Dishwasher, Disposal,
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE IN CTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT H A H D��ARTMENT
ERED AND PUT O USE. ION OF THE jNST„f'CI,�.A�,I f� IS GQV-
I f ! �' 1 /! l
Date approved:
Well:
Sewage Disposal:
By:
--- � -�--
(' ,�;�ity � ,
Counter- C�� .
oigne
(Owner or his represen ative)
Ce:ti�cate of Comgletion f ��
/ lt � ,
— ] � � i� �
Date Approved: Ey: �
Sa itarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
rTOTE: � sketch of installation showing lot size shape, location of house, septic tanks, ��es, water
supplies, etc. Note special roblems existing on lot. Write in measure ents in order that installations may be located
at later date. Note ion of water supplies on adjacent lots.
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The Distxic;� Healt� D�partment
Orange, Person, Caswell, Chatham, Lee Counties
Water Supply and Sewage Dispo�al
IMPROVEMENTS PER�IT �' o. �/
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Owner. , i� ,. G� i.� �� ,1,.,.� � .,.r�:
Location:;���-f x'_r.._�.� -Zi `
���' i�)�.
Contractor: h� �z ; L�-��
.-
Water Supply: �'vate �! Public
�' j
t
Sewage Disposal Facililies: No.
washing machin oth r automatic appliances �
-r
Size of tank: , Nitrification line: '� �
�
"' � ''�� � -��—� �' �
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTEI3 AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved: �''��r
Well: �''�
�
Sewage Disppsal: -
By:
`�. . c� ��, `� ��
Signed� � ti j ;�
� Sanitazian� �
V
Counter-
signed
(Owner or his representative)
Certificate of Com letion � !
7 ' �'�' �`'__
Date Approved: ' �'" �� �'� ! � �s�"r.
� . /JSY:
itarian
(OVE
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
su�plies, etc. Note special problems existing ori lot. Write in measurements in order that installations may be located
at� later date. Note location of water supplies on djacent lots.
(i�j (2)
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Application Date: � ' �g "�7
Amount Paid: -��� ! r
Receipt #: � � �_
-r�
,
O Improvement Permit (Site Ev,
�200.00/$300.00 (if> 600
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
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7C��s�,v����¢�.Il ]E3C��.Il;E.II�
Services
for Services
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
Tax Map: �
Parcel#: � 3 �'
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Dec.
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:p 1 ,
Name: O.V ► d �� t T te
i Address: O � �
��.��e 1v.�1\S. 1.1L�7���
2) Name and address of current owner (if different than applicant):
Name:
' Address:
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
Phone (home): 3 3 6— 3 6�- 7 7d 3
(work/cell): 33L - S�1 g-� 3 a T
Phone:
Lot #•
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does tt►e site contain any existing wastewater systems?
❑ 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 Structurei
❑Residential ' � �_
❑ New Single Family Residence Maximum number of bedrooms: 3 / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
�Repair to Malfunctioning System Will there be a basement? 0 yes ❑ no With plumbing fixtures? O yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
� —
5) Water Supply: ❑ New well xisting Well ❑ Community Well ❑ Public Water O Spring
Are there any existing well , spnngs, or e�cisting waterlines on this property? O yes 0 no
Please note any known ground .water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
� Conventional � Accepted ❑ Innovative ❑ Altemative ❑ Other 0 Any
I certify that the info,�'mation provided above is c plete and correct. I also understand that if the information provided is
inaccurate, the sit�/i,� subsequer�tly alter�a; or e intended use changes, all permits and approvals shall be invalid.
�
Signature (Owner/ Legal
* Supporting documentation
�- I �-�7
Date
Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
A compteted `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
Application Date: �"02 �-��
Amount Paid:
Recei; t#: r„
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Application for Services
(Septic Svstems and Wellsl
Services
❑ Improvement Permit (Site Evaluation)
�200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$I50.00 (if site visit re uired)
Well Permit (New/Replacement)
.. . � . �� ��p,rs,Q
Tax Map: � 3 �
1'arcel #: 3 �
FG X `f-o �3 a►���
weI �
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❑ Construction Authorization
(Fee is dependent on the type of sys
G Permit Revision
$75.00
❑ Repair of Existing Septic System
No Char�e
Important: If t/re infor�nation in tlae applicatio�: for a�t Improvement Perfnit is incorrect, falsified, or i/te site is altered, the�z tlte
Improvem�Permit and the Authorizatioi� tn Cazstrirct,�lrall become ir:valid.
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• � � (�����,��..'// i�y'• �
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Phone # (home): 36 �" ' � 7Q 3
(work/cell):
2) Name and address of current owner (if different than applicant):
Name: _ _ � a � �
Address:
��
3) Properly Description: Lot Size: q' � Subdivision: Lot #:
Address andlor directions to Property: __
4) Pr�posed Use and Type of Structure:
Residential Business/Type: Other
Number o edrooms / Number of people served (seats/employees):
Basem t: Yes No _(with plumbing: Yes _ No � Garbage disposal: Yes _ No _
App ximate size of building foundation: Length Width
5) Water Su�
Private ell (Proposed E�istin� _)
Cam niiy Well: Public Water System:
Are ere wells on the adjoinin� properties? No Yes
(please show location on site plan)
Note: A completed anvlication must also include:
➢ A platlsite plan of tlze property that shows propert�� dimensions and tlte size and location of all
proposed structures.
y A signed copy of the `Lot Preparatiorz' form verifyr►tg that the p��operty is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. The information
provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become
invalid. �
Signature (Owner/Legal Representative
Date: �-' � �J' ' O �
11/07 Person County Environmental Health, 32i S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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I���a� � �.���.¢�.Il IL�L � �.71�1�.
WELL PERMIT (New_Repair �
Tax Map: ��✓Z Parcel• 3�� �
Subdivision: Lot:
Applicant's Name: � r �
Mailing Address: I D i
Phone Numbers: b
I:ocation of Property:
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 fi•om the date of issue.
Other Conditions/Comments: �� ���,r��� i5 _,�r.t 4�r� 2.�.��i2 �
Permit issued by:
Date• � a �'
CERTIFICATE OF COMPLETION
New Well Inspection: Liner Inspection: �
EHS/Date EHS/Date
Location: Installer: ��_
Grouting: Depth: � 3'
Well Log: Grout: .9-Z-D$ SS
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: �e�„; P_ Pr,,�;-� License #: 3 37 �
Pump Installer: License#:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573 .
Date:
Date Results Mailed:
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
1�1a�ne:
Add�es
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Comment Sheet
Page:
Ta� N�ap: -�3Z
Pa�cel #: ��
DEPARTI�ENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH, ENVIRONMENTAL HEALTH SECTION
ON-SITE WATER PROTECTION BRANCH
SOIL/SITE EVALUATION
jor ON-SITE WASTEWATER SYSTEM
(Complete all fields in full)
Shee1 � of 2-
PROPERTY ID #:
COUNTY:�
O WNER: p Av�d W��{-, o I� APPLICATION DATE 1- l S- l 1
ADDRESS: � DATE EVALUATED: r- 2S (�
PROPOSED FACILITY: �j) PROPOSED DESIGN FLOW (.1949): �(�0 PROPERTY SIZE:
LOCATION OF SITE: PROPERTY RECORDED:
WATER SUPPLY: ❑ Private ❑ Public ❑ Well ❑ Spring � Other
EVALUATION METHOD: ❑ Auger Boring 0 Pit 0 Cut TYPE OF WASTEWATER: ❑ Sewage ❑ Industrial Process � Mixed
P •
R SOIL MORPHOLOGY � OTHER
0
F (.1941) PROFILE FACTORS .
� .1940
L LANDSCAPE HORIZON
E PROFILE
POSITION/ DEPTH .1942
# SLOPE % �IN•� .1941 .1941 SOIL .1943 .1956 .1944 CLASS
STRUCTURE/ CONSISTENCE/ WETNESS/ SOIL SAPRO RESTR •& LTAR
TEXTURE MINERALOGY COLOR DEPTH CLASS FIORIZ
�$'� C w Z.s iR 4ft
G �o l.�.seab�c N
1 � �g J'� r� � l%
�
� C_ o - � s �
G S--�o ., - P s u�6c� p5
2 2� �� Z
�x;st;�g -f-G�K �S .�,.. �.., „ d� P
3
,
4
DESCRIPTION
Available Space (.1945)
System Type(s)_
Site LTAR
INITIAL SYSTEM REPAIR SYSTEM OTHER FACTORS (.1946): ►J%}�
SITE CLASSIFICATION (.194 ):
EVALUATED BY: 5
OTHER(S) PRESENT: ��;� 1,; g f����u� �
COMIvIENTS:
C�. 0 Nn v�iP�N �
Updated February 2014 �
LEGEND
_ use the followin� standard abbreviations
SOIL CONVENTIONAL LPP MINERALOGY/
LANDSCAPE POSITION GROUP TEXTURE 1955 LTAR* .1957 LTAR* CONSISTENCE STRUC'fURE
CC (Concave Slope)
CV (Convex Slope)
D (Drainage Way)
DS (Debris Slump)
FP (Flood Plain)
FS (Foot Slope)
H (Head Slope)
L (Linear Slope)
N (Nose Slope)
R (Ridge)
S (Shoulder Slope)
T (Terrace)
I S (Sand)
LS (Loamy Sand)
II SL (Sandy Loam)
L (Loam)
III Si (Silt)
SiCL (Silry Clay Loam)
CL (Clay Loam)
SCL (Sandy Clay Loam)
SiL (Silt Loam)
IV SC (Sandy Clay)
SiC (Silty Clay)
C (Clay)
O (Organic)
1.2-0.8 0.6-0.4
0.8-0:6 0.4-03
0.6-0.3 0.3-0.15
0.4-0.t
None
SEXP (Slightly Expansive)
EXP (Expansive)
MOIST
VFR (Very Friable)
0.2 • 0.05 FR (Friable)
FI (Firtn)
VFI (Very Firm v. Very Sticky)
None EFI (Extrcmely F'um)
*Adjust LTAR due.to depth, consistence, structure, soil wefiess, landscape, position, wastewater flow and quality.
G (Single Grain)
M (Musive)
CR (Crumb)
GR (Granular)
SBK (Subangular Blocky)
ABK (Angular Blocky)
PL (Platy)
PR (Prismatic)
WET
NS (Non-sticky)
SS (Slightly Sticky)
S (Sticky)
VS (Very Sticky)
NP (Non-plastic)
SP (Slightly Plastic)
P (Plastic)
NOTES VP (Very Plasec)
HORlZON DEPTH In inches below natural soil surface
DEPTHOFF/LL In inches from land surface
RESTRICTlVE HORlZON Thickness and depth from land surface
SAPROLITE S(suitable) or U(unsuitable)
SOIL WETNESS Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less - record Munsell color chip designation
CLASSIFICATION S(Suitable), PS (Provisionally Suitable), or U(Unsuitable)
Evaluation of saprolite shall be by pits.
Long-term Acceptance Rate (LTAR): gal/day/ft2
Updated February 2014
January 24; 2017
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Person County
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Esn, Inc., Person County GIS
For Reference Onfy -Always refertothe original swrce.
Person County is notrespmsblefor Iheuse, misuse, or misinterpretation ofthis irdormacon.