A32 51- -rr-------..._ ........, �.J +� � 3 ,
Amount Paid: �v�j d
Receipt#: ,5 � �j��
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.�1_.r':[-1. b+:i iC�aY.'D ItT.::I-YT.�R�.^ ]iT.'d::.tl),.II �L Jt ¢��`�.GIL 11 �CL' �L7
��p�ie�tgon fo�- S��ic�s
_ (Septic Systems and Wel3s)
C Improvement Permit (Site Evalnation)
$200.00/�30Q.00 (if> 600 apd)
G Mobile Home Replacement or Building Addition
_ $150.00 (if site visit required)
r Well Permit (New/Replacement)
�225.00/� 125.00
laxMap: �— s�
Parcei #: .�-�
����
v�
�e�ace� Re uested
,f�lConstruction A�thorization
(Fee is de endent on the e of
� Permit Revision
$75.00
❑ Repair of Existing Septic System
� No Charee
Important: If tlie infor�nation in tl:e applicatiodi for at: dmproveme�tt Aertnit is itzcorrect, falsifted, or �he site is rrllered, tlie�t 1{ie
Improvement Permif and the.Autl:orization to �'n�tstruct s1ia11 becvrne invalid
1) Services Requested by:
Name: /�-- /�at;!
Address: 3 qZp ��,,,��,,,, �
__ t,�►�i� c�
Phone #(home): 33�-597 ss 3 g
(work/ce11): __ 336 —z2t— t�44j
2)1Vame and a�idres� of curren� o�vt�er �if �iii%reat than agrpiiea�t):
Name: ,�t,��.�� ,Ei , /-�.�w,�,.�
Address: _ S'� C�/6,r,�;eAJ ,��,
/�� (� /►�tTi�S sKt Z�{ I
3) Propexty Descriptiosa: Lot Size:s��
Address and/or directions to Property: t{ 7
Subdivision:
Lot #:
4) Proposed Use d Type o�Stra�etutre: �oc�� w��,
Residentiai � Business/Type: Other
Nuanber of bedroozns 3 / Number of people served (seats/employees):
Basement: Yes No (�umbing: Yes _ No � Garbage disposal: Yes No _/
Approximate size o�' building foa�nda�ion: I.ength �� Wic➢th �_
S) Water Supply:
Private Well (Proposed Existing � �
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
�(please show location on site plan) —
Note: �4 cnmpleied ap�nl�cati�n �au�� also itzclude•
� At pladsite plan of the pr�perty thut sltows ,pro,��rtj� dir�aensions and dhe �ize and locatdon of call
proposed structures.
� A signed copy o.�`'the `.Lot �'a•eparut`iosa' foran verifying thrxt tdie �rmpep•�y i� �erady to b� evaluaie�l
I am submitting this applicataon to r�quest serviee� from tbe �'er�o� Coannty �ea�tia �epa��nent. T'he in�'ormation
provided is accurate. I undea-stand that if aa�y sit� is alte�ed or t�e intended use s�nanges, ali peranais s�aall become
invalid.
Si�s�a$ure (Owner/Legal Representative): ����. ,� 3 a
1 1/07 Person Cour.ty Environmental Heaith, 325 S. Mergan St., Suite C, Roxboro, N 27573 {3�6-597-1790)
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nsuring a healthy environment
March 20, 2008
Re: Application for Improvement Permits for Tommy Hawkins off Hawkins Loop Rd.
Dear Mr. Hawkins:
The Person County Health Department, Environmental Health Division on
March 19, 2008, evaluated the above-referenced property at the site designated on the
plat/site plan that accompanied your improvement permit application. According to your
application the site is to serve a three bedroom residence with a design wastewater flow
of 360 gallons per day. The evaluation was done in accordance with the laws and rules
governing wastewater systems in North Carolina General Statute 130A-333 including
related statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative
Code, Rule. 1900 and related rules.
Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina
Administrative Code, Rules .1940 through .1948, the evaluation indicated that the site is
UNSUITABLE for a ground absorption sewage system. Therefore, your request for an
improvement permit is DENIED. The site is unsuitable based on the following:
Unsuitable soil topography and/or landscape position (Rule .1940)
X Unsuitable soil characteristics (structure or clay mineralogy) (Rule .1941)
X Unsuitable soil wetness condition (Rule .1942)
X Unsuitable soil depth (Rule .1943)
Presence of restrictive horizon (Rule .1944)
X Insufficient space for septic system and repair area (Rule .1945)
Unsuitable for meeting required setbacks (Rule .1950)
Other (Rule .1946)
These severe soil or site limitations could cause premature system failure, leading to
the discharge of untreated sewage on the ground surface, into surface waters, directly to
ground water or inside your structure.
The site evaluation included consideration of possible site modifications, and
modified, innovative or alternative systems. However, the Health Department has
determined that none of the above options will overcome the severe conditions on this site.
A possible option might be a system designed to dispose of sewage to another area of
suitable soil or off-site to additional property.
For the reasons set out above, the property is currently classified UNSUITABLE,
and no improvement permit shall be issued for this site in accordance with Rule .1948(c).
However, the site classified as UNSUITABLE may be classified as
PROVISIONALLY SUITABLE if written documentation is provided that meets the
requirements of Rule .1948(d). A copy of this rule is enclosed. You may hire���ts�ir��t��• 1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
to assist you if you wish to try to develop a plan under which your site could be reclassified
as PROVISIONALLY SUITABLE.
You have a right to an informal review of this decision. You may request an
informal review by the soil scientist or environmental health supervisor at the local health
department. You may also request an informal review by the N.C. Department of
Environment and Natural Resources regional soil specialist. A request for informal review
must be made in writing to the local health department.
You also have a right to a formal appeal of this decision. To pursue a formal appeal,
you must file a petition for a contested case hearing with the Office of Administrative
Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form,
you may write the Office of Administrative Hearings or call the office at (919) 733-0926 or
from the OAH web site at �vww.oah.state.nc.us/form.htm . The petition for a contested case
hearing must be iiled in accordance with the provision of North Carolina General Statutes
130A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C. General
Statute 130A-335 (g) provides that your hearing would be held in the county where your
property is located.
Please note: If you wish to pursue a formal appeal, you must file the petition form
with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS
LETTER The date of this letter is 3/21/08. Meeting the 30 day deadline is critical to your
right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with
any informal review that you might request. Do not wait for the outcome of any informal
review if you wish to file a formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative
Hearings, you are required by law (N.C. General Statute 150B-23) to send a copy of your
petition to the North Carolina Department of Environment and Natural Resources. Send the
copy to: Office of General Counsel, N.C. Department of Environment and Natural
Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy
of the petition to your local health department. Sending a copy of your petition to the local
health department will NOT satisfy the legal requirement in N.C. General Statute 150B-23
that you send a copy to the Office of General Counsel, NCDENR.
You may call or write the local health department if you need any additional information or
assistance.
Sincerely,
Adam C. Sarver, RS
EH Program Specialist
Encl.: Rule .1948d
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Date: �r`�- r�-`-'.y This permit Void After 5 Years
Owner: i ..�,Ji''��✓"J✓'.:l i. �t��:��'r', jVI. '�
Permic # " ,�'
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Sulzdivision Name: ,- ----�`-�--�_�-% ���«.... �-- Lot #
Lot Size: ��-�"'"-�-°�- ��-'-�--:�' ' Ty�e of Dwelling: �� ��-' jy %� '
.�s� ,_.��...�.-� �.. z._�
ildater Su�piy=' Pnva • �,�Public: Communiry:
Bedraflms �� `�ge Bispasal �� e
Basement y��'� Basement Fixtures .%.� w'
INF'�RMIiTI(3I�I CERT�IED BY
, � - owner or mpresentative
Envi�onmental I3ealth Specialist: ,�:�f.�•.�=., , ,��,�
1��2: REEVAI.U,a.TI�Pd:
._._ — — — — — — — — — — — — — — — — — — — — — — —
�ixe off 5ept�c Tanlc: ,+�'�'�`' � gall�ns 5ize of �amp Tank:
NitrifiCatimn Li�e: _..� �"�7'� a�' .� r
Depth of Stone: 12 inches -
Ahax i3epth of Trenches: �-�-��--��r. , ,� -.���`�'`�
Al�er�ative System: Conv. P p `'Y.PP �ump
Remarlcs: •� _��`�,�-��-�
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D�te WeYi A��a�oved: � ell should � iiiD ft �ra► �y sewer system
ao
��C � %` � �r'"=' Environmental Health Specialist
I�ate Sev�age �ys9. m,;�'�pprove�: 7 - � ' `" �
BY �%i •-r =l-� ..��-��-s-�.-� Bnvironmental �Iealth Specialist
�TTIF��A'� �F �C�MPLE'1��1V �
�onS�cior. �'� -� � z� � �
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��o�e�e����.�������������� ¢
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Sev✓age System location, installation, and proteciion must me�t state and lccal �
regulatiflns. Septic tank should be �umped out every 3 to S years and shall be maintained .
by owner in su�h manner as nflt to czeate a public health hazard. Septic tank and •:�
nitriiication line must be insFected and approved by a member of ihe Pezson County �
�3ealth 1")apazunent before any portion of the installation is covered and put anto use. If ;�
the site plans or intended use change ihis pernrit is subject to revocation +
(G.S. 130 A-335� `�
I.acation of sewage disgasal sewage system sketched on bac?c.
�OW��
G �7Amount paid . �U�� ' 6� � �s– •
Receipt .�� • � lQ`t6 / — _ Date
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1, permit requested by: . -
o`i /prospective owner/agent:�T �'���5��
Address: /9ao � ��✓'�Dl � �'1 �`' �S n
ome Phone #: � �� a� � 9
usiness Phone #: � - � � 7
7. Dime �ansor Prop+
Width: �
,-,,.�.�,.
Structure:
8. What type (if any, additions, expansions, or I
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
/!i/T 1rla���- -
Name and addre�s of current owner: 9. Water su ply t5•pe:
�f� � -� �,¢�� �,,v S � private public ❑ community ❑ spring ❑
/p a v� /� u�c � L.� til /� �/� D• Are any wells on adjoining property?Yes C�No �.
,c�.. � n � i /L1 I L LS �t�- �- a 7-►-y� If so, identify location:
�
ion: Lot size:
Tax Map#: � fi' 3 � - �'
Parcel#: S � - ��
Township: .�3vs�(..y G��--
Directions to property: State Road #& Road
ames,�tc.
aL���, l.s-�/,u -S
10. Type of structurelfacility: Proposed: xisting: Q
Type of dwelling:
House: ❑ Mobile Home: (�1 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �._
Garbage Disposal? Yes ❑ No 0
B asement? Yes ❑ No �1 If so, # of basement fixtures:
'6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES• .
I hereby make application to the PeI'sOn COUIIty Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall b�come invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to-the Health Dept. wi�iin 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
W �/
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Z Signc wner or Authorized Agent
t �
permit Issued ❑ Signature Date
Permit Denied ❑
Plat Observed ❑ �.�t�, .�.
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9. SliECLASSiFICATION(SEEBELOVn �
SOIL SERIES
S-SUITAIILE PS-PROVLSIONALLYSUtTAIIIE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �ill
areas, wells, water bodies, slope patterns, etc.� C:�AMiPR01DOCS�APP5EC.5r4FlNANCE.PC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IN�ROVEMENT PERMIT
B 17i 8
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # �} �� _ Parcel # S�
Zoning Township �v�H y /'o,z,�
Owner/Contractor /� �' i . , • ,4 c� /c ��.�5 Date � - �-�' �
Location/Address j5-;7 i o r!.¢�.�.��.v� Lc��� �2 �� %
/�l, r..� �.v � c�%-� S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area , o. Sv�3 .4 Size of Tank /!>O�d Cf-�4L
SFD - Mobile Home ;/ Size of Pump Tank �,4
Business # of Bedrooms�_ Nitrification Line �,So � x 3�
Max Depth Trenches � �y < <
Permits may be voided if site is alt ed or inte�ded use changed: .�
Well and Septic Layout by �-� �' - �
Comments: " �- c f � ��`'•
G�it/`C`. S d�/ Gc�'✓' O�t� �L
Date �-aG �7 Installed by� Approved by�
ell Permit Paid ❑
Site
Well
Comments:
Date
WELL SYSTEM SPECIFICATIONS
Semi-Public
Installed by
Required Slab
Air Vent
Well
Well Lo
Approved by
�
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. 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.
c:\amipro\permit.sam O1/95 rev.l.l