A32 59A� Person. County Health Department
Sewage.;S.y.stem Improvements Permit
�� Date: '��.This Pernrit Void After 5 Years Pemut #�%� %� d g
O.wner: - �'o I� n � K� O %��S�d� ;, :,.---." Sl�# ✓7r�,3 :
Locaaon/Directions: �vi Y�- �-�� >>� � L -
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Subdivision Name: ��� � Lot #
Lot Size: Type of Dwe ' g: �
Water Supply: Priyate: Public: _ '� tiCommu �
� � . ��,; .,
Bedrooms: � Gartia e Disposal �_ �
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Basement Basement Fixiures '�;
INFORMATION CERTIF�D BY _ ` ' t��
Environmental Health Specialist• � �•RP� 4ve
��K: REEVALUATION: ��� �
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Size of Septic Tank: __ l l�aD gallons Size of Aunp Tank:�'
Nitrifcation Line: l,t� p r� 3'�
Depth of Stone: 12 inches '
Max Depth of Trenches: •
Altemative System: Conv. Pump Lpp pump '-- �„�
Remarks: ,---•
Date Well
BY
ell ould be 100 ft, firom any sewer s stem
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Env�i�nme�ntal Health Specialist
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Sewage System locadon, installation, and pzotecdon musc meec state anfl local �
IBgU12I1011S. $OptIC �3f�[ sllould be pumped out every 3 to 5 years and shall be maintaine3
b}!:OwlleZ I1l SUCh matliier as not to cieate a public health hazard. Septic tanic azid
nitrification line snust be ;nspected and approved by a member of the Person County
Health Departrnent before any portion of the installation is covered and pu[ iIt[O Use. If W
t}ie sife plans or intended use change this Pecmit is sub�ect to ICYOC3L10A.
(G:S::130 A-335� ?
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Locatian of sewage disposal sewage system sketched on back. ` ��
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Application Date: �b �6 �
Amount Paid: �
Receipt #:
Ap�
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if > 600 gpd)
0 Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
���,:).� ���� `U�l V Tag Map: l�3�
�;, � Parcel#: .��
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7C.an�n�o+r* �* a�an��Il 7H[�ffiIl�
tion for Services
Services
equested
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
' $75.00
Repair of ExistJi� p System
' Application{No Char�e CA $150.00 or $300.00
'"'� 1) Applicant Information:
Name: f�n �� � �� � 5
Address: ii K�o Nur�►�� y'bt � Ils �eA�
Na��ai..� Y1�,�IS T Nc. .���,�4i
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home):
(work/cell): .3n � <J.3�9 ff095
Phone:
3) Property Description: Lot Size: Subdivision: Lot #t
Address and/or directions to Property:
0 yes C�'no Does the site contain any jurisdictional wetlands?
C�}'yes ❑ no Does the site contain any existing wastewater systems?
❑ yes L9'no Is any wasfewater going to be generated on the site other than domestic sewage?
❑ yes C3'no Is the site subject to approval by any other public agency?
O yes [H 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: 3 / Occupants: �
� Expansion of Existing System If expansion: Current number of bedrooms:
Ga'Repair to Malfunctioning System Will there be a basement? ❑ yes C�'no With plumbing fixtures? ❑ 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 l�'"Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? (�'yes ❑ 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 ❑ Alternative ❑ Other � Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
S�gnature (Owner/ Legal Representative*)
* Supporting documentation required.
)D —/o � lb
� Date
Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
A completed �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)
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Applicant;
Address/Lc
Tag Map:1�'� Parcel:_yZl�
Subdivision
Phase/Section/Lot #
Permit Valid for: Five Years
Type of Facility:
Number of: Bedrooms / Occupants
Proposed Wastewater System:
Proposed Repair:
Permit Gonditions:
Autherized State Agent:
(X) Owner or Legal RE
I�pr�o�etn�r�� Per*e�i�
Non-expirin�
New Addition Vt�'ater Supply:
/ Employees / Sea . Projected Daily Flow:
Type:
Type:
Date:
Date:
gaIlons/day
The issuan�e of this permit b e Health Department does not guazantee the issuance of other required permits. It is the responsibility of
the applic�ndproperty o r to insure that all Person Gounty Planning and Zoning and Building Inspections requirements aze met. This
lmprovement Permi subject to revocation if the site plan, plat or the intended use changes. The ImQrovemeni is not affected
by a change in ow rship of the property. This permit was issued in compliance with the provisions of the North Carolina `Luws
mid Rules for Se►vag� Treatment and Disnnsal Svstems'(15A 1VCAC i8A .t9U[�). Neither Person County nor the Environmental
Health Specialist warrants that :he se�tic system will continue to f�nciivn satisfactorily in the future, or ihat t�e water supply witl
remair pota5le.
Authorization to Coostruct Waste;�vater �ystem
See site plan and additionai a�tacrirrzents (_).
Proposed Wastewater System: �i/��j ��il�
New Repair � Expans on _
Type �f raci3it�: ���
(*)Type �� Design Flow �_ ga(./day
Soil L"Cf�R: gal./day/ft2
Bssemen�: _ Yes _�IQc�
(*) System Typ�s III6, IIl6g, IY, und v, require perio�flc system inspections by ih.e Person County Health Department.
, /��l✓ Wast��vaxQr System Re��irpme�t�
/Y
Tank Size: Szptic Tank /OOD gal. ���� Pump Tank gal
Drainfield: Total Area � sq. ft. Total Length _ ft.
Trench Width ft. Min.Soil Cover in.
Grease Trap gal.
Max. Trench Depth
Min:Trench Separation
Djsiriba�tio�: Distribution Box / Serial L�istribution_� / PrP�s�re 1Vlanifol�l
S�ecifications:
�t�thor�z:,� Sta.e Agent:
Issue Date: �
Permit Expiration
in.
ft.
7'he system permitted is: Conventional %r /Accepted / Alternative / Innovative . I accept the co�iditions
an� spec:fcations �f this permit.
{X} Owner or Lega; Representa�i�e: Daie:
Person Counry Environmental Health, 325 S Morgan St, Suite C,; Roxboro, N(: 27573/ph: 336-597-1790 (rev 5/12)