A32 75� ` licatlon Date• r ��
�►mount Paid: �
ecei t #: 1
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1'
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Person CountY Health Deaartment
Envi�onmental Health Sectfon
Tax Maa #•
�arcel #•
. APPLICATION FOR SERVICES .
�F THE INFORMATiON IN 7NE APPLICATION FOR �AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED, OR THE SITE 1S
ALTERED. THEN'THE IMPROVEMENT PERMI7 AND AUTNORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Pertnit requested b� ^ Ownedagent/prospective owner): �h°X ��i'''�iG/.�c+-�- ��v-� .•Tirc.
Home Phone: �'� � Addr��. U�c' 8 S'�-�
Business Phone: - /3� lZOr��3D�..d .d�a�'73
2j Name and address of current owner. ��, "—" ��lg/ 3�' 'Z `f�`�
✓�
�}c+�aS r
3) Prcperty Description: l.ot s�za 7�7 � Townsttitp: ��5� f"t����
Directlons to the aroaertv (induding r�ad names and n�ur�bQrs): �
4) Proposed Use a Structure Description: answer each of the foUowing questians:
e
a) Proposed Exis�ng 0
b) Stick Buiit Q Modular ngle Wide �, Double Wide 0
c) Number of Bedrooms:� � Number of occupants ar pecple to be se[ved:
e) Basement Yes Q No 1��Tf yes, # aseme� fixtures: ,
�� Garbage Disposal: Yes �� No p�
g) Dimensions of Proposed Strudure: Width:,'� Oepth: SO
b� Water SuPP�Y TYPe: Private �"{new 8 or existing �)� Publtc q Co�niiy �, Spring �
Are a r ry weUs o� a d Jointn g pro p e R y? Yes o � If yss, loca$on
6) Pleaae Indicate Oesii�ed System Type: (systems can be ranked in order of your prefe�ence)
Convantio�al Modified Comre�tlonai _ Attemative lnnovative
Other (sPe�Y):
-% CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY P�AT OR SfTE PLAN TO THIS APPUCATIaN
I hereby rtiake applicatiort to the Peraca County Health Depanment far a site e�aluatlon tor the on-atte aewage disposal system for
tha above-described property. I agrea that the conte�ts of this applic�tion are true and represent the maximum faa7itias to be
placed on the propecty. I understand if the site is altered or the irrtended use changea, the pertnit shaU become invalid. I understend
that as applicaat� i am responsible for identifying and marlcing property lines, camers and making the site aaessi'ble fo� the
perso�nei of the Person Cour�ty Heafih Department to condud their evaluatlons. l understand that 1 am responsib�e fo� notiffying the
Health De ent if rtry party n s any wetlands as designated by the A�my Corps of Engineecs.
��33 vC�
Owner or Legal Representative . Oate
� Ce'Y�-�-C� �-CJ'
. PERSON COUNTY ENVIRONMENTAL HEALTH
-- � ��:�_EASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM l
Tax Map #: � ` � � Parcel # [ �
Zoning Township_ _,�uSliy �D�%G
Applicant: i�8.ls..e�+7- � . ��a
Location: I S 7 S L�-J B a�� ��-�,c. QS K� /ih ,� �Q ( Q� �r��p
L� �.s H L� - .� '�z � .e.,��� ro� .
Subdivision: ^ Section: Lot: —
Improvement Permit
A buildinq permit cannot be issued with onlv an Improvement Permit
New ✓ Repair Addition Type of Structure Water Supply
# of Occupants J-� # of Bedrooms � Other
Basement? � Basement Fixtures? N�,
Projected Daily Flow: ��og.p.d. Permit Valid For: �ve Years ❑ No Expiration
Proposed Wastewater System Type: (aif/I��NTi��/.�� -�.,.//aw �/�f ��jmp �,;,, Ft.
Pump Required? Yes ✓No
Proposed Repair :_r'�Nv -S�. �/e L..,
Permit Conditions: _ c� ��,4 S/cv,���
Owner or Legal Representative
Authorized State Agent:
Date:
Date: S ^ � �"°�
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit
holder is responsible for checking with appropriate goveming bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Buildinq Permit)
Type of Wastewater System �/il/U,�NT/D/U/�LWastewater Flow: 360 a.p.d.
Facility Type: �/1 /'rs�'vle.v�e /
Basement? O Yes [�-Pfo-
Wastewater Svstem Requirements
New ��epair DExpansion ❑
Basement Fixtures? 0 Yes �tda'
Septic Tank Size: '� 00 gallons Pump Tank Size: _�J /", galtons
T
Total Trench �ength: �'�O feet Maximum Trench Depth: �� inches Aggregate Depth:� in.
Maximum Soil Cover: 6 i�ches Trench Separation: 9 Feet on Center
�.
Other: �6 ���-�,�Co.�i� iZ.eeo��[ fre.+c,�s .� ,�- cz�9�r�Jc�J
Permit Expiration Date: �- a 3-�'
Authorized State Agent: /�1��1�,P �' . Date: � �3-�
The type of system permitted ❑ does L�l oes not differ from the type specified on the application. I accept
the specifications of this permit
Owner/Legal Representative Signature: �
PCHD, rev. 11/18l99
__ _ . _
_.__._. _ _._.._.___.__ _ _
Person County Health. Department
� � Environmental Health Section Tax Map #: �' 3�
, ,-: Parcel #:
v SITE SKETCH
�,�-er�- � . Lo� N/�
Appllcant's Name Subdivision/Section/Lot#
� ,�.�' s—a3—o-o
Authorized tate Agent Date
System con�ponents represent approx3marte cnntours only. The contraclor must, flag the system
prior to beginnin.g the Installation to insure that proper �rade is maintained
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Person County Heaith_ Department .
?� Environmentai Heaith�Section • . --7�-
Tax Ma� #: c� Paresi #:
Zoning: Tovmship: � ��
Subdivision• Section: ��
A ticant . ��
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l.ocatlom � �� " "� �
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Ope�rat�on Perm�t
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System Type (in Accordance With Tabie Va):
THIS SYSTEM HAS BEEN INSTALLEf? IN COMPI.IANCE WITH APPLICABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FOR SEtAIAGE TREATMENT AND DISPOSAL,
.AND ALL CONDITIONS OF THE IMPR�VEMENT PERMIT AND CONSTRUCTION
AUTHORIZATiON.
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PCHD, rev.10/12/99
• �
Person County Health Department
Environmental Health Section
Zoning: Township: 1� CY� �
Subdivislon: Section: Lo :
Applicant: LO .
Location• � L � � �--�_
. . �
Operatvon Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements �
B) Distance from system to any wells �
C) Distance from septic tank to foundation � /
D) Distance from system to property lines 0 /
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank �
B) VisuaAy inspect the interior walls, baffle, tee, filter, riser, ids, air vent,
bottom, and water tight outlet �
C) Date of tank manufacture �—�-0a
D) Tank serial number � /�d
E) Liquid capacity of tank /'o aD gallons
3. SUPPLY LINE TO TRENCHES
A) Grade (1/8 inch per foot minimum ,r
B) Material s pply ling�is constructed from c O��/ �
C) Diameter �
D) Length �,/'�--
E) Distance from tank to drainfield/distribution device /�
4. DISTRIBUTION DEVICE(S)
A) Type
B) Is Device water tight
�C) Distance from the distribution device(s) to the trenches
D) is the device on a ievel foundation
E) Does the device perform according to its design specifications
F) Record the inlet and outlet elevations
5, NITRIFICATION FIELD
A) Trench depth �� inches / �
B) Trench width � inches �
� C) Distance between trenches
D) Number of trenches 3 �
E) Length(s) of trenchgs I70' �7s ' ��f �= ya9
F) Aggregate depth / � inches
G) Aggregate materiai and size 1� S%
H) Record septic tank outlet elevation S' Y
I) Trench grade 5� ra�; �_ (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth -�
b. Proper rise over step down ��
c. Solid pipe used r `
d. Elevations of step owns �- �Recor elevations and show on as built)
�
See "as built" plan on attached sheet.
,�
PCHD, rev. 10/12/99
A iication Date: D��"� Z' Tax Map #: i� 3 L'
A�mount �aid• �� ,��
Recaipt #• Parczl #•
C�'�'�' ���,'�� ���.� ��
�" - - <C � �1� °7L" �
1�a�.�aa-�aa�-� �ea.�mll ?E�om71�I�s
APPLlCATIOPI FOR SERVIC�S
IF '�HE INFORflflATI�M IN THE APP�1CATl0�l FOR AN lMPRO�IEMEPIT PERMIT IS INCORRECT, FALSIFIED
CHANGED OR THE SITE IS ALTERED THEiV THE IMPROVEiV1ENT PEi�MIT AND AUTHORIZATIOtd TO
CONSTRUCT SHALL BECOME INVALID. �
2 ���.�� � -
1) Permit requested by: (Ownedagent/prospective owner): �-•�•� �� • 1n-t�,
Home Phone��:t- �0�4'7 Address: � � �p�s L-rs�'�
BusinessPhone:s�g- G97-cao�� ►.� KcLL, t-P-C'. 2-�5��
2) Name and address ofi current owner:� oF3�r ��o I�K ���
� �3 3 t`7+�s c� L.�a N� -
6-�o2DL�c►�.1. l L� I,Q �`.
st+ e�, r�I
3) Property Description: Lot size: 7?l� Township: Subdivision: �t-t��.o�, /V�a��iot #�
Directions to the property (Including road names and numbers): � � �
.
4) f�roposed Use apd Structure Description: answer each of the following questions: , �
a) Proposed ✓ Existing , Type of Structure:��T�u►� ��czaco� �dth: 3� Depth:.�_
b) Number of Bedrooms: c7 Number of occupants or people to be served: o �
c) . Basement: Yes , No ,� Will there be plumbing in the�basement?�_
d) 6arbage Disposal: Yes , No ,�
N��5) Water Supply Type: Private (new _ or existing�, Public , Community , Spring
Are any weils on adjoining property? Yes_ No _ if yes, please indicate approximate location on the
�site plan.
6) Does your prope�ty contain_previousfy identfied juriscdictional wetlands? Yes_ No�C
PLEASE NOTE TFIE FOLLOWING:
� ➢ A Pl.AT OF THE PROPERTY OR S1TE PLAPI NIUST SE SUBMIITED WITH 'PHIS �►PPL9CATION.
� ➢ PROPERTY LINES APID CORNERS MUST BE CLEARLY MAR�CED. �,
` 9 iiE Pl20POSED LOCATION OF ALL STRUCTURES MUST BE STAQC�E� OR FLAGGEi'�.
', 9 THE SITE MUST BE RE�►DILY A�CESSIBL� FOR API EVALUATION BY THE liE4LTii DEPARTMEiVT
��, STAFF.
'�I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described prope res that the contents of this application are true and represent the maximum
�aciiities to be pl�d on the property. i un rstand if the site is altered or the intended use changes, the permii shall
`� / w r oc Legal
�
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■
PCND, rev. 06127102
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Tax Map #� Parcel # ` �
Existing Sewage Spstem Report For.
Mobile Home Rep cement �
� Addition Type: �J �� Z� qQ{�Q '�-
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Original Permit Located• 5
Septic System Designed For. Residential
Water Supply: Ulf'� � (
Business Other
# Bedrooms �_ # Employees Other
System Type: �' Tank Size: _ �Nitrification Li.ne: d,��
+• .
� Date Installed: �_� �� �� Certified Operator Required: ,�,� � �
On-site wastewater disposal system shows no visual signs of malfunction on g� ��_� a
Permission is granted
Comments•
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�
Environmental Health Specialist Date: � ���a�
e .dwA ea.
/ M C�d�/�
r . eou�ep ar
n ocdL�a
pnal� oC laid.
as nr
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ticias m el�.
�s eo pooirfsi�+�
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risioa plat as
i final appro�
ibdirisioa �
r oF �
ce�titr tnat
� trom an ottucl
descripf ion
—,eef.) (othet);
o�lr indicatcd as
is 1: l��t ;
: vrith G.S. 47 - 30
on nua�ber, and
, A.0:,191�•
--I.—ZL�48
STWITION N�1M6ER
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SAMU�L J. PARKER, �,
DAVID NII�HAEL Pi4Ri�ER,
NELS01� COOPER PARK�R,
� BAR�AF�A PARKER VVC�OD
8ushy Fork Twp., P�erson Co., N.C.
Sept., I996 ScaIQ I"= Z04'
. 2oC iod o 2od �od
Ernest 8. �11bod, Jr. RLS-2648, Roxboro, N.C.
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� PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: � � � Parcel # � �
Zoning Township � ��1�_ rlL
AppUcanG ,�� IW �/1�� � � ""'^' ..'
LocaUon. � S 7 � �� ��I�SS
��. � S t� I-�< n e
Subdivislon: SecUon• - Lot
Well Permit
ype of Water Suapiv: �ividual Community Public
Requirements:
Site Approved by .� � / oa
Grouting Ap�roved by J Oo
Well Log ✓
Well Tag
Air Vent '�
Hose Bib �
Concrete Slab
^� �
Well Driller:,�__�
Well Approved By: - � � �
Date: l� � ��
**See Attached Site Sketch*�'`
Welis must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
r�
PCHD, rev. 11/29/99