A32 91Application Date: � 3 1 �� ��� `��.5 f�' �����
Amount Paid: --i� �--__ ,.,�-..� ; � � r
Receipt #: �� �� ^ �� � ����
C � ][�;.�a v.in-•can�ttaaa ,cni.rnIl � �a^rn'�1.�n
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Re�u;r� _�
�-�2���'� Application for Services
Improvement_Permit (Site Evaluation)
� $200.00/$300.00 (if> 600 gpd)
Mobife �iome Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
Tax Map: � 3 �
Parcel#: �_
Ca 11 �-o Mee�'
q da ; u ad v�
Services Re uested 'f'v ee
Construction Authorization
Fee is de endent on the e of s stem ermitted
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: ��i�p�vn �9-�n.f'ry Phone (home): 33 (� -3 !� 5� 20 �'I
Address: /dd! ,�w�7u �o��o (wark/cell): �/l'_.1��i��2/!�, er-���ad
�r�l� /�lr�s, ,J� 2��4! �qen��( V�Goranq�courl�/ �� ��°�
2) Name and address of current owner (if different than applicant): J � J -/
Name: Phone: �
Address:
3) Property Description: Lot Size: �.�r�7 Subdivision: Lot #:
Address and/or directions to Property: ��/ �C��>�<L��� fhu'4!e /'hir�t �G
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
'� yes ❑ no Does the site contain any existing wastewater systems?
❑ yes '�J no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes � no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
�Residential
L'� New Single Family Residence Maximum number of bedrooms: 3
,$j Expansion of Existing System If expansion: Current number of bedrooms: �_
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes jS�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 � Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? � yes ❑ no
6) If �pplying for `Authorization to Construct', please indicate preferred system type(s):
�Conventional [?Accepted �novative ❑�Iternative �her ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is subsequentl� altered, or the intended use changes, all permits and approvals shall be invalid.
gnatur�(Owner/ Legal Represerftative*)
Supporting documentation required.
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naty,
• 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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map: 3Z Parcel:�_
Subdivision
Phase/Section/Lot #
Permit Valid for: ive Years
TypeofFacility: i✓
Number of Bedrooms �, �
Proposed Wastewater System:
Proposed Repair: J�f,/J�P�
Improvement Permit
Non-expiring
� New _ Addition �
l� / Emnlovees / Seats:
Permit Conditions: ��'� ��� ar�5
Ai�thorized State AgE
(X) Owner or Legal
Water Supply: LtiQ C � �
Projected Daily Flow: 3(�v gal s/day
Type: i —
Type:
Date:
Date: S' Li �
The issuance of this permit by the HeaCth Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicanbproperty 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 t6e 1�lorth Carolina `Laws
aird Rules for Sewa�e Treatment and Disnosa! Svstems'(15A NCAC 18A .1900). Keither 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 System: � o o �n1) (�)Type � Design Flow �¢ (L gal./day
New Repair Expansio Soil LTAR: , 3 gal./day/ft2
Type of Facility: — i4 Basement: _ Yes _ No
(*) System Types Illb, Illbg, IV, and T�, require periodic system inspections by the Person County Hea[th Department.
Wastewater System Requirements
Ex�S%i n9 -
Tank Si�e: Sep�ic Tank � Do0 gal. Purr�p Tank �--�- gal. Grease Trap --gal.
�1�f0 q �.�5� `�� �o�
Drainfield: Total Area s. ft. Total Len � Max. Trench Depth _� in.
D. c�
Trench Width 3 ft. Min.Soil Cover � in. Min.Trench Separation __�__ ft. ,
V
Distribution: Distribution Box
Snecifications: �.
/ Serial Distribution / Pressure Manifo(d
i ,. _�_�• _ ��„i •A�_�t_ i/ �
The system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions
and specifications of this permit �
(X) Owner or Legal Representative: Date: S 2� /¢
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ ph.• 336-597-1790 (rev 5/12)
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SITE PLAN
Name �� Tax Map #�ZParcel # q _�___
Subdivis' n � Section/Lot#
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Au orized State Agent Dat
System components represent approximate contours only. The contractor must,/lag the system prior to beginning the
insta!lation to insure that proper grade is maintainecL
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Applicant: �o c�, i�t � i�.�
Lacation: 981 -NAwN•15 � '4-D
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Taz Map A3�- Parcel #� �
Subdivision
Phase/Sectian2ot #
# of Bedrooms 3
System Type (From Table Va): 7��a �� Product (IIIg): �Z iww
Type V& VI Expiration Date: — Type V& VI Renewal Date: —
This system has been installed in compliance with applicable North �arolina General Statutes, Rules for
Sewage Treatment and IDisp�sal, and all conditians of #he Improvement P�a�mit and Construction
Authorization.
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(.Authorized Agent)
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(Licensed Contractor) �• 'I�
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Scale I�TS �'Qi�p
PCHD, rev. 12/14/12
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Line Length
_ . _ �c�b ^1�00�
� 9v'
�. 90'
��L. 3�10'
Tax Map: A32 Parcel #: i �
Septic Tank System Checklist (Type II-IV) System Type•�� 6
Septic Tank InitiaUDa4�e
State ID & Date; ���
Capacity: �,sn�
Tee and fiiter p�s s ��-
Baffle
Vent
�Riser �v��r �,� 0� 5 ty-
Outlet boot
Perm. Mazker
DistributiQn
D-box levels set)
Serial ��
Pressure Manifold �
LPP
Notes:
� 1�1ih�ification Lines IaifiaUDate
Trench Wid�h: ;3 i"t. �s c�. 5��k-
Trench De th: 15 in.
Total Length: I$O ft.
Min;mutn s acing: � ft.
Rock de tl�// uality --
Dams/ste downs � ia �`4°
Grade < .25" in 10')
Cover 6" minimum)
Setbacks
Fro�a wells ►� �`�
Pro erty lines
Foundations,�basements
SurfaceWater
Other: �
Pamp System Checklisi
Pum Tank InitiaUData
State ID & Date:
Capacity:
Riser (6" niin.)
NEMA 4X Box
Model:
Piggy back lp ug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pres�uYe Manifold
Number oF ta�s�� ^_ _
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
Tank Co� onents InitiaUDat�
Pump model:
Block (4")
Nylon retrie�al ra e
Float tree and attachments
On/Off float swing: in. j
Alarm float (6" se aratior_)
Anti-si hon no?e
Check val��e
Threaded ur.ion
G�te valve ~
Conduit sealed
Outlet seated
A proved a�d secured riser
S� ! � Line #
Size and material: _ in. sch. j
Length: ft.
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Building Additions/ Mobile Home Replacements
Tax Map #: � 2 Parcel#:�_ Address: a �oo �,
. L 15
Approval Requested for: ��e Home Replacement
Building Addition .
Applicant Name: �,��q, � �. 3er►-�,1
Address: l o j�� L� oo� �
G
Phone #'s: 33(�-3Lo�l- 20l 1 a1q - 2�(5- 2G [ 2
Permit Located: V Yes
Installation Date: a -( o -1(L
No
Design flow: Z..� (gpd)
Current Contract with Certified erator on file (if required):
Water Supply: Well Pu�lic or Community
Wastewater system skows no visual evidence of failure on: �j� �- �� (date)
(Applicant's signature if site visit is not required)
� g0 � �XDAn S%n �
Si�e SKe��)
Addition/Replacement Approved
Envir nmental Health Specialist
� 20 /�
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.�,ersoncountv.net
Tax Map: �
Subdivision:
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. � � � ����
'�° �cn�vn�r�sn.�ra���ra�.�.� ����.��:�n.
Parcel: ��
WELL PERMI'�
(New_ Repair�)
Applicant's Name: J vGQ�
Mailing Address: 00 p
Z� 5
Phone Numbers:
Location of Property:
- � Pi,,,n.o ✓-h/
Lot:
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 5 years from the date of issue.
4.) Issuance of a permit does not guarantee a po able water su� ply
Other Conditions/Comments: I. f.� l_) ��i,7� �rsn m pH� (�) q i�l ��c� ��1kt n S Z
Permit issued b. \ Date: _S- 2/-��
�New Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additiona! Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Certificate of Completion
OLiner:
EHS/Date
Depth:
Grout:
O4Abandonment:
Date: a i'}
Method/Materials: �,b
Co�c:c�.-� Lcc��o��.�
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 fax:336-597-7808
11/26/13