A33 13A iication Date: 7��d - � `
' 2 Amo�int Paid: .��—
Receipt #: '��S
Person Countv Nealth Department
Environmental Health Section
APPLICATION FOR SERVICES
Tax Map #:
Parc�l #:
1) Permit requested by: (Owner/agenUprospective owner)�^ �'lLr� �� �����17'
Home �hone:l l����f �(��'(� Address: 9�� �lu� <�:u 2
Business Phone: �!Q s"C/�' L� / ' �[�n�r A/-- e. �,`7713
2) Name and address of current owner: �ik�Y �S qTl«'Ftc.rL,CI
� Lt.: �_14-YU�,
� i�/DL/✓� �w �L'fCSL11 p�D3(o
3) Property Description: �otsize: �Township: Cvn�in �,ar►�
Directions to the property (Including road names and numb�ers):
�D� ,�= f,aNLS�.s CVw �Q d e/l. rvt�-
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed �, Existing ❑ .
b) Sticic Built �, Madular� Single Wide ❑, Double Wide ❑
c) Number of Bedrooms: �_ • d) Number of occupants or people to be served: 3�
e) Basement: Yes 0, No�lf yes, # of basement fixtures: � � _- �.. --
fj Garbaae.Disp4sal� YPs ❑, No � . ______ _ _ .. _ _
g) Dimensions of Proposed Structure: Width: Depth:
5) Water Supply Type: PrivateYd (new � or existing ❑), Public �, Community ❑, Spring ❑
Are any weiis on adjoining property? Yes ❑ No.� If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
_Conventional _Modified Conventional _ Alternative _Innovative
Other`(specify):
CLE�4RLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
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 praperty. I agree that the contents of this appiication 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 become invalid. I understand
that as applicant, 1 am responsible for identifying and marking property lines, comers and making the site accassible for the
personnel o e Person County Health Depart t to conduct their evaluations. I understand that I am responsible for notifying the
It rtmen ifi pr contains etlands a esignated by the Army Corps of Engi eers.
�� Q7lc0
Owner or Legal Repres ative Date
PCHD, rev. 10/12/99
��n.�n���n��c����.� �c��.���n.
September 19, 2001
Ms. Esther Lynch
933 Bluestone Rd.
Durham, NC 27713
Re: Application for improvement permit for Wastewater system for property at
Ephesus Church Road.
Dear Ms. Lynch:
The Person County Health Department, Environmental Health Division on September 18,
2001 evaluated the above referenced property at the site designated on the plat/site plan
that accompanied yotir 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 Statue 130A-333 and related
statues and Title l 5A, Subchapter 18A, of 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 reqttest for an
improvement permit is DENIED. The site is unsuitable based on the following:
1. Soil depths to expansive clay & saprolite (Rule.l943).
2. Unsuitable soil characteristics (Morphology) ( Rule .1941)
3. Soil wetness conditions indicated by chroma colorization (Rule.1942).
4. Available Space (Rule.1945)
These severe soil or site limitations could cause premature system failure, leading to the
discharge of untreated sewage on the ground surface, in surface waters, directly into
ground water or inside your structure.
For the reasons set out above, the property is currently classified UNSUITABLE, and an
improvement permit shall not be issued for this site in accordance with Rule .1948C.
nhone 336.597.1790
fax 336.597.7808
20-B Court Street, Roxboro, NC 27573
t
.
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 a consultant 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 a soil scientist or tfie 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 an 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 Ofiice of Administrative Hearings or call the office at (919)733-0926.
The petition for a contested case hearing must be filed in accordance with the provision
of North Carolina general Statues 140A-24 and 150B-23 and all other applicable
provisions of Chapter 150B. N.C. General Statue 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 iile the petition form with
the Office of Administrative Hearings WITHIN 30 DAY5 OF THE DATE OF THI5
LETTER. Meeting the 30-day deadline is critical to your right to a formal appeal.
Beginni�g 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 Statue 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 Statue
l SOB-23 that you send a copy of the Office of General Counsel, NCDENR.
You may call or write the Person County Environmental Health Department if you need
any additional information or assistance.
Sincer � y,
� �,
,
Adam Sarver, R.S., E.H.S.
Person County Health Department