A33 28Applicadon Date• � 3�
Amouut Pa;�r�: • � �0 . Oo
Receipt #: i�13 � N Z
C+r-c-�� � ,
Improvement Permit (Site Evatuation)
�200.00/$300.00 (if> 600 �pd)
�� Mobile Home Replac.ement or Building Addition
$150.00 (if site visit required)
�� Well Permit (New/Replacement/Repair)
$3 00.00/$200.00J$7 5.00
1) Applicant Ir
Name:
Address:
Z) Name and address of current owner (if
Name:
Address: __ _
�-.���,� f �1te�� `L1�� Tax Map: /�—�Z� d
�,,,, � . �,,,,�.. Parcel#:
"', ������
��sa.� nn-a�ua n sn a� nn+I:�a.A. IE"7C �.m A�E:I�
Services
for Services
(l_ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
�1 Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
than appticant):
3) Property Description: Lot Size: lc.fi��Subdivision:
Addr�ss and/or directions to Property: i'//'.�
Phone (home): � �� � -' ��C � �� �' �
(work/cell): ��� �,�—/ t�JU �
Phone:
l
#:
C7 yes o Does the site contAin any jurisdictional wetlands?
C] yes �o Does the site contain any existing wastewater systems?
0 yes �o Is any wastewater going to be generated on the site other than domestic sewaae?
❑ yes ��►o ls the site subject to approval by any other public a�ency?
� yes G:� 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:
C'�Residential
❑ New Single Family Residence Maximum number ofbedrooms: �l Occupants: �
❑ Expansion of Existing System If expansion: Current number of bedr ms:
❑ Repair to Malfunctioning System Will there be a basement? � yes no With plumbing fixtures? ❑ yes 0 no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of.Building:
Maximum number of seats:
5� Water Supply: ❑ New well 0 Existing Well ❑ Community Well � Public Water ❑ Spring
Are there any e3cisting wells, spri.ngs, or existing waterlines on this property? � yes Q`no
Please note any known ground water resirictions or sources of contamination:
6) If applying for `Au#horization to Construct', please indicate preferred system type(s):
� Conventional ❑ Accepted � Innovative ❑ Alternative ❑ Other ��Y
I cert � tlTat 1he informalion provided above is complete and correct. l also understand thae if the infornzation provided is
iytaccut' , t6ie site is subse uentdy alt ed, or the ntended use cl�anges, all perinits and appr•�vals shall be invalid.
j � / f�
.� � �-r� ,�..�,
Signature (Owner/ L gal Repr entative*) Date
* Supporting documentation req red.
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
. A completed `Lot Preparutiori' form must accompany any appiication requiring a site evaluation.
(10/IS) Person County Environmenta( Iiealth, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
� 'a
� �� / / �
�.`' � � �- �� � t�7 �`� �� �
��n.�vnu av �in :c;�n <c�:rn.tL,en.]l ��- a� <c��en.�I tt:Iln.
March 13, 2018
David A. Humpl�rey
I 156 Horseshoe Trail
Alton, VA 24520
Re: Site Evaluation/ Ta� Map: A33 28
Dear Mr. Humphrey:
nsuring a healthy env�ronment .
On .lanuary 1, 2018, you submitted an application to the County Health Department for a site
evaluation at the property referenced above. The site was evaluated by the Person County Health
Department on March 9, 2018. The evaluation was done in accordance with the laws and rules
governing wastewater systems in North Carolina (GS 130A-333, NCAC T15A: 18A .1900).
Based on this site/soil evaluation, the property would be classified as Unsuitable for the
installation of a septic system.
The soil/site is classitied as Unsuitnble for the following reasons:
Rule .1941: Mixed Mineralogy
Rule .1942: Soil Wetness
Tl�e soil conditioiis listed above would prevent a septic system fi•om properly treating and
disposing of wastewater.
You have the option of hiring a soil scientist to review our decision. A soil scientist may propose
a system in the evaluated area that meets the requirements of Rule 1948(d), or they may identify
anothe►- portion of the property that could serve as a suitable off-site system area.
You also have the right to request an Ir for�nal Review of this decision by the State Regional Soil
Scientist. A request for informal review must be made in writing (forms available) to the local
health department. An informal review is conducted at no cost to you.
Lt ac�dilion, yozn c�rve �, i�ight !o purszie a formal appeal of our determination. To pursue a formal
appeal, you must file a petition foc a contested case hearing with the Office of Administrative
Hearings, 6714 Mail Seivice Center, Raleigh, NC 27699-6714. To get a copy of a petition form,
you may write the Oftice of Administrative Hearings or call the office at (919) 431-3000 or
do�vnload it from the OAH �veb site at http://www.ncoah.com/forms.html . The petition for a
contested case hearin� must be filed 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.
phone 336.597:1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
If you �vish 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
tl�is letter is April 12, 2016. Meeting the 30 day deadline is critical to your formal appeal.
If you tile a petition for a contested case hearing with the Office of Administrative Hearings, you
are required by law (N.C. General Statute i 50B-23) to serve a copy of your petition on the Office
of General Counsel, N.C. Deplrtment of Health and Human Services, 2001 Mail Service Center,
Ralei;�h, N.C. 27699-2001.
(No�e: Do not sei�ve the petition to your local health department. Sending a copy of your petition
to the local health department will not satisfy the legal requirement ofNCGS 154B-23).
Please feel free to contact our oftice if you have any questions or need any additional
intorn�ation.
Sincerely,
Harold Kelly
Environmental Health Supervisor
Person County Health Department