A34 101N 0 T F 0 R L E G A L U S E
Person County GIS
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Legend -- z/�/zoi8 �v o�� F o r; F ��; �� �_� ,�
E-911 Addresses Easements � Tax Parcels AdministrativeAreaBoundaryLine_1K County undar
— Conservation County
Easement I�I� j. �`'"r�l�� ���I 0 50 Feet 100 150
.,
i 1
uti�iry i��� 1� ���I�%��' C �
0 0. 01 0. 02 0. 03
— AllOther � ����1�� �Lf lJ,� �����'�I��/����
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Building Additions/ Mobile Home Replacements
Tax Map #:-.�����- Parcel#: D� Address: �l�b f����'� �i-�%,�D-
Approval Requested for: � Mobile Home Replacement '-C'�.,�o�_c,.�
�c Building Addition � �� �.D� �c� ���
Applicant Name: __�'��r,= �,,� �--� •
Address:
Phone #'s:
Permit Located: ✓Yes No
Installation Date: �o o Design florv, �o (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: _�� Well Public or Community
Wastewater system shows no visual evidence of failure on: 1� (date)
(Applicant's signature if site visit is not required) �
l���r��i�i y���IG�� �
Addition/Replaceme�t Appa�oved
Environmental Health S ialist
Z. � e �
Date
Persan County Environmental Health, 325 S. Margan St., Suite C, Roxboro, NC 27573
Ahnno• Z76,_507_170(1/Fov� ZZ�_SQ7_7Q(1S2 v�,,,..-_..------ . , .
ca�ss-�-
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PERSUN COUNTY ENVIRONMENTAL HE�"H
E SEE ATTACHED PLAN FnR snit eR�e eNn S�cT�M i evni rr
Taz Map #: __�
2oning
Appllcanh !� �
Locadon•
Parcel i� �C' �
Township (`�� v1�'J/i-tl',__�
✓ ---
Subdivislon: Section: ^� �a�; �---
Improvement Permit
A buildinq permit cannot be issued with oniv an Improvement Permit
New � Repair Addition Type of Strudure 1���er SuPP�Y �
# of Occupants � #�of Bedrooms �_ Other
Basement?� Basement Fbctures? r 9pS .
Projeaed Daily Flow: ,� g.p.d. Permd V lid For. t�'�` Years O o pi #'� '-^� �L
Proposed WastewaterSystemType:_L�.� �i�rk�.e��,pe. �,�/_�/`�a�/�d�/�,-�,p/�G�rcu��7"�"`�/
Pump Required? _ /Yes No �'
Proposed Repair :_ rk.c.r as .�
Pe[mit Conditions: �s � � :�p.^.o,�o� �_'�., o�� /.� ��cn�.�� ��
.SC� arc " � " G�a,l�e� f "C�, S. " � , � � �
Owner or Legal Representative Si atu�e: � Date: l D—j 3-0 v
Authorized State Agent: Date: � "� '�
The issuance of this permit by the Heatth Department in no way guarantees the issuance of other permits. The permit
holder is responsible for chedcing with appropriate goveming bodles 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 pertnit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatrnent and Disposal Systems of the North Carolina Administrative Code.
Authorization To Const�uct Wastewater Svstem (Required for Building Permitl
Type of Wastewater System �w �i�ssu �e :'t�. Wastewater Flow: 36o a.p.d. �. �o� :���c���,,�K�'
FacilityType:3l3IZ 1''�a�P.�_ � NewEYRepairOExpansion❑ no�'� u«��i�tS f��"
Basement? C9'Yes 0 No Basement F'ixtures? �Yes 0 No fYe.l��� �'� ^�. �J� �c -
Wastewater Svstem Requirements ' -
on �i� r/�'s�'�a�L 9-J3-oo.
Sep6c Tank Size: fDa c� gallons Pump Tank Size: 00 O gallons ���
Total Trench Length: 7�0 feet Maximum Trench Depth: �_ inches Agg�egate Depth:� in.
- �°o .�-�-- �
Maximum Soii Cover. � inches Trench Separation: S Feet on Center
other. See. �s /"// � /% �r �PIAS��zsJ�s�n , r�-t,'� c:olt.al�'�'�i�iis � �cci j4'C���s
Permit Expiration Date: � �_�" --d S
Authorized State Agent: " .: � � Date: !D -l�-.�� •
� � s
The type of system permitted � does ❑ does not differ from the type specified on the application. I accept
the specifications of this permit
Owner/Legal Representative Signature: v" .� pa{�• � G' ��--6C� .
.—
PCHD, rev. 11/18/99
�rson County Health Departme�
Environmentai Health Section
Tax Map #• ,��� Parcei #• ��f
Zoning: Township: �,.�n1' a�
Subdivision: �— Section: "— Lot: --
Applicanfi �1/lti nsZ- �
Location•
O�eration Perm it
System Type (In Accordance With Table Va): ._l�-.
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
..�;/�S .- S-�
Authorized State Agent. Dat
i�
Tax Map #:
c��
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S� �!'t s �� °
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2. %!I4n�o��� _���"�-m`�
3. Tit.,.�s - /��
!�-, ��Pl.,et��� Ti.�rn u �O.S � � �S✓
/
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rJ. �n�rc-�-c�W�� �^��'1�1��r'c`�
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Parcei #: ���
PCHD, rev. 10/12/99
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Person County Heatth Department
Environmental Health Sectio�
Zoning: Township: ��r� �'
/�.��� �Ol
Subdivision: � Section: �— Lot: -,
Appllcant: � �
, ,� ��9`�
Location: � '
. • � �"
Operation Perm�t
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements
B) Distance from system to any welfs /i'��-� —
C) Distance from septic tank to foundation �
D) Distance from system to property lines
2. SEPTIC TANK �
A) Visually inspect the exterior walls and top of the tank �,l�
B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet�
C) Date of tank manufacture � �
D) Tank serial number
E) Liquid capacity of tank � gallons
3. SUPPLY LINE TO TR NCHES C� � S� s�
A) Grade (1/8 inch per foot minimum ��v�
B) Material su ply line is constructed from �' �
C) Diameter � "
D) Length �s� �' �
E) Distance from tank to drainfield/distribution device �
�TS /D�c� .
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4. DISTRIBUTION DEVICE S)
A) Type ������
B) !s Device water tight
/
C) Distance from the distribution device(s) to the trenches �,il.
D) Is the device on a level foundation _�Qt '
E) Does the device perform according to s desi n specifications L�,���'� ..-
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth �-� inches ��� S
B) Trench width _,�_ inches
C) Distance between trenches � S o�1 C'Qs �
D) Number of trenches �
E) Length(s) of trenches �.20'
F) Aggregate depth S- 9 inches
G) Aggregate material and size �./'/�
H) Record septic tank utlet elevation
I) Trench grade f''� , (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed eart _�%�
b. Proper rise over ste wn
c. Solid pipe used
d. Elevations of step wns (Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
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P��N COUNTY ENVIRONMENTAL ALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: � �/ Parcel # / ��
Zoning
Township �aA N N �r.n A!a`/�
Applicant: � S
Locatlon: ��C �]–�"-�p �� �///��i' •
�—
Subdivision:
�'ype of Water Supply:
Requirements•
�
Sectlon: �� -
Well Permit
�dividual Community Public
Site Approved by /%r��
Grouting Approved by
Well Log
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller:
Well Approved By: Date:
'`*See Attached Site Sketch**
Wells 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: �
�H �
PCHD, rev. 11/29/99
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM NdO1VITORING REPORT
�1� 3 .�2� 15' �oo� � L � (
Date of Inspection System Installation Date 'ype ax Map Parcel #
S(Sa /t'leG1�-aes �t�`(7 I�cQ. .
Property Address
Instrucrions: Check yes or no for appropriate items and explain inspace prQvided for remarks and
comments. If au item is not applicable, indicate by "NA". if an item is not or cannot be evaluated, indicate
by "N" and explain. Nata that this monitoring form is not totally inclusive for all systems. All mainte�ance
and monitoring items specified in the permit are to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks T
Tank risers accessible, free of
infiltration and surfacE water diverted 7
Septic tank needs pumping ?
Inches of solids: < 3 �'
Septic tank filter cleaned ?
YES / NQ
❑ �
� % ❑
❑ � �
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FFFLUENT DOSIlr'G SYSTEM:
Required pumps preseat & functi�nal ? r I.�
High water alarm operating praperly ? i❑
Floats, valves, etc. in good condition ? /❑
Control panel & components in good
condition ? � ❑
Eff:uent free of excess solids ? r, !❑
Inchss of sotids(pump/dose tank): < ,3
Elapsed time readings ?
Counter readings ? • �_
Drawdown rate:
DISPOSAL FIELD:
Evidence of efttuent sarfacing ?
Evidence of effluent ponding in trenches 7
Surface water ��ectively divert�d 7
Dii��rsioasls�Nzles properly tnai*+±aine�i ?
Vegetative cov�r maintained 7
Protected from trafiic/unauthurizzd uses ?
Distribution devices in good coadition ?
Field free of settIed or Iow areas ?
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REMA.RKS
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PRESSURE DISTRIBUTION SYSTEM:
Tumups/cleanouts/valves/taps intact &
accessible ? � � ❑ ���,t,,� � �,� �'Qg�.�
Pressure head properly adjusted ? /❑� �� ��� ti
COMPLIANCE:
Compliant
Non-compliant
Nee�s Maintena.n�e
AUDIII �, cor��Nrs:
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