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A34 28Application Date: � � !/ Amount Paid: Receipt #: IZ/0 2/ '�.�mprovement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ��+� (� �� Tax Map: .._.., �- � � ��,�� Parcel#: Z IE"nrn�s nn-xnvnaxnc�:sn9;m.11 7Hlaom.11.4;�,Ln. ication for Services Services Re uested ❑ Construction Authorization (Fee is de endent on the e of ❑ Permit Revision $75.00 ) Applicant Informati n: Name: �/flG�/� /I�d�� Address: � �. ��X /� �2'v ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 Phone (home): �3� — ��'� �� (work/cell): �� - S"�5: �"L S� 2) Name aad address of current owner`(if different than applicant): Name: � �/ /f d�12J-a� -- �pC�� Phone: Address: �� 3) Property Description: Lot Size: '� Subdivision: Lot #: Address and/or directions to Property: � us �- na5�l- � i� �- t_ �ce55 � a� � ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? � yes ❑ 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 �, ❑ New Single Family Residence Maximum number of bedrooms: � ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Syuare footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well ❑ Existing Well 0 Community Well ❑ Public Water 0 Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no -6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently a�red, o�the intend�cl use changes, � permits and approvals shall be invalid. Signature (Owner/ Legal * Supporting documentation �L � i/ ate • 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/I 1) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � �/I�i � a�A lYb r ��° 4� ��-� -�� crv� ��o (t:�� `�- ��?'�� . __ .. . . . .�.._. w�......�.�....Kn_. .s . .�_�. ,. . .. ..� .. _._ .w�,_. . _ _ {�12�1� � .Y_.. _..�.....�� _....�. _._..._�_....._�....._ .�__��.�_L I��t-�� c��( 553� �l��iees � � ��,e� � �� ._�`�f� � � < �,„ .� .�,, �e:�,a_� �` � , .e�� ' " �� n�n��a�n��,� ��,��,�n January 13, 2012 Hilda Norwood PO Box 1386 Roxboro NC 27573 nsuring a healthy environment Re: Application for wastewater system Improvement Permit Person County Health Department File: Tax Map #A34, Parcel #28 Dear Mrs. Norwood: The Person County Health Department, Environmental Health Division on 1/10/12, evaluated the above-referenced property at the site designated on the pladsite plan that accompanied your improvement permit application. According to your application the site is to serve a two bedroom residence with a design waste�vater flow of 240 gallons per day. The evaluation was done in accordance with the laws and rules governinb wastewater systems in North Carolina General Statute 130A-333 and related statutes and Title 15A, Subchapter 18A, of North Cacolina 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 UNSUITAQLG for a ground absorption sewage system. Therefore, your request for an improvement permit is DGNIED. The site is unsuitabfe based on the followin;: L Expansive Clay Mineralogy (Rule .1941) 2. Soil Wetness Conditions (Rule .1942) 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. Tl�e site evaluation included consideration of possibte site modifications, and modified, innovative or alternative systems. However, the Health Department has determined that none of the above options will overcome the severe conditions on this site. A possible option might be a system designed to dispose of sewage to another area of suitable soil or off-site to additional property. �or the reasons set out above, the property is currently classified UNSUITABLG, and an improvement permit shall not be issued for this site in accordance with Rule .1948 �O. However, the site classified as UNSUITABI.E may be classified as PROVISIONALLY SUITAl3LC if written documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. You may l�ire a consultant to assist you if you wish to try to develop a plan under which your site could be reclassified as PROVISIONALLY SUITA[3LE. � phone 336.597.1790 fax 336.597.7808 325 South Morgan Street, Suite C, Roxbaro, NC 27573 You I�ave a riglit to an informal review of this decision. You may aiso request an informal review by the N.C. Department of Environment and Natural Resources regional soil specialist. A request for an infonnal 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 bet a copy of a petition form, you may write the Office of Administrative Hearings or call the oftice at (9I9) 431- 3000 or on-line at www.oah.state.nc.us/forms.htm. Tlie petition for a contested case hearing inust be filed in accordance with the provision ofNorth Carolina General Statutes 140A-24 and 150B-23 and all other applicable provisions of Chapter I SOB. 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 file the petition form with the Office of Administrative Hearin�s WITHIN 30 DAYS OF THG DATE OF THIS LETTER. Meeting the 30 day deadline is critical to your right to a formal appeal. Thc date of this letter is 1/13/20/2. Beginning a formal appeal within 30 days will not interfere �vith any informal review that you might request. Do not �vait for the outcome of any informal revie�v if you wish to file a formal appeaL If you file a petition for a contested case hearin� with the Office of Administrative Hearings, you are required by law (N.C. General Statute 150B-23) to send a copy of your petition to the North Carolina Deparhnent 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 Statute 150B-23 that you send a copy to 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. � Sincerel , � Adam Sarver, REHS Environmental Health Program Specialist Environmental Health Division Person County Health Department