A34 47Application Date: 3-� `J �• �, � Tax Map: ,�t- 3`t'
Amount Paid: Q��. C[� C�t.S� Parcel #: �.�
�����pt#: recu p�51000�1
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Application for Services (Septic Systems and Wells)
Services
❑ Improvement Permit (Site Evaluation)
�200.00/$300.00 (if> 600 Qnd)
❑ Mobite Home Replacement or Building Addition
$150.00 if site visit re uired
❑ Well Permit (New/Replaceme /Repair)
$300.00/$200.00/$75.00
1) Services Requested by
Name: �(' n'1 �( i i 1.kne v
Address: F=� '� r1 �1 C. C�V l�� (Y11 I ��
5 e m crrc� � N���- y�
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $I50.00 or $300.00
Phone # (home): �J 3L ,� q�-�'(' l� �o
(work/cell):
2)Name and address of currgnt owner (if different than appticant):
Name: J�: m�. ,/� 5 f� � oVC�
Address:
3) Property Description: Lot Size:
Address and/or directions tq Property: �
I ,� ]-1— O Y-
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4) Proposed Use�nd Type of Structure:
Residential ✓ Business/Type: Other
Number of bedrooms �_ / Number of people served (seats/employees):
Basement: Yes No ✓(with umbing: Yes No _)
Garbage disposal: Yes No
5) Water Supply:
Private Well (Proposed Existing _) '
Community Wel(: Public Water System: _�
Are there wells on the adjoining properties? No __� Yes
Lot #:
c �h���� !71 i 1
(please show location on site plan)
Note: A completed anvlication must also include:
➢ A plat/site plan of the property that shows property dimehsions and the size and location of a[I
proposed structures.
➢ A signed copy of the `Lot Preparatioh' form ver�ing that the property is ready to be evaluatecG
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is su6sequently altered, or if the intended use changes, all
permits and approvals shall become invalid.
Signature (Owner/Legal Representative): �C' 1XY��C?"� �'�l� Date : `� �- �
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Rh�:s�e Sect+ion`Lot �
Improvement �ermit
�'�rmii �Talid for � �ive 'ile�rs _ lYo E�piration
Type of Fac ' New Addition
# of Occupants Bedroorr�s � Projected Daily Flow
Proposed Wastewater System: �
Proposed Repair. �
T
PCIIIltt COIId1t10IIS:
Owner br Le egrese
Autho � State �Agen�
�Vate� ��PP�Y
g.p.d.
Type:
Type:
Date:
The issuance of this permit by the Health Deparanent in does not guatantes the issaance of other pezmits. It is the responsibi7ity of the �
applicant/property owner to in siue that all Person County Planning and Zaning and Building Inspections requirewements are met This
�mprovement Permit is snbject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affected by a ci�ange in ownerslrip af the property. This permit was issued in connpliance.with the prnvisions of the North Carolina
`Laws and l�ules for Sewa.�e Treabnent and l)isnosal Svstems' (15A NCAC 18A .1900). Neither Person �onnty nor the
Enviranffiental �eaith Specialist�warrants tb�at.the septic tank system wi71 continue ta function satisfacton7y ia the futvre or�tI�at
the water supply will remain:potable. - -- .. � �
Authori�ation �m Constraet Wastewater Sysfem (Reqnired for Bu�ding Permit)
* See siie plan and additional attachments (_). .
Proposed Wastewater System: /��a� �� D� �� Type `— Wastewater Flow --g:p.d.
New Repair�, Expansion _ � Soil Y�TA,R: '— g.p.cU ft 2 �
Type of Facility: — Basement _ Yes _ No � �
�aste�vater System ]�equiremen$s
'�ank Size: � Septic Tank: r D�0 gai Pnmp Tank: — gal Grease '�rap: � gal
�rainfield: 'Total Aa�ea: '-- �q ft �Total Length — ft � 1V�a�ffium Trench Depth — m
T�emci� �dth � ft Ngini�anua SoiY Cover: -- � in M'in'lmn� Trench Separation: ^ ft
�istrAbutaon: ^ �istribution �oa " Serial �istribnt�on —' Pressnre Manifold
Speci�cations• ��� d� S/�-e�i�'�
Antho�izeai State AgQnt: �
Permit Exniration Date:
Date:
The type of system permitted is Conventional Acc�ted Alternative. I accept the specifications of the
permit. �
i�w�e�/�.�gal �epges��tative: ����,C`, i�c�.�-�-�. Date: � - � � — ( �
� PG'� rev. l l/10/OS
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STTE PLAN
Name � � � Tas Map #�Parcel #�
Subdi si Section/Lot#
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Authorized State Ageat Date
System companeais neprrseat appmximare rnarours anly. T3e contr�ctormusr9ag the systrm prlor m b� 'b nnI �o t6e ins�ation m
;.,�,,.,r �pr pmp�grrde is maiabiaed
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Operation Permit
Applicant:
Location:
Tax Map� Parcel # �
Subdivision
Phase/Sectoin/Lot #
# of Bedrooms �
This system has been installed in compliance with applicable North Carolina General Staiutes, Rules for Sewage
Treatment and Disposal, and all conditions of the Improvement Permit and Constxuction Authorization.
System Type: (In Accordance with Table Va):
Initial: Repair: � Expansion:
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Tax Map: � Parcel #• �
Septic Tank System Checklist (Type II-VI)
Notes: �A�' � G!/as t�fE�+�� �U:T' �
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System Type: ��
Nitri�cation Lines InitiaUDate
Trench Width: ft. �f �,
Trench De th: 2 �,'�
Total Length: !/v ft.
Minimum s acing: ft.
Rock depth/ uality —_
Dams/stepdowns --
Grade (< .25" in 10')
Cover (6" minimum)
Setbacks
- From wells
Prope�rty�liries ----_------ - -._. .
Foundations/basements
SurfaceWater
Other:
.� 7� K 1/2 C�� d-�tYti
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Pump System Cliecklist
Pum Tank InitiaUDate
State ID & Date:
Capacity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back plu�
Hard wired
Alann functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (if applicable):
Notes:
'�a ��c��r��.
Tank Com onents InitiaUDate
Pump model:
Block (4")
Nylon retrieval rope
Float tree and attachments
On/Off float swing: in.
Ala�m float (6" separation)
Anti-siphon hole
Check valve
Tl�readed union
Gate valve
Conduit sealed
Outlet sealed
Approved and secured riser
Su ly Line
Size and material: in. sch.
Length: ft.
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