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A35 2��, sf ��.� �� I��aa-�� .Il IFZL��.11�I� Applicant: pAK �� Gt�� Location: 85y oAr. �a.�. t�s�r �u�a.� �vao Taz Map g35 Parcel # Z Subdivision Phase/Section/Lot # # of Bedrooms O�eration Permii �-raa�, oa��, � System Type (From Table Va): T�� Product (IIIg): Type V& VI Expiration Date: Type V& VI Renewal Date: This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. ��-1C.'�. Ih . 5M� (Authorized Agent) i 2 ate) Jiss�, s�r�ft�.�" 1� i �� (Licensed Contractor) � � �� .�� ( ate) � Scale f�i's • PCHD, rev. 12/14/12 �"-�'`' S-1�00 $,CQ- l�'a- Z-1�- \"3 � oW►�.�. '�1=r�ii� w�ts � l�+e..�t�'i�p ... c:,,�. a�U� -�a� . .� c�-�.�' r�-��-� �' a�zcs�ai, wA�`�wa`t �. C�.wc.N . =� -SAn�`�, S'e-w�S �A�-i1Cr�Z Q�ik��.�10 ri �ikr�111ES . � Soi� i✓i ��nK ��- 1� :�� / Tax Map: A35 Parcel #: 003— Septic Tank System Checklist (Type II-I� System Type: Se tic Tank InitiaUDate State ID & Date: a 1`� �'3 �s �'� ,�� s-m- � �.. Capacity: P-i s-• ��, Tee and filter s �o � Baffle Vent Riser Outlet boot Perm. Mazker Distribution D-box levels set) Serial Pressure Manifold LPP Notes: ' 1 � '�P�c�.c1��- ��LY. Nitr�cation Lines InitiaUDate Trench Width: ft. Trench Depth: in. Total Length: ft. Minimum s acing: ft. Rock de th/ uality Dams/ste downs Grade (< .25" in 10') Cover (6" minimum) Setbacks From wells Property lines Foundations/basements SurfaceWater Other: Pump System Checklist Contracted Certified Operator (Type IV Systems): Noies: ;:: ;:�.,.� � � �; �v�. � ;� j ,.; :�;i: •% :� � ;.� A �� '� �erson.or f� , AcTdress .,;.,; 1:";;Nq;'�of persi ;�`' AdditionaT' 'machine : :, Recom�reni ::�t; .y ; �titrificatiqi -,. `A,�oye�eca "'$oil conditii . BPProved li ;' any pOrtiOI ,".`. �� '. `° Date APPri By. �; �Coiiptersigi ;-�.�:; . ,. ., f : ., ..,. j 'j •' �'?'1 .�''' .}.; , " "�� . �� 's �� ' . �� ■ ■��I�r■ � . . . ■�■ ■��(��■ �� _ - : r ��■■■��■�■ �� " - , ��■�� _ �� t� ■■��■■■� � ■�■�■■■�� ■■■■■■ ;� ,. �� e�� ■ �. �: - ��s�■ ■ 9, /. �� _ �■■■■■��■� �� ■��i�� . ., ■��;��11 t� . j . �� i� � :�.. �I��i�� = .��■■��■�� : - ■■�■■■�r�� ' ��■�� ■■■�■�■��1� ��.�� ■��■��■ �� = . �� , y �1FS�} �;:' ....._'. .. .._... ..�.�..' MSX14�j� ' . ��`fi��'Fj:, ,,c yit?::�i.� � Amount paid ��,pn � . Receipt .�� ',_��.2� L�_. ��5�3 � H O � � ' � APPLICATION FOR SERVICES - i � -,� S� --ci 1 Date 1. Permit requested by: .�f�K. G�U� uN �7� 7. Dimensions or Proposed Structure: owner/prospective owner/agent: �U�D � U Width: Ari�ress: 502� S�/►��(Zft �� Depth: � � w U � a W d z �X�RO �L 2!Si3 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility P�� that this sewage d'sposal system is intended to serve? ome Phone #: q 10 S9� — 2�f � ��o So 3-�3R7 ncJi /�s�f-r'��ms hd41, � i �:, usiness Phone #:91�5°I�i-"763� � N� ' y °�- � � � . Name and addre�s of current owner: 9. Water s ply t5�pe: �j� OF �JS'`£ti� �Q�_�Qr��IE U/►'1 _ private public ❑ community ❑ spring ❑ � ,v Are any wells on adjoining property?Yes ❑ No j�. If so, identify location: : Lot size: Tax Map#:�A'�� Parcel#: � _ Township: ; A 9 . Directions to property: State Road #& Road � mT. Zro rJ 10. Type of structure/facility: Proposed: DExisting: [�'' Type of dwelling: House: ❑ Mobile Home: C� Business: ❑ C�u%��1� Type of business: Gi�UI� Number of Employees: Number of bedrooms: _,,,/ Garbage Disposal? Yes C�%No L�" �uM%g� Basement? Yes C�Nofl If so, � of basemcnt fixtures: 6. Number of occupants or people to be served:N 00 �� s„ M��n� CLEARLY STAKE ALL CORNERS OF THE PROPERTY D CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PerSon County Health Depat'tment for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application 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 before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. Signcd Owner or Authorizect Hgen� ?ermit Issued ❑ Signature Date ' � � Permit Denied ❑ Plat Observed ❑ u ;� .... .:, �.�. .;FncroRs=srrEEvnivnno?�r. :` . ;;:..... ��+xFat. �.,.... ..' nx�2 fs.,.�s _ nx�a..., . 1. SIAPE (%1 S S 5 S PS PS PS PS U U U U 2. SOIL7'FJC7l1RE(12-36IN.) S S S S (SANDY, GOAMY. CLAYEY, NOTE 2:1 CLA� PS PS � pS U U U U 3. SOILS77tUC1URE(t2•161N.) S S S S (QAYEY SOILS) PS PS PS PS u u u v. 4. SOILDEP7'Fi(IN.) S S S 5 PS PS PS PS U U U U S. RESTR1CiIVEHORIZONS(fN.) S S S S- (AIPERVIOUS STRATA. ROCK) PS PS PS ps U U U U 6. SOILDRAINAG&GROUNDWA7ER S S S S �DCTERr7pI, A pn-ERppL� PS PS PS PS U U V U 7. SOILYERMEABiLifY S S S S (PERCOLAATION RA7� PS PS PS PS U U U U 8. AVAII.ABLE SPACE S S S S. PS PS PS pS U U U U 9. SifECLASSiF]CATION(SEEBELOW) SOIL SER]ES S-SUITADLE PSPROVISIONALLYSUffAIILE U•UNSUTfABLE RECOMMENDATI ONS/COM MENTS : STI'E CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �ll areas, wells, water bodies, slope patterns, eLC.> Q�AMIPRO�DOCS�APPSEC.St�1 FINANCE.PC Yerson County Healtil Department Existing Sewage System Report For: Mobile Home Replacement �Addition • �_ !.� � �► ii.t� t �a �� ' �rs �� ► �,1� 1 g � �ita . i Home Phone# �JT� au�� B�r; �rn� # !��(�� 97 'Pax Map# �� — � Location/Directions: ,��c� (�-I�e��l V1 � l 1 V�( �'�- Ci�il�(Tf C11��' mT � b�� Original Permit Located 5eptic System Uesigned For: Kesidential Business Other (specify) ��i� # F3edrooms # �mployees Other Uate lnstalled 1`—�� Water supply r1V `Pype of System ��1,� P�'�1��..� _ Nitritication Line / (�� X�� T a n k S i z e 1 VLJ �UC • Certified Operator Required �/1� On site wasL-ewater disposal system showes no visually apparent malfunction on �V��(`� /`T � . Yermission is granted to: According to the attached site plan.. �� i�I �' �. � 1� l.�I� : ' • -/i / /,� � � ..�/� � � / � � Agp(icatfon Date: 36 `�S� . Tax Ma� #: � 3� Amount Paid: 1 � � RecEi t : Parca! : �# �.��_�� '�Q G gOS - - _� � � �r.�T°�`� �o� X ,� �aa�.n.a-oaa--�--�- �eaa�so_71 ��o.m.7L�I�a �aY�� APPLICA7101d FOR SERVIC�S � IF THE INFORMATIOIV IN THE APPLlCATIOM FOR AN _IMPROVEMEPlT PERAAIT IS IPICORRECT, FALSIFlED, CHAiVGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT APID AUiHORIZ,4T10T1 TO COIVSTRUCT SHALL BECOME IIdVALID. • 1 Permi# re ested by: {Owmer/agentlprospective owner): � ^ � �C � �� %�S 1 � �� r �� ' �� f'I � H�me Phone: e �r?� � Address: � Business Phone: `',��%'88l0 ' • �� .2) Name, and address of curre�t owne� s�1'YI (? a- - . -�--�• � - 3) Property Description: Lot size: <�� Township Directions to the property (Including road names and 4) 5) 6) ---'— Lot # — � �►�7T13►�i�i�i■ • La��:!S�C'1�iil�C�J.�i�� •• i � �. proposed Use and Structure scriQfion: answer e of the f llowing questions: a) Proposed , Existing Type af Structure: � Width: . Depth:_��- b) Number of Bedroo .� Number of occupants or peo le to be served: �.� c} Basemen� Yes � No Will there be piumbing in the basement?� d) 6arbage Disposal: Yes �No _ �{ � Water Supply Type: Private �(new _ or existin ' ,�Public_,, Community , Spring Are any wells on adjoining property7 Yes� _ If yes, piease indicate approximate location on the 'siie plan. Does your property contain previously identified ju�isdiciional wetlandsT Yes Ido ✓ �. , ; PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY QR SiT� PLAN MUST BE SUBMITTED WITH THIS APPLlCATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. •, � ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STA6�D OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBL.E FOR AN EVALUATION 8Y THE�HEALTH DEFARTMEiVT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposaf system for the above-described property. I agree that the contents of this applicatlon 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 Owner or Legal Representative a o� Date PCN�, rev. 06127102 ��. � I�I�I�.� ��T � � . - - -- �c�� . ��, �.-� m�.�.�. � ��.��. . SITE PLAN Nam � l i O ��%� Taa Map #� Parcei #� S� . . . Seaion/Lor# — �--t� j Authoazed State Agent D� � System rnmpmeats rrptrsear app�aximste caatours aaly. The caa�mustSag the sysaem priar m begmnmg the ias�nrba to ias+ur rharpmpergndei�mariaraiaed �' 1 ' . .. _ . . ��i� �'�h-ov-�. — �I/l�• ��v� � � .. s�� ,'I� � PC.T�, rev. �/12/QI �� S 1I��I�:� ��TT � ... � ��-ti ,., � � ��:: �'��T��T� �]KII.�YSL]L 07tA3C]CD.�7L'A.�.�C1L� .��.�L:�.IM.' . WELL PERMIT PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map � � Parcel # � Township: Applicant: �urG� Subdivision: Lot # Type of Water 5upply: � Individual _ Community Requirements: Public Site Approved By: Liner: Grouting Appro}�d By: �� Installed by: . Well Log: �/ Depth set: _ Pump Tag: Grouted: _ Well Tag: Date: Air Vent: Hose Bib: Water Sample: Casing Height: Concrete Slab: Well Driller: �✓ �'e-� Well Approved by: ****See Attached 5ite Sketch**** Wells must be 1:0 feet froin property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: Date: PCHD rev O1/27/04 Barnette Well Drilling Inc 386 598 9275 09/12/05 09:46A P.001 North Carolina J�epartmenf of Envirorunent, Health, & Natural k�esources � ' bi�riszon of Environmental Managezz�enfi Groundwater Section � ' 1'.Q. Sox 2957$ - k�leigh, N.C. 27626-0578 ' �LL ABArrnor_rn��r� �co�a ....,....., . .�....-.., iI . ( r. _r� w �� ' REG. 1. WE�,L LUCATION: (ShQw a ketch af the location on back of form,) �• Nearest Town_�(�ox � o� /U`C�.�Cdunty P�S � I� � .._ A.J � � . - A. ' �,,Subdlvision, Lot • �; � '+ r � ,, , •��- �� - �• . �� 4. TOPQGRF�HY ; draw, slope, hilltop, vaIley, fla ' 5. LJSE OF WELL: DATE: - �S � ., 6. TC7TAL D�PTH: ��DIAIVI�TER �^, 7. CASING REI�IOVED: f� N c� , s�i�t � 8. SEA? [NG MATE�2JAL: � me n . ba�s of ceznent bags of �ement �als. of water yds. of sand �y�1 �,��.� . ��t, r�� gals. of water S?�1�:. • , � 'Type material �� dl�_. Amount • I 9. �XPLAIN OD EMPLACE�rTENT OF MATERLAI,. /� f� /�A� Quadrangle No. WE�,L bIAGRAM: Dra�tr a detalled.sketch of the well siiowing total dcpth, depth and dia- meter of screens remaining in the are�i, g�-yvel fnterval. Lntervais of casing pexforattons, and depths and types of filI materia�s used. r...4_. � i i do he:e�� ce.-ufy that thi= we1 ab�ndQnm�ai re�ord is true a,nd e�ract. � -.`--r'_"�----�—�-• _.,._ . /'�3�� .�`�, ts . . .�. �� _ I .Sld2ature of Contrartor or A�ent �„ �,,��_Date �`/ 2�O� � W�LL LpCA?ION: Draw a location sketch on the reve;se of thts sheet, showin� the direa • tion and diszance of the n�e1 to at leas� t�vo (2) �rte3rby rcfe:ence points su�k� as roads, inte:sections and s�reams. Fdent�fy roads with State Hi�h . �vay road ide.-�tification numbe:s. • Subr�it origirizl to the Aivision of Environmc�tal Manageme�t, one �opy to the T7riller. and one copy to the o�vner. GW-30 Rc�ri�r3 � /. p6 " : ( �ao� ��.�� _ :��,,) f �� • � � -.--..- (�o�p� �� r nC��-�e G� e 1 �� 1( � fr �C � �1��": . IEsawaso�ra�:�;,-„ a��rn.�.�n:Il IE��.31�]�n: � �Q '�s � � - � �.. n Grout Log � Owner: `/A� �}rove C h�fC h TaxMap�S Parcel# Z Location: �ht 7 � �, ( I,� „ � �{�(� 1, � Subdivision: Lv / /�. Lot # ,�p(�_ Well Construction Distance From nearest Property Line (Minimum 10 feet) � n Distance from Septic System (Minimum 60 feet) � O P Total Depth: �� ft Yield: � S� GPM � Static Water Level: 2 S ft Water Bearing Zones: Depth j�T ft 16 n ft ft ft Sg.i io �«i Casing: Depth: From . r� to i o 5 ft. Diameter: � t in Type: Galvanized Steel ✓ Weight: Thiclmess: � � 88 . Height above Ground:, � in Drive Shoe: _� Yes No Any problems encountered while setting casing? Yes `��o If "yes" give reason: Grout: ` Neat: Sand/Cement Concrete GraveUCement . Annular Space Width Z- inches Water in Annular Space Yes �o Method of Grout: Pumped Pressure Poured �/ Depth (� to � Ft. Materials Used: No. Bags Portland cement � Weight of 1 Bag �_ Pounds If mixture (s , gravel, cuttings) — Ratio to_-� ID plates: _ Yes _ No 4 x 4 slab ✓ Yes _ No Liner: .,, Depth: Date Installed: Grout: Installed by: _ Drilling I.ag Location Drawing From To Formation '�' � A � � � _ ` a � � � , � 1�'�+ 2: o � Gh..�c� 1 � I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth by the Person County Health Department. � Signature of Contractor � /�w=� ID#� Date l 7" D� _ Pump Installment Pump Installation Contractor: I, a rn c� e•�/ e� 1 �r: I �%�y State Registration Number: '� Z 6� Pump Depth: ft Static Water Level: Z ft Pump Make & odel: 'RtZ �'a ��—e � Pump Size and Rating: ��Z hp �� gpm I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect on this date and that a copy of this record has been provided to the well owner. `� `�%�,,N,. Date: y� 7' n � PCHD rev O1/27/04 Pump Installer Signature �_,..,:.. Application Date: 9 �� 3 � `��+� ("" ��T Tax Map: �_ Amount Paid: � SO� �`� .._,. ,� Parcel#: 00 Z— Receipt#: $►�`}q � � �� TE�..rrn-s nn-a�nnnxn.�:m.d.m.11 IHIoc�,m.11d�n. ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition 3150.�0 (if site visit required) ❑ Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 �lication for Services Services Reauested ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision ,glf3.00 pair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Inform i • Name: ��J-� Phone (home): Address: (work/cell): _ 2) Name and address of c nt owner (if different than applicant): Name: Phone� Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: L�t #: ❑ yes E3-rno— Does the site contain any jurisdictional wetlands? ❑ yes �� Does the site contain any existing wastewater systems? ❑ yes B no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes �-� Is the site subject to approval by any other public agency? ❑ yes �B'tf'- 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 expansinn: C«rrent number of bedrooms: ❑ Repair to Malfunctioning System Wil; there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes �7 no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ 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 1 cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the subs uent Itered, or the intended use changes, all permits and approvals shall be invalid. ' 3a f3 Signature (Owner/ Legal Represe tative*) Dat * Supporting documentation required. • 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. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��,s� ��..�� 7L��.�a��.� ��.� IE-�� .Il�I� Tax Map: l�3S Parcel: Z- Subdivision Phase/Section/Lot # Applicant: �AY. 6Rav-'� �-1'��1'4.�,N Address/Location: 8s`4 ot�r. �vb.;a. MY- �Lwa Qoao __ Permit Valid for: Five Years Type of Facility: Number of Bedrooms / Occupants Proposed Wastewater System: Proposed Repair: Permit Conditions: Impruvement Permit Non-expiring New Addition _ Water Supply: / Employees / Seats: Projected Daily Flow: � Type: Type: Authorized State Agent: ___ _ Date: (X) Owner or Legal Representative: Date: gallonsiday The issuance ef this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applicanbproperty owner to insure that all Person County Planning and Zoning ar.d Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected by a change in ownership af the property. This permit was issued in compliance with the pr�visions of the North Carolina `Laws nird Rules 1'ot Sewage Treatmer.t antl Disposal Svste»rs'(15A NCAC 18A .1900). l��either Person County nor the Environmental Health Specialist ��arr:�r.ts that the septic system wil[ cor_t�auc: to funetion satisfactorily in th� future, or that the watcr scppiy will remain potable. Authorization tu Canstruct Wast�water System S'ee site plan and addit:onal attachments (�. x Proposed Wastewater System: �� Q��.vu.vc��t�T (*)Type Design Flotiv _____ gal./day iJew Repair iC. Expansion _ Soil LT.AK: gai./da}•/ftz Type of Facility: C17�1f,R,CN Easement: �C Yes _ No (�) System Types Illb, Il,ibg, li ; and V, requir� periodi�c system inspections by [he Person County Health Departmeni. Wastewater System Requirements Tank Size: Septic Tank t OOp gal. llrainfield: Totat Area — sq. ft. Trench Width '-' ft. Pump Tank '-' gal Total Length -' ft. Min.Soil Cover — in. Grease Trap � gal. Max. "french llepth '- in. N1iri.Trench Separation '-' ft. Distribution: Distribution Box / Serial Distribution / Pressure 1�Ianifold Specifications: �i��,Q � C4�s� � F�v.. �s��1,(e (;,psce �r Q�� (i�oc�� -Z+A+J�` a' Authorized State Agent: Issue Date: t0 � �� Permit Expirat�on Date: l0 1�$ Tt�e system permitte3 is: Con�entional /Accepted / Alte ati�e / Innovative . I accept the conditions and specifications of this permit. � (X) Owner or Legal Representative: Date: �-�� ` Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) � Application Date: � �6 � 7 � Amount Paid: a 00 . 00 Receipt #: 1 �f 3 3 � ( �_ C�r�, r Ap� r' mprovement Permit (Site Evaluation) Mobile Home Replacement r Building , $150.00 (if site visit req ' ed� � Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 � j�� f �� A. V Tax Map: i`� 3� �,,�_- � . Parcel#: � �� .�� / �.cn�an-�sa��n.�mIl. IHI��s,]L�,I�n. �� r �%v[/�✓K�'�5+ ?�� -�'�'-z�� lication for Services - 1 Services Construction Authorization (Fee is dependent on th�e t��e of system permitted) Permit Revision $75.00 Repair of Esisting Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant formation: /�r ( Name: � v'aV ' � e �ii l�i1u�-/l . Address:8,-r, Z�v�v vr- �pl�. arc��k 1U -L- o�7,-rS7�F 2) Name and address of current owner (if different than applicant): Name: Address: � 3) Property Description: Lot Size: Subdivision: , Address and/or directions to Property: I 3S Phone (home): ��% ��-bDoZO _ (work/cell): �.�G,_5O� � ( I � Phone: #: ❑ yes 0 no Does the site contain any jurisdictional wetlands? ❑ yes � no Does the site contain any existing wastewater systems7 � 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? Q yes Q�7 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 Structures . OResidential ' ❑ New Single Family Residence Maximum number of bedrooms: / Occupants: ❑ 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 �❑Noa-Residential �M I � , /_ v �Q �� W�`►b Type of business: u �"�-h Total Squaze footage of Building: � , Maximum number of employees: Maximum number of seats: - 5) Water Supply: ❑ New well 0 Existing Well ❑ Community Well ❑ Public Water ❑ Spring . Are there any existing wells, springs, or existing waterlines on this property? ❑ yes io Please note any known ground water restrictions or sources of contamination: 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional � Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Sign ure (Owner/ Legal Representative*) * Supporting documentation required. L,��v -%7. Date 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. (10/15) Person Count.y Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � ,.----'� � ,� �� l �, . i.. � �. �.� �� n.��,�. ��.�� May 19, 2017 Margaret McAllister Oak Grove Methodist Church � 854 Oak Grove Mt. Zion Church Rd. Roxboro, NC 27574 Re: Application to Construct Fellowship HaIU Oak Grove United Methodist Church/ Tax Map: A35-2 . Dear Ms. McAllister: You submitted an application on Apri16, 2017, requesting Health Deparlment approval to construct a 250 seat fellowship hall. Based on our review of the church records and subsequent site visits, it appears that the church is served by 2 separate septic systems. The original system was installed in 1963 and appears to be located in the same location proposed for the fellowship hall. The second system was installed following construction of the church addition. The septic tank serving this system was replaced in 2013. In order to construct the building in the proposed location, the original septic system would need to be replaced. The replacement system would need to be significantly larger than the current system as a result of State rules that went into effect after the current system was installed. Unfortunately, there does not appear to be adequate space on the church property to construct a replacement septic system. Setbacks from the church well and the footprint of the cemetery limit the usable septic area � � The property is unsuitable for an expansion/replacement of the existing septic system for the following reasons: Rule .1945: Available Space A.) You have the option of hiring a soil scientist to review this decision. A soil scientist may propose a system expansion that meets the requirements of Rule 1948(d). B.) You also have the right to request an Informal Review of this decision by the State Regional Soil Scientist. A request for informal review must be made in writing (foim available). There is no cost for this service. C.) You may also wish to explore the possibility of pumping off-site to a property that has an adequate area of provisionally suitable soil. The Person County Health Department can assist you with this option. D.) In addition, you have a right to pursue a formal appeal of our determination. To pursue a formal appeal, you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mai! Service Center, Raleigh, NC 27699-6714. To get a copy of a phone 336.597.1790 fax 336.597.?808 325 South Morgan Street, Suite C, Roxboro, NC 27573 �/ petition form, you may write the Office of Administrative Hearings or call the office at (919) 431-3000 or download it from the OAH web site at http•//www ncoah.com/forms.html . The petition for a contested case hearing 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 properly is located. ff you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative Hearings �VITI�N 30 bAYS O�' THE DATE O�' THIS LETT�R The date of this letter is April 12, 2017. Meeting the 30 day deadline is critical to your 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 Statute 150B-23) to serve a copy of your petition on the Office of General Counsel, N.C. Department of Health and Human Services, 2001 Mail Service Center, Raleigh, N.C. 27699-2001. (Note: Do rrot serve the petition to your local health department. Sending a copy of your petition to the local health department will not satisfy the legal requirement of NCGS 150B-23). Please feel free to contact our office if you have any questions or need any additional information. . Sincerely, �� Harold elly Environmental Health Supervisor Person County Health Department