A40 26Site Evaluation Application Date: .� - a g— 9�
Fee Collected YES ✓ NO
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�Dh „S'i' � � APPLICATION FOR IMPROVEMENTS PERMIT
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1. Permit requested by:
Address: �
Home Phone�
owner/prospective owner: ��
agent: c�,
✓v�n....� �- � o k �
_� g9__� �1 �9 Busine s Phone ��:
2. Name and address of current owner:
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3. Property Description: Lot size: .�.��o Q�Jz.a.-d�
4. Tax map ��: Township: ��(7�,�--��,�--e.�.
Subdivision Name: �n � p, ��,.z6,�R. A.�7a�.-� Lot 4�:
—��--�" � �
5. Directions to property: State Road �� & Road Names, etc.
6. Permit requested for: New Installation: � Repair:
Additional Renovation re-using present system:
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7. Number of occupants or people to be served: � • ``� \
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8. Dimensions of Proposed Structure: Width: Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10. Water supply private? ✓ public?
Other source? (Specify):
Are there any wells on adjoining proper
11,
community? spring?
If so, identify location:
Type of structure or facility: Proposed: t/ Existing:
Type of dwelling: House: Mobile Home: Business:
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes No
Basement? Yes No If so, number of basement fixtures:
12. Clearly stake all corners of the property and the corners of all proposed structures.
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I hereby make application to the Person County Health Department for a site
evaluation or existing system 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.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A-335(F) ,
Signe Own o Authorizen Agent
Permit Issued
Permit Denied
Plat Observed
i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 ARFrA 4
S S S S
1. SLOPE (�)
. SOIL TEXTURE (i2-36 in.)
�Sandy, loamy, clayey,
Note 2:1 clay)
. SOIL STRUCTiTRE (12-36 in.
(Clayey soils)
4. SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.)
(Im�ervious Strata, rock)
. SOIL DRAINAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Ra.te)
$ . r OTFiER (specify)
. SITE CLASSIF
(See below)
SOIL SERIES
PS
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S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOt�NDATZONS / COrRIETITS :
S2TE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
aet areas, fill areas, wells, water bodies, slope patterns, etc.)
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Appiication Date: �-�"�"�'
Amount Paid: ,54'.�
Rec�iat #: „1 I �2.�
Person Countv Health Department
Environmental Health Section
Tax Map #• �
�
Parcel #-
. APPLICATION FOR SERVICES . .
IF THE INFORMATION IN THE APPUCATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CHANGED OR THE SITE IS
ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHAIL BECOME INVALID.
� , . _
�j` Permit requested by: (Owner/agenU�aspective owner):�
'- ` Home Phone: 3�-�94 OS7.S Address:
Business Phone: � -c� ��/ ��
�, . • i
�� 2j:) Name a�d addcess of current owner:
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s; 3� ; Property Description: �ot size: Township:
�' Oirections to the property (including road names and numbers}: �� -+
�3
4 Proposed Use a�d Structure Description: answer each of the foilowing questions:
' a) P�oposed �, E�dsting 0
b) S6ck Built C�; �Aodular �ingie Wide Q, Double Wide �
c) Number of Bedrooms: ..3 d) Number of occupants or people to be secved:
e) Basement: Yes 0, No � If yes, # of basement fixtures:
� Garbage Disposal: Yes �, No �
g) Dimensions of Proposed Structure: Width: �� Oepth: 3�'
5) Water Supply Type: Private ��ew Qq� existing �), Public q Ccmmun'ity �. Spring ❑
Are any welis on adjoining property? Yes 4YISo � If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
�Conventional Modified Conventional _ Attemative Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LlNES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SRE PIAN TO THIS APPLlCATION
I hereby make appiication to the Person County Health Department%r 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 faaGties to be
placed on the prope�ty. I understand if the site is aitered or the intended use changes, the pertnit shall become invalid. I understand
that as appiicant, I am responsible for idenGfying and martcing property lines, comers and making the site accessible for the
personnel of the Person County Heaith Department to condud their evaluations. l understand that I am responsible for notifying the
Heait e artm�nt if my p perty co �ins any weUands as designated by the Army Corps of Engineers.
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Owner or Legai R �e entaGve Date
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PERSON COUNTY °"`°°"
October 30, 2000
Elaine Copper
75 Somerset Dr..
Roxboro, NC 27573
PERSON COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH PROGRAM
20-B Court Street
Roxboro, North Carolina 27573 .
(336) 597-1790
� Re: Application for improvement permit for Wastewater system for property on Huff
Road, Lots B-1 and C � �
Dear Ms. Copper:
The Person County Health Depart�nent, Environmental Health Division on October 20, 2000 evaluated the above-
referenced property at the site designated on the pladsite plan that accompanied your improvement pernut
application. According to your application the site is to serve a three bedroom residence with a design wastewater
flow of 360 to 480 gallons per day. The evalualion was done in accordance with the laws and rules governing
wastewater systems in North Cazolina General Statute 130A-333.and related statutes and Title 15A, Subchapter
18A, of North Carolina Ad�niiustradve Code, Rule .1900 and related rules.
Based on the criteria set out in Tiile 15A, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940
Q�rough .1948, the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system.
Therefore, your request for an improvement permit is DENIED. The site is unsuitable based on the following:
1. Soil depths to saprolite unsuitable (Rule .1943).
2. Unsuitable soil characteristics (Morphology) (Rule.1941)
3. Soil wetness condidons indicated by chroma colorization (Rule .1942)
4. Available Space (Rule.1945)
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.
.� The site evaluation included consideration of possible 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 anotlier area of
suitable soil or off-site to additional property.
For the reasons set out above, the property is currently classified UNSUITABLE, and an improvement permit shall
not be issued for dus site in accordance with Rule .19480.
However, the site classified as UNSUITABLE may be classified as PROVISIONALLY SUITABLE if written
documentation is provided that meets the requirements of Rule .1948(d). A copy of this Yule is enclosed. You may
hire a consultant to assisst you if you wish to try to develop a plan under which your site could be reclassified as
PROVISIONALLY SUITABLE.
You have a right to an informal review of this decision. You may request an informal review by the soil scientist or
environmental health supervisor at the local health department You may also request an informal review by the
N.C. Department of Environment and Natural Resources regional soil specialist. A request for an informal 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 from a
contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714.
To get a copy of a petition form, you may write the �ce of Administrative Hearings or call the office at (919) 733-
, 0926. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina
General Statutes 140A-24 and 150B-23 and all other applicable provisions of Chapter 150B. 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 petitiori form with the Office of Administrative
Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. Meeting the 30 day deadline is critical to
your right to a formal appeal. Begiiuung a formal appeal �vithin 30 days will not interfere with any informal review
that you might request. Do not wait for the outcome of any informal review if you wish to file a 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 send a copy of your petition to the North Carolina Department 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 �vrite the Person County Environmental Health Department if you need any addiUonal information
or assistance.
Sincerely,
��i�
Rob Snow
Environmental Healdi Specialist
Environmental Health Division
Person County Health Depart�nent