A40 260Q Person Courty Health Dept
�m o u n t p a i d ��d � O 325 S. Morran Str�et � G
Receipt � ' ,�(�_rJ z
Roxboro, N.C. 275?� � — � � � !
- Gourier *02-?3-15 D a t e
��� � APPLICATION FOR SERViCES
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J( Imorovements Permit. (EstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing)
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fmt�ovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
_, Bacteria � _ Chemical
nit requested by: .
p�rospective owner/agen
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ome Phone #: . S� � - 9m �
usiness Phone #: � � �-� �"
Name and addre5s of,current owner:
�n
. Property Description: Lot size:
Tax Map#:
Parcel#: _
Township:.
epair/Replace existing Septic System
,_ Permit for New Well
_ Replace Existing Well
,_ Petroleum I Pesticide � _ Lead
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. Directions to property: State Road #& Ro��
[ames,gtc.
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. Number of occupants or people to be served: .
7. Dimen�ions pr Proposed Structure:
Width: �v �
Depth: �l � � ,
8. What type (if any, additions, expansions, or I
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
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9. Water s pply t} pe:
private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �
If so, identify location:
10. Type of structureJfacility: Proposed: I�Existing: Q
Type of dwell'�,rSg:
House: C�Iobile Home: Q Business: ❑
Type of business:
Number of Employees: _�
Number of bedrooms: �
Garbage Disposal? Yes No �
Basement? Yes ❑ No If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PersOn County �ealth Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree tha[ the con[ents 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
deliveced a survey plat of the property to the Health Dept. within 60 DAYS after the date oE the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
SiQncc� Owner or Authorized Agent
PERSON COUNTY
Dear �'j� ����V K������ �
PERSON COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH PROGRAM
325 South Morgan Strcec
Roxboro, Norch Carolina 27573
(33G) 597-2371
Date: l�'Z�J�7/
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The above referenced lot has been evaluafed by the Person County -
Envi�onmentai Hea(th Department. The results of the evaluation, a copy of which is
attached, indicate that the site is unsuitable for insiallation of a ground absorption
sewage system for the following reasons:
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Due to the limitations on your site, this Department is not aware of any
modifications or alternative measures that can be implemented to upgrade the
classification from `unsuitable° to "provisionally suitable.' Your application for an
improvement permit must, therefore, be denied.
You have the right to an informal review of this decision by the environmental
health supervisor of this health depa�trnent and also by the regional staff of the
Depa�tment of Environment, Health, and Natural Resources. You should contact the
health department to arrange for this further review.
You may a(so wish to obtain the services of a private consultant to collect
site-specific data and submit such data and a system design to the health department
for technical review. A site may be reclassified to provisionally suitable provided
written documentation, including engineering, hydrogeologic, geologic, or soil studies
indicates to the local health depa�tment that a proposed septic tank system or a
proposed altemative system can reasonably be expected fo funcfion satisfactorily.
Page 2
The substantiating data from these studies must indicate that:
A. The effluent (wastewater) will receive adequate treatment;
B. The effluent (wastewater) wili not contaminate any ground water or
surface water; and
C. The effluent (wastewater) will not be exposed on the ground
surface or be discharged to surface waters where it couid come
into contact with people, animals, or vectors.
Finally, you have the right to a formal appeal of this decision if you file a petition
for a contested case hearing with the Office of Administrative Hearings, P. O. Drawer
27447, Raleigh, NC 27611-7447. A copy of a petition form will be provided to you
upon request. The petition must be received by the Office of Administrative hearings
within 60 days after the date of this notice. The hearing will be held in the county in
which your property is located.
If you file a petition for a hearing, you must send a copy of the petition to Mr.
John C. Hunter, Office of General Counsel, P. O. Box 27687, Raleigh, NC �
27611-7687.
Please call or write this office if you have questions or need additional
assistance.
Sincerely,
� � ��2��;vu,�d��I
Environmental Health Specialist
Environmental Health Division
Person County Health Department
Enclosure