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A40 277Application Date: � � �i "U � Amount Paid: Receipt#: ��_S� ��.�..�� --�- � � 1�.7' 1�7 �IC" .� J.E:' �caw�i.n: a:nu�..ir.aT...e�n-n.�.en.11. 7�".Jr'.c�.w,u.R::�la. . Application for Services � (Sentic Svstems and Wells) Services L Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) C Mobile Home Replacement or Building Addition $150.00 (if site visit required) � C Well Permit (New/Replacement) $225.00/$125.00 Tax Map: /4 4 v Parcel #: ��7 � ❑ Construction Authorization (Fee is dependent on the type of sys ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System No Char�e Important: If the information in t/te application for an Improvement Permit is incorrect, fulsified, or the site is altered, t/:en the Improvement Pern:it and the Authorization to Co�tstruct s/:all becnme invalid Services Requested by: Name: �� 1 C f�/��.Li� ��' Address: �7�'1 � J-f� i �- Q'Jy ��C/'�D�ZD hJ� �7_S7 t% Phone # (home): �%/�7- ,5��'j - ( i5"fC (work/cell): g/ 9 - 5�% 7 - �,� �{C 2)Name and address of current owner (if dif%rent than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: b�� ,C /�C'.Q�S Lot #: � Address and/or directions.to Property: 7�I 2��.r �-rQr� C'Q11�U� GO � .qT Nur!' � /��11D7 l.�i L 1� D�IZ ��"' G�t1F, 4) Proposed Use and Type of Structure: Residential Business/Type: Other �C7-i4�f{� G-/�Q-'/�� Number of bedrooms / Number of people served (seats/employees): Basement: Yes No �_ (with plumbing: Yes No �� Garbage disposal: Yes No _� �,5) Water Supply: - Private Well (Proposed Existing � Community Well: Public Water System: Are there on the adjoining properties? No Yes (please show location on site plan) Note: A completed apn[ication must also inc[ude: ➢ A pladsite plan of the property that shows property dimensions and t/ze size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am sabmitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. � �� Signature (Owner/Legal Representative): �-�� Date : � � � 06/07 Person County Environmenta] Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� . � ,� � �� y � �J `V� �J ,� `� � � �ml.�Ji.]r`KD�11.�.aL7rn.�.�..{1 .!L 1L�:�.Jl.tE.lt�. Building Additions/ Mobile �ome 12eplacements T� Map #: _i� �-%0 Parcel#: � � Approval Requested for: Mobile Home Replacement ✓Building Addition Applicant Name: � C� � l--u Address: " � � R.oXba �; c� �1 �7�{ 74 Phone #'s: Pernut Located: �Yes No Installation Date: �-(-p � Design flow: 3 60 (gpd) Current Contract with Certified Operator on file (if required): Water Supply: �Well Public or Community Wastewatex system shows no visual evidence of failure on: � �'�'�� (date) (Applicant's signature if site visit is not required) .� i-� •� t.�� .! t � � � • ■ ... f � � RZ � • .�' � l t� �� Addition/12eplacem�nt Approved �� Environmental Health Specialist 11/15/OS 5 �3/glo;z-- Date Rug 07 07 09:58a VIC�N��Ysr' ry�AP ^ �� ,�� a' , o` p.2 . � �,c>`�, �s��1c6 �q� yur� � �X ��. ,�.c. � 7 57� �s ' �qK �e��- � �' S Ld?��. N , ,�G�� 3� C�At� t S� "` , �E' f =Ca � . _ PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT Tax Map #: ri �� Parcel #�/ 1 Zoning Township Fla� R( v�r Applicant: / ��m�' /• 1�'X LocaUon:,J��7c� ��-FF ^O� �� n Subdivision: �� n rl ci9G /�}C iCS Section: LoY: ` Improverr�ent Permit `' A buildincl permit cannot be issued with onlv an Improvement Permit New ✓ Repair _ Addition _ Type of Structure�{ Water Supply el"►t,�c'� �� # of Occupants ? # of Bedrooms 3 Other Basement? N�—Basement Fixtures?� r'rojected Daily rlow: 3�g.p.d. Permit Valid For: �'Five Years ❑ No Expiration Proposed Wastewater System T e: �'.Of11iC-(1'��0�1a-� ��rQU s'�/ "� Pump Required? Yes �No Permit Condition� /�'' Gr t�� r1 u�' ��- For la.vo�� Kc.� ScAt� C �� F r f i C � D /� �r` 'Cr�O� Owner or Legal Repres tive Signature:'� � / Date: �` ��`6 � Authorized State Agent: � Date: .�—/ 7—�v The issuance of this permi by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Authorization To Construct Wastewater Svstem (Required for Buildinq Permit) Type of Wastewater System �(11J�.1 iv Dilu � Wastewater Flow: c�oC�g.p.d. Facility Type: Db� �L ►i�m� New �Repai� DExpansion 0/ ��p(��i C�r1J� On � Basement? 0 Yes - o Basement Fixtures? 0 Yes fi�'I�lo 5j(L� m�`'�� Wastewater Svstem Requirements �,� rG ,w, b� mct btFo Septic Tank Size: �/�� gallons Pump Tank Size: '`�� gallons � Pow�� Ca-n b� -�n td On � Total Trench Length: �� feet Maximum Trench Deptht�_� inches Aggregate Depth:� in. Maximum Soil Cover: �01 inches Trench Separation: —r Feet on Center Other:�t 9`�iG � D 0' From c�� I I, IS ` From d� t.c.�,, Permit Expiration Date: � � 1 oiCMJ Authorized State Agent: Date� "" �� w The type of system perm' ed a does d es not differ from the type specified on the application. I accept the specifications of this permit. , �� av Owner/Legal Representative Sign ure: Date: PCHD, rev/ 10/12/99 Appiication #: Tax Map #: Ay0 Parcel #: a77 Person County Health Department Environmental Health Section SITE SKETCH ��` �omc, f�lax �,Kr� d� � Acr�.s 2- A I' ' Name Su ivision/Section/Lot# pp ica s � r I ��0� Authorized State Agent Date System components represent approxin:ate contours only. Tlie conlractor must,flag the system nrior to beQinnin� the installation to insure tliat proper grarle is maintained. i�� — �. — — l� � � R � � �� } �� . � �-nr a_ m '� �b� yo 50� �, tB" _�r �= — — —r _ .� 15, , vc�� TF n�s��r t _ — -_-._,— — �t �o-� Or�gi nal �� bY 3anL C�Qy ton �- �c�vid 3�� t � �t � {, r`�'� b��n � n a „ �► o«.d a F Sa i I-�o P lacc � 2 �� n o F co�c.� o�t�� -��s t�w 1� ��a. to rc-diTcct �G-fc.�- � �(ow �' p�cv�n.-� e�o5�an '�` scale: ��=V �� ( Dt I'le�S 'fA %� larld�c��' d � �,y ;-�(n, � raSS �S�E� ��Shcd c:� i �t� �n � �c� �� CHD, rev. 10/12/99 � ��`na( ScP-�'� ��s-bal(�-�� 0 �� `• Person County Health Department , � . Environmentai Health Section � ' �� ' Tax Map #• l"t �� Parcel #: �% % � Zoning: Township: �� 1�,�(� Subdivision• � ' Section: �at: 2 Appiicant: ��.1� Location: �� O eration Perm it System Type (in Accordance With Table Va): � 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 AUTH IZATION. ',� , 3 _'� �� uthorized State Agent Date � b't � 3r�� 9,, ZZ' -�5' �1S �oo� 51� �'� a 12��3'qq Tax Map #: �"�� _ Percel �: ' ��1 PCHD, rev. 10/12/99 Person County Health Department Environmental Health Section Zoning: Township: ��'" �� P� Subdivision: � ur;�i��reS Section: Lot: �_ Applicant: �Yl� P MQ�� Location: �� c� Operation Permit 1. LOCATION AND SEPARATION DISTANCES � A) System meets .1950 setback requirements B) Distance from system to any wells 0 C) Distance from septic tank to foundation • D) Distance from system to property lines j,.(�j �- 2. SEPTIC TANK A) Visually inspect the exterior walis and top of the tank _� B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, ai� vent, bottom, and water tight outlet C) Date of tank manufacture ` D) Tank serial number "i" � 2 E) Liquid capacity of tank gallons 3. SUPPLY LINE TO TR CHES A) Grade (1/8 inch per foot minim m B) Material supply I��e is constructed from �. C) Diameter D) Length ' E) Distance from tank to drainfield/distribution device 'Z-� 4. DISTRIBUTION DEVICE( ) A) Type B) Is Device water tight C) Distance from the distribution device(s) to the trenches D) Is the device on a level foundation �� E) Does the device perform according to its design s�P� cifications �� F) Record the inlet and outlet elevations �IV't 5. NITRIFICATION FIELD A) Trench depth a�l " inches B) Trench width Tinches C) Distance between trenches �i-�'%�. D) Number of trenches E) Length(s) of trenches 393 �'�-. F) Aggregate depth ,,�r inche G) Aggregate material and size Gr'av�e � H) Record septic tank outl t elevation I) T�ench grade S� � (< 1/4" per 10') J) Step downs a. Minimum of 2' of undisturbed earth/ ✓ b. Proper rise over step wn ✓ c. Solid pipe used d. Elevations of step downs (Record elevations and show on as built) � See "as buil p�an n attached sheet. PCHD, rev. 10/12/99 � , ' � � PERSON COUNTY ENVIRONMENTAL HEALTH ". ..' PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT . Tax Map #: / Y � v Parcel # � / � Zoning Township ��a� � � V C� Applicant: ��m� 1`,a'X LocaUon: �«' �" �M � " �-v t 2 Subdivision:' � 1�rr Q�' �� Section: Lot: Well Permit �pe of Water Supplv: �Individual Community Public Repuirements• Site Approved by � �'� � Grouting Ap roved by /�/o s'� � Well Log �?N �+ a :�5�� Well Tag ��- - �� -� Air Vent � 3-6 -oo Hose Bib rk� 3-G-o� Concrete Slab` � -�s �� Well Driller: f�rr�7T Well Approved By: i% G, /e`S- Date: .�-6 oe� **See Attached Site Sketch** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: cc (,�c. ID` rOM � D � l�Ls F rf7 f�"1 ct[� Or an y 6�Q� c- SySfcm cs�r c�5 t_mc/��s � PCHD, rev. 11/29/99 � . . Date: z. �' Owner. � .��-i� Location/Directions: _ PERSOH COUNTY ENVIRONMEHTAL HEALTH WELL LOG SR# Subdivision N�une:Q�� Lot # Drilling Contractor: ' WELL CONSTRUCTION --- Distance from Nea.rest Properry Lin�_ L� Distance from Source of Pollution IC'�O ' Total Dep_th:_�; `� _ Ft. Yi�ld: ��_^ GPM Static Water Level ` �_i=t. Water Bearing Zones: Depth Q� :=t._ � F� Ft�_�_�� Casing: Dept}i: From�_to�_Ft. Diamcter: / Inches TYPE: Steel � Gzlvanized Steel � If Steel, does owner app:ove: Yes No � Weight: Thickness:. �,�3 Height Above Ground:� jnches Drive Shoe: Yes ��10 Were Problems Encountere,d in Setting the Casing? Yes No .�� If "yes" give reason: Grout: Type: Neat Sand/Cement ./" Coricrete Annular Space Width Inches Water in Annular Space: Yes No _ .. Method: Pumped - - Pressure � � Poured � �. � � �. . Depth: From � :o �'� Ft. � - MateriaLs Used: No. Bags Portland Cement Weight of .1 bag__lbs. If mixtule (sand, grave]; cuttings) - Ratio: to -ID Plates: Yes�Alo � � •� � �� 4 x 4 slab Yes � No � I HEREBY CERTIFY THAT THE ABOVE TNFORMATION IS CORRECT AND THAT THIS WELL WAS CONS�'RUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH �y�THE PERS0�1 C�uidTY HEALTH DEPARTMENT. O� ignaturc of Contrac�or D1� `