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Persor� c;�urty Haaith Ce�: 6°
325 S. Morr,2n S�re�:i 1 �22�' q�
Roxboro, N.C. 275iu a b-�-7� �� /�%�
Cour'er ��?2-�3-15 P��Q S`�� D a t e
� v� 1 Tra"11T T/1T ATT�1T/11'�[�
Improvements Permit.(Established/Recorded Lot) I_ Reinspection of Exis[ing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot)
lmprovements PecTnit (Mobile Home Replace)
Improvemen[s Permit (Addition)
Repair/Replace existing Septic System
_ Permit for Ne�v Wetl
_ Replace Existing WeII
l. Permit requested by:
ow� /prospective ow
Address: • �ys��
�� . Dime sio�p Pr�clp�se� Structur`e:
°�� �-
;ent: Width: T
�Pn yr,;��, /� � Depth: r� � ,
�s�i�!..e�v � 1� .�e -,� 7s� 3 g, at type i any, a itions, expansions, or
replacement is anticipated to the structure or facility
���� that this sewage disposal system is intended to serve?
Home Phone #:�3 �
Business Phone #:
2. I�Iane and addre�s of cutrent owner: -s'�'� � 9. Water s pply tS•pe:
� + private �public ❑ community ❑ spring 0
A�e any w�lls on adjoining property?Yes�No �.
If so, identify location:
Property Description: Lot size: /� 6�
. Tax Maprr: tt" � �
Parcel#: a �
Township: ��/}: i �-
. Directions to property: State Road #& Road
�-�T .:� �.
Number of occupants or people to be served:
10. Type of structure/facility: Proposed: OExisting: Q
Type of dw,�ell' g:
House: +L�i Ivlobile Home: [� Business: ❑
Tyge of business:
Number of Employees:
Nu of bedr
Garbage Disposal? Yes ❑ �
Basement? Yes ❑ No f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY ANll THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PersOn COunty Health Department for a site evaluation for the on-site
se�vage disposal system for the above described property. I agree that the contents of this application are true
and represen[ the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the pecmit 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 even[ I have not
delivered a survey plat of the pcoperty to the Health Dept. within 60 DAYS aEtec the date oE the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
G'�^-�'Y'^�-. ��
cc� Owner or Authorized Agent
_.--. _ _.. _._.
---.,._._,_- - -� _ . _ .
TIMOTHY M.
�8 255
:ON rF
CORNE
�.;MMY �AWK:NS
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shali be issued until Authorization for waste water system construction
, has been issued.
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Tax Map # 1� �' � Parcel # � g�
Zoning ,Township � ��i�
Owner/Contractor Q S hl a
Location/Address i.s7s;
Subdivision Name �
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Lot# -
Date /,, -.3U -
� C� /C.� �G,� I�OuC V fZ/'IV.f �
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s.x.# //<i !
SEWAGE SYSTEM SPECIFICATIONS
RepairS�no��.-Eiuc Lot Area �,U s� Size of Tank )UC�
SFD ✓ Mobile Home Size of Pump Tank Pum p i F r�c.cr S Sury ( � ya
Business # of Bedrooms 3 Nitrification Line yUC�' x 3 �
Max Depth Trenches � �j''
Permits may be voided if site is Itere�
Well and Septic Layout by �'. cr,---
Comments: �c G'o.:� ,' ;,� s o
or intended use changed.
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Well Permit Paid WELL SYSTEM 5PECIFICATION5
Individual Semi-Public Required Slab �
Public Replacement Air Vent
Site Approved_ Required Well Log ��
Well Head Approved Well Tag
Grouting Approved -{p� (3,`b
Comments:
Date �-a 3-U� Installed by Approved by,
This report is based in part on information provided the ho4�neowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
�lon�
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TIMOTHY M. TAYLOR
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Person County Health Department
Environmental Health Section � ��
Tax Map #: � �a Parcel #:
Zoning: Township: �f� /�,� 1����
Subdivision: Section: Lot:
�—,
Applicant:
Location•
Operation Perm it
System Type (In Accordance With Table Va): Cd/1 dE��
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.
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Aut rized State Agent Date
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Tax Map #: Parcel #:
PCHD, rev. 10/12/99
Person County Heafth Department
Environmental Health Section�l� ��
Zoning: Township: � � (/P/�-
Subdivision: Section• Lot:
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Applicant:
Location•
Operation Permit
1. LOCATION AND SEPARATfON DISTANCES
A) System meets .1950 setback requirements� �T
B) Distance from system to any wells /oo
C) Distance from septic tank to foundation o�
D) Distance from system to property lines / o
2. SEPTIC TANK
A) Visually inspect the exterior walis and top of the tank _�
B) Visuafly inspect the interiar walls, baffle, tee, filter, riser, iids, air vent,
bottom, and water tight outlet -e.� 9
C) Date of tank manufacture
D) Tank serial number �7g '� �
E) Liquid capacity of tank jdo0 gallons
3. SUPPLY LINE TO TR�NCHES
A) Grade ec ��l�a�; (1/8 inch per foot minimum)
B) Material supply line constructed from � UG ,SG�i yG
C) Diameter
D) Length S /
E) Distance from tank to drainfield/distribution device �.�,
4. DISTRIBUTION DEVICE(S)
A) Type
,� f(�/ B) Is Device water tight
� v r� C) Distance from the distribution device(s) to the trenches
D) Is the device on a levef foundation
E) Does the device perform according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD .�
A) Trench depth a y� inches -
B) Trench width ��6 ` inches �
C) Distance betwesn trenches
D) Number of trenches �
E) Length(s) of trenches �y' 6S' �i � 99 � 9y � 65�= y/8
F) Aggregate depth ! �- inches
G) Aggregate material and size ��S7
H) Record septic tank outlet elevation .�'io/a-
I) Trench grade e� c �a�.�•�-. (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth �
b. Proper rise over step down ��
c. Sofid pipe used -�
d. Elevations of step owns l� �� �Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
oPERSON COUNTY HEALTH DEPARTMENT
355A S. MADISON BLVD.
ROXBORO, NC 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
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Name of O�vner or Tenant �1lQ.�i�a �,�5
Address_ K61 �-� ��, County���S�►�9
Collected By �s
Date Collected �— �7 /v Tiine Collected 3� sa
Source: �Il
❑ No Charge
0 Spring ❑ Well Tap �ther
C�Charge
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Rescclts
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