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Persoe Cou�v Heaith Deaartrnent
Errvironmer�l Heaitt� 9ectlon
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1� THE INFORMATION IN THE APPI.ICATION FOR•AN 1MPROVEiI�ENT PERMIT IS FAL91Fl�. CtiANGED OR THE SiTE I5
AITERED. THEN'THE 1MPROVE�IIENT PERMR AND AUTHORiZATtON TO CONSTRUCT SHALL BECOME INVAUD
i� �11� i�i� `�7• ��W(1Riig6Q�f'0�6C�Y0 OWI�10��y:� c`?�1 m m� t �� �..>� S r��.
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B� PhOr1e: � � ' R by h r� � n
2� Name and addrsss of eutrent owner: ��io .,,, �
3) P�opaity �lptioc� Lat siz� I, c� 0 7'a� ��.
D'andtons to tha prapecty g d nameaa� rntrt�ess� 1� �� lol t�a k 1. , � �.
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4) P[oposad Uss and Structure Description: answec eadt oithe to0oa�rin9 questbna:
� ProPosed [�E� 0 :
b) Stidc Bu�t q Moduiar Q WId Double Wide C�
� Numbe� af Bedtoomx ��� c� c� Number of oca�ani� ac people to ba setved: �
e) Baaament Yea Q No �yes. # Y�rt fbdtuex
• t� Garba6e Diaposa� Yes Q No � .
� Di�aionsof Proposed Strv�una: YVfdth: �K Depttr,�
���PPhI �jlpes Private q(►�ew � or aod�a�n9 �� .P�6c 4 Cortu�nu�1Y o, Spdnq 0.
Ar+e any weqa an a�oining propeciyt Yes D No L�f"'yes. toc�Ion
6j P� Indlcab D�sii�ad Syabom 1j�pe: isyatama can be ranio�d In crd� oi Y�' P�l
!/Come�tttorwl Mod�ed Com�rttlonal _ Aliu�tw �nnovalWa .
Ott� 4�p+dtyj:
CLEARLY STAKE ALI. CORNERS AND UNES OF THE PROP9tTY.
3TAKE THE CORNERS OF ALL P�tOP08ED STRUCTURES.
PLF.ASE ATTACN SURVEY PtAT OR SRE P1.AN TO THIS APPlSCATION
��Y �� bo fha Pe�on Camly Health Da�tr�nt tot a ai�e avalustlon tw ths on-sibe sawaqa disPoaai sy�em
tha sbave�desc:ibed propeKy. l agreo tltat the contenb af tt�is a�p�YCatton acs huo and tepcesent the ma�mrtuun f�ies bo
aecad an the pooQecty. ! unde�tand ii the si�e is aReced or the inmrdad ua ct�pes. the pamit shaY bacoma inw�d. I�
ttt�t as app6cant� I am rospons�le ta identiiiyirq and �9 P�Y iinea, come�s and �aalcin8 the ai�e �is tar
pecsonnel af the Person Ccuniy Hesll� [�trnart io conduct their a�vaktstlons. l t�stand It�t f am t� ��9
HeaRh 1f rt�y prapqri_y��� any v�etlands as dai�na�ed bY the Acnry Cacps of �-
C�h jJ _ �. ,(�- v .
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Application Date: ,�r j, ) � ` 1%
Amount Paid: Ik'"
Receipf #: �
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❑ Improvement Permit (Site Evaluation}
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Buiiding Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
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�Iication for Services
Services Re uested
I : Construction Authorization
(Fee is de endent on the e of
I Permit Revision
. $75.00
Tax Map:
Parcel#: 3�I
�� �'�-�a�
Repair of Existing Septic System
\ Application: No Charge/ CA $ I50.00 or $3Q0.00
1) Applicant Information:
Name: -
Address: - u, ,�
e ,
2) Name and address of current owner (if different tlian applicant):
Name:
Address:
Phone (home):
(work/cell): �/Q� (pTj' - �/l,�4_ j/
Phone:
3) Property Description: Lot Size: �� Subdivision: Lot #:
Address and/or directions to Property: ,3 � R' -(� ,�����
❑ yes C3'no Does the site contain any jurisdictional wetlands?
❑ yes Q^no Does the site contain any existing wastewater systems?
� yes C�yo ls any wastewater going to be generated on the site other than domestic sewage?
❑ yes C'1no Is the site subject to approval by any other pubiic agency?
❑ yes E�"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 Structure:
C�Residential
� New Single Family Residence Maximum number of bedrooms: �j _
❑ Expansion of Existing System If expansion: Current number of bedrooms:
C�Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fxtures? ❑ yes ❑ no
ONon-Residential
Type of business:
Maximum number of employees:
Total Square footage af Building:
Maximum number of seats;
5) Water Supply: ❑ New well C.'1 Existing Weil ❑ Community Well � Public Water ❑ Spring
Are there any existing wel[s, springs, or existing waterlines on this property? [�'yes O no
6) If applying for `Autharization to Construct', please indicate preferred system type(s):
�'Conventional � Accepted ❑ Innovative ❑ AItemative ❑ Other `, ❑ Any
1 cert� that the information provided above is contple�e and correct. 1 also u�tderstand lhat if tlie inforntatiort provided is
inaccurate, or if the site is subseguently altered, or the i�tended use changes, al! permits and approvals shall be invalid.
Signature (Owner/ Legal;�epresentative*)
* Supporting documentation required.
ll-1��/l
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparcrtion' form mast accompany any application requiring a site evaluation.
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�`i Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 {336-597-1790)
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Applicant:
Location:
T�x M�� i i P�rcel # '
Scibci'ivi�s�ion / i� - � '
Fh�s�e Sec�t�ion Lot #
� Improvement Permit
Permit Valid for �/ Five Years No Expiration �,.,t�
Type of Facility: S','„� ��j�,"�,�,s,'�a/�,��� New �Addition _ Water 5upply G�/e!/
# of Occupants L�# of B ooms Projected Daily Flow 360 g.p.d.
Proposed Wastewater System: ' Type: �'
Proposed Repair: ' /' s— rPss r .s�'•Q rP ,iFr ype: 7I�.6
Permit Conditions:
Owner or Legal Represe
Authorized State Agent:
Date: � ���Z..
Date: ,� —_S'--c� �
The issuance of this permit by the Health Deparhnent in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperly owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Seivage Treatment and Disposal Svstems' (15A NCAC 18A .1900).
'� Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (��.
Proposed Wastewater System: �n �/2'�(vnc�, f'f �L Type � Wastewater Flow �6o g.p.d.
New ,/ Repair Expansion _ Soil LTAR: • 3 g.p.d./ ft 2
Type of Facility: 3,6/2 S;;,p /-e ���, �,.�s��� Basement _ Yes ✓No
Wastewater System Requirements
Tank Size: Septic Tank: /O� gal Pump Tank: -- gal Grease Trap: -- gal
Drainfield: Total Area: �ZDO sq ft Total Length �o ft Maximum Trench Depth �� in
Minimum Soil Cover: � in Minimum Trench Separation: �_ ft
ution: Distribution Box �Serial Distribution Pressure Manifold
�Specifications: S� S";'�
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Authorized State Agent: ,i``ti�c %�, /� ,
Permit Expiration Date: a- �—O 7
Date: ,�- s- O2
The type of system permitted is �Conve ional nnovative Alternative. I accept the specifications of
the permit. � � �.��
Owner/Le al Re rese ' �'"`� Date:
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IF�aa�vnsaDnanaa.�na.�an.11 IH[ a�mll�]Ln
Name C�a� r►� e C'�'P`S
Subdti��ion ' �
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Authorized State Agent
SITE SKETCH
Tax Map #�%� Parcel # 33 9
Section/Lot# Lo� S/
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Date
System components represent approximate contours only. The contractor must, flag the system prior to
beginning the installation to insure thatpropergrade is maintained
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PCHD, rev. 09/12f Ol
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Zoning: Townshlp: � �
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��bdtvision: � ���_: �:_ � -�� ,Sectlon: � Lo�
Applicatt� '�°"1
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L.ON�011: .-
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�per�ti+�n Permit �
. System Type (in Accordani� With Table Va):
TflIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCIE WITH APPLlCABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FOR SEINAGE TREATMEiVT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEiIAAEiVT PERMIT AWD CONSTRUCTI�N
AUTi�IORIZATI N.
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� Authorized State Agent � Date _
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oc�c�w� r�t`�� 11vTY E�t\/IRi�NME�ITAL 6iEAL�H
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� Wel! Permi� '
Tv�e of Water Suapl� Individuai _ CommunitY ,= ubUc
Reauirements:
Site Approved� by 1 't—
Grouting App. roved by � � �t ��
Weli Log ✓ 2 5' �
Weil Ta � � �
Air Vent
iiOSO BI� - . .
� COt1QE�B $�3b .
wet� �riller. �' `�i .
Well Approved By: �
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Date: �� �� ��°2
*''See �►ttached Site Sket,cfi'�*
Welis must be 10 feet fram property lines• .
11,yelis musi be 100 feet from se{?ti� sy��,,jding foundation.
Weils must be'at least 25 feet from arry
Other conditions: � .
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Owner: �
Location:
Subdivision:
Well Log
Tax Map �iO Parcel # � �
Lot #
Well Construction
Distance From neazest Property Line (Minimum 10 feet) / U
Distance from Septic System (Minimum 60 feet) � G�O
Total Depth: ��_ ft Yield: � GPM Static Water Level: c�i S ft
Water Bearing Zones: Depth � ft�B'0 ft ft ft
Casing:
Depth: From �_ t
Type: Galvanized Steel
Thiclrness: � Height above Ground: / c, _ in
No Any problems encountered. while setting casing? Yes � No
o � ft. Diameter: �_ in
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Weight:
Drive Shoe: _yGYes
If "yes" give reason:
Grout:
Neat: Sand/Cement � Concrete GraveUCement
Annular Space Width � inches Water in Annular Space Yes ✓ No
Method of Grout: Pumped Pressure Poured �/ Depth C� to av F�
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gra.vel, cuttings) — Ratio to
ID plates: Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log . � Location Drawing
From To Formation
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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 Deparhnent.
Signature of Contractor ID# Date
� PCHD rev O1/16/02
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