A40 386application Date: S� 3--t ��� �S ������ Tax Map: �0
:�mount Paid: '206. oo �(�G�O �.: ^��- ,� Parcel#: ,���
Receipt �: `��_ �� ~ � � �7��r �
Jl�]mV>SR`O7CLICIISl4:]I'R1�.Ot1! �LC1/1.�1:�
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Impro�•ement Permit (Site Evaluation)
S200.00�5300.00 (if> 600 �ad)
�iobile Hone Replacement or Building Addition
S I SO.OQ (if site r•isit required)
:Vell Perr,iit (ve���/Replacemzn:/Rzpair)
S304.40l�200.OD/575.00
ication for Services
Services Requested
Construction Authorization
(Fee is dependent on the type of
Permit Revision
�75.04
Repair �f Existing Septic Sys.e�:
Application: No Charge/ CA $150.00 or $300.00
1) Ap�licant Infor ation: q -
\ ame: �`�"'��
Address: �'
-► ` � 'q ,�
2} \ame and address of current o�vner (if dif�erent than applicant):
\ame:
Address:
Phone (home): -3 �� � a` S �y
(work/cell): _i' j � � ! �. 9
Phone:
3) PropErtz Description: Lot Size: Subdivision: GA�I�r q�'� r Lot #: I� �
Addrzss and�'or dirzcti�ns to Property: A 4K'FS
O yes ❑ no Does the site contain any jurisdictional wetlands?
O yes O no Does the site contain any existing wastewater systems?
� yes � no Is any wastewater going to be generaced on the site other than domestic sewage?
O yes ❑ no Is the site subject to approval by any other public agency?
O yes 0 no Are there any easements or right of ways on this property?
(if `yes' is checiced, please provide supporting documentation)
4) Proposed Use and Type of Structure:
ClResidential
�\e�+� SingIe Family Residence Maximum number of bedraoms: �/ Occupants:
C Expans:o� of Ezisting 5ystem If �xpsr.sion: Current number of be ooms:
❑ R�pair to 1�Ialfunctioning System Will there be a basement? ❑ yes O no With plumbing fixtures? O yes ❑ no
❑1on-Residential
T�pe of busincss:
vlaximum number of employees: _ _
Total Square footage oFBuild:ng:
Maximum number of seats:
5) ��ater Suppiy: � New weli ❑ Existing Well ❑ Communiry Well ❑ Public Water � Spring
Are there any existing �vefls, springs, or existing waterlines on this property? O yes 0 no
Plzase note any known graund �vater restrictions or sources of contamination:
6) If applying for `Authorization to Consiruct', piease indicate preferred system type(s):
O Com-entio�al ❑ Accepted ❑ Iru�ovative ❑ Alternative 0 Other ❑ Any
1 cert� that the injornration provided above is complete and correct. I alsa uitderstartd that if the inJorntation pravided is
ifraccirrate, the site is s:rbsequentiv altered, or the intended use cnanges, all perrnits and approvals shall be invalid.
` Signature (O�vner/ Lega! Representative*}
' Supporting documentati�n requircd.
Date
■ Permits are valid Por either 60 months or are non-expiring �vhen accompanied by an approved plat.
• A campleted `Lot Preparation' form must accompany any appticatian requiring a site evatuation.
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Tax Map: a�{D Yarcel:�_
Subdivision Oa K i ap_ u�s
Phase/Section/Lot # �(�
/ Improvement germit
Permit Valid for: Five Years ✓ Non-expiring
Type c,f Facility: � �,,,�; (,� �,,�,,e((;,,Q New �Adc�ition _ Water Supply: I�e/�
Number of: Bedroo �/ O cupants�SEmployees / Seats: Projected Daily Flow: 480 galions/day
Proposed Wastewater System: �v��� � Type: �_
Proposed Repair: Type: �
Permit Conditions: �j�. Q;,,�r �(�,.� P,�,,�,`
. �.M�in%in.�tll._�acl��------
Authorized State Agi
(X j 6wner or Legal
Date: �-ZZ-II.
Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure 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 �r th� ente�ded use char.ge�. The Ir.2praver.�ent cs not aff�ste�
by a change in ownership of the prc►perty. �'his permit rvas issue� in �ampliaace v-ith t6e pr�s•isians cf the North Carotina �Laws
mrrl Rules for Sewase Treatmen[ and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will cantinue to function satisfactorily in the future, or that the water sapply will
remain potable.
Authorization to Construct Wastewater ystem
See site plan and additional attachments (
Proposed Wastewater System: en►,ve�;e„a � {*)TypP�_ Design Flow y8a gallday
New ✓ Repair _ Expansion _ Soil LTAR: • 3 gal.;day/ft2
Type of Facilit-�: • — Basement: Yes No
(*) System Types Illb, Illbg, IV, and V, reguire pPriodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank _(' �� gal. Purrip Tank — gal.
Drainfield: Total Arza �_ sq. ft. Total Length �33 ft.
. Trench Width 3 ft. Min.S�il Cover_� in.
Distribution: Distribution Box �/ Serial Distribution ✓/ Pressure Manifold
^vrease Trap gal.
Ma�c. Trench Depth 2� in.
Q.c,
UIin.Trench Separation � it.
Specifications: _l�-y�o�c o� Ser�a ( OK ; Zf d-bo,� n�;»'t�Hl�1°�� ���M
Authorized 5tate
Issue Date: 8-23-1�
Permit Expiration Date: � Z3-21
The system permitted is: Conver�tional �/ /Accepted / Alternative / Innovative . I accept the conditions
and specifications of this permit. ` � ��
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 325 S. l✓Iorgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Applicant:
Location:
Operation Permit
Tax Map Ayo Parcel # �(�
Subdivision Oakr�'daP Qcre<
Phase/Section/Lot # q 1�
# of Bedrooms �(
System Type (From Table Va): Product (IIIg): �„-F,
Type V& VI Expiration Date: Type V& VI Renewal Date: ,v/�
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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( thorized Agent)
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(Licensed Contractor)
Scale �
PCHD, rev. 1 /14/12
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s-r-17
(Date)
S-I-
(Date)
Line Length
I
2
3
Total Z.
Tax Map: �� Parcel #: . R�A
Septic Tank System Checklist (Type II-I� System Type: �
Se tic Tank InitiaUDate
State ID & Date: 3-s
-2 ✓
Capacity: Q-�_ ,�
Tee and filter ,/
Baffle ,�
Vent �
Riser
Outlet boot ,r
Perm. Marker ✓
Distribution
D-box (levels set)
Serial ,/S
Pressure Manifold
LPP
Notes:
Nitrification Lines InitiaUDate
Trench Width: 3 ft. ,/ 3S S- - t
Trench Depth: Z in. ,�-
Total Length: pZ ft.
Minimum spacing: q ft. a.c. ,/
Rock de th/quality N
Dams/ste downs ✓
Grade (< .25" in 10')
Cover (6" minimum) ,/
Setbacks
From wells S _ _
Pro erty lines
Foundations/basements �/
SurfaceWater ,/
Other:
Pump System Checklist
Pum Tank InitiaVDate
St ID & Date:
Capacity:
Riser (6" mi
NEMA 4X Box
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Manifold
Number of ta s:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
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WELL�'ERMIT
(New�/ Repair_)
Tax Map: �Q ParceI: 3B(e
Subdivision: oAK f�,��� Lot: �( ,
J �
Applicant's Name: � �n�, K;„�
MailingAddress: �y�� �� ;��s aa,
e� e re IJ C 2� 5�lli
Phone Numbers: 3(,W - 2�G 2 5qg - Z� 2R
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.J Issuance of a permit does not guarantee a potable water supply
OtherConditions/Comments: N1a;N�ha;n all Sef�a�Ks
Permit issued by: � , Date: - 23-/
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Certificate of Completion
1ew Well:
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller: s-1.�,
Pump Instatler:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Rnvhnrn N!'77C73
DI.iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #: ���1�1��
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
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Si,r_ .
Name Tax Map# Parcel# �g to
Subdivision Ssction/Lot# � —
� R' —23-1(�
� uthorized State Agent Gate
System components represent �ppraximate conlours only. The contractor must,Jlag the system prior to beginning �he
installation to insure that propergrade �s maintained. . .
Note: An Accepted systerrt may be used in place oja conventiona! s,vstem without permit aulhorization or modiftcatio.n.
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