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� Pers,;r� County F,aaitt; ��i;;�
Amount paid ����
� — 32� S. �torc�an Strept
. ��xcoro, N.C. �:57�
R�ceipt �� Q
' - ��o:i<;er �??.?3-15
e �a " APPLICATION FOR SERVI
1 ✓.�-r�� � x £• �,. � , �t...K � :..x �. �F�;- tiP*•S �eY..: - � w^cai '9.ti..C3z � c..,F.r ,
t s . < ,z . '� �����KSeryices;Requesfed
x ...: ..-[w..„ . �..:,..w¢a-+.�..-.=.. a... !'a.C�-,�..�LS'.+..>. . ..eRa•,.w.
_ Improvements Permit. (Established/Recorded Lot) _ Reinspect
Imt�ovements Permit (Unrecorded Lot)
Improvements Pecmit (Mobile Home Replace)
Improvements Permit (Addition)
_ Bacteria
" Permit requested by: .
wner/prospective owner
,ddress: • �O��Y�� C
�8C.5 �
ome Phone #:�, 3
usiness Phone tt�
_ Chemical
tQ-�- `i`�
Date
n of Existing System (Loan Closing)
Repair/Replace existing
Permit for New Well
_ Replace Existing Well
_ Petroieum � _ Pesticide
ic System
Lead
a!Dimensions or Proposed Structure:
Width: _ �� X � �
Depth:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
Name and addre�s of:current owner: 9. Water supply t5•pe:
Sc„�,� private �. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
. Property Description: Lot size: 1/4 C. _
. Tax Map#: � � �{ �
Parcel#: �
Township: F1q� . _ � V ��'
. Directions to property: State Road #& Road
o�ba v e
SS
. Number of occupancs or people to be served:
10. Type of structurelfacility: Proposed: �Existing: Q
Type of dwelling:
House: ❑ Mobile Home: a Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: _ _ —
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ No�I 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 PeL'SOn COun�y Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the contents 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 germit 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 pla[ of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signcc� Ownec or Authorized Agent
. ___._ -- -_.�..�,.�
Yerson County Health Department
tixisting Sewage System Report For: Mobile Home Keplacement
�Addition
Requestee: �c�,-tr�cia M� Nur� _ Hone Phone# 3(ay'qa91
J`'�� S%�urdle M� ��S �d ausinessn
�oxborol NC o?7573 �rax Hapn `lD Pa��� I 4
Location/Uirections: Leo�.v� %ZOxbara Or1 �c5 % J`�, la0 Tv _
�#- �g(,S No�se. on le�-��
Original Permit Located � �
Septic System Uesigned �or:
Kesidential _�_ Business
� f3edrooms ? # Employees
�
ather (specifyl
Other _
Uate '1'nstalled 7 Water supply P�����te
Type ot System Vr0.Vi`f�,l, POSSible �� S�rS���''� _
Hitrification Line ? — ___
Tank 5ize 7
Certified Operator Required NO
On site wasL-ewater disposal system showes no visually apparent
malfunction on ����Gr 9 l
Yermission is granted to: �(-�� Id a la� Xay � vto�-aqe bu� �ci�nq •
u
According to the at�ached site plan.
comments: .L ��Oc,i.l� /18`t �CtC#ViS� (.�Si�n� ��i,.5 (�ui Idt n9 F��
�f,oraqt, DF Cl,cmiC.a(S Or p��-Eici�IcS Ciue� to i-tS �-'105�. prnxih'�it�/
to �.l..t l� � 1 I
Environmental Health �'�1�`G• . �� �%r 99
DATE
1MiilN�Id prop.
�:�i:
n
Fli�t �lil�INd Kp.
Fli� Whitfitid D�'aD-
Application Date: l� �� �� /��.rj ��� � (� ��4 ���� Tax Map: " ��
Amount Paid: �l� r.. -" � J Parcel#:
Receipt#: �r �'�����
IE":.nn� nn-anan.v.xa�.sn.dau..Il IHL�.s�.7L�::�r.
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/ReplacementlRepair)
$300.00/$200.00/$75.00
tion for Services
Services Re uested
❑ Construction Authorization
(Fee is denendent on the tvpe of
❑ Permit Revision
� $75.00
pair of Existing Septic Syste
Application: No Charge/ CA 50. or $300.00
1) Applicant ��formation:
Name: ` �� c•GtCti- � 'v�r�
Address: �2 �.
C�-�rn �(����147 �{
2) Name and address of current owner (if different than applicant):
Name:
Address: �'S �
�
3) Property Description: Lot Size: \l�c, c� Subdivision:
Address and/or directions to Property:
Phone (home): � � � - �'��
(work/cell): ��fG-50��-63��
Phone:
Lot #:
❑ yes l�fio Does the site contain any jurisdictional wetlands?
�es ❑ no Does the site contain any existing wastewater systems?
❑ yes CiLno Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes � Is the site subject to approval by any other public agency?
❑ yes Ct]-riD 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 5tructure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
ll�'Repair to Malfunctioning System Will there be a basement? � yes ❑ no With plumbing fixtures? ❑ yes 0 no
❑Non-Residential
Type of business:
Ma�cimum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well �'Existing Well ❑ Community Well ❑ Public Water 0 Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system�t e(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. 1 also understand that if the information provided is
inaccur or if the site is subse uently altered, or the intended use changes, all permits and approvals shall be invalid.
� �, / �
�d �
Signature (Owner/ Legal Representative*) at
* Supporting documentation required.
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
Application Date: �-aa a �
Amount Paid: �
Receipt #:
_...--
_� .�_--_
Permit te Evaluation)
�30 . (if> 600 epol
`�-.�,:;�J , ��J10.�`�.l � Tax Map: �- � a
y � � ���� Parcel#: �
�� nawnn-aDan uxa �r; mi �m Il 3HIr. �n.1�dlin
Ao�lication for Services
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$3 00.00/$ 200.00/$75.00
Services Re uested
Construction Authorization
Fee is de endent on the e of
Permit Revision
$75.00
pair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant I rmation: �
Name: ��
Address: � �
���,��,'�`���! �
2) Name and addr ses of current owner (if different than applicant):
, " Name:
Address:
3) Property Description: Lot Size: i Q t Subdivision:
Address and/or directions to Property:
Phone (home): 3�c ' ' � �gy
(work/cell): 33 f� - So u- t35'
Phone:
Lot #:
❑ ye� C�fio Does the site contain any jurisdictional wetlands?
�s [J�io� Does the site contain any existing wastewater systems?
� yes C�'no Is any wastewater going to be generated on the site other than domestic sewage?
0 yes �o Is the site subject to approval by any other public agency?
❑ yes �o 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: ��
❑Residential
❑ New Single Family Residence Maximum number of bedrooms: �_
❑ Expansion of Existing System If expansion: Current number of bedrooms:
C3"I�epair to Malfunctioning System Will there be a basement? ❑ yes C�tio With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
�Ifapplying for �Authorization to Construct', please indicate preferred system type(s):
� Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccu a, or if the site is subseq ntly altered, or the intended use changes, all permits and approvals shall be invalid.
` �. �o I.�
Signature (Owner/ Legal Representative*) ate
* Supporting documentation required.
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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TM A40 Lot 4
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Mapped by Person Co. GIS Dept
11 /30/2011
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I ��� ��I � 1R I; L�� �� �.
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�sa-5'�s�o„�,r„�, «7rn.�.m.�. �1LaL.�.�i�1,t�.
Applicant: i C ►
�
�x Ma� � � � �rc I R
Suibd�ivi iom
h�.se; Sectian: � t '
�pra�e�eaa� �?es�mi�
��r�t °►�alid �mr ��'ive �eaa-� I�io �iaa�ion �
Typ - New A�dition _ � �T�ter Saa �
# of Oc�upants # of Bedrooms Projected Daily Flow .
Prflposed Wastewater em: � � Type:
Proposed Repair: �n, � • Type• �
P�xmit Conditions:
Ownez or Legal Representative
Antiiorized State Agent:
Date:
c.�� � v.� � � . . . ..
The issuancr of this permit liy the Health Departme� in does not guara�ee the issuanc� of other permits. If is the mspons�ility of the
aPPli��Pr�P�TtY owner to in sure that aIl Persnu County P3anuing and Za�g 'and Bu�ciing Inspeitions requsements aze met Thas
�anp�ovement Permit is smbject ta revoca#ion if the sa�e plan; �pla�'oi� t3�e inteudesi use cleanges. �e Rm�sgoveffient Per�t is nm#
a�teeterl3i� a ci�amge in odv�uer"ship of the property. T�is permit was is�ued in c�mpliance �vith the provisioeas of the Noa-th �Carolima, .
`Z8►vs arad Rules for Sewa�e ?'reabnen� aaid I)ismosal Svsiems' {15A NCAC 1�A .1900), l�eithes� �Pea�on �C�un#y;mor�:t��.��'�
L�nvu-�nmental �ealth Speeialist wa�-s�ants tha# the septic tank system m71 cantimue to fnnetion satisfaeio�-iIy in tlae fut�re�or:��#.
th�wat�r supq�ly will remaia potabie. � • .
� A�attno�a�i�n tm Const�uct �astev�ater 5yst� ($��c�e� %r �aa�Ydi�ag P�a�t) � �
*. Ses site plan and additional attachmenLs (_�. � • � . -.
,q
Progosed Wastewa#er Syst�m: ��1� .. �it (. ' � f Ty�pe �— Wastewater Flow __�.p.d. .
New Repair,� Expansion � � � ,� Sofi L��aIB: — g.p.dJ ft 2
Type of Facility: S� ' � Basement _ Yes _ No
'����wa�e� S�s��mn �eqaaHr��ae��
'�� Si�e: 5eptic'Tank:'�!l�gafl �p Tan�c:�
I2r�e�d: Tot�ll ��: — sq ft Total Lengtfa � f�
� � � .
�r.t�aac.�a `4�id�lt ft I�iaina�am Soifl �ovea�: `— i�
--- ` —
IDistrai�ution: �is€�iba�#non �o� Seaial
5pe�ifficati ns• �� �
c,� � r H !�-�c-.
�u#9ao�es� State P�gen#: i
Per�it Ex�iration Date: �
�o
gai �Gresase Ta�pa ` g�l
. �ffi�a Trenc� Depg9a � a�
lvTomiaeraxnari �e&!�i a�ejH��to46• ^ f#
� �res�e ��oid ' .
� S-� � � � ��`' � -
.n1D -. ..
Date:
The i.ype of system perimite� is � Conven�' nai Ac�sptea Alternaiive. I ac��pt the sperificatio�s of the
P��- � ^l
�e�ll:�g�l �8a�a�p��s���ave: V� Date: � ! � -36 — I (
PCHD rev.11110/05.- �
. ,. .. . . .
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I��.����.�-»-,� ����.11 IFZL��.]L�I�
Applicant: '' �
Location:
�
Tax Map �`� Parcel # �
Subdivis on �
Phase/Section/Lot #
# of Bedrooms
Operation Permit
System Type (From Table Va): Product (IIIg): � t� �
This system has been installed in compliance with applicable North Carolina eneral Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization. � � � � � • N
(Licensed Contractor)
Scale: 01�.�.,
-_.,,�"'/►Lc�2..
�� ��
Tax Map: � Parcel #: �
Septic Tank System Checklist (Type II-I� System Type:
Se tic Tank I itiaUDate
State ID & Date: —( —( t( �
S�t Z ✓' •
Capacity: �p
Tee and filter
Baffle
Vent
Riser
Outlet boot
Perm. Marker
Distribution
D-box levels set)
Serial
Pressure Manifold
LPP
Notes: �
Nitrification Lines InitiaUDate
Trench Width: ft.
Trench De th: ;,�
Total Length: ft.
Minimum s acing: ft.
Rock de th/ uality
Dams/stepdowns
Grade (< .25" in 10')
Cover (6" minimum)
Setbacks
From wells
Property lines
Foundations/basements
SurfaceWater
Other: �
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Capacity:
Riser (6" min.)
NEMA 4X Bog
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure Manifold
Nuxnber of taps:
�1`LC ciriCi Si;�l: � �
Contracted Certified Operator (Type IV +Systems):
Notes:
NOTIFIED BL7ILDING INSPECTIONS:
(Revised 12/09 BH)
Tank Com onents InitiaUDate
Pump model:
Block (4")
Nylon retrieval rope
Float tree and attachments �
On/Off float swing: in.
Alarm float (6" se aration)
Anti-siphon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
Approved and secured riser
Su ly Line
Size and material: in. sch.
Lengii�: i'i.
Copy of OP e-mail Date: