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A40 39� � � U �. cd a � r � ., . . E,��4/R �� ,� T%� A 0 01 14 6 PERSON COUNTY HEALTH DEPARTMENT WELL AND SE�AGE SITE, LOCATION IlVIPROVEMENT PERMIT T� Map # �(7 Parcel # �� Zoning Township Owner/Contractor �/&R�1 oni Elvr� Date y/� Location/Address ��w y/s� r/tl ��' �•�yN�=s � a vC �z^i i� � a r'�� c�n� Nv i- ��r� ?�No.�� a� �i � l,� T S.R.# //b�7 � Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area �p f Ac,2� ize of Tank �x � 5 T iN � SFD �,�_ Mobile Home Size of Pump Tank Business # of Bedrooms�_ Nitrification Line Ex /5 >/� � Max Depth Trenches Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is ter d or intended us ch ed. Well and Septic Layout by G � Comments: ic i� P tN� vF 7AnlK s�NI� Gfi��X -c��Gc� t�/PC ��2 j3CVCkA-CrC �Ni� Date Installed by Approved by Lon� �� i i v�l �: v N<. � Site Apprd Well Head WELL SYSTEM SPEC CATIONS emi-Publ' � Req ired Slab i�Vent ell Tag Well LQ� . � �� ZZ� � �� 7� r � �� Comments: � ` c � � � � Date Installed by Approved by �� o This repoR is based in part on information provided the homeowner or his/her representative in the application submitted for this permit The ?1 �,� environmrntal health specialist is not responsible for false or misleading information contained in the application The environmental health specialist v� L� � is also not responsible for concealed rnnditions on the property or for statements in Uus report that may have resulted from false or misleading ' r m Z statements provided to him in the application Neither Person CouMy nor the environmental health specialist wazrants that the septic tank system will ^� D � . �. continue to function satisfactorily in the future or that the water supply will remain potable: c:�amipro�pemritsam O 1/95 rev.1.0 Application Date: Amount Paid: Receipt #: � ' � � � �.Z � �6 •O� ��'?, ) f �11�� l � Tax Map: /�- � � S `..'- �-.�- r�.. � ��,�� Parcel#: 3� �b I� �.."".�ra�a nn-anvnaxn�3n4:.tn.Jl IHI�o.ei.71��:�a. Application for Services Services Reauested ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $ i SO.O�if site visit requireci) ❑ Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 ❑ Construction Authorization (Fee is dependent on the type of system permitted) ❑ Permit Revision $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: T � ,. Address: r.t/ . 2) Name and a ress of current owner 'f different than applicant): Name: Addre s: Phone (home): � 3�� s'� 9�►- �� d 1 (work/cell): Phnne: 3) Property Description: Lot Size: Subdivision: Lot #: Address and%or directions to Property: ___ ) � � � � �� . � ❑ yes C�?"�fo Does the site contain any jurisdictional wetlands? ❑ yes � o Does the site contain any existing wastewater systems? O y s no Is any wastewater going to be generated on the site other than domestic sewage? yes ❑� n� Is the site subject to approval by any other public agency? ❑ yes C'1'no Are there any easements orrightu�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: ��J pansion of �xisting S�stem If expansion: Current number of bedrooms: pair to n�alfua�tionir.g System Will there be a basement? ❑ yes ❑ no 'vVith plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Total Square footage of Building: Maximum number of employPes: Maximum number �f seats: 5) �i'ater Supply: ❑ New well Existing Well ❑ Community Well � Public Water ❑ S ri , 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 type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any 1 cert� that the information provided above is complete and correct. I also understand that if the ir�ormation provided is inaccu�e, or if the site is subsequently alt'ered, or the intended use changes,` ll permits and approvals shall be invalid. ,• $ignature (Owner/ Leg(�!/Represec �` Supporting documentation required. *� ��-�� Date 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) _�,��s� ��.�� l � � �� 7[�a�.�a��.-„-„ ��.11 IL�I�.�.Ti�I� Applicant: l/�0✓l iTLt� Address/Location: . Tax Map: � Parcel:�_ Subdivision Phase/Section/Lot # Improvement Permit Permit Valid for: Five ears � Non-expiring Type of F cility: 3�� 5{��ew _ Addition _ W Number of: Be r / Occupants / Empioyees / Seats: Proposed Wastewat Syste • " Proposed Repair: ` Permit Conditions: Authorized State Agent: (X) Owner or Legal RE Daily Flow: gallons/day Type: Type: � Date: Date: -i he issuance of this permit by the Health llepartment 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 or the intended use changes. The Improvement 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 nnr! Rules %r Sewage Treatment and Disnosa! Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (�. Proposed Wastewater System: �S� • i�� (*)Type�_� Design Flow � 60 gal./day New Repair � Expansion _ Soil LTAR: . 30 gal./day/ftZ Type of Facility: 3� S• Basement: _ Yes No IV, and T! t� �� Tank Size: Septic ank �00 gal. Drainfield: Total Area [ i%� sq. ft. Trench Width 3 ft. v the Person Counry Health Wastewater System Requirements Fump Tank ^ gal Total Length 3� ft. Min.Soil Cover � in. Grease Trap ~ gai. Max. Trench Depth � in. Min.Trench Separation � ft. Distribution: Distribution Box� / Serial Distribution / Pressure Manifold Specifications: ��ii J�—�o1C l✓i �� 3) �� / KPS• Authorized State Agent: �� + �1 �"'�'�� Issue Date: � l3 � Permit Expiration Date: / The system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions and specifications of this permit. ,,/ (X) Owner or Legal Representative: �- V�P'"^'e''`J Pcv� � Date: �"��l�2-°Jy- Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) :��y 7�� • , `"'� ' "�'^ �� ]Enaw�iu•m,*,,,�„-„ �ya.�.11 7H[�a]l�lia , .� - �.LL, . �l. � . .. . ..1 � ��,i�•-r �� • ■ ' • ' � - � SiTE S�TC� Taz Map #�Patcel # 3�` _ Section/Lot# � /3 /Z Date . .� �(�r.,� p a-�- ��; c�'+�H !�- ah o� ivl5�ec-� 1,��mS��, s��h�c ��.k i �' P�� S��k(�i�-c(+-r.4� i ✓� �4�r'� �y . �ils�,q (' �,.Qtn/ ��.� ► 5 YiO� $��Ut�(�• �Ii1 S� l j �/('�U1 � a �� -��, ��r Ye� aYo� ��Pss. � (� w/� , 2[�''� �',P�c �r ha�� --t� S .S�Pn-► � 5 i �5-�� ► � w�-2.�.�- -�e(oQ. . `Z-'� �,p„t�(,� �o�-�aY►-, � � �S�.p,�,,t ;S i �, S�tlf� �� A,�-- -1-� e(�r ��ss ��..� �� I��.�a��•-n-r ��.��.IL I�IL��.IL�II� Applicant: �/2v�noh �1,,r� Location: Operation i�ermit � Tax Map � Parcel # , 3�_ Subdivision Phase/Section/Lot # # of Bedrooms 3 System Type (From Table Va): � Product (IIIg): U'� 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. Authorized Agent) �•�• �n�vmon (Li�er.sed Contracter; �u5� ` � g ..�2 ` \ ��r 3 � ' � ` �,�x ` , � _ _ Scale: ��Ca�e, (p- ZC�-�Z (Date) �-2�-/Z (Date� � I��a�- �`�� , NZa Lin� — — — Cv � e/ -, I '. �� .. , � Tax Map: t-��D Parcel #: 3�_ Septic Tank System Checklist (Type II-I� System Type: _.LQ Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes: NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP e-mail Date: ; 1 '� �� '�'1 `�"� A 1317 _ �. . � PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT Tax Map # �-�/� Parcel # 3 �% Zoning Township Owner/Contractor � � � f {� ; � �S Date 5 d �- � Location/Address 1 Z. �S �� • S.R.# Subdivision Name�� G�('il,eJ� Lot# SFD Business Layout � As Installed ._---- � �� J� �Jd' �� f N ��jv�,eii SEWAGE SYSTEM SPECIFICATIONS �ot Area Mobile Home � # of �cirpoms Size of Tank Si��Pump_Tank �' Permit Void afte�l�8-�nonths. � Permit Void if r� compliance with zoning � Permits may be voided if site is altered or intended use changed. � Well and Septic Layout by � � H Comments: Date Installed by Approved by WELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Slab , / Public Replacement Air Vent Site Approved _ t/ Required Well Lo� Well Head Approved Well Tag Grouting Approved �L �� L Comments: Date Installed by. r M�_Approved by. This report is based in part on infortnation provided the homeowner or his/her representative in the application submitted for this permit The environmental health specialist is not responsible for false or misleading infonnation contained in the application T'he 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 wazrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\pemut.sam 01/95 rev.1.0 ORIGINAL Date:��" — � �, Owner: � Location/Directions: ; Subdi�►;�;on N�rne: , C � tractor• P�RSON COUNTY ENVIRONM�NTAL H�ALTH WELL LOG a c SR# , L�t � Dnll�ng on . - WELL CONSTRUCI'ION Distance from Nearest Property Line _ Distance from Source of Pollution Total Dep.th' Ft. Yield• 2-o GPM Static Water Level Ft. Watzr Bea.ring 2or.es: De th Ft. —Ft. Ft.�'—�t �ches Casing: Depth: From= o�= t• Diame � y TYPE: Steel � Galvanized Steel If Steel, does owner approve: Yes No Weight:_______ T�i��s� •� Height Above Ground:______ Inches Drive Shoe: Yes No . i Were Problems Encountered in Setting the Casing? Ycs _ No_ ;� "ycs" givc rcasor�: v Grout: Type: Neat SandJCement Coricrete Aruiular. Space Width __ Inches Water in Annular Space: Yes _ No_ Method: Pumped_ Pressure_ Poured �= Depth: From O to 2.0 Ft. Materials Used: No. Bags Portland Cement______ Weight of .1 bag______lbs, xf mixture (sand, gravel; cuttings) - Ratio: to _ ID Platcs: Ycs= No._._ � 4 x 4 slab Yes ✓ No I HEREBY CERTIFY THAT THE ABOVE TNFORMr�TION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORD�INCE WITH REGULATIONS SET FORTH BY•THE PERSON COUNTY HEALTH DEPARTMENT. - . • 6-I-q� Signanire of Contract � Datc �