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APPLICATION FOR SERVICES
� -11,`1�� . .
Improvements Permit. (EstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing)
Impxovements Permit (Unrecorded Lot) Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Permit for New Well
_ Replace Existing Well
�_:--
_ Bacteria __ Chemical Petroleum _. Pesticide _ Lead
�� �
1. Permit requested by:.._.. � 7. Dimensions or Proposed Structure:
owner/prospective owner/agent: Width: � U X� 0
n a,�,.a��• `ia. l,� � S-�-e.Ve�.l S Denth:
3G
ne Phone #: 9 19 -` q 3-' �( 3 S'
iness Phone #: R I 4-�_q �' � 1 3 S
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 address of.current owner: 9. Water sup,ply type:
y=jo � e�„�c.sz Qc-�. private�ublic❑ community❑ spring❑
►7Q (('u j Mo�.� u S� . Are any wells on adjoining property?Yes ❑ No [j.
�akbo V-o N C C/0.i. Onkt� If so, identify location:
Property Descri
Tax Map#:
Parcel#: .
Lot size: 3� a 8' ./� ��
d
Directions to property: State Road #& Road
�ames,�tc. _
R es s��- p a�'� c.� '� �
Number of occupan[s or people to be served:
10. Type of structure/facility: Proposed: C�Existing: Q
Type of dwelling:
House: ❑ Mobile Home: Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No 0
,Basement? Yes ❑ No� 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 Pet'SOn COunty 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 permit 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 event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluatiorn of
the site by the Health Dept., this application shall become void and all fees paid forfeited. �
Signec� O� or Authorized Agent
� . ., ,
Permit Issued �T
Permit Denied ❑
Plat Observed ❑
�.
' .. ,. :
Signature Date f �� , ,
,�
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__ __
, '< ' FACTOILFSITHEYALURTION 1 i �RP�1 , _ ;: . .. A;?E142 ; % ARFA3:: AREAd,
,,: _ .
I SLOPE(%) S S S
PS O��/n PS PS PS
✓ /V U U . U
2. 50[LTEXNRE(12-36IN.) ����� S S S
(SANDY. LOAMY. CLAYEY. NOTE 2:1 CLA� PS PS PS PS
U U U
3. SOILSl1tUCTURE(12•361N.) S S S
(CLAYEY SOiLS) PS j�'� PS PS PS
U U U
4. SOTL DEP'T'}i (IN.) S S S
P ��� PS PS PS
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5. RES7RICT]VEHORIZONS(IN.) S S S S
(IMPERVIOUS STRATA. ROCK) S � C_ 1� PS PS PS •
�v U U U
6. SOILDRAINAG&GROUNDWATER S S
�EXiF]LNp� A IT7lERNpL� S O� L PS PS PS
���� U U
7. SO[L PERMEABiLTrY S S S S
(PERCOLOATION RATE� S PS PS
U� 3�� U � �
8. AVAILABLESPACE S � S S S
S ,OS PS PS PS
�- U U U
9. SfCECLASSIFICA770N(SEEHELOW) �
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SO1L SERIES
SSUITAIILE PS-PROVISIONALLYSUITAIILE U•UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:V�MIPRO�DOCSIAPPSEC.SM FINANCE.PC
�- • ._ .... � i
��5'O6'45"E
� � � 210.00 CM
� , CONTf
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,n � �IP � � 'v - 118'
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" � � i N85•43'S4"W ROXBORO TWp_
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;n '1 1n�� wQ�� il� l�QjLl�" IS FLAT RIVER TY/P. � '—' —•.
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��+P �� 5.62 AC. EXCLUDING CENTEL R/W � N
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• 1 IS �-'� � 12. _�
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IF `D CENTRAL TELEPHONE C0. � � ���� �3 �p6� �Z"W MP _ � _ -
UBSTAT I ON R I GHT-OF-YYAY �- 35 • S80 _��
► D.B. 229� P. 684 �-� 3 N�-"�~
, 86 ^ � ' �
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B 1019
PERSON COUI�TY I�EAL'Y'II DEPARTMENT
-' VJEI.L ANr3 SEWAGE SiTE, LOCATION IN�ROVEMENT PERMIT
Not for waste wa�er system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � ��
Zoning
Owner/Contractor ��.1 p -f-P�
Location/Address ('� r
Subdivision Name
Parcel # `/�
Township / ' � �
� �-� 5 Date
.��� � s7 �- s. � . ► � y 7
Lot#
SEWAGE SYSTEM SPECIFICATIONS
S.R.#
air Lot Area �,D$ �'te Size of Tank ODb
► . Mobile Home Size of Pump Tank /1�
iness .� # of Bedrooms�_ Nitrification Line �CY1' x 3
Max Depth Trenches o�� � ��,�.
Permits may be voided if site is al ered or intended
Well and Septic Layout by .�.��
Comments:
Date
ell Permit Paid
te Approved
ell Head Approved
-outing Approved '
i omments:
Approved by
SYSTEM SPECIFICATIONS
_Semi-Public jRequired Slab � �/
Replacement Air Vent
_ _ Required Well Log
Well Tag I/
Date � � Installed by.
Approved by.
�I'his report is based in part on information provided the homeowner or hisiher
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
cont�iined 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 irom 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 potdble.
c:\amipi•o\permit.sam Ol/95 rev.l.l
Application Date: O�6 �� �� ��q ���� Tax Map: ��
Amount Paid: � � -{�?.£'SQ � �." � Parcel#: //2
Receipt #: S�yl�� �— �� �' � ���� �—
�an.�e+�in-acD�enmcn.c-�rn.tL',ai.11 JHjc:rn.��d;�{n
A
Improvement Permit (Site Evaluation)
$200.00/$300.00 if> 600 d)
� Mobile Home Replacement or Building Addition
$150.00 (if site visit re uired)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
tion for Services
Services
Construction Authorization
�Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $I50.00 or $300.00
1) Applicant Information:
Name: �.�..Ip�pc.�� �1.��cz
Address: � Z38p �� MA;v2.� �2.�
'Ti n�F3��,,s�r i��- -
2) Name and address of current owner (if different than applicant):
Name: . � �� ! � �r�\�S
Address: �B�It- �i � Dr.►.\�eL t2t�
(2c,ce�o rzv
3) Property Description: Lot Size: 31Q$_ Subdivision:
Phone (home):
(work/cell): _
9�9- �,�g- �gb .� Ca�l �
�� �
Phone: �74- �ZT-'S�o.�-
Lot #:
Address and/or directions to Properly: �t�,�,� ,�n iU.� ,¢ �..�._� ��-��,�17�� �' c��� ��i�,J�EcS,
r�=�i'7 �n1z.� (>rzivE /�33�
❑ yes L! no Does the site contain any jurisdictional wetlands?
Q yes ❑ no Does the site contain any existing wastewater systems?
❑ yes L7no Is any wastewater going to be generated on the site other than domestic sewage?
� yes C7no Is the site subject to approval by any other public agency?
❑ yes Q�no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4�roposed Use and Type of Structure:
esidential Pa�ti'� G�'��E
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no 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 properly? ❑ yes ❑ no
P(ease note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ lnnovative ❑ Alternative ❑ Other ❑ Any
1 cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequentl altered, or the intended use changes, all permits and approvals shall be invalid.
� l t'�� a2/ds��
Si�gna.t�re (Owner/ Legal Representative*)
* 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.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-17901
'/ � �/ � � T
/
i � \ •
�,�,��,�,I.�.
i�t��.�.�.
Building Additions/ Mobile Home Replacements
Tax Map #:�� Parcel#: % Address: I�S ��I �ieSS i e na n �� I�.
��,h�rbn,r� �Ic; 7_�57�(
Approval Requested for: Mobile Home Replacement
� Building Addition .
Applicant Name: `�a f, �, �i r� es
Adcl�'ess: � R a�l_PjesS i Q �c� h �� � �
� �7S'1
Phone #'s: �1N- 52� - s�oy Ir
Permit Located: V Yes No
Installation Date: �(,- I(�48 Design flow: �(. �(gpd)
Current Contract wi#h Certified Operator on file (if required):
Water Supply: �`Nell Public or Cammunity
Wastewater system shows no visual evidence of failure on: 2. - I l- I(e (date)
tApplicant's signaiure if site visit is not required)
Addition/Replacement Approv�d
� �
Enviro ental Health Specialist
2-t1-«
Date �
Person County Environmental Heatth, 325 S. Morgan St., Suite C, Roxboro, NC 27573
0
��� s� I�I�I�.���T
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7E��Sso�sma�em��mIl" 7E��em�ll�7la
SITE PLAN �
Name hGif2Y1 IIIY�C�i
Subdivision
�I s�(s�
Authorize State Agent
Tax Map# /"� � b Pazcel# ���
Section/Lot#
"j t
IDate
Syslem componenls represent appracima/e conlours only. The conlraclor must Jlcrg the system prior to beginning lhe
ins�allation to Insure thQ1 propergrade ts maintained
Note: An Accep�ed system may be used in place oja conven�iorra! system without permit aulhorization or modifcation.
0
:i!'-� i:�-�'.
�"' �':.�-' , �. ..6Q$g �
Date: � - a ' �� '
Owner. � �
Location/Directions:
� . . 4
w.:� - .:. � . .. . ..
. � � ... . . � :�._ . . .: _.._
.PERSON COUNTY ENVIROITMENTAL HEALTH ' •
WELL LOG '
SR#
Subdivision �N�une: .__ Lot #
Drilling Contractor: � l•� o�<�Qr..1 ��� y
.- , .. : wp[��yw�� y'.
i �:}ur � j:
�
. WELL CONSTRUCTION d' --
Distance from Nearest Properry Line !U Distance from Source of
Pollution �f'D `
Total Dep_th:� GQo Ft. Yield:_��_ GPM Static Water Level q?S=Ft.
Water Bearing Zones: Depth Sfr Ft. /3S". F� Ft� Ft.
Casing: Depth: From O to ��5 Fc. Diameter: Inches
TYPE: Steel - Galvanized Steel �
If Steel, does owner approve: Yes No
� Weigh[: Thic�;ness: ./ � Height�Above Ground: /`� Inches
Drive Shoe: Yes�_ No . �
Were Problems Encountered in Setting the Casing? Yes No .— �
- If "yes" give reason:
���;+ Grout: Type: Neat Sand/Cement -� Concrete
Annular. Space Width Inches
Water in Annular Space: Yes No
- -. Method: Pumped . ._ Pressure � � Poured � .._ . . . , . _
Depth: From_ G to �c� Ft. - �
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes ./' No � � =� �
�� 4 x 4 slab Xes_i No
I HEREBY CER'IZFY THAT THE ABOVE TNFORM�ITION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�ui�1TY HEALTH DEPARTMENT.
� ,�--a , 9Y
ignature of Contractor Dat�