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A41 13B� � u �C ° Pq a � � The Distr�ct Health Department Orange, Person, Caswell, Chatham, Lee Counties Water Supply and Sewage Disposol IMPROVEMENTS PER T oy. � _ te�.— _ Owner: n Location• " i .. -,,�`. � . Contractor:.--�1 Q��-� % _ - : .,_. r -, Water-Supply: Private blic �,,�` � Sewage Disposal Facilities: No. washing machine, other au omatic appliances Size of tank: � � � � Nitrification >inP� �� Other disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTEB AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFOR,E ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. Date approved: O � - Well: Disposal: ✓ By: � � Signe � ^ - Sani ian Counter- �, + signe �2 ��' �'�' . 'r � �: i - (Owner or his representative) Certificate of Completion � Date Approved: 1 v-� 7 By: � �-^f nitarian (OVEft) Location of well and sewage disposal facilities sketched on back. NOTE: Make sketch: of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Wnite in measurements in order that installations may be located at later date. Note>location of water supplies on adjacent lots. (1J . (2) . . � �^� u �., o '�( Pa �� a � � The District Health Department. Orange, Person, Caswell, Chatham, Lee Counlies ' Water Supply and Sewage Disposal ; IMPROVEMENTS PER T o _ ,: `� te _ Ownei: Location: � - ;."_ Contractor: ' �� 1 �Q _ f ' , - .- + . - Water•Supplp: Private blic �. Sewage Disposal Facilities: No. washing machi e, other au�qmatic appliances Size of tank: � b�"�-�� Nitrification line: �-� Other disposal facility: Water supply and sewage disposal facilities location, installation and � protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years and shall be main-' tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. Date approved: � � ' � Well: Disposal: ✓ By Signe Sanit ian Counter- signed (Owner or his representative) � � _ ��,_�'`�.� Certificate of Completion � ��, . (' � Date Approved: l�—(�/ By• `�-�' itarian (OVEft) Location of well and sewage disposal facilities sketched on back. NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Wr.ite in measurements in order that installations may be located at later date. Note location of water supplies on adjacent lots. (1� (Z) z Person County Health Department � �wage System Improvements Permit 4 a/� Permit Void Af r 3 Y � � �� j. �M� �� 1 jt :,i- r Sx' � f -r- Subdivision Nart�,e.: � � L,ot # Lot Size: �-� y� Type of Dwelling: r _ r� '� Water Supply: Private: Pablic: Semi Private: ff not Private Tax Map# Parcel # of Water Supply or Name of Supplier# Bedrooms: ✓ Garbage Disposal . Basement Basement Fixtures INFORMA � D, �BY '.� _ ,�! �;i;, ,�. � Sanitarian:! � ti.^�'�' owner or representative REPAIR: �"� ' REEVALUATION: � ------- ��} ----------- � —� ~ Size of Sepdc Tank: gallons �� .� ` � Nitrifcation Line: f • Depth of Stone: 12 inches �_-� Max Depth of Trenches: ; : -� " OPERATIONAL PERNIIT: yes no Remazks: -s----------------- Date Well Approved: ISh � Well should be 100 f� hom any sewer system BY Sani Date S ge s pproved: BY Sanitarian CERTIFICATE OF COMPLETION� � Contractor. � ------------------------ � Sewage System location, installation, and protection must meet state and local � regulations. Sepdc tank should be pumpeci out every 3 to 5 years and shall be maintained by owner in such manner as not to create a public health hazard. Septic tank and nit:ification line must be inspected and approved by a member of the Person County Health DeparUnen[ before any portion of the installadon is covered and put into use. I.ocation of sewage disposal sewage system sketched on back. (OVER) qqZ � �� °° � A�piication Date: � D� �� I`�� d � '� � Tax �Mau �: Amount Paid: b . � Recaipt �#: 29'{�_ � Q I Parcai �: I � 1^heQd : �� ..� �� - a � � /� ____ _ � C � �, � ZCT1��Y � I � � ��-s.a-.m��-r-� ��.��.Il ��,�.Il.�.7� dPP�iCAT10M FOR SERVICES I� THE IiVF06iNIAT1�R! IN TiiE ,�PPLICAT10f�! FOR �iV IMPFa�!lEi�IENT P�'Rllfll'i IS INCOi�RE�T F�►LSIF�ED CHd�It�GE� 06i TFiE SiT� !S AL'iERED 7i�E�! 'i➢-iE lMPFSOb'EbliiEAJT PERNiIi' AND A,llTH�RIZvAT1OR1 Tt3 COMSTRUCT SHAL.L BE�OME IAIVALID. . - 1) F'ermit recgae�ted by: (Ovuner/agentlprospective owner): i 2 �D 1 Home Phone: _ �� - � (��il -�/� Address: � t�1 � ' 1 S !3' c� , Business Phone: � � • r •� ' , . ,r'y� , 2) Name and acddress of current owrner: 3) Property Descotiptaon: Lot size: Township: �.�,_ Subdivision: �1�b Lot #��— /� ,� Directions to the property,(Inciuding road�n�ar�es and nu�nbers�: 4) propos�d Use and S�ructur� Description: answer each of the follow'iJ�g questions: � � a) Proposed y/, Existing _, Type of Structure: J1�16� i,2. H O/N e Width: �� Depth: %D b) Number of Bedrooms: �_ Number of occupants or people to be served: �_ c) Basement Yes_, No � Will ttlere be plumbing in the basement? d) 6arbage Disposal: Yes � NoL � 5) !�/ater Supply Type: Private t�,/(new _ or existing�, Public� Community� , Spring _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the �site plan. 6) Does your property cantain prevBou�ly identif�es� duPcsdictional wetlands? Yes_ �o� PL�SE NOTE TFiE FOLLOV!lING: 9 A PLa�T �F Ti-!!E �ROPE�ZTY OR SfiE PLAP! i1flUST �E SUBNii�TE� lA(ITf-i Tl-BIS �►PPL9C�►T90�1. 9 PROPERTY L1P1ES APID �ORAIERS I�UST BIE CLEA►RLY MARRl�D. � 9 THE PROPOS�D LOCATIOId OF ALi. STRUCTURES iUIUST 8E ST.�►6CED OR FLAGGE�. 9 Ti�E SIT� MUST �E 3�E�►DILY ACCESSIBL� FOR AR� EV�4LUAi1�iV B't i9iE HFra►LTI-B �EPARTi�liEfVT STAFF. I hereby make application to the Person Caunty Health Department for a siie evaluatio� for the on-siie sewage disposal system for the above-described property. I agree that the contents of this appiication are true and rzpresent the ma;cimum faciiities to be placed on the property. I understand ifi the site is altered or the intended use ct�anges, the permit shal! become invalid. ?�: . ��.�'n.Q�� 9 -z��" Cwner or Legal Representative Date PCtiD, rev. a6127/02 .� . �=��. �_�� _� � � �� I�a�..�-a.a-��.� ��a�.lt IE-3L��. Applican� Location . , . .. � ��,: � T��x �1G� �� -� rc :.► " � 5+��f� cl i�ui:�i c}aa P�6r�;��.c� 5 e c ti o �i�:��L.n�c � P�a�t Va�ai f�g� ✓ �'ive �eaaa. �ype of Fac�i�: � # of Occupamts ma x lo # afB�i r�apo8ea w�w� s�: Proposed Repair: Pernat Condifirn�s: �,��itHCP � �p��e� 1'e�t 1�T� �' rira#�an '. / - New T/ �ddition i�� upply . ` � ,3 � �. Pmjected Da�y Flow ,�� g.p.d � � r��J�►'r�ria I • _ TYPe' - q ' � 'T`ype: �p I� O� or Legat R�esentativ ign$tmre- %� � �� . �}'� Date• !d � � �"a�" Autharized Sta#e Agent: _ - � - Date' 'Tho issuance nf itiis peimit by . Health Daparhmaat in does nut guarantea the issnanca of other permits. It is the responsib�lity of the �PP�P�P�Y o�r to in sara that aIl Petson Couniy P'lanning and• Zoning and Bw7d'mg Inspections requirements are met T� 3mprovea�►ent Permit 3s sub jcet $n revraca� !� t�e �it� Plan, Plat mr thg im�ended use eba�ag�s. T7ae Impa�veffie�e# �ermeit is no� a�ected � by a'eh�nge nn ownersbip of #he P�P�Y• �hi� permit waa issued hi c�plianc� with tiee prmvieioms of the PToa-th Cmr�Iina `Lmvs and a„�a. a,. ra.,�Aee Treataeiestt uetd J7isnosal `�ems' (15A NCAC.I8A .1900�. N�r Person �o�tp nor the Envisn�ea�tal �ealtli 5ipecialist wnrrante d�at tLe �eptic t�nk systeai wID cont5u�ae tn fnmca6on satiatactorit� in Uhe futare �r that the vvater seap�sly will rema�a po#able. - � � ' �Antho�daon � Co��ac� i�a��aat�r� SFsteffi �]�eqnired for �uildang �'ca�t) . ; . , . . �` See site plan and additia»cs1' c�ttachntertts (• i. � � • �' 1 � Type �A Vil'astewater Flow 3(�a . g.p.d. Praposed . ater System: �o/l vf,w. ovi�r, �_ New ��Repair ansion �_ 30�1 I..T.�i.t: � 3 g- -d.! $ 2 Type of Fac�ility:. e� ' • � • 'Basem�at �Yes �a � i��tevv�� stem �uireme�ats . • . Siae:lS�p� ��c:1 u v �� . • �p � � �i' . Grease Trap: . field: Total Area: � 26D sq ft Total Le�gt�t � �D fi � �e3i Dep#la 2 l4 ffi eh �ii� �� f� So�. C�ver: �'(p, in M'inimum Ti�nch S�epazation: �� ft lbuti�: Distn'b�rtion Boa �eri�1 Dista�utian �Pressure l�tanifold �� l��f ��, ; � /� �• :�: '. .k;: ',r. :. •� ;��. �i+u'�. � �1�111, i�t . � � 1 t .i ' Date: /o /3 0 T�,e �ype of s�ystem pe�itted is �Conventional Innovative �lternative. I ac�ept #h� specifications cF the pezmit ' f mi ��er/�.��i �pr�se��re: X �U%Y.L�� ... Date: l � " �'�" 4� � " i'CI3D7/30/2002 � :�1��,�� ---. c�;QQ .�nT.�^,� �� TA��rn irmm �C`]L3¢.2�.J1 �l. �1.iL�ffi.11� / ...- � � � �� .. • . � �..il.� ��....�� ■ -• ' •:r� ��. ��. Tag Map # ��_Pa�cel # l� Se�on/Lot#_ . , / ate `� System corrsponents represent u�iproxis8aate�contours only. The casstractor snrrst, flag the systesn pru�r to beginning td:e instaAatiora io i�asure fhat pm�iergmde is maantai�ed � � Scale: � = Sb ;� ,3n t-�i a � s S�W► @`�'��,� � ,3 be�raa�m � 3� � �� - � � � QJ/.3�-r� � ��Ob Cdn�6n�loh � � Z�" -fren��i ba-Hrsms . � � ..� �oo{� Ah "�b Q1ClS�Y14 � o wr�er i s�o, n� .� e�� _� S I'G��, rev. 09/L/01 ' _�� J.�� ' ._._...� .: -�:_ � � �-�� I��s-m,=-�, ,�-�,-„ ��.�.�1 �L��.b�1� A{�plicant: Location: 8 ��_ ��1 � �� a�e�o 00 3 . i �i na�n i, t� : ":.�' `�? � :'� ,�- � � ��': y;. - �. - Sys#em Type (ln Accordanc� With Table Va): THIS SYST�I�i HAS �E�i� If��LEi3 IN COf�lPS�NC� U1�1T}i /�►d�PLlCA�LF NORTH GAROLdf�i�, GEiVE�L STe�;�'ilT��, RIiL�S FaR S�i#IIA�� T�ThdIE§VT AAID �ISPOSAL., AND ALL �ONDIT1�iVS OF ` THE IMPR�VE3�[E�T PE�IIAIT AND COi�STRUGTi�N �llTt-fORl�T1�N. . � � �2f/3� .� - .. Authonzed State Agerrt � Date � lnstalled By: �G'o � � Date: /Z�3�0,�' � ' _.! S � , /�a r m Rc� � �Yi J'e ! � � ' ;. L FCHC, r�v. G7/2G/GL 5 ��"�� R�S��.h� ��1��;��d a { i ��r� �� a � Ta :(Vla� # Parca� � 5ys��r+ Typ� (ia�ie V2) a� �wr�erlA�plicant n � Subdivisios� Address/Locaiion Se�fPhase Lot � State�lDldat� S�-1�% Ca�aciiy � -/oa0. Tee and Fiiter Baffie Sealant � 4�ises- (if applicabie} iank Outlet Seai Permanent �Uiar�er Pum�s Tank 1Sealant Riser !�l��9tl��'�� 14PlY��'�90�9 9,9P9�� - � - � -r��,�t, �r�tt, � . 3 . �. �� Trencl� De tt� Ge � in. . _ T.rench Lenaih lf2l� fi. : Che�ic Valve/Gate Valve � � Anti-s� an o e Fioats/Swi�ches .Alarm visable and audib(e Electrica{ Corn onents � Rate m � A rover� Pum iVlode! iV Slac� Under Pum � �um Removal Ro elChain . � Dists��u�ioa�. �y��s�a � Seriai Disin'bution � ressur� �lian o �ov+� Pressure Pi e A r. Pi e Itn�terial and G�ad� � iJat�es Tr�nch G�ade � Tr.enc� S acin � Roc� De th and Qual' Dams/Ste downs eYc. Pres�ure Laierals � Hole Spac9�g � o e �ze � Pipe. Sieeve Re�uia-�d� Seffiac�� rom� Wells � From PropertV IBnes � SurFace 1Alaters Pubiic Water Su lies - �/erticai Cuts >2 ft. Water Lines Ve�icle�Traffic � Ca�ramen� , ; . . � �49ae�' � � Recorderl rci�d 2t�. 3I1 �/01 m Application Date: jot 1] `�� Tax Map: __�1�}j Amount Paid: �_G� ..,,. ,••� Parcel#i 1� � Receipt #: � � � �� E":�mo nu-rcnTM*�*T-+�antian.Il ).HLe,s.]I�'�La. Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 endl ❑ Mobile Nome Replacement or Suilding Addition $150.00 (if site visit required) ❑ Well Permit (New/Reptacement/Repair) $3 00.00/$200.00/$75.00 for Services ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 Q Applicant Information: Name: � U� s S e�� a 1�� tU - Address: • 3' �yRd 'lJs 1� N� rt ?��y�, �t s�,� . a tij"� 1 � Name and address of cur'rent owner (if different than applicant): Name: � 2 �• i, S� �) J f� o�{ � 0 1 V Address: '%�3S }J tl R d 1 e 1��1 i� 1 s bZa(, �yRdl � N►%l�s AI c �7s'�fl Phone (home): � � (� ��Zj..� � �.,,�- (work/cell): '� �fl3 -��fSl �, � � Phone: �� C�� '(� Property Descripiion: Lot Size: Subdivision: Lot #: . Address and/or directions to Property: ,� t�Q �rurn� 7 D Do .ev�,�Qe, ��{� � yes �� no Does the site contain any jurisdictional wetlands? � yes ❑ no Does the site contain any existing wastewater systems? ❑ yes � no Is any wastewater going to be generated on the site other than domestic sewage? � yes '� no Is the site subject to approval by any other public agency? ❑ yes � no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) �Proposed Use and Type of Structure: ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of Uedrooms: �Z. '�.Repair to Malfunctioning System Will there be a basement? � yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residentiaf Type of business: Maximum number of employees: Total Square footaga of Building: Maximum number of szats: � Water Supply: � New well �I Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no (6�j 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 a•rrd correct. I also under.stand that if the information provided is inaccurate, ot- if the site. is subsequentiv altered, or the intended use changes, all permits and approvals shall be invalid, Siguature (Owner/ Legal Representative*) �` Supporting documentation required. j�-� �13 �K 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. (10/111 Person Countv Environmental Health. 325 S. Mor�an St.. Suite C. Rnxhnrn NC' �757� �Z�F,_547_� �Qm �� ` Tax Map: �_ Parcel: �3�Q � _ � , � ) � �� Subdivision �� — �`'� � � � �'� � Phase/Section/Lot # )[�s��a�-�� .Il IL—��.Il�1� lmprovement Yermit Permit Valid for: Five Years Non-expiring Type of Facility: S�� New _ Addition _ Number of: Bedrooms �/ Occupants�/ Employees / Seats: Proposed Wastewater System: Proposed Repair: AGC�� 2S � �e,�A� �o�� Permit Conditions: �gj�-�Q j n a I( Se{�acKS Water Supply: ��r W C� l Projected Daily Flow: ?�1 �_ gallons/day Type: Type: � Authorized State Agent: (X) Owner or Legal Re The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applicant/property 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 a�:d Rules for Sewage Treatment and Disposal 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 wili remain potable. Authorization to Construct Wastewater System See site plan and additionad attachments (�. Proposed Wastewater Sys : ��,,p�� 'f5% 2�U on �(*)Type � Design Flow Z�D gal./day New Repair Expansion Soil LTAR: ..3 gal./day/ftz Type of Facility: Basement: _ Yes o (*) System Types IIIb, IIIbg, IV, and V, require periodic system inspections by the Person County Health Department. Wastewater System Requirements Ex� s�h rg Tank Size: Septic Tank Oo gal. Pump Tank �--$al. S�5pa Ce? A��owS Drainfield: Total Area �Q� sq. ft. Total Length D ft. Trench Width � ft. Min.Soil Cover � in. Distribution: Distribution Box / Serial Distribution� Pressure Manifolc Specifications: Grease Trap gal. Max. Trench Depth 3� in. o•C, Min.Trench Separation �` ft. 0 Authorized State Agen • Issue Date: I Z"5'/3 Permit Expiration Date: f Z-S—/h'' Tl�e system permitted is: Conventional 1Accepted ✓/ Alternative / Innovative . I accept the conditions and speci�cations of this permit. (X) Owner or Legal Representative: �.w�� Date: .% L"jj -�3 Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/l2) �� I��.�`��,T �� 1�,�c2-s ��c•�„-,,,�-t,-,,,�.��,m.]�. ��oam.11TC�a ��"I'E :��`I"��"I Natne �1 u5�-�� r'%� � Ta,g Ma # p �� Pa:rcel #�� Subdivision Sectian/Lot# , ,� L -�'� --- uthorized State Agent Date System cvmponents re�iresent apj�raxirtzu#e�contours only. 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