A41 29� � -�
A�alication Date: . 8 �
Amount �aid: •
Recaipt #:
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Tax Mau #•
Qarrx! #:
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APPLlCA710N Ft3R SERVIC�S � �
IF '�i-lE INFORMATIOM IN THE APP�L�CATION F�R ;4N IMPRO�IEMEAIT PERAAIT IS iNCORREC�', FALSIFIED.
CHANGED OR THE SITE IS AL'T�RED THEN iHE 1MPR�VEiNENT PERMIi' AND AUTHORIZ�►T10(d TO .
CONSTRUCT SHALL BECOAAE INVALlD. �
1) Permit requested by: (Ownerlagerrtlprospec#ive owner): r` � vi S �O� e. ��
Home Phone: � �o� 10 Address: �6G la '
Business Phone: ,��t� �� � � S-- C-
�/d ��
2) Idame and alddress o�F curreM ov�vn�ef: �7 �
3) Property Description: Lot size: Townshlp: Subdi�
Dire�tions to the property lncluding raad ames anc�numbers): S•
� '•�-�Z S� P s � �`N �O IrE
4)
5)
Proposed Use and Structure Description: answer each of the following questions:
a) Proposed . Existing , Type of Structure: Width: � Depth:
b) Number of Bedrooms: Number of occupants or people to be� served: -
c) Basemen� Yes . No Will there be plumbing in the�basement?
d) 6arbage Disposal: Yes No _
Water Supplb Type: Private ✓new _ or existing�, Public . Communiiy� , Spring _ .
Are any weils on adjoining property? Yes_ No _ ff yes, please indicate approximate locatiori on the
�site pian.
6) Does your property cantain_previously identified �urisclictional wetlands? Yes_ No_
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPE3�TY OR SITE Pl.AiV A�IUST 8E SUBMITTED WITH THIS APPLICAi10N.
➢ PROPERTI LlNES APID CORNERS MUST BE CLEARLY MAR6aED. �,
9 THE PROPOSED LOCATION OF ALL STRUCTURES flAUST BE STAICED OR FLAGGED.
9 THE SITE MUST BE RE�►DILY ACCESSIBI.E FOR API EVALUATION BY THE HE�A1.TFi DEPARTMEAlT
STAFF.
I hereby make application to the Person County Health Department for a site e�aluation for the on-site sewage disposal
s r the above-described property. 1 agree that the contents of this application are true and represer�t the maximum
cilities t be piaced on the property. i unde tand if the site is altered or the intended use ct�anges, the permii shali
become in alid. � /�
Cwner or Legal
O '020 "� �
Qate
PCND, rev. 06127/02
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uthorized Sta.te Agent
SITE. SI�TC� L�
Ta.x Ma #�.Parcel # �
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_ Section/Lot#
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� Date
System components represent approximate�contours only. The contractor must, flag the system prior to
beginning the installation to insure that jiroj�ergrade is maintained
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WELL PERMIT
PLE�lSE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
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Tax Map #: _ I� Parcel # "� Township
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Applicant: �
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Subdivision: Section• Lot•
Tvne of Water Su�vlv:
Rec�uirements:
D� Individual Community Public
Site Approved by "�� �-z3- d'�
Grouting Approved by � s s Q-2�z
Well Log c� s c-23..��
Well Ta,g ��S � - 2 �z_
Air Vent
Hose Bib
Concrete Slab
Well Driller. ��l�i �S �'�'�-` �� i�c.s'J`'�.
Well Approved By: Date:
'�See Attached Site Sketch'�°k
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic spstems.
Wells must be at least 25 feet from any building foundation.
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Other condirions: � �
PCHD, rev. 09/07/01
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Owner: ...� /. , � . /� I �e�� Lob
Location: �
Subdivision:
Lot ��
Tax Map Parcel #
Distance From nearest Property Luie (Muumum 0 tee �onstructiou
Distance from Septic System (Minixrium 60 fect) � v
Total Depth: �$ yield: _ L 0 GpM Static Water Level: %
Water Bearin� Zones: Depth � �} � �} _ ft � �
ft
Casing;
Depth: From �_ to f}. Diameter: --- �.._ ln
Type: Galvanized Stecl � �
Weight: %'����ss: _ /�� Iieight above Ground: _� �- in
Drive Shoe: ✓YeS No p,�y problems encountered whilc settin T casin T?
If `�es" give reason: . b b' _Yes `—�1Vo
Grout:
Neat: S121CUCCIIlEIlt `� Concretc Gravcl/Ccment
Annular Space Width �_ ill�hcs Watcl• ui Annul�u Space Ycs No
Method of Grout: Pumped Pressurc; • Poured ��
Matcrials Uscd: Dcpth _/i to ��j Ft.
No. Bags Portland cetnent zr, .S c, s Weibht of 1 Bab y'�{ Pounds
If mixtlue (sand, gravel, cuttinbs) — atio �— to (
ID plates: ✓yes _ No 4 x 4 slab �cs No
Drillui�; Lo� , .. __
1 hereby certify that the above infonnation is conc;ct �.uid tliat tlus well was constructed in accordance with regulations
set forth by the Person County Health Deparhnent.
Signature of Conh-actor ID #
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PCHD rev O1/16/02
L-�g�-t�
Application Date: ,2 ) I� ��� S �T Tax Ma
AmountPaid: Do� 00 ��0.°O `,�, .►• � ������ `� Parcel#p.
Receipt #: °I 3� I,2 7 2 3 .2� � �% �����
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Application for Services �
Services
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/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 In�formation:
Name: � � ��
Address: �� - L9
cSLC� lD�1 i l s � Cr
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): ,3� 6' � � � � Z �,S
(work/cell): �l/q' � ����f%z /M�(,�le�
� li - (�8t - �Zz.3 (t,��rK�
Phone:
3) Property Description: Lot Size: ��G� Subdivision: Lot #:
Address and/or directions to Properry: �,,al Mil\ � �O �� Glav l_oha �
.�J 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 .C�9'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)
4 Proposed Use and Type of Structure:
esidentiai 3
ew Single Family Residence Maximum number of bedrooms:
Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes �no With plumbing fixtures? O 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 .C�I Existing Well ❑ Community Well ❑ Public Water ❑ 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 type(s):
� Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the informat' n pr vided above is complete and correct. I also understand that if the information provided is
inaccur e, or if the sit�i subs quently altered, or the intended use changes, al! permits and approvals shall be invadid.
Signature (Owy(epl Legal Representative*)
* Supporting dy�S,iimentation required.
1� Z�-!s
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 (336-597-17901
�� (� j���� �� Tax Map: �(_ Parcel:�
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`�" ` �'{ � � ��� � Phase/Section/Lot # /�
).C�e�rawaaL-��raaan��n.��,Il ����n,�.��n
Permit Valid for: Five Years ✓
Type of Facility:
Number of• Bedroon � /�
Proposed Wastewater System: �
Proposed Repair: a��„�
Improvement Permit
Non-expiring
�New �Addition
Employees / Seats:
Permit Conditions: �n; in Il S�c1C5
Authorized State Agent:
(X) Owner or Legal R�
Water Supply: j�e ( l �Sl,ate� �
Projected Daily Flow: 3Go gallons/day
Type: �
Type: �
Date: -17-/
Date: (�— / �'�"'
The issuance of this permit by the Health Departm�cloes not guazantee 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 aze 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 t6e provisions of the North Carolina `Laws
mrr! Rules for SewaPe Treatment and Disnosa[ Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmeatai
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water sapply �vill
remain potable.
Authorization to Coostruct Wastewater,S-ystem
See site plan and additional attachments (�.
Proposed� tewater System: �p���5�j �Q�d�o„ SuS�m� ('�)Type � Design Flow 3� o gal./day
New _�! Repair _ Expansio Soil LTAR: , gal./day/ft2
Type of Facility:�,[e ��(��„a -- _�� Basement: _ Yes o
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(*) Syslem Types IIIb, lllbg, IV, and V, require�eriodic system inspections by the Pe�son Counry Nealth Department.
Wastewater System Requirements
Tank Size: Septic Tank �'� gal. Pump Tank ^—�--gal. ^vrzase Trap `�—�al.
Drainfield: Total Area �00 sq. ft. Total Length 3_� ft. Max. Trench Depth � in.
o. G .
Trench Width 3 ft. Min.Soil Cover (R in. Min.Trench Separation q ft.
Distribution: Distribution Box ✓/ Serial Distribution ✓/ Pressure Manifold
Specifications: D-bex or s�r�e ( c,�is{z� u�ie DK •=�F d-hex a�;r�a,� P.Qka� %,of-� �n�
Authoriz�d State Agent:
Issue Date: ___ (�- /7-/S
Permit Expiration Date: � - /7-2a
The system permitted is: Conventional / cep ed / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date: 6-� ���5
Person County Environmental Health, 325 S Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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SITE PLAN
Name�
Subdivision
A thorized State Agent
Tax Map #� Parcel # �
Section/Lot# /�(%A
. ���Q"�-'�+
Date
System components represent approximate contours only. The contractor mustJlag the systemprior to beginning the
ins�allation to insure that propergrade is maintained
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Applicant:
Location:
era
System Type (From Table Va): l/
Type V& VI Expiration Date: �c�_
I1 ��rri11t
Tax Map � Parcel # �
Subdivision
Phase/Section/Lot #
# of Bedrooms
Product (IIIg): C�a'"�'�
Type V& VI Renewal Date: �
This system has been instalIed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions oF ihe Improvement Permit and Construction
Authorization.
r'� � ����
(Authorized Agent) �
�2( Yr''k� �", �/1 „7, S .
(Licensed Contractor)
Scale Oh�.,
PCFiD, re . 12/14/12
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(Date)
lo���c��5
(Date)
Tax Map: Parcel #:
Septic Tank System Checklist (Type II-I� System Type•`--�''`"���'''' �''r
Notes:
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 Mani�old
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes: