A41 157Application Date• �' ~ � �' � 3
Amount Paid: 02 04. U D
Receipt #: 17 I e26 6 �
� ����
�/ . �31 �,S'U '��� Ap�
`-.�?,).f �1l�11�� `l.l'�. V Tax Map: `��l
�... � � ��,�.��. Parcel#: �
lE'.' saw5a-ozaa�nosa�:eal J�oal4:fla
Services
Permit (Site Evaluation) �
$200.00/ 300.00 (if> 600 gpd)
tte'i3'8rie 1Zeplacement or 13uilding Addition
$150.00 (if site visit required)
for Services
Construction Authorization
(Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair of Existing Sepdc System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: 7�5o n FI ��hQT
Address: `]b 1-} p�1-t� F�,('rh �d •
1-� �� ,,.J,Q 11'1 � 11�, , NC. 2�5�-1 l
2) Name and address of current owner (if different than applicant):
Name: (1Jf��IGu�� Cf�+es
Address: '?l2 E. Cha+hc�.��� S-�.
j��; N G a:�_ a_
Phone (home): 33(v-��oy-y487
(work/cell): _?,�(o -�py - 9�1�-1�-I
Phone: ct Iq -3b�7- IS�'
3) Property Description: Lot Size: 11.33� Subdivision: N c�ne Lot #:
Address and/or directions to Property: -�'rnrn 1-1��c�1e_ f�"1�IIs 1Zc1. �i-,��r1 c��� Clc.�u L-c��c, 12d •
rupe�� is o� -� le� �as+- �t �3 Gau Lr.n� `Rc� .
❑ yes � no �boes 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? �
� y_es ._ 0 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: �� �
�kesidential � �a��b �S
G�'New Single Family Residence Maximum number of bedrooms: � 3 8� `
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes � no With plumbing fixtures? G7 yes ❑ no
�r,kh���rl,nkke�y i F �jes�-Ytlerewi(t b�'•
❑Non-Residential
Type of business: Total Square footage of Building:
M�imum number of employees: Maximum number of seats:
5) Water Supply: CI'New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no Unknow;�
6) ,` If applying for �Authorization to Construct', please indicate preferred system type(s):
� Conventional ❑ Accepted ,❑ Innovativ,e _❑ Aiternative, D Other_ � Any
I certify that the information provided above is complete and correct. l also understand that if the information provided is
inaccurate, or if the site is subseguently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
(. N
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)
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Applicant:
Tag Map: � parcel:��,�
Subdivision
Phase/Section/Lot #
/ Improvement Permit
Permit Valid for: Five Years V Non-expiring�G
Type of Facility: Si " ' New �/ Addition Water Supply: _�e��
Number of: Bedrooms �/ Occu ants� Employees / Seats: Projected Daily Flow:� gallons/day
Proposed Wastewater System: ���on (2Su�„ Re �; ;,„ �,S T e:
Proposed Repair: n,�; � `-� �� Type: .��
� - . � . �� i �
c � � '.�1! i �� ,� � s �tn�. , i I ' I f � � I / ! � / , i , v .
�1��L � . � ��-s�'.7,ld! �■�..�
Rutnorizea �taxe wgent:
(I� Owner or Legal Re
The issuance of this permit by the Health Department does not guarantee the issuance of other required petmits. 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 chaages. The Improvement is not affected
by a change ia ownership of the property. This permit was issued ia compGance with the provisions of the 1Vorth Carolina °Laws
mid Rules for Sewage ?lreatnient and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Enviroamentai
Health Specialist warrants that the septic system will cantinue to function satisfactorily in the future, or that t6e water sapply wili
remain potable. �
Authorization to Construct Wastewaier System
See site plan and additionad attachments (�.
Proposed Wastewater System: ���� � j, �� e,�S�iv► l (*)Type � Design Flow �� ga1,/day
New � Repair Expansio�— Soil LTAR. , _
(� gal./day/ft
Type of Facility: ;� p Q M� �.-� Basement: _ Yes _ No
(*) System Types Illb, Illug, IV, and [; require pariodic systein inspections by the Person Gounty Health Department.
Wastewater System Requirements
Tank Size: Septic Tank DO gal.
Drainfield: Total Area D O sq. ft.
Trench Width � ft.
Pump Tank —gal.
Total Length -��p ft.
Min.Soil Cover� in.
^vrease Trap gal.
Max. Trench Depth � in.
D�G.
Min.Trench Separation � ft.
Distribation: Distribution Box ✓/ Serial Distribution / Pressure Manifold
Autl�oriz�d State Agent:
' rermrt �xpiration Date: _(p - Jq- )�
The system permitted is: Conventional /Accepted p�/ Alternative I Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: � ' Date: S I'
l�nvnnv� i�neiaafii Fm��ivn�ns�nnv�Ml �inn/f%. ?7C C' A� ...�..rn (�f C�...:f,. /"� D....1.n..� ]1Ti�7^7C79/..1 ��i �n.. ....�,. . _.
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� SIZ'E-S�TCH
Name �_ �Q�on ����/ Taz Map #_��.Pa:tcel #��
�Subdivisi n �. Section/Lot#
� �-9-1 �
Autho�ized State Agent Date
System co»r�ionents rrepresent a1bpmacimate�contours only: The coniractor must flag the rystem prior to
._. __---- beganning the i�rstalla�ion to i�sure thatpropergrade rs maintained --- -
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VV�I,�. PERIVIIT (New �/Repair�j
Taz 11�Iap: ��%% Parcel: /�; 7
Subdivision: Lot:
Applicant's Name: ��� S o n �I �_t� e�
Mailing Address: 1 p I-I�Y �nn �Q � r,,, �� ,
I-�ur�l(e M� 1(s. ��('� Z�S�1
Phone Numbers: �31, - 3 (� � - y �{ � � 3?� i� - 5n � - q �1 �{ �
Locatiun of Property:
7
7
Permit Conditions: .
Ij Seg attached site plan for proposed well location.
Z) All applicable State and County regulations governing construction and setbacks apply."
3) Permits expire S years from the date of issue. �
Other Conditions/Comments: M ai a;,� � I l Sefb GcK� -
�
P�ranit issued by: � ]�ate: �,� - / g -13
�
C�R��FiCATE O� C�1V]�L�'�'ION �
New Well� Inspection:
` � EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
-� �-�s
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material (s):
Well Driller: . Lh�cn�{� License #:
Ptunp Installer: '' '` � License#:
,
�Vel1 Approved
Date Sample Collected: i-'� "��
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date: _I Z -/(�' (5'
Date Results Mailed: '
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
Barnette Well Drilling
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Location:
System Type (From Table Va):
Type V& VI Expiration Date:
Operation Perrnit
Tax Map � Parcel # 51
Subdivision N %�
Phase/Section/Lot # n�
# of Bedrooms �
Product (IIIg):
Type V& VI Renewal Date: �
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.
� �
�
uthorized Agent)
� -�K.. �! l. ri rrS1f11�
(Licensed Contractor)
Scale
PCHD, rev. 2/14/12
�Z-/!�-/S
(Date)
lz-����s
(Date)
Tax Map: � Parcel #: ��
Septic Tank System Checklist (Type II-I�
Septic Tank
State ID & Date: S7p, - :
i rp 3b -
Capacity: �j � _ 1 �
Tee and filter
Baffle
Vent
Riser
Outlet boot
Perm. Marker
Distribution
D-box (levels set)
Serial
Pressure Manifold
LPP
Notes:
System Type: �
InitiaUDate Nitrification Lines
- - Trench Width: ,3 ft.
Trench Depth: in.
Total Length: ft.
Minimum s acing: ft. °'c.
Rock denth/aualitv
Grade (< .25" in 1
Cover (6" minimu
Setbacks
From wells
Property lines
Foundations/basements
SurfaceWater
Other:
Pump System Checklist
Pum Tank InitiaVDate
Sta ID & Date:
Ca acity:
Riser (6" min.
NEMA 4X Box
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure Manifold
Number of ta s:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
InitiaVDate
TG l9_li �i
Z-��-
Tank Com onents InitiaUDate
Pum odel:
Block 4'
Nylon retrie ro e
Float tree and a chments
On/Off float swin • in.
Alarm float (6" se a tion)
Anti-si hon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
Approved and secured riser
Su I Line
Size and material: in. sch.
Length: ft.