A23 148Person County Heaith Department
Sewage System Improvements Permit
Date: 12"�� This Permit Void After 5 Years Permit # ,. _ � L
Owner: SR# �_
Loca[ion/Directions:
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Subdivision Name: Lot #
Lot Size: � elling:
Water Supply: Privat,e: �~� �Public: Community:
Bedrooms: 3 Gazbage Disposal
Basement Basement Fixtures
INFORMA BY - -
$���: own tauve
REPAIR: VALUATION:
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Size of Septic Tank: _���� gallons Size of Pump Tank: s
Nitrification Line: �
Depth of Stone: 12 inc � , , �1
Max Depth of Trenches•
Alternative System: Conv. Pump LPP Pump 1�
Remarks: � _ i . . . .. � %_ '� �
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Date Well Approved: Well should be 100 f� from any sewer system
BY Sanitarian
Date Sewage System Approved:
BY Sanitarian
CERTIFICATE OF COMPLETION ,.,,3
Contiacwr. �
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Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be ptunped 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
nitrification line must be inspected and approved by a member of the Person Counry
Health Depaztment before any portion of the installation is covered and put into use. If
the site plarts or intended use change Ihis pemiit is subject to revocation.
(G.S.130 A-335F)
Location of sewage disposal sewage system sketched on back.
(OVER)
NOR'E: Make sketch of instaliation showing lot size and shape, location oi house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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Site Evaluation Application
Fee Collected YES �
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Date
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APPLICATION FOR IMPROVEMENTS PERMIT
1. Permit requested by: �owner/prospectiv wner:
gent:
Address:
Home Phone ��:
2. Name and address of current owner:
Business Phone
3. Property Description: Lot size:, . �
4. Tax map ��: Township: (�-lc ,t� � c-
Subdivision Name: � ���( ( ����/o�Lco,c/ Lot ��:
5. Directions to property: State Road ��_& Road Names, etc.
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6. Permit requested for: New Installation: ��Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served:
8. Dimensions of Proposed Structure: Width:
Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10.
11,
Water supply private? !/ public?
Other source? (Specify):
Are there any wells on adjoining property?
community? spring?
If so, identify location:
Type of structure or facility: Proposed: Existing:
Type of dwelling: House: Mobile Home: Business: _
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes No
Basement? Yes No If so, number of basement fixtures:
12. Clearly stake all corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system 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.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130 -335(F)
ig Owner o Au rized Agent
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Permit Issued
Permit Denied
Plat Observed
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rACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
?.. SLOPE (X)
2. SGZL THxTUItE (i2-36 in.)
(SandS, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTURE (12-36 ia.)
(Clayey soils) �
4. SOIL DEPTH (in.)
. RESTRICTIVE HORIZONS (in.;
{Im�ervious Strata� rock)
. SOIL DRAI2IAGE/GROUNDWATER
(�cternal � Internai)
. SOIL PERMEABILITY
(Percolation Rate)
�3. OTHER (specify)
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9. SITE CI.ASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitabie •.-U - Unsuitable
�2ECOiR�ENDATI0IIS / COrRiErITS :
SITE CLASSIFZCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
Wet areas, fill areas� wells, aater bodies, slope patterns, etc.) '
Apntication Date: 0 '� -6 J
Amount Paid: �00. OC�
i�ec�ipt #: �7<f 7 7
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APPLICATION FOR SERVICES
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IF Ti-IE INFORMATiON lfd THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIEDs
CHANCED OR THE StTE tS ALTERED THEN THE IMPF�OVEMENT PEFtM1T AND AUTHORIZATION TO
CONSTRUCT SHAL�. BECOME INVALID. . �
1) Permit requested by: (Owner/�gent/prospective owner): �1r� C-'- V C� U
Home Phone:�•� �l-,��%"���;� Address: �'-f ��'� � i�r'�ic'_ 1
Business Phone: � . �' ? ��
2) Name and address of.current owner: n�Jh f' �, ,� �Q.��%�C�� n��� �-�
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3) Property Description: Lot size: �/��' Township: Subdivision: ,r�' i � rd �av n�I �ot #_j__
Directions to the property (Including road names and numbers): ' � � �i � � � �r' !�r� ` � }�,��
�'Ll!` (1 C> f\ t ll. � � ��I '',.�y r �� , - K� �/�l� ' I �..�' 1'1�
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4) Proposed Use and Structure Description: answer each of the fQllowing questions: � � �r1
a) Proposed �, Existing Type of Structure: ��-}l�'� �'� 1^.� ► �(_ �' Widt�i: �_7 (� . Depth: ,-:���
b) Number of Bedrooms: .� Number of occupants or people�to be served: � � u��j�{,2�;�
c) Basement: Yes , N� Will there be plumbing in the basement? t1�� l_ Ctl ' �S
d) Garbage Disposal: Yes . No �,
5) Water Supply Type: Private �, (new _, or existing�, Public_, Community , Spring _
_ Are any wells on adjoining property? Yes_ No _ if yes, please indicate aaproximate locatio� on the
� site plan. . .
6) Does your property contain previously identified jurisdictional weilands? Yes_ No�
PLEASE NOTE THE FOLLOWIiVG:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED lAf1TH TH1S APPLtCATtON.
➢� PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. '
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READtLY ACCESSIBLE FOR AiV E1lALUATION BY THE HEALTH DEPARTMEWT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposa(
system for. the above-described property. 1 agree that the contents �of this application are true and represent the rrTa.imum
facilities to be placed on the property. 1 understand if the siie is altered or the intended use changes, ttie permit shall
6E±r.nmF+ invaliri
Owner or Legal Representative
7 � �;(�
Date`
PCHD, rev. 06/27/02
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December 15, 2003
Eve McVey
437 Neese Drive
Burlington, NG 27215
Re: Application for Improvement Permit for wastewater system for lot # 1 Kelly Ridge
Subdivision located off Kelly Ridge Road.
Person County Health Department File: Tax Map #A23, Parcel #148
Dear Mrs. McVey:
The Person County Health Department, Environmental Health Division on December 3, 2003, evaluated the above-
referenced property at the site designated on the plat/site plan that accompanied your improvement permit
application. According to your application the site is to serve a three bedroom residence with a design wastewater
flow of 360 gallons per day. The evaluarion was done in accordance with the laws and rules governing wastewater
systems in North Carolina General Statute 130A-333 and related statutes and Title 15A, Subchapter 18A, of North
Cazolina Administrarive Code, Rule .1900 and related rules.
Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940
through .1948, the evaluarion indicated that the site is UNSUITABLE for a ground absorption sewage system
Therefore, your request for an improvement permit is DETTIED. The site is unsuitable based on the following:
1. Expansive Clay Mineralogy (Rule .1941 (3) (B)).
2. Topography and Landscape Position (Rule .1940 (d)).
3. Available Space (Rule.1945).
4. Soil Depth (Rule .1943).
5. Soil Wetness Condirions (Rule .1942 (a)).
These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated
sewage on the ground surface, in surface waters, directly into ground water or inside your structure.
The site evaluation included consideration ofpossible site modifications, and modifed, innovative or altemative
systems. However, the Health Department has determined that none of the above options will overcome the severe
conditions on this site. A possible option might.be a system designed to dispose of sewage to another area of
suitable soil or off-site to additional property.
For the reasons set out above, the property is currently classified ITNSUITABLE, and an improvement permit shall
not be issued for this site in accordance with Rule .19480.
However, the site classified as iJNSUITABLE may be classified as PROVISIONALLY SUITABLE if written
documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. You may
hire a consultant to assist you if you wish to try to develop a plan under wluch your site could be reclassified as
PROVISIONALLY SUITABLE.
phone 336.597.1790
fax 336.597.7808
20-B Court Street, Ro�oro, NC 27573
On December 9, 2003, an inforxnal review was conducted by Michael Cash, Person County Environmental Health
Program Specialist. The results of the review were conclusive with the original soil evaluation. You may also
request an informal review by the N.C. Department of Environment and Natural Resources regional soil specialist.
A request for an informal review must be made in writing to the local health department.
You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition for a
contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714.
To get a copy of a petition form, you may write the Office of Administrative Hearings or call the office at (919) 733-
0926. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina
General Statutes 140A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C. General Statue
130A-335 (g) provides that your hearing would be held in the county where your property is located.
Please note: If you wish to pursue a forn�al appeal, you must file the perition form with the Office of Administrative
Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. Meeting the 30 day deadline is critical to
your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review
that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by
law (N.C. General Statute 150B-23) to send a copy of your petition to the North Carolina Department of
Environment and Natural Resources. Send the copy to: Office of General Counsel, N.C. Department of
Environment and Natural Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy
of the petition to your local health department. Sending a copy of your petirion to the local health department will
NOT satisfy the legal requirement in N.C. General Statute 150B-23 tl�at you send a copy to the Office of General
Counsel, NCDENR.
You may call or write the Person County Environmental Health Department if you need any additional information
or assistance. - �-
' cerely,
����
J el Hicks, RS
nvironmental Health Specialist
Environmental Health Division
Person County Health Department