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A23 174H O � W d z da Amount paid lJ�� Rece:pt 0' � a, . � � � � Pers�n Courity Health Dep. 325 S. Morgan Street Roxboro, N.C. 27�?a Courier'�+J2•�3-15 00 _ _ � aa��� P a'3 . � g" � ► - 9� �, •Date �. �� F,� � provements Permit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing) Im�ovements Permit (Unrecorded Lot) Repair/Replace existing Septic System Improvements Permit (Mobile Home Replace) _ Permit for New Well Improvements Permit (Addition) _ Replace Existing Well _ Bacteria � _ Chemical l. Permit requested by: . owner/prospective owner/agen Adciress: '�±ic �.� � - usiness P o I�ame and ,� � �: 33�--s9�-s 3�9 ne n: s of,current _ Petroleum I _ Pesticide 1 _ Lead 7. Dimensions or Proposed Structure: ��� idth: '�� ,o,d Depth: 7 `S 3� 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposai system is intended to serve? =rcznl�t�� 9. Water supply t}•pe: ,n� Yv�`► l I private �ublic ❑ cor,i.-nunity ❑ spring � 343 Are any wells on adjoining property?Yes ❑ No � If so, identify location: . Property Description: L,ot size: oZ—.� ACCeS . Tax Ma�: �. a3 �'o b E Parceln: S9 �-1.� � Township: C` � � r�nc r�a 1�a�n �`"' . Directions to property: State Road r& Road ames, tc. / ��i ��. Y� e�a 1�Q�-s- �Y1 i 10. Type of structure/faciliry: Proposed: �xistir.g: Q Type of dwelling: ur House: ❑ Mobile Ho�e: Q �� �'� Type of business: �� Number of Employees: � ��,� S Number of bedrooms: � � ge�` Garbage Disposal? Yes ❑ No �—' Basement? Yes ❑ I�Iol��o, � of basement fixtures: �6 I�Tumber of occupan[s or people to be served: � 1 CLEARLY STAKE ALL CORI�IERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PerSon COunty Health Department for a site evaluation for the on-site sewage disposal system for the above described propeRy. I agree that the contents of this application are [nze 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 invaIid. I understand tha[ 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 aftec the date of the evaluation of the site by the Health Dept., this appiication shall become void and all fees paid forfeited. Signcc� Owner or Authorized Agent t � tl `� �� } ►� �� � �� `�� t1 ��`C�,i( �� .,A� �l � � `� � �� `� (Q�� � �� �I � ii�L� �I i � ,� � �� � � f� ��� i l , ,, S� --� �� �\ � a w � a B 3192 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Not for waste water 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 # f't c�+?� Zoning Owner/Contractor 1i1C��ps �t Location/Address ��c:.n.-c�a. . Y1C� S.R.#. Subdivision Name Lot# _ SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area Size of Tank ��jQ� Q(�� SFD Mobile Home Size of Pump Tank Business # of Bedrooms Nitrification Line �i{-0' X 3� Qp ��t Max Depth Trenches �l � ' n.e Y�e.►vin Permits may be voided if Well and Septic Layout by_ Comments: S� tQO' Date ell Permit Paid Installed by. altered or intended use changed. ,. ����_ a..� WELL SYSTEM SPECIFICATIONS by Individual ` Semi-Public Required Slab '�� p' ', Public lacement Air Vent Site Approved Required Well Log —� Well Head Approved Well Tag Grouting Approved � ��Q' Comments: 1"Ylv� �� i 11 Qp ru.�.S lo�X l�' �l�zh This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained 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 from 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 potable. c:\amipro\permit.sam Ol/95 rev.l.l 0 � AUTHORIZA?ION FOR WASTEWATER SYSTEI�I CONSTRUCTION. (Void sixty (60) months frorri date oi issuance) DATE: ' — ��ROV�:ti�:�1T PER�IIT � r��J �- T�Y �L-�P �: 2 �J P�RCEL T: ow�,-��,�owti-��s ��s��r:�TrvE: /1��GiGJ�S/U�l/ � �n_ �iS�G a��'�GI LOC�TION/. � ti SL�BDI�ZSION �±:�:tiiE: SECTION OR BLOCK: LOT �: .TION FOR CONSTRL'CTION ISSL�ED BY': AUTHORIZ�TION CON�DITIONS 1. 'Ihe Wastewater system construction and mstallation must raeet all of the c ditions of the attac�ed site pian and specifications as set fonh ia lmprovemenu Pemzit ��. The consnuciion and ins�allation must also meet all applicable rules and Iaws. 2. No portion of the Wastewater system shall be covered or plac..-d i�o use uatil inspected and approved by the Person County Heaith Depar�ent. 3. Any akeratiQns in site or soil conditions (including structure locations) or modification in use, desigu wastewater flow, or wastewater c�aracteristics as specined in the associated . improvement permit and application, may void this author�ir�tion aad associated permits. 4. Conditions: Schedule 40 solid pipe over dams Keeo seotic I00 fe�et from anv wel1. IO feet from anv_ ptopertv Iine 1� fee�t from basemeat wall 5 feet frorrt anvvart ofthe house. Kew well at _ least 25 feet from anv foundation and I O feet from anv nropert�line — . : - Persan Rrquesting: � Person County Health Department Environmental Health Section Tax Map #: � 2'/ _ Parcel #: �� Zoning: Subdivision: Township: C�� �11�1�1/ / `M Section• Lot• ,. �•• 1/ . �.. � / . . 1� • /, � � 1..�. �� � Operation Perm it System Type (In Accordance With Table Va): 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. r1.lIL�' I I ./L.il/ �I�/.i �� . -. - �.- � � �, � � ,, ,��� ,, � �- �i � , t� �3'la- �►p���' � i i i � �� 5' �' , ,, � ►► � �,,� i► � —4 ' �o Date M � ��rs ,�,��i► � Tax Map #: %� 2� Parcel #: ���' PCHD, rev. 10/12/99 Ib-11-0� �3� Apclication� Date. Tax Maa: �k � — AmourttPaid: .�O D � � - �� . . _ . - R�c2iqt�: �.��%��— '. . . � . . R'arcE��� � 7 �% � � ��� � � �� � . � � �. �� I�'I�I�. _ - ._' �_ . . - � �-����- � . . . ���.m�„ w„m.���,.� ���L� . � � �QucatnoN �� s�vnc�s � sHa� sE�o� nwauu. � 1) Permit requ y: (Ovrnedagent/prospective ownery: ih � U" �ees l� •��!�°`P+ 5f HomePhone: 336 s97- 3'l ��-(/'a,{�e Address: o0o w. G-a�es :lc Business Phane: R��,�JC�j sz,�r�� n� �. 2� 3 y 2) Name and address �f carrent owner. ,� 0.»�c a s 0. tia�� � 4) � ���} �- . , Properly D�escaiption: Lot size: `�•7`�'7�Tawnship: c•w►�:.�� Subdivisicn: Lot �� %�% �tf'-V�� Directions to th� ptoperty (Induding road. names and numbers): Propased Use and �vcture Descriptton: answer eact� of the Ilowing questiQns: , , a) Proposed ✓'� E�astin9 � TYPe�ofStrudure:�llowsti:p �(/ Width:. `�� Depti�: �a b) Number of 8edroams: � Number of ocaipants or people to be served��� c) BasemenC Yes _, No ��11'ilI the� be plumbing in the basement? // , d) Garbage Dispasak Yes _, No ✓ ���� . �\ Water Suppfy Type: Privafie �new or " g�, Public� Community _, Spring _ �'�` Are� arry wells on adjoining prcperty? Yes�No _ tf yes, ptease indicate approximate locatio the site plan. 6) Does the prope�ty �ontain previousiy identifted jurtsdictionai w�lands4 Yes _ Ido f PtEASE NOTE THE FOLLOWING: %��..�--� '➢ A PLAT OF THE PROP�TY OR SITE PLAPf IWST HE StlB09TrTED WITH TNIS APPLlCAl70N: 9 PROPERTY LlNES AN� CORNERS MUST BE Cl.�ARLY NARLCED. ➢ THE PROPOS� LOCA770N OF ALL STRUCTURES NUST BE STAK� OR �i.AGGED. • 9 THE SiTE NUST BE READILY ACC�SSiBLE �OR fl►Pt EYALUATION BY THE HEALTH DEi'�RTlIIE�iT STAF�. !• hereb}� make appl'�cation to the Person County Health Department for a site evaluation for the o�-site sewage dis�osa! system for the above-descnbed properiy. 1 agree that the cante�ts of this applicatian are true and represent the ma�num faaii�es to be placed on the properiy. I understand ifi #he site is aitered or the intended use changes, the permi� shall became invalid. �� . 1 p— l I- 0 2— � Ovmer or L.�gal Represeniative � �� ,�-- �o, rev. �an7ro� FR'�MK�F 2�,� . !\ � � ' a� .5�,� 6�� S �`� � � iY'p-�� � �9' 8 �8 �� S 7 .� � _; ; ; / % � � 3� 49 37 � �r �'�' --v , , � , � �ot, 84,� ! , yZs r__ O L•�' M � �� N �� �- ! r' �� � � � a�P t,fpG ���]1 �� ` N � SEPT�c' Da�+�,�F���c ta :, , � _ - I.'� " _ � ��c.� _ -- : _ � �� -- - - J� '� �v .— - � .-' �, _ - �oo.� ,-� - -�' � � � i �� N _:��� I a P�t�'' � ' � > N ��.�i3�s�► �1 � � 0 1 T 1 � � ; - � _ t�1 � � , �' i�rT 1 � 1 � 1 � 1� ul I' 1� V 1 �`�l 1�1 11 �� � � �� � � ' ;� � � ,�� 1 d� � �� •�I l�;�.. ' � ,N � 1 J 1 '• �� i4D1 1 1 ' 1 � � � Z �� � � i � � 1 j�� p �_ � , � � � � 1 —� � •N �� , � � N , � � 1, �� 1`�; i1 ,� s i,,,�a r� N�_� 1c91 �1 ��'�L P�,ar�'i� t '_S• . 1 �:_... 1 7G Tv�f 1 1�'` _ � ?°I j• � - s�. • ' 1 � 3� �� "`— fy g�, 36, �� ��� J � �,��,y. W , r— h R�qV�s �� � . �� j'R IYq-r E R,Ctqp : 0 � � r �..1��,s� I�������T � �= �-. C� � ��T'II��Y I���aa-��� ����.11 R33L��.Il�7�a. Applicanl Location: T��x N1�a� � Parcel +- s���h����-�.���o�, Fh��•se Sectioio Lot � Improvement 1'ermit Permit Valid for ✓ Five Years _ No Ezpiration Type of Facility: ����y,���l.� New ✓Addition Water Supply ��� # of Occupants # of Bedrooms Projected Daily Flow �aS g.p.d. G�Vf�l Proposed Wastewater System: C'.�,�/��/�ia,J� . Type: ��- Proposed Repair: G'Q�%/�/,�t6,✓ - TYPe� -� . Permit Conditions: Owner or Lega1 Representative Authorized State Agent: � 0 Date: Date: //-!� -o � The issuance of this permit by the Health Department i�does not guarantee the issuance of other permits. It is the responsibility of the applicant/property owner to in sure 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 Permit 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 and Rules1'ar Sewa�e Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health 5pecialist warrants that the septic tank system will continue to function satisfactor�ly in the future or that the water supply wi11 remain potable. Authorization to Construct Wastewater System �Required for Building Permit) * See site plan and additional attachments (_). Proposed Wastewater System: C'd�✓✓,,��zv.t/.�t-e Type �c� Wastewater Flow o� .p.d. New Repair Expansion X Soil LTAR: d•� g.p.d./ ft 2 Type of Facility: �1��J�D_�� - Basement Yes X No 'T - Wastewater System Requirements Tank Size: Septic Tank: /O�i6 gal Pump Tank: -- gal Grease Trap: — Drainfield: Total Area: /3.�b sq ft Total Length �d ft Mazimum Trench Depth _ Trench Width 3 ft Minimum Soil Cover: � in Minimum Trench Separation: . �C Distribution Box Serial Distribution Pressure Manifold Specifications: � �i�x�,�r�ia.� �f�5 �� � ���-� �� d D�� Authorized State Agent: --�/� Permit Expiration Date: ��� Date: /��lo -� `� The type of system permitted is � Conventional Innovative Alternative. I accept the specifications of the permit. Owner/Legal Representative: :�.s,,,� :,, �,� ��✓� Date: � �^?� � Z. PCHD7/30/2002 �..��� 1 f ���� �� V.; } l� � i-• `oJ ��� 11 11 ,r^1� �w 1LgIl.�]L7C�ffiaLa�a9.'��.JL �c@EO.JL�JY� SITE SKETCH Name Nl� �;�ss s�//� - Tax Ma.p # �3 Pascel.# /�� Subdivision ��'�" Section/Lot# /��� //-��oZ Authorized ta. Agent Date System components represent approximate contours only. The contractor must flag the _. .. system ;�rior to be�innin� the installation to insure that �ro�er r;rade is maintained. � _._ _ , l � �� � . �����q � -.�. ! � u�i' � � � � � � a�'° S $� °3�,/� a ��,��' � � � � �� � � � � � lPd�✓o �cl L�«D� �✓� ��OdvD � � � � rdt Gr�� �'Go'u � � � � � 1 � �u �R�✓g �'`� • � �o �v���e ri� Mu�7 ,�£ � ✓,yL/..o%�J . �n�o��� � axa ,Auow �4 � '�1 � � ��X `� � t�o � ��c. � -�a�t t� �/ � N` , .�+- F ���, — .�i � �a� f-- � � �L.Oy,,, . ¢ •-•�- ..r.•� �D��/ia� � .. g'/� -/`L-/ � � 1 � �_—�--.....r--' . �I� ��'Y`7 a�Y s.s--�--." � ��,...e � � ,Gon/7vv.� ' � — • '�'QK v r C�) � ., : �� � ,. �� M�a � �,.,,,,., � ,•.:......--�----`"'"'" �^ . �. M . � .,-,,,,.__----"'"`_-.-- 3 �- � • .NiiY. ` ` �� �� � 7��.���/ �f_c,,,�j , �,',`��� �— � � �. �'�'o yn/. ��" ;�.,,,.�;� ��iar� � d �S ��f� Cv �o ' 1 � _ _ ,��� � ` �/.��v �'�� �� • � �!��/� /�'� � � • %�GOGcI /�/ 4�/ D�� t �j�'�e�a R. ► .r—v�% • 2 ',� - ,� p�(��4 t �Q"� • �'D�'� / c�� �'��'c'iv'r% /Z "7'��c: � = /�/ .�'f�� C�'� ��.�,�-t�'� ���� . � �" ca✓�f� ����,�� � ' � � t � ��� _ � ���/�. � � 1� v �G�� � J� sa � 0 - �1x �vl��� - F�rc�el r ��� I �: � � � ��� � . ,�„ . Suhci,i,►5�ion �� ���> � � V"1��� F�h�,se-5ec�t�i:oia:�Lot ;�� i ,., , ... , ,_,_, . ,_, � i i i = _ � , i_, , • � , , - .. . �. � + � � � - • . �_ � . � System Type (In Accordance With Table Va): . � THtS �YSTEiVI HAS BEEN INSTALLED IN COMPLlANCE 1MITH APPLJCABLE �VORTFi CAFFOLdLVA GEPIERAL. STATUTES,. RULES .F�t� .$EWAGE �Ti�TMENT a1ND� �DISPOSAL, AND A!.!. CONDIT1�IdS � OF TH� IlIAPROVIEAAENT ' PEi�IifllT . AND C�NSTRUCTiON �►►UTHORt� .�N .. . . . . � - - . � . �. .. . . . .. � ' � � • . . ... . .�• ��-2�-c�3 � � . Acrthorized Sta Agen , • �,�o: � • - . . : •Date • • . .. Installed By. � �� ��5. Date: Il- a�^03 '� � _ '��z . .� , . �. . / � �0 Z ' ' ---'.' �'2 . ^ :. ( ... � . �. • � �x�-Z �.-�� l c� �a tto c�� w- s L�a . cc�� �t►, Mne.�.. �..�c,.5 �� � � Z � �� �.,1��,��, �4� � �� . 5' ���� �� .... 5'Z • ��� 5'1 . .�S;I' .. J . �,5.'. _ , 5'�� .... .. . . �-� � . `' �'? ' ,`►:,���a `►,/y . 4% �_ .���� 3,� � ��l . ,6, L � � 3�� c�3 ,3'� s, �� 1 a . � a-ac�-�3 � , P"SS-10.x� � 5� 3-3�y �2�U� 2F'j i , .� ...1 •• �•� . . .. • • . .. . . v (Y� C . G e ' -Q------ -______ J � rC;-iD, rev. G7/29/02 S��iiC� T.4�IK [N���C'��N C�fE�9�LIST (1'�� II - � . Tax Ma¢ #� 23 Parce! # i� System Type (Tabie Va) �� OwmeftAQQiic�rrt �rv����.�, r�,,a � ��,g�- C'�.�. Subdi�rision AddresslLDcation � �t �«->y�r �� SerlPhase Lot # � St�te iDldate C��?(�-03 CaPa�! ��(D� � Tee and Fiter Baffle Sealarrt Riser (ifi applicable) Tank Ou�et: Seal Permanent Mar�er � � : P�� Tank Waterproof /Sealar�t � � . Riser . � Water Tigtrt � � � Pu�np � �beck Vatve/Gate Vaive . - • � -sip on o e � FioatslSwitches � � � � � � � � . Alarm visable and audibie � Eiectricai Componet-�ts Rate g m Approved Pum Model Blocic Under Pum Pu Removai Ro e/Chain �Dist�i�ufion Syst�m Seriai Distribuiion .-'� ressure an' o Low Ptessure Pipe • Appr. Pipe Material and Grade Valves 1Md�ttt ft. Depth � � . � c/ tn. Lenqth u �-�, ft. - Trench Grade 3s Tr�enct� S ac�ng -�-� Rodc De th and Qualiiy , _2� Dams/Ste downs etc. � . �� v� Pressure Laterats Hole Spaang . o e. ize .. . . . � . Pipe Sleeve . � . . � - ' Turn-ups}Protectors . . . ��equis�esi Setbac9�s � � Ftom Welis �. � � .Q, ,,,,;,.,, � Frnm Property lines � . ✓ . `__ .Structure"s/8asemerrts.:: � �.. � . - � �i es.- ra�na - e ays � � . . . . _ . � �Surface` Waters � . . _ . . . _ .. Public Waier Su plies Vertical CuEs �>2 ft . ,/ V • � Water Unes . Vehicfe Traffic . ' � Easemerris/Ri � ht of 1N< �e�.. »-2�-�� Easemer�ts Recorrled -. .�_ C�aninerais� 0 pct�d rev. 31131Q1 0 �/�� z �' '1�- �,/�s . . � � ��-r� �� �o�, �t, �� �i " �' �2"f9 ��� �S'p.o��j 2 � � / - � <.���Q ,�,�5 � U't��G /'�'p'�'��,y� �6 'yf,�� • �� �!/aT�� �d/c,y�a,t/ �✓5� a,�,� �'� °� s��-f$. ��'��� #� Ttij�D DaS�.r/r D`" �,¢-�.f/ , y�1�GZ'� it�'� �v� oj�oN ��✓ �'v�t/.¢� ,y� ���c� �,���.