A23 188Application Date: 7'6r `� tl� q, t 0 Tax Map: � 3
Amount Paid: O�— l�o � 7� Parcel #: /�
Receipt#: 9 O � 0 `� 0$ I
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� Application for Services (Septic Systems and Wells)
Services Re uested
0 Improvement Permit (Site Evaluation) � Construction Authorization
$200.00/$300.00 (if> 600 �pd) (Fee is dependent on the type of
0 Mobile Home Replacement or Bnilding .
$ I 50.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
j'�1) Services Requested by:
Name: �,�,5� �Qta..V�S
Address: �Oq l��nu�; �N _
�o r C 7
$75.00
❑ Repair of Existing Septic System
No Charee
Phone # (home): 33 � -
(worWcell): �3l0- S0�- c1 7.�
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: (n �a 4'ch�ubdivision: Lot #:
Address and/or directions to Property: S�ir,v Q,� Q�o►�+�
4) Proposed Use and Type of Structure:
Residential � Business/Type: Other
Number of bedrooms _'QZ / Number of people served (seats/employees): �_
Basement:_Yes No �_ (with plumbing: Yes No _)
G ge disposal: Yes No �( _
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;' S) Water Supply:
Private We(1 ✓ (Proposed '� Existing _�
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
(please show location on site plan)
Note: A completed apnlication must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, ar if the intended use changes, all
permits and approvals shall become invalid.
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Signature (Owner/Legal Representative): %� Date :
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applicant:
T�x M�p : P�rcel # : :
Su,bdiivi�sion
Ph�s�e Sect�ion Lot #
Improvement Permit
Permit Valid for Five Years No Expiration �
Type ofFacility: P�iva ic�P.n�P. New ✓ Addition Water Supply Ic.JeI
# of Occupants �� # of B drooms 2 Projected Daily Flow 2 o g.p.d.
Proposed Wastewater System: �O n�/Q,Y�� 011 a� Type: �a
Proposed Repair: � ,c�,,,,{.�d ' Type: 7.t�
Permit Conditions: Nln i n-�r� � r� a�� Sef�a c KS
Owner or Legal Representati ignature: �
Authorized State Agent: '
Date: �/ �"� ^' � �
Date: 7-g —10
The issuance of this permit by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicandproperty owner to in sure 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 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 Rules for Sewa,2e Treatment and Disnosal Svstems' (15A NCAC 18A .1900). 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.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�.
ProposedJdVastewater System: Conve.n-h orva I Type -I-�a Wastewater Flow Z�fO g,p.d.
New �� Repair_ Expansion Soil LTAR: 2.7s g.p.d./ ft 2
Type of Facility: Pri va-� %�S t c� 2�r�� Basement _ Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: I b00 gal Pump Tank: gal Grease Trap: gal
Drainfield: Total Area: g 7U sq ft Total Length Zqo ft Maximum Trench Depth Zd in
Trench Width 3 t Minimum Soil Cover: Le in Minimum Trench Separation: � ft
Distribution: �Distribution Box �`�erial Distribution Pressure Manifold
Specifications:
Authorized State Ag
Permit
Date: '7 � "/6
The type of system permitted is ✓ Conventional Accepted Alternative. I accept the specifications of the
permit. � _ � ^ � /�
Owner/I:egal Representative: Date: l/
PCHD rev. 11/10/OS
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� SITE S�TCH � . �
Name �ps � P �P��� � Taz Map # L� 23 . Pa�cel # I R8 .
Sub ' �sion �' . � Section/Lot#
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Authorized State Agent . � Date .
System cvm�ionents r�e�bresent u�'i, proaaimate�contours only.� The contractor must, flag fhe system prior to
beginning the mstallation to insure that prolbergmde rs maintained
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VVE�I, �'ERMIT (New �2epair�
Taz Map: �.� Parcel: 1g�
Subdivision:
Applicant's Name: �)eSSie (�iea�ieS
Mailing Address:
Phone Numbers:
Lot:
of Prop�:_ __ M���jPPS �r �� 7�� o� �e��es lh • 7 Z��
Permit Conditions:
1} Seg attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply. �
3) Permits expire S years from the date of issue.
Other Conditions/Comments: � . . , -
P��mit issued by ;
I)ate: %�� /0
C�R'TII'ICATE OF C�11dIPLE'TI�1�
New Well Inspection:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
tiVell Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Aibandonment:
EHS/Date
Completed:
Method/Material(s): _
License #:
License#:
Date:
Date Results Mailed: ' �
Phone: 336-597-1790 Fa�c: 336-597-7808
8/1/08
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Applicant: �
Location: M �
Operation Permit
Tax Map f123 Parcel # ��
Subdivision
Phase/Section/Lot #
# of Bedrooms 2-
System Type (From Table Va): �-a Product (IIIg): �i�Q e
This system has been installed in compliance with applicable North arolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
AutLorization.
uthorized Agent)
Mj I�e Lew�s
(Licensed Contractor)
/-�-If
(Date)
l- � -�l
(Date)
Scale: /'���q ��.
Line Length
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Z
Total �q �
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�eAves
Ln,
Tax Map: � Parcel #: )��
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Septic Tank System Checklist (Type II-I� System Type: �1
Se tic Tank InitiaUDate
State ID & Date: STg' 32 5-3- I
y-21- b ✓
Capacity: � S-- U
Tee and filter
Baffle ,/
Vent
Riser
Outlet boot
Perm. Marker
Distribution
D-box (levels set) � � - 3-�
Serial
Pressure Manifold
LPP
Notes•
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Ca acity:
Riser (6" min.)
NEMA 4X Bog
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV +Systems):
Notes:
NOTIFIED BUILDING INSPECTIONS:
(Revised 12/09 BH)
Tank Com onents InitiaUDate
Pump model:
Block 4")
Nylon retrieval ro e
Float tree and attachments
On/Off float swing: in.
Alarm float (6" se aration)
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.
Copy of OP e-mail Date:
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