Loading...
A23 198Application Date: � �'� � Amount Paid: o�' C10 .DO :� �' 7 3 , R e c e i p t#: J 8��� 5' 0 ��� �� i 3���� �-� � � � � � � �..,���5 �� I�I�I�:� ��T � — �— c� � �L7���Y" ia�a� �'� � ��.�.����a�.�,���a� ����,�.n���. C G�`'+ S) Application for Services (Sentic Svstems and Wells) 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) $225.00/$125.00 Tax Map: Parcel #: Services Re uested Construction Authorization Fee is de endent on the e of s: Permit Revision $75.00 Repair of Existing Septic System No CharQe Important: If the information in the application for mi Improvement Permit is incorrect, falsified, or the site is altered, then the Imnrovement Permit and theAut/iorization to Construct s{:all become invalid. 1) Services ues ed b� Name: p OS '� -,� � Address: J r� �-c ; v: . �ay9 Phone # (home :33�' y`�� `��93 �o cell): � ' - S -� 7G �y�-/ a � � 2)Name a� ddress of current wner (if different than applicant): Name: Y�-Or�,l�e55 �h�� rc3 l( Address: 3) 4) Proposed Use d Type of Structure: Residential � Business/Type: Other Number of bedrooms � / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No _� Garbage disposal: Yes No 5) Water Supply: Private Well �(Proposed Existing _) Community Well: Public Water Syste : Are there on the adjoining properties? No � Yes (please show location on site plan) Note: A completed application must also include: ➢ A plat/site plan of the property that shows property dimensions and tlie size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing tlzat the property is ready to be eva[uated I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representative): Date : � � / � � U 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � ��� ���I ����� -� I �' � L 1'i �� � �./ ���� � 1L�.Y"SS �O ^�-� �rrrn «�!-�.�. � � � �ie.�t� Arn�iiCant 1%U� h fls� . r =�_�__. . . ��s-� ��lac� ��r � ; Type af Fac�iiy: # of Oc�ants G� � 4 _ Propose3 Wastewater ti Pronosed Repair: �;, � # ��c � ��� r�c�l � � Q � �--�—� �:, a� o C� I �'Y�4 7 ' ���JC��O 0 yr �pr��e�ea��_�..�i� _ t�o �a���n , .New � Atiditi�n � ���� ���g��p �P�� �o�ffis Pro;e,�te,�Daiiy Flqw 3 � g.p,d L✓, Type: q �IP�� Ownei or Lega1 Represeniativ� S}'�� tnre: � Lat�: Au�orized State Ageu� ,�.I.G�Ia - . ' �� . � Dat�: �� T]ae issuamcs of this paman# liy -tiie Health Department iia daes not g�e� the issuanc� of other pex3nits. ?� is t�e responsioilai�j of the a�plicant(�rOPert`l owner m in sure tiaat all Peison. Cowaty P3anning and. Zo�iag and Buai�ing Insp�tions rec�rements aze me�. � �npa����e� �'�z�aai i� s�dsjext t� rew�a�tno� ii tiae sa� ���; �pT��'�� #� inntes��e� �a�e �3n�ng�. �� �g��aeffie�t ��at i� s�ot a�e�i� i�g► � c��e in ova��� o� tta� gnr�p�►o � p�it �as issnged i�m e��lian�r �ri� th� �ar���� mf ih� 1�Iortt� ��ralimm�, .: `Z�ws ran�' I�aades far 3'ewa..�e '�'re�en� �razd �ismosal ,�`vs�esaas' (1,�A I�T�� �SAA .19�0}. I��str�� �raso� ��timmiy.: mc�a��:t$r�.`. -: �aa���nt� �aI� �}�e�i�asi �rars�ani� t�at tla� se�ti� *.� sy� vv�l c��a�ase t� f��a�n s����y i� #.�ae f�a�e�oa��#���- t��-w��r su�g�iy wiII remafn �So�a�ie. . . , - � �ua�n�a��ttio�a � �s��ta-�et ��t��a#�� Syst� ' .� ��r �a�d� ���� � *. Ses site plars and addi#ia�aaal attachmen�s (_�- � . � . . " � • � � l ���s�. w�,� s�: �' a' '� �! �?�'�Ive�fTy-���°� w��.� ��� 3�o�.�.a. IVew � Re�air Exgansio� � .� Sa�� ��� � 2� g.}�.si.! ft 2 Type of Facilit3r: ?7� � S. • Baseffient �C Yes _ No � . �10r'� ✓�c�P( `t�� .�����a��� Sp����������� l�o� . . - . .� � 1/po��, (� ��rc- ��-a��C '.�� ��: ��a#ac '�� � ��d �g� '�� f�, g�i ����-�`�; � � . ���d: Ta� ��: �8�9� s€� i� '�o�sl L�� �00 � ' ' � ����a� �e�� � a� � - � . ��.�� �a�.� — � S�a� �n��r: �P ?� � '����a �����aa� 2 #� �3�b�on: ���aa�'ao� ��� �e� ��ra��a���a x ���ss�� I��o�d.�� ! _ . ` '���� � G�vci'� � ���tioaasa s � '� i�'14� �'11*l�� a � ��Si` �G t� !�1�. � - -. . li � ! `� �?CC o-e r` � `l - D n� � . Sa � l a�rc�all . . . ��.� �g�� Permit Exp: The tyne oi system per..�iiea is Con.ven�anai Ac:.�tea P�t- ��7� ��a ���r¢s���.�a�rs: ,�i�ra��� SySdP,�-� Date: A].tsxnaiive. I a�cc �t �e �er,ificatios�s ai the �aze: _�cED-rev. i =1iq14��_ � �� � .. � i � � � � , '. � / / � � � � // � /� / / Randy Charles Budzinski & Kelly Lee Budzinski 292/527 P.B. 11, Pg. 63F � � '� / � / i, �\ � j, ' \i i � / . �', /'/' / / i � i � �� / /" ,,��,� _- � � ^ i _ ��'' A. �';� � , \,,. ,� i�_= ,, � � /�-;' / � �/ I� � I ;�'� ',`� ; J� .;; � ; �,, =� ��, � �. / __ � , � � , .. /' /: / --. ��� r � 1 ���� �'f � ����J , - I lj �.� i ` • �' � �s• /• : ��� \� +'� ,�' �. i' /' �' /��.�'/ � ° , - ,� �A / / , , ��� d '� - `� a ,,�'' �_`_ /,i � /- �`�/�,a /� /� C�,1„" � . �.��.� ` �\ _ .. . �,1\` '� d � ��C /� /� . \ „� A \ � v�, � � ,. ��a_ . ��� ' � 1i�� . � � ���` 1`� /� � ,�� �'/ , - `�-�.r , �-�__� ,� � ' ��P \ � � `� � � � ' _ i� ,- , �. ,� � � ��. ��- �>> ���� �� �i�� �� ,/ .r�.�, . \N s. � �� � � A �.�..��,. � � �� - ' °� / , . , . . �.� _ � ---- ,- , _ , . - , \� � _ _ _ �; '� � / � /, � � \ j _ . � / J � ------------- ' � .. `� ' � // �' ,� \ `� `r� '�`� � .,�� �' � � '� 1 m /� _ - - � -�,\ �,� , / j ,- : , . : � / _. � ;� . � .______. � � : > _ .. _. / ,� � f; � t --�;-. �` - . . \ , � � ',\Q^ _.-/ . ._.. � -._/" � .i C�, ���/ /� � � / �----_,,, . , /' t `�. ��'" d \- - - - -� _. . _ . _ - j ' - �.• , �. . � S�V `` . . .. .- :' _ __ ' .,.. ,'y � . . _. . - . . �, f ' � \ � . . - � ., r. ___. . . _.. _� � _ .. �.� � • , `_.. � j � . � - ' / .. __:....._ . . ..� / / _. _..._. ... __<._�- '_ .'..... /. '_ '" � � /' � ' , �> � ���-'� ; � �' � i f' `�O � `� �� ' ,/ 1 � � i �� , j 9 /' / % . � � � ' �,,_�--�,.� / � �' C� \ / /, Jf :. ' \, � � � . � ,j � � \ / / � � � � �_ _� / / !, � � � / ,, : � - %� � PROP. ;' ;�� 0o HOUSE jr �'�, ° LOCATION ;� �.� . � . , '� � ., d , �� ._ - �,.c ?-� J ` . _',�"._ , . � �.o ,. �' r� �� . �`�!� �'' '3S fyti" " _��--'�'+1�� -..`_\.. �\, � ...1 '^jy �--�� � _` . -_- �'��_ - .. . - � . `\� - . . . . - . '. - _ .. `\ '-- ---�_� ✓,i _,-,"�'� f � / �r _ . .. J/ : �: : u � G-►�,,,,• Sew�� - L� r►� -- � � `t � '�`c � �f ���%�J� �Ii�G�LAIl� �3�� I�NG��� 5�9 � i� '�' Y SJ RT r'i('Pt'�'ia �' I� ry�: T 4 7'"1 T1�,:t?'i � f. � ii 1�(^y � fti� � ,' J `J . _ .�_,, --,v nm�� ..t .� �. �•,:�=-1 _J±:�- :a �.::. � ;; ;-,- s : i %; v;,,=- :.�-;� � ._^ ,T J w T-.� - T � r= J - ._._ ••_ 1 il ?� s r ___ • _ .•_" _ ,. . , _'; �-�-_ � J J �-� J ,I�_�; '! _ _ . ..� , , , - _ { � l t�d 0 �� �• � •�' ; j d �umP C�,orr� ( Pane � . ° � : ,, � APPROX. 24 40 BACKWASH L.F. 1.5" Sch� PVC GRAVITY RETURN LINE. PROI'OSED 1,100 GAL. RECIRCULA,.TI01°� TA�1�� �IITH EF'F�LJEI�T FILTER. (See Detail 2 Sheet VEI�i-3). .A.nticipated Invert In =438.7 Anticipated. Outlet to Pump Tank= 438.5. 1'1,���a �' �► I • ������� s1� N0. _.__ _ �- f� . .� , '_' � � � _- ,� / ' . � " 8� , � ` / Fm-�-'-... �. � . '. - , -^ � F+:7 � . � . � � !- � _ - .� . A. . „'.,-� , . 4_"'� � � r.',,. �� .... �. .:. . � ., _ `�-- `.�-� F�,� � � _. � _ ,� - --- � , _ . _ _ -- _ _ _ -- . ., � _ - - - _ ,�� � _ � � - - _: ,.. ., �, . ; . . _ ,,. . � _ __ _ - — , , . , ; _ — — _ � .- � -- ._._ -- - _ _ _ FM � I .� , , � , , j i _.._ _. _. _. . - l �,� . J ,. j = , -_, _ ` _ �' � � --"— - � , . , . � ,/ i - �' . — — - , _ .. , . � � . -: �,,�' � � - -- - : �"``' _ �' � . / .. � . � ,._ . __ �' � � � -- / � - � — . .. .�'''��", � �.� � / � .. +! �� . �f � �rl � �. .. �� ���- / / , / - - / � , / � 1 / - - � 'v�'= — — � � .,' � � . .. ./ : � / .," � % � � ,� - Y-.. � / � -- - ._ " � .../' ; ' i '� � '� / :' �'� �/ � � / .. �` __ _ 'tW / � � ' �� � � ' . _ --- "a = ��- _ -- ,��'3 `'- S . , , , , � , �' DF �LOT, � �' �, � -y -i� . _ ° -� �,y„�- � � :..� , _ ; , , yr . ; � , � � , ,. - - �-�� . ,�� , . . .. _ � � / �� . / , / � ;' / ,,,� , ; i,� �1 °', ��'� � ,�� �� _ - 13 _ ,�. .� �/� - . _ � . ; ,. � � - ; / � �. , , � r t �\� ��-� - �: i � �_ r : � �— c,. � ,' i � � :� i / ..-- la:-P�� c'� 1 J".- .-! "-'� .y j-�.- , � � i _ . . _. , � ,,. \ y�/� .. , . / . , i � ,- ,,., i ,i , . - �. -i - „--` �- i z;, .F ; �' . , r �--` " -':.-� , ,, � f ' � / ' /. /.,� ,' � � 14 �,i� �� i '�' � '��� i . ; ..-� ,,. �����,✓� ��'`.,`�, �� � ; � � , a / , , ,,( ' � �4� . ���� � ,:.� � : f �'� /" o / •"�' . / �r �" ,. ��\'� � / , , 10 pine �// f,l'1 r �Sira� /' r � -� �-�,� fl' "12. �� , / i ' � � ' � // i , � �/ � .-.,-,�'�' �',y''-'� . /. • �. / / �`' � � � / i� �l �{ �� �.;.., / ;� %�! 1 / /� �/ ,t /,,±.�/z`+.,�'t51Y_1� �/ .% / � ,.. -� i i;.. _- _ i i l � y .- • i�, � , / � j , � ,/ �/ � /;�,,,� �`��,. f, -� � ic p� �:i�r-�;a e F,� ! = / / , � " � � � / i ;�/ f / �' .,✓� 12 nl�e' /. 1�u�,Y;i . — � � j� �� � � f ,, � �p � i �j ��� � '. . � '�:y `� ��.,� ' � ' l �� l a� t , y i ��/ �l /.� l / /.r s ' ����� � ,. � `�'` ��� �1� � me� � / � � � �. ._ l � � � � R / l� , 'j � I /"����a�ire�� �����%/ / � ��f / � . � % f f r i,� / / ,:-' � / � � � ! 4 I ; � ; / � /� J ! � l ! ,°1(}' ,a � ,r�s�e�7,�� � " . , �,,,> ' � ' I � � � � � � � ���� �� ll,j�/ /f /���,' �' ���d � � ��� � l -�� � , � ; � ,- , � , + f � I � �' t' � � �j4� � .ree( '� '�� � ' / � :`�� � � / � , � � � � I I I !� �� ��'j r / i '' � ) � � I � � � � ��/� � � �n� �l`n� % � „, ��,pinF:� g � /% / % ' I k1 / I � i � � � � � \ � 1 � � t� �� �� �� g �� � • �� � , � � ` � � � � � � I� � � �� � ��� � �%�� �j� � s J�i�� � � � / � � /" � I `. � i � i � � I� I I� � � I �' 4' /;� .� � I �4 i�` � r, , � � � i� `� � i �� 1' ' � ���I�I�I�I 1 � e;!A ��� " I ' / / , � � ; q �" �s° � I � �i � ' ,1_e ��� � � rL� � j',� � � �� � ���,^� �� � � o�� �� � : � 1' � � � �l 4� � ' � c:5 � � '� � c::, � I�� � � � � � �\ e 10; P��'�-�'� 181 P� � � � �, / � � �� � � \� � �-� � � � '� � � � � � �� � � � �� � i � � � c1;. �l � \ \ \ � � / / ` . \ , ' � ��� ', 1 ' . `--� � ���� � �� � �' `, k� �� ` I =� l `;�� � � � ' 1 �. � `, � '; ��, � �� � .� �,�� � �� e��. �,I� ��ti ' �,� � � � � � DFI LO�T 1� \ \ \; ��a� `\ � `�� � \`` r � �,� `'12� i�1�e ' ��` , � � � � , ' I �� ,. \\ \ U+� �. �.t� \ ,\� \ , ��1 ���� � \ \\� � \ � I / . � � � `� � � ` � �a\ � i ` \ \ I, � ', 0 � 1 � � I � � � \ '. Q � � \ � ,, \ � � 1,. � \ , ` `, \ , � ,� � � � � \ 4�\ \ � � �`� \ �'`� � \� � `� \ , � �\ l�;�pu`;,� , � � 4 1 I� � �' ,�.; A � � �,� � �:� � A ��, �� '� �� ,, � �����\ `'; `. �� ���� V � `� '� ��, � j � `��`�� � � � � E �� � ` � `� A � � �,. � '� � 1 . � � � , �� � �' � � '�, � , � � t � �� � �� ����� � \ � � ' 1 � �' �\ ' ., \ � ' A�� � �� , �� , � � � A� � �'F �, '��' � � `�. � A� 1 � , �� . �' �':" \ ` �� ` \ \` _ _ � _ � � � \ \ \, . � �\ \� �, `.� � �` \ , � � \ �\ \ � ��, \ � \ ` �' � 't ; )' . , l.: I , ; � j ; � \: � � ' � � \ � ;;,, ` � � � \ \ \ �` � � � ' �\ �� ' , � � � �� � �\ � \ 1 •� � �.. � , �� � \ \ � � \ � , . ,: , , _ � . 1 � ,_ � � � � , \ — --- ---- --- ; -- - - � ..,� � � � . A � ', Y � \ , �< \ . __ � � . ., � � � � � — — �� � � <.;�e , \ t � � � \ �\ ,� � .�C.�`"`; ' ` .�.\ � ,_ — ,�, � � 1 ` �, � � , \ , � � � � ,.� � � \ \ � '`, � ` ��,�, .. � � \ \ � . `� .��/ � .'��O �.\ \' � �tl,. � �' .. \ \ \ \ `�: � � \ � \...... • . �, . .. . ` ' �, .. � - - / ' �� �; �� \\ \ `� �..r�l '\ .. � \ \ \ \ ? � , �' \ � ` . - ' �• � �{ ��.. , � � '��.; �\ \ k � � � \ •` � � � .i � � - � \ , � \ .. ` � � ,,�\ � r \ '` \ \ `,.,\ \ \ � � \ ,, \ , � 1 . ,,. � �� � . �� , . � ,, _ � , ,� �, � � � �• _ - . ,\ �. \ �. � I i , _ � �, � �. � . _ , __` , , � - ` ;- , ;: �' , , ._ �.. ', � � � � �, � , � , �� � - �F� L�T � 5� , � , - % , ,-- %. ^ �- , . � ;,:,.. ��� ` , � � ,, ;� � � ; , .� _ � �� � �, ` . � � � � � ` � % � .. i -�C��Y,,` � \ � . ) `� � � � �: , / � l � 1 � I � � _� ; .. . _� � i I . � r , � ,' �``""' ",�,,J � � ' '�. ` ' , / ', - � . �- ; ; , � _�._ ; / � � , -- � . ",' �� ..' - � ' / . � � i ', � , ,- , _ , �.__..� �. ; . , ; i � � i � / /�� / � ' /� . , / -" �.-' ,_ �� ; / /, � ' � _ / lli�'� / I % .-�-F'' LOT' � - �' - ' ' � , %� � ' ��` � i � I � ' i ,- , .. . .- r , _ 3' � � � � � , � � � ' ,� ,; �� ' ; � l � � � l ,'� i . , . . : . . _. : . � � ; �� ,� :� ,�.-� � . :. � , � �Q � , - � .. � . ;. , ,. I 1 � � � , � • __. _ � ; � / ,.. � � /� , � ; / i' � --- - '" � , � i - , - .;. � � � D�' LOTi�4 , � � . // / /� ���/ / �� / � ', // / ,' � ; , - �_,,� ,.,- � ,: '� : - , ��,�'" . ; , , �, ; ,- i / � _� � , , � � '� .� � � � � � _����� , ������ �, ,- �---�� � � � � J!. � �:����.�� �a-m.<� �.�.�.Il IHI �.�.11 �1� '���,� �����' (I*1e�v��e�air� �ax Ii�gap: ��-ce�• l � 8 �ubdiyision: Q � . I,ot: A�plicant's 1�iaane: ��b 1CpS-�. PN��iling Addr�ss: Phone i�Tuffibers: I'ermit Condi#aon�: 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing consiruction and setbacks apply. 3) Permits expire � years from the date of issue. �dher �`onrlitions/�'ona�nents: 1'e��nit issued by: U�►'�/'Pi✓ ��te• 3 Y 4 ��R�'�'��A�'� OF ��1VI�I,�'I���I� l��e� �eli Ins�ect�oa�: EHS/Date Location: Grouting: Well Lag: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: We�l Dr�lle�-: Pump Installer: �eil �pp��nved by: L�ate Sample Collected: Persan County Environmental Health 32� S. IViorgan St., Suite C Roxboro, NC 27573 I,iner I�aspeetion: EHS/Date Installer: Depth: Grout: '�ell A��nc�o�ffieaa�: EHS/Date Completed: Method/1Vlaierial(s): _ Lacen�e #: License#: �9ate: Date Results IYlailed: Phone: 3�6-�97-1790 Fax: 336-597-7308 giiios ' � �) � �) �, � � � .)�/. � ��`(��� \'I`�� �',ii� i i•<��i� iiic-�i�� a � �� c� a� �� CLEARWATER S/D PERMIT CONDITIONS Information for tl�e Installer: nsurinb a healthy environment 1. System shall be installed per approved engineered plans. 2. Contractor must be certified by the drip and pretreatment manufacturer in order to install system. 3. Contractor shall have a set of approved engineer's plans on the job site througlio��t installation. 4. Pre-installation meeting mandatory (Design engineer and drip/pretreatment inanufacturer rep. must be present). 5. Contractor must re-flag drip lines on contour after clearing and have layout approved by health dept. 6. When clearing drainfield area disturb soil as little as possible. 7. No site work should be done under wet conditions. 8. Contractor, design engineer, drip and pretreatment manufacturer rep., and certified operator must be present at system start-up. 9. Before operation permit can be released a registered professional en�ii�eer ar certified designer and drip/pretreatment manufacturer rep. must certify in writin� that the systein was installed in accordance with the approved plans and specifications. 10. All tanlcs must be accessible from grade. phone 336.597.1790 fax 336.597.7808 325 South Morgan Street, Suite C, Roxboro, NC 27573 � ����)� ' ' '� �� �. s � � , , � �. � < <o>t ��I��� I�;��. ���<.,������ �� :�I [-_i��:�f� I CLEARWATER S/D PERMIT CONDITIONS Information for the owner: nsuring a healthy environment 1. Before the operation permit can be released a copy of the signed certified operator (ORC)contract must be given to the health dept. (a contract for operation �ind maintenance with an American Certified ORC shall remain in effect for as lang a� the system is to remain in use.) The ORC must be both a Grade II licensed wastewater treatment facility operator and a licensed subsurface operator. 2. Grass must be established over the drainfield area and cut when needeci. 3. Caution must be used concerning volume of water entering system and what is put down the drain(ex. Grease, personal hygiene products, cigarette butts) phone 336.597.1790 fax 336.597.7808 325 South Morgan Street, Suite C, Roxboro, NC 27573