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A23 19Am u 0 P4 a m � The Distr•�ct Health Department , Orange, Person, Caswell, Chatham, Lee Couniies �IVater Suppiy and Sewage Disposal Date `r ` ��'�T ' d�wner: � `� Location:��•��y'a. �e �p ��+ci o�" S,�P/33I '�t-g–J�'� `�rk.._y__T'� � 1i►�i, �r;�t *�s �t,�%�7— �Q�o�V �• Qria Contractor: ��2� �,�(�1rS Waier Supply: Private �.•►� Public w�r/ � Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal, washing machine, other automatic appliances Size of tank: 0 � Q JNitrification line: � x 4� �--- Other disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Above recommendations based on information received and observed soil condition. Septic tank and nitrification line MUST BE INSPECTED AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE- PARTMENT STAFF before any portion of the installation is covered and put into use. Date approved: �' �Q�" � ERTIFI weli: Sewage D�S��: ✓ aignei By, � The � � G ounters' ed OF Health Department (OVER) Location of well and sewage disposal facilities sketched on back. NO • Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water ?, supplies, e. special problems existing on lot. Write in measurements in order that installations may be located at later date. ,.-. �1J'� : �' (2) �� Jun�19-02 10:04A � P.OZ .F . J� . • '.• �ece � , • $3 ,�e��: � ? 3 J o �— . . . � N, a' ,L. �� M� . �: / - amourrtF�a_:, " � . � � � - � ' N g a' �.3 l�� : . ��•�: - � �S - � ��+ f : ��T�� . v � �� !' � _ I � � . iF+w�. `Z C►w. �.� paa�..+� �l�� " i��. •' . :ti.1.��.�: 9} psnn[t requa�tad by: Own A9d�P�PedNQ owne�: a �vo�C Z i v1 k� Home Phane: 5 — q7 Address: o ,��.P D� . Business Phone: 14 91— SY�"o �- 7 2) Natme and oddn�ss o( curr�st ownar. Sa'� � 5 K��/�or" 3) .propertY �acrlption: L� slza: �_��cwnship: ��t.Sul�dlvbioa: l�t� Di�tions to the prvperty (lndum�g noad n�mes and nu ers): ' S'� cc-t"-%Gt,�,n P�o 4) Proposad llse and St�trcture Oescrlptlon: answer eaci� ofthe iqlio�wfng questicna: , � a) Proposed �/ E�dsting Type o4 Sirudure: S-f'; �k g� � I�-' �m opP�(a r Width: ,� Deptt�: � b� Number oi Bedrooms: ,� Numbar cf cccUpattib or people fio be served: _� c) Basemen� Yes �No _ Wlil ther� be ptumbi�g in the b�sement? �� d) Gari�sge Disposat Yes ,_, No �„ 8) Wa�r Supp[yl �IP�: Private �r�w cr exia�ng }�Pub�c,_., Communfiy ,_,� Spring _ Ace any weOs on adjoiNng proparty? Yes � No ✓If yea, pl8ase i�clicaie approximabQ locaticn an the sit�e plan. 8) Does tha property contaln p�viousy Id4ntniad jurisdtctlonal w�otl�nds� Yes _ Nv ✓ Pi�ASE N01'� TF� FOLLOWINQ; � ➢ A PLAT OF THE RROP�itTY l�R SI'fE Pl.Ii1At MlJ3T BE SUBMTfiED NRTH TNiS A1�PLiCATICN. D PitOPE3�TY I.iNES /1ND CORNERS NU37 BE CLEARLY NARI�. ➢ THE PROPOSm ��CATiON OF /11,.L STRUCTURE$1�USY �� S'PA1�D OR �LAc�ED. ➢ THE SiTE Ml1ST BE R�1D�L-Y AtY�ESSIBLE FaR AN EVALUATION BY THE HEAI.TH DEPARTI{I�Nt STAE�. l�.hereby make applica8an to the Person Courty Health �epartment far a s� aveluaticn tb� the a�-site sewaga dispvsa! sysLern far the abave�descr�bed properiy. I agrea that tfie conberrts of this applicarion are tn�e and represertt tf,e maxtmum iad�t[es tfl be placed on ti�e roperty. i undarstartd if the siUe is altered er the inte�ded use ch ges, t�e permit shaii �� ud. . � � oZ er ar Lega! R pneaenta�ve ' D xtto, rev. �nn7�o� �,��,sf ��I�.��T y.Y � � �� s_a�aa-�aa.,,-,r,� ��n��.� ��.Il.��a Applicant: t�,G.nd (3U�Zi�SK.� Location: -1 ti1 K, I I`1 � �-��ac��c5, a,t �` ga.rrvl�t � � , T��x M�.�� • P�rce�l # S�whciiivi�s�ion ' ' ' ' Ptra�se Sect�ion Lot # Improvement Permit Permit Valid for �Five Years _ No Ezpiration Y / Type of Facility: (11c�du.�ar New Addition V Water Supply ri�h. W<<� # of Occupants (�'1ax # of Bedrooms a max � Projected Daily Flow oZ4l"� g.p.d• Proposed Wastewater System: �X�Sti n� � . Type: � Proposed Repair: 1�1 / �i Type: Permit Condirions: �(J�M �ram N� �c�mc- L�ca.'4,o� 'i�D ��- �X��ti,n.1 S�Ot1`� S vs�c.m . � -- M (7 Owner or Legal Represe Authorized State Agent: .7V7 .ZCfFTE vF Date: f / � a� Date: -3-� The issuance of this permit by �e Health Department in does not guarantee`the issuance of other pernuts. It is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspecrions 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 Zaws and Rules for Sew�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 satisfactorily in the future or that the water supply will remain potable. ' — >�� Autho.rization to Construct Wastewater System (Required for Buildin Permit) �E� pPSGl�JPr[.. PE2rn�7 Fo� sys7E^'► * See site plan and additional attachments (�. i� FJ�/''�� i��"� Proposed Wastewater System: Pu m p to �X � S-�i rt� 5 ySt�'► � New Repair Expansion t/ TypeofFacility: (Y1oc�,ular Type �� Wastewater Flow c�� g.p.d. Soil LTAR: !J' � 1� ,.g.p.d./ ft 2 Ba�ement � Yes _ No Wastewater System Requirements �_ Tank Size: Septic Tank:) ��D gal Pump Tank: (� gal Grease Trap: IJ / R gal , q gth � ft Mazimum Trench De th E in Drainfield: Total Area: o�� s ft Total Len P Trench Width �,� ft Minimum Soil Cover: in Minimum Trench Separation: ft Distribution: Distribution Box _ Speci�ications: Tan k�4 (J - L i�� s a 5c i� t,i. K ' bc. rc � Authorized State Agent: Permit Exnir ion Date: Serial Distribution e..�wb�E.i�q , D�c�-tv Pressure Manifold � �ow1 � l�lac� ti � 11c� q S �/S-Et.� � Date: 9'3-�a The type of system permitted is Conventional Innovative Alternative. I accept the specifications of the perrnit. � Owner/Legal Representative: �-: Date: �/ � 0 Z PC /30/2002 s��?, Sf ��.� �� I� �.�a � � � �.� � �.�.11 1�3L � �.11 �]� Applicant: Location: T��x M�r� P�rc�el � S��ahc1'ivi�s�ion 'Fh��s�e`Section Lot � Improvement Permit Permit Valid for _ Five Years _ No Expirataon Type of Facility: New Addition _ Water Supply # of Occupants # of Bedrooms � Projected Daily Flow g.p.d. Proposed Wastewater System: � Proposed Repair: Permit Conditions: Owner or Legal Representative Signature: Authorized 5tate Agent: � The issuance of this permit by the Health Departmettt ' � applicant/property owner to in sure that all Person Co ty Improvement Permit is subject to revocation If the site lan, by a change in ownership of the property. This permit was Authorization to * See site plan and additional Proposed Wastewater System: � New Repair Expansion Type of Facility: � � not or Type: Type: Date: Date: issuance of other permits. It is the responsibility of the and Building Inspections requirements are met. This use changes. The Improvement Permit is not affected e with the provisions of the North Carolina `Laws ar:d SyStCIIl �Required for Building Permit) Type Wastewater Flow g.p.d. Soil LTAR: g.p.d./ ft 2 Basement _ Yes _ No System Requirements � Size: 5eptic Tank: gal �'ump Tank: gal : Total Area Trench Width Distribution: Specifications: 7 sq ft Totial Length ft ft Minimum Soil Y'Cover: in Distribution Box ` Serial Distribution Authorized State Agent: Permit Expiration Date: The type of system permitted is Conventional Innovative the permit. Owner/Legal Representative: __ _ Grease Trap: gal Maximum Trench Depth . in Minimum Trench Separation: ft Pressure Manifold Date: Alternative. I accept the specifications of Date: . �' , ,. „ _ . . ��` 7� )�� . �� ' `L..� � �1' lv` �L � ' , '�' �mvaa�m��ae��m.n. g7'r�mIl�%a SITE. SgE.TCJH[ . e Rand� �wcizinSKi _, Tag M'ap # Ro'�3 Parcel # �9 li ub ... n er.i tu c. }�}arbor .. Section/Lot#� _ . 9 3_� Authorized State .Agent - . Date . • sy� ��o� „�� p„�,� �� ry. The co�racior mrast, flag the system prior to� beg�srnsng the rnstalla�4ion to insure thatprnpergrade is maintained Sf9.4c�` Scale: N°�� — �'n�s-��i � I,000 5al(on �cPffc,� Qu.mP TanKs. . � -� �c,i.rnP -�j E��stin�.. ranK. — Fo � to� p��n p 5 pu.� F,��a-w o�, s. '_ KC,G� Tan KS 2Q� f(�■,' 1�►aa �la�l °�'SO�M�inimur�r� FroM LaK�� PG�ID, rev. 09/12/01 " 9ZC7� Con�f�r L,�nt i5 ��.t, � ProPcr h t i nc �- r+r►�s�t ma ��t�-�n �• ►O' M� nimu.m Stt6�uC :, $� �C�7Cd 91�C FCC neCti2[� � $�ec�ficatioos t � i 6" _ !!� = tll = 111 111=1tt=nt= � ►�I = t �t = � tl , _.,�• .. - .,. . > ' • lhxlergrv�md Cabie In Cood�zit pith Suitable SeaLer In Both Ends Of Ca�uit �, _.�� . _ ... _ .. �. - _, . - .-� . .. -. .. ..� .. �... . . - . . • .._- • - - ■ �• _� . � ■- .�� • #II� ' `!� ' � ��1 -- rQf C.�ttit Ja�LKt 5'� to d c[ i ucr '� � :Ic�oSk��c�sl�YGl� -- = n + i ��• - Sc�bQersible � Efflcs�t A� ��a � �� Concrete Blodc r . . M ' ��r_.�i rl�� ' : • ' �� 'J .�• a � h�r, n+ �r • uca .� • •�� c� � • ` � �i • •v�: �-t o t Grade 1li -. �ti _ �tj = )tl .- J►1 =. _��t_��I-��-t�i =rc� _.,... ^�-_ . 1� 1= i�1 _ I ti _ i I 1 =�u--•--�_ . . , ._ :,.,..�: • .. 30" > I,� callan r� . � • I . •� � �Supply Lu�e 'I° .� �` . � . Diane[er Schedu.Ce 4Q PVC ..• pi� 1ai Ptstp ��1 � �� a � • CsdCE' �i�Ve � �]L�� 1011 • , Chedc ' Valve 3/16" Syp� erealces F�ole '� Iadd.r,c� stra��s� Atmsr.l A,u c3�3s � Alas�n Float (elevati.ort) � "Ra� On" Flaat (elevation) ' ` "Ftmp Of£' Float «��-�n� f I ' .. , ,• . , a o � • • ' •n ' � � � a�a ' '. • . . a d � � • . � . • . . • �is �k� s�.0 be aE a sr�ke � R�p �.�' � � sa�. �e r�x � a�-�i� . PUMP SYSTEM DETAIL SHEET �� Scr �' cS Zoc � lu' p� E�t,�i Ja��^£' pUHP EtATING Pump Must Be Rated To Detiver �$ GalLons Per Minute Against �Feet OE Tota Dqnamic Head (I'DH). See Folto�ing Sheet For AdditionaL SpecificatioRs, No[es, And Explanations. a0' Ltcu�-�+�'on tS't�^ k = �s' t �,�8 =�fa•� S �-� gx Zota = 3a, � 3c� � � � 33' Tp�' _ __ _. _ _ _ ___ _ �.�� )� �L �� * � �� IE�.�a-�m. � ��¢�.71 IE��.Il�. c T�x M�� P�.rc�el � � S�uhci!ivi�s�ioi� Fh��s�e Sec�t�io��'Lot � Applicant: �qnd y �Ci Z� �S ��; � Location: � . C)peration: Permit . � System Type (In Accordance With Table Va): .� � THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH � CAROLINA GENERAL STATUTES, RULES .FOR .SEWAGE �7REATMENT AND DISPOSAL, AND ALL CONDITIONS OF Tk1E IMPROVEMENT PERMIT . AND CONSTRUCTI�N AUTH TION. � � . . . : (�..c� . � . � � "3�- � 3 . .. . A orize tate Agent � � � � � � : �Date - � . . � : . . . �"� � a8-� � : Installed By: Date: 3 • ��1'L v,V`�� (� L�6 Q . ' . �� l a,n � ��(` al 4�� . � .. .. . . ..: . . ....: .. �o .� h . � `� ar . �;,� G ,l�` .. . . . .. ..... _ . ., _... . . . . . �� k; � .:. y , r ��'``� �. _. �r � �� Ls�. C°/ �� . . . fi r .. .. . .. .:.. .. .... _. � Q�"� �'�fi �� b�� b�� a�L,� �,`5'� � . . . � j�Q. `rb��. ��`� �yb `i '�' �,�,b �`'b � o � �G . \ ' '� � �. Qa `�1 �r � \ .. c ,� , w�� \ � ��. . xSa y\1 �� , �� • � c .� �C �� `� �(,o�` ' ~'�� •� s � 2 � .� 3 ij� � �0� � T � � `ati � �,� �� e ��p.ti ��' � �a � "� �`� . � . •D� ... . - _ ; � �,?�. .. r _ .. .... .. -`�-,�� `�� \�; . - . � ��5�� b� \r � \ti� �.� �� , L 'a , .�`"� \� ��, . � o �y��e�,�� .'j- Z �--03 ,��e.c�a.�d t�� / T � G�� P�P �, �P��.,��,"��' �u'� PCHD, rev. 07/29/02 S��i'HC YANK 11VS�ECTiON C�IE�KLISZ (Type lI -11� Tax Map #� a 3 Parce! # 01 � p� System Type (Table Va) �? Owner/Appiicant `P.andU 8u.d z-��,sk; Subdivision �-�crr`�� J�arb�r Address/Location 5�38 1��'��t f-(��5�� Sec/Phase Lot # � Septic Tank n� a a �tn cat�on mes n�tia ate State ID/date S a J L I ao- �;J1{ '1 agz� Trench Width ft. E ' Capac9ty. f0� , gal. Trenct�.Depth rn. • Tee and Fiter ✓ Trench Length ft. Baffle ,� Trench Grade � Sealarrt �/ Trench S acing Riser if ap licable �/ Rocic De th and Quality Tank Outiet�. Seai �/ Dams/Ste downs etc. � Permanent Marker ,/ Pressure Laterais . Pump Tank � Hole Spacing tate ate � o e ize � Ca acity . gal. Pipe Sieeve . � � Wate roof /Sealant Tum-ups/Protectors Riser � �Requiresl Setbacics Water Tight From Wells �: ` � � Pump From Pmperty lines � �heck Valve/Gate Valve :.. Structures/Basements.:: . . nti-si on o e � �tc es ramage ays Floats/Switches � � � � . . . _ : . _ . Surface` Waters � � � � - � �� Alarm visable and audible Public Water Supplies Electricai Componerrts Vertical Cuts (>2 ft. . Rate pm Water Lines � Ap roved Pum Model Vehicle Traific Biocic Under Pum Adjacent�Systems � Pum Removal Rope/Chain Easements/Right of Ways � Distrihution System Other Serial Distribution ' Easements Recorded . ressure an' o e erator ontract Low Pressure Pipe � Tri-Partate Agreement. Ap r. Pipe Material and Grade � Vaives � � Comments� . � pchd rev. 3113/01 Application Date: 7 02 C�"� � . Tax Map: �o? 3 Amount Paid: �� Parcel #: �� Rcc�ipt#c LI U I I �p � I ��_ � I�I�I�.�� 0. � �� a�� 0. d Y 7f:�.sta.wn�r-.rnarn.:irn-na.�n-n.S�n.Il. IE 7C.c:�.enll.d:.;Ea. 11� �v�1JC�- � Application for Services � �x (Septic Svstems and Wellsl �� Improvement Permit (Site Evaluation) $200.00/$300.00 if> 600 d) obile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Services Re uested ❑ Construction Authorization (Fee is de endent on the e of sys ❑ Permit Revision $75.00 ❑ Repair of Ezisting Septic System No Char�e Important: If t/:e infor`nation in the application for an Improvement Permit is incorrect, falsified, or tlie site is altered, tl:en t/:e Improvement Permit and the Authorization to Construct sltall become invalid 1) Services Requested by: Name: �e•�.�y 1Q v� Z j 5�� Phone #(home): 33�' 23 �{— 9 7(¢� Address: S3 � Hef i kav► � f��C✓��✓' b✓`• (work/cell): `�l `j CP37 - SZo �(27 Se.�ov�a, �vc 2�3�/3 ' , �;-., ;_. 2)Name and address of current owner (if different than applicant): Name: Address: i a � , G 3) Property Description: Address and/or directions Lot Size: a �e5 Subdivision: f., _ . . ,,,� #: 4) Proposed Use a d Type of Structure: Residential � Business/Type: Other Number of bedroof�s � / Number of peo e served (seats/employees):�— Basement: Yes ✓ I�o _(with plumbing: Yes �o � Garbage disposal: Yes _ No � Approximate size of building foundation: Length �y Width '� � 5) Water Supply: Private Well ✓(Proposed Existing � Community Well: Public Water System: Are there wells on the adjoining properties? No t/'Yes (please show location on site plan) Note: A completed application must also include: ➢ A platlsite plan of the property that sl:ows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated. 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: a� � � 11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) 0 T�- x Q��°�� rc.�l �D t I $3 �-a3 1�'� LOT D HERITAGE HARBOR P.C. S, P. 620 , � �. � � � � � � � � � CONTROL � CORNER �1 � �O�G/�v , J 5 e, J,�� CAROLINA POM'ER d LIGHT �p , . I,) I. I•� . J\,/ \. T�x M�p � Parc�el # � r � � �� • � - � - � - Suibdivision . ' ■ � � � . r. .. I : � � . � � , � � � , � � � � , I � I � Phase Sect�ion Lot # Improvement Permit Permit Valid for Five Y ars No Expiration Type of Facility: ' 'ci New Addirion _ # of Occupants x(n # of Bedrooms � Projected Dai Flow Proposed Wastewater S stem: u La �� t 8`` Proposed Repair: u '- • . • L /, � rt . ,! ��/r�I�ZJ � Owner or Legal l Authorized State ture: Water Supply ��t� g.p.d. � Type: Type: Date: Date: ��—og' The issuance of this pernut by the Health Depariment in 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 Inspecrions 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 %r Sewa,�e Treatment and Disposal 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 (lZequired for Building Permit) * See site plan and additional attachments (�. Proposed astewater System: e�c 1" �� '�� Type �b,-f� W�stewater Flow 3(ao g.p.d. New � Repair Expansi Soil LTAR: �� g.p.d./ ft 2 Type of Facility: ��y� Si ChcP_ Basement Yes _ No Wastewater System Requirements rx�'sfin� Eiv'sfi n� Tank Size: Septic Tank: /��a gal Pump Tank: Oov gal Grease Trap: gal / atoi✓'il S/e�p2 Drainfield: Total Area: /200 sq ft Total Length 00 ft Maximum Trench Depth �� in p.C, Trench Width � ft Minimum Soil Cover: _� in Minimum Trench Separation: �_ ft Distribution: � Distribution Box Serial Distribution Jl�'ressure Manifold ns: Authorized State A� Permit The type of system permitted is permit. Owner/d�egal Representative: ;,�, ;� lr( �,p� , D � _ �, -------.��---� � � � ,,�„ Date: 8'- /3- 08 � �-13- /3 Conventional Accepted lternative. I accept the specifications of the Date: PCHD rev. 11/10/OS •�1��,,/� ��! �� • �� 1.� �./ � �7��7�-�y `�L� �L3^PIl]C`f.D]m�t33�OT:a."��.JL JL.11�a.S�tA I r ,.�- ►�.� � , . . �� .:, r:�� ► � -.. � �� - �� •■ -• ' .-� SITE �i�TCI-� Taz Ma.p #�Par.�el �� Section/Lot# ��.�-a� • Date Systena cnm�ionents ne�ii�esent a�ti�rroximate �contours or�ly.� The contractor mrrst fYag the systesn prior to beginning the inrtallution ta i�sure that pro�ergrade rs �naintas�ed � ------�� wn C "�' O �a �� W N 2 > • G m S 0 '\:�,- 6 � Q � �� _ __ � �or`0 0 ��fi�� Sys�m � 3 � o < < �1. �3 6�� gP � t�oo' uw} � �-� Q �$"� P� �o �, ce.v► �r I Z.'' -{re ►� C 1, �o�w► � c�owc�lsfo� Place �o�Sa�1 o�er �-�hc�es ( �o � � n�o-� b� � l I ��, (,� f � sa�� ('�cr� llre 'wJ, o , m � h�aa a�� ,, clac� � N -1 < v ��j��/�J)� ^ nI� �� z'� ' � ft.�_ ��liC�� _ `�..�� /.r l Ll.`i, � V.. � % ��3_ V C.f 6 0 �J11UUt! � . L � f � � �--,'�-''`�-� ,� � � � � � � �1 t��l�'� a�L�� W . � .Z'�.R��yT �O _T'y "*"�'"'� � �1. ��'1.� :.Y_ 1L � �. � ZG_1C�1. � � o � a� o a v ?,nplicant . . Loc�tion: � — � ` a Lof o . . . �. �� ` . . ��-� �� . Sysi�m Type (in Accordanc� Wifih Table Va): �'� � ��S ��i5��1� ��S ��.:.1� ��.�.� �17 ��i C�� $"j �P��i�.��i...� . ��fTj"� �'AROLii1�A GE�E�L ST�TilT�S, RU�.Ej �'OR Sc'�iIAC� iR�A�1V1Es�T ,�,tVD DISPOSAL, • �ND •�LL COI�I3lT�t7PdS OF' � TI-lL II1�FR01/��tE�3T P��lii1T A�lD GONSTRllCT10(� At�THORI�+TI . �> � � '� - . --� � Q—/G -a g' � Qaie D�t�: � 9— �� -a � Cxis{; Pu„� ka,� K . . � � � ��:�►� �- -�f�r ��p �aC�d ;I � .� � �D' 3 ..�� $D' . t�'� , i�q . �� ConC�e�e,7'I �I D-boX �'� � r� D7v ro � � . � �' � ti �Sys�ev�" was S�ra�d `f-�ov� �1Favi, ra�h5 - � , Re+rac. is � l�ea�e sys�ew� �,��o��ered u�' � l�-` d r i F.5 0 ui- S"S `� -IG-c� =C��C�, i ev. G i (Z�/r='. s �� '�� v'u�'°��'�a�� a� 3�i�1� �B a i�� : � IVi�p � Z3 �arca! � �� A Sys�e:� Type (Tat�le Va) -� O��ne:-,A�piiccnt � � � S�bdivision 2ri�- AddressJLDca�ion Se��Phas� L�t � � d��.'��n� ��i�aa�l�a� �ii�a��c��c� �� tn��a d�e � � State�ID/da�e -o _!�-a � re�cfi �d#h fr. S. - -o Ca aci o0o aal. � � Trer�c� De �t in: Tee and Fiiief •/ - T.renc� Lsn o o �. ��5 T Baf�ie ✓ - Trenctl G�ac+e � - Sealant Trenc� S ac�n - � Risef ifi appiicable �✓ � � Roc:� De and Qu�t" N/� � � � �'ank Outle# Se�d ✓ Darns/St� dOwns �tc. � Permanetrt Marker ✓ Pressa�re La�rals � ' � . Pum� Tank • � Hale Spacing � �� . � State /date - o e �z� - � Capac' ai. � Pi �. Sieave . � ' � Waie raof /Seaiant � Tum- slPm#e�tocs � Riser �s�ua�' Se#b�� Water Ti ht �� From� llllells � -o � � ��m� �rom Prape�ty lines � �/ . Che�ic VaivelGaie 1laive IStruciuresl�aseinenis _ � � . Alarm visable and audi�le) �3ectricat Com onents • � Rate m . A proved Pum Niode! 81oc� Undes Pump - Puen RemoVa! �Ro e/C�ain . �•D'as��baa�aon.: ��rn � S�rial �istribufion - �ressure anrro Law Pressure P� � � A� r. Pip� lUt�te�iai ar�d G�d� � ' �Surfac� Waters * Public V�Iater Su i l . V.e�#icai Ctris �2 ft. 1lVater�Lines �— Ve�iici� �Traf�ic � 0 �� .. . ;�.,. :.;;� ,,.., . �.�«. 0 nc7d r�r.31a3/c� Application Date: � � 9 —J 3 Amount Paid: i�� Receipt #: l 7� 0 Improvement Permit (Site Evaluation) $200.00/$300.00 if> 600 gpd) Mo6ile Home Replacement or Buildiog $150.00 (if site visit required) 0 Weil Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ��„�) f ��lL�l��l � Tax Map: �v� 3 �, ��- �� Parcel#i ��A �.�cav*aa•�an.axaa��ndan.]I �I�,..�.Il�a. Services for Services ❑ Construction Authorization (Fee is depend�nt or. the type of 0 Permit Revision � Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 Applicant In ormation: Name: �o,r.o..�j'�„` �� ro�r•.-- Address: 91.Z'7 �;�,P�� l�� (L�J_ LC�� . G. �.7�� 2) Name and address of curre t owner (if different than applicant): Name: �a��ti � v� Z � �S �i Address: � 7 �. j.� �rv.f �..�-c,r V►•-- . S��,ra. 1J • e, Phone (home): 3 3� I`' � I 3� (work/cell): �� « Phone:�9 � q� �� 3�' S� L� a 3) Property Description: Lot Size: _ Subdivision: `Lot #: Address and/or directions to Property: ❑ yes ❑ no Does the site contain san.ny jurisdicti�nal wetlands? ❑ yes G no Does the site contain any existing wastewater systems7 ❑ yes ❑ no Is any wastewater going to be generated on the site oth�r thau domestic sewage? ❑ yes ❑ no Ts the site subject to apprc�val by any other public agency? ❑ yes O no Are there any easements or right of ways on this property? (if `yes' is checksd, please provide supporting documentatiea) 4) Proposed �Js� and Type of Structure: C7Residential ❑ New Single Family Residence Ma.Yimum number of bedrooms: G:F�Expansion of Existing System If expansion: Cunent number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement7 ❑ yes ❑ no With plumbing fixtures'? ❑ yes ❑ no ❑Non-Residential Type of business: _� Total Square footage of Building: 7v �� -' �� y Maximum number of employees: _ Maximum number of seats: 5) Water Supply: O New well ❑ Existuig Well ❑ Community ��Vell CI Public Water ❑ Spring � Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted 0 Innovatir•e 0 Alternative � Other ❑ Any 1 cer•t� tli�t tha infarmation ��ovided above is cvffiPlete and carr�ect. I also urtderstand that if the infvt�matian provided is inaccurate, or if ihe site is subsequently altered, vr tl:e i::tende� rase chunges; all pErmits and approvals shall bz invalid. r-- ��j res c� Signature (Owner/ Legal Representative*) * Supporting documentation required. � � .Z � -- � � Date • Permit§ are valid for either 60 months or are n�n-expiring when accompanied by an approved plat. • A compteted `Lot Preparation' form must accompany any application requiring a site evaluation. � �' �� ` f �� ( � � � � . J , �� \' �� j %� I� � ' � � � V �,,, y D e « .� � ��'� � �� " ' �� ' �� 1 ^r 'T v `...,>��.z.�-�.1r��=r��.��A-�.�L<�n,�l ..��-� ��.�n..l �:. � �a��di�� r��m��/ I��ba�� a�� fl�a��a��n�� Tax Nlap #:�� Parcel#: � 9� �,ddress: ��.`j f.�€��wF��.'�. t,�A�� Approval Requested for: Mobile Home �eplacement x Building Addition Applicant Name: ��a� Mc3vAv�•, Address: q►�`( g►qc�v�v�a.ti Yo�p 1.3�� -�SC�ILC: i, C Phone #'s: 51�! - St3� Permii Located: Yes No Installation Bate: q 1 �oa� Design flow: �b0 (SPd) Current Contract with Certified Operator on file (if required): �_ Water Supply: x Well Public or Community Wastewa#er system shows no visual evidence ef failure on: 5�q i (date) (Applicant's signature if site visit is not required) Comrnents: A�pv.�iv�Q �ci� 5� x t4 �� PC�� a� �� +� �� A�r1��/��s��g�sat r��p�-��1 d�.L...�. �. .� Environmental Health Sneciaiist � �.� t3 Date Pe:son C�unr�i Env:ronm�ntai :�ealth. 3?5 3. ti:orQan St., Suite C; RoYboro, NC 2 i�� 3 Fhcne: ��6-�97-??9C/ ra�:: ��5-�9�'-780� � �v�:v��.�ersoncoun�t��.i�e� �-..��,� 1L �11�1�:' �1�'� • � � �� lE��s�� -�-�..8,�,.��.Il IHi.0�.11�7� SITE PLAN Name J V�FC�1�C1� (�C.(�oCT'1 T�x Map #�_ Parcel #�� SyJ�divlsipn Section/L t#_ o��sti..k � aq i3 Authosized State Agent Date Sysrem rnmpoaeats repre,cat appraadm�te caurorus oaly. T'ne contracrormusrllag tbe sysrem pdor ro begraning rhe iasr�!laaon ro lasure thztpmpergrade is maa�Gvoed. PERSON COUNTY HEALTH DEPARTMENT SUBSURFACE WASTEWATER SYSTEM M()1vITORING REPORT .�-�- �3 � - I l¢ - �g 23 T�ate of Inspecti�n System Instaliation Date Tax Map � %,.�-- —��J��n��. Pn��-- Property Address � Parcel # Instructions: Check yes or no for appropriate items and explain in space provided far rerrarks and comrrients. If an item is not applicable, indicate by "NA". If an itein is i�ot er cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and mor.itoring items specifieri in the permit are to be carried ou� II+iSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tznk risers accessible, free of infiltration and surface water diverted ? S�ptie tanlc needs pumP�ng ? Inches of solids:�_ Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: Required pumps present & funciional7 High water alarm operating properly ? Floats, valves, etc. in good condirion 7 Control panel & components in good condi�on ? Effluent free of zxcess solids ? Inches of solids(pemp/dosz !^ Elanse� ti�-ne readings 7 Cnunt.r readings ? '�i Drawdown rate: �� YES / NO ❑ � ❑ � Ll� �� ❑ DISPOSAL FIBLD: �cidence of effluent surfacing ? ❑ / Evider.ce of effluent por.ding in t er.ches ?❑ / Surface water effectively diveried ? [[� ( Diversions/swales properly maintsined ? ❑ / Vegetative cover maintained ? �,_.,/ / Protected from tr�c/unauthorized uses ? lyf / Dutribuiion devices in good con�ition ?��[�/J f Field frae of settled or low areas ? j� ! REMARKS O',I� ��A�w� � r�►�� : �s►d�n� ❑ LYj 13�d ��i°t ❑ ❑ PKESSURE vISTRIBUTION SYSTEM: Turnupsr'cleanouts�'valves/taps intact �k :t: cessible ? ❑ / ❑►J�J� � Pressure head properly adjusted ? ❑ l❑�1i��- �u �p � tJy b�� CO�LIANCE: � Compliant Non-compliant ❑ I�`etds Maintenance ❑ EHS � . � IM I '� �S