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EXISTIN� PARCEL "A"
��.� 1 ACRES
Application Date: ���"� � ���.5 J" ������ Tax Map: ��
Amount Paid: � �.. � �,�- � � ��,��,. Parcel#:
Receipt #: ` �a a _
�['1.an�-na-cmuaa�rna�uadra� ��.�c�.�n���a
A
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
WeU Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
�lication for Services
Services Re uested
Construction Authorization
Fee is de endent on the e of s stem ermitted
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $I50.00 or $300.00
1) Applicant Inf �ation: // �
Name:
Address•
2) Name and address of current owner (if different t an applica�t):
Name:
Address:
3) Property Description: Lot Size: ��'c`S'ubdivi
Address and/or directions to Property: �%�
Phone (home): � � � "S ��" �g�i Y
(wark/cell): 2�= ���I � � ��
; �- ��'�1_ �^ ���-
Phone: �S-F� �4 � �4�
_ Lot #: �
N��,
❑ yes �I���n �' oes the site contain any jurisdictional wetlands? p�73y�
❑ yes Ja"p6 es the site contain any existing wastewater systems?
❑ yes C�J n s,any wastewater going to be generated on the site other than domestic sewage?
❑ yes n Is the site subject to approvalby any other public agency?
❑ yes , no Are there any easements or right of ways on this property? O� � � t
(if `yes' is checked, please provide supporting documentation) �1 �-�- � O�j-
4) oposed Use and Type of Structure:
ential 3
New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes '�no With plumbing fixtures? � yes �no
❑Non-Residential ,---,
Type of business: Total Square footage of Building:
Maximum number of employees• Maacimum number of seats: �-'
5) Water Supply: ew well ❑ Existing Well O Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If lying for �Authorization to Construct', please indicate preferred system type(s):
Conventional ❑ Accepted O Innovarive ❑ Alternative O Other - ❑ Any
1 certify that the infarmation provided above is complete and correct. I also i�nderstand that if the information provided is
inaccurate, or if the site is sy�bseguently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
� �
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applicant: AL.M�q, WAv..qc�
Address/Location: i-1w� 5`7 *1 �� fA,��.+� �o -� ��ncn�'t�c5
�l aA�. CAv � D2 � ��.�rt aa. .
Improvement Permit
Permit Valid for: Five Years � Non-expiring
Type of Facility: S:ab� i�ar���,-t R�s►cr.k� New )C, Addition _
Number of: Bedrooms �/ Occupants b'''�/ Emploxees / Seats:
Proposed Wastewater System: Rir�P Rtu�.-O w�S��v
Proposed Repair: pilr�p l��p�o �+ a57o
Tax Map: �3 Parcel:
Subdivision
Phase/Section/Lot #
C�D -� � QAy.
ZZo
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Water Supply: 1�+vr�cF.. W�,v.-
Projected Daily Flow: 3ba gallons/day
Type: I�LDb
Type:73Sn6
Permit Conditions: M���rc7� Sc� � sc�`- 5��5��4ac�s"c Wt's�� Cu�Y��t,�,� 4�ita�F��CJ �� �
Cp►u. pc�1D W I O�s-�S 3�� - 59'1— I�lqp
Authorized State Agent: QE4-14W�. fk. 5r�ct�,� Date: 'l � 1�}
(X) Owner or Legal Representative: Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
tl�e applicanbproperty owner to insure 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 is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the Nort6 Carolina `Laws
m�d Rules for SewaPe Treatment and Disnosa! Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system wiU continue to function satisfactorily in the future, or that the water supply wili
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: 1�� Ac.�r4ZriJ w) a51c� (*)Type 3�L�re , Design Flow 3b'� gal./day
New � Repair _ Expansion _ Soil LTAR: �, a5 gal./day/ft2
Type of Facility: 3��k,-pp�p� }}a,�bE Basement: _ Yes No
(*) System Types Illb, lllbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank tOOb gal. Pump Tank 1Z gal. Grease Trap � gal.
Drainfield: Total Area �080 sq. ft. Total Length 3b0 ft. Max. Trench Depth �_ in.
Trench Width 3 ft. Min.Soil Cover (o in. Min.Trench Separation 9 ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold x
ns: Do
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Authorized State Agent: 0���, f!. S�+cT�i�1 Issue Date: '1 a� �`i
Permit Expiration Date: �l Z► tq
�e�P
The system permitted is: Conventional /Accepted %� / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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(,*�O SC`10� SITE PLAN
p , Name �L7t'� WNMy�I�
� Subdivision
D��.A�ca�. �! • sr��
,� <9uthorized Stite Agent
Tax Map � Patcel # ?'�
Secrion/Lo #
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Date
/ Sysrem camponents tepresent appmxrmate contorus only. The coatractarmust flag t6e sysrem prlar ro begianing the insrailadon to
w�� insure rhatpmpergnde is maintained.
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lE;aa.�aa � �ean��.li IHi�,m.11�E�a. Owner: ��'�► W
Tax Map: � 2 Parcel #: ZZo Date: � a► i
I,ene Tap �ap (Sc�a) Tap �lo� Line L�aagt9� �oav / f�ot
# Diaaneter(�a) ( m) �:. ft)
1 a. � $0 5.5 b4' , aq a.
2 ��
3
4
5
6 �/
7 v� a Qr�
8
9 -�a-��.. : 35 6'�N1 3bC�'
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3b0 ft of line x 65 gal. per 100 ft =��`� �3� = I00 =�_ gal
75% x�_ ga1= �') b gai per dose �� gal per minute (gpm) _�+'lo�v l�ate
Friction �ead �
�,6ss: a•�_ft per 100 ft af supply line x`7� ft of supply.line � 100 =�`7 -`1g ft
�'1•�1� ft x 1.2 = a 1 ft of friction head �.
lO�Ianifold Size: 3 "�'orce lYlain S�e: �- " PVC
� Tot�l Dynamic �ead =��ft of Elevadon head + a ft of Pressure head +�1 ft of
Friction Head = 4L_TDH
��tnp Reqaai�ement: 3.5 GPM @`1 �• ft of Head
�rawdown; �`��n gai per dose : 2't ga1 per inch =�_ inch drawdown per dose
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S�:e �Llnt¢rial FTow G�'�i1
+,.s " ScFied 30 �..i
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5/, �• Scl:ect 80 1 �11
=, •� �'cl:ed s0 23.a
Inlet F'mm Septic T
+t" SCH 40 PY�C Pipo
NEMA 4B Simpkx ContmlPa�1
4" X 4" Prnss�ue T�ated Poit � �—j
Sloped To Shed Water 12' Separatioa
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H�t Watex Al�ixm Laval
(S° Separation�
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. • Low Lavel -PamP Off'
Axt SedHotk Cox�crete R'var
Ends Of The Co� '
24" Mamsaut�• �
' � ' � ' �° Sepuati,on
Tlmesded Gate Yalve : _
II�on • . - � :�..r1Gt' -
' � Portland Cone:ate Gzout •
• �iSt]C • • ' •
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Zlp Cord �. � OP�g Filled With �
Tie� �P�9 -'ti Portlaad Camaut C*ront
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Ontlet To D�utioa
Z° SCS40P9C Pipe
��� P77cat Rtires .' :
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�.: ' P:ecait Conczete Taalc 4" Coz�c�ts
; ; Mat.zial Stte >3500 P �lock � 1 • •,�;
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I�b GL�LLtIN FUiwIIP T1�1rTK
PUHP EtA?ING �
Pump Piust Be Rated ?o Deiiver
� Gallons Pet Hinute
Against —�4 Feet oE ?ota
Dynaraic Aead (rDH) .
Ll'�ti� �l.—�00 S��S
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7.o�a'�- 18�
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Tax Map: �3 Parcel
Subdivision:
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WELL PERMIT
(New X Repair _ )
Applicant's Name: AVN1�A w+AM�Acl�
Mailing Address: 300 �4tl�suS Ck� •'�
sFc�vaw , c, a�1��3
PhoneNumbers: 33b -Sgg � b$9y _
Location of Property: �lW`t 5`1 1,. �
.� vAti Qc���'c. 0�. � dk� �ct•�F,
Lot:
7
t��w Rfl %
Permit Conditions:
1.) See 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.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments: W�- '1'►us�c i�C �ft0� Efi�°t' 1�.. ��►�- �'°'�`'�ae1�:�r`�cS
d' 50� YA+�h�. �►SE
Permit issued by: S�,i�t1�. �1- Sl�+�i'!�
�New Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date: '1 1 1�}
Certificate of Completion
�,iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13