A23 50z
Person County Health Department �
Sewage System Improvements Permit
Date:3-.� -�h;c permit Void Afte 5 Years Permit #��" � 3�a
Owner: SR# .����—
Location/Directions: �
Subdivision Name: Lot # ' /
Lot Size: � ype of D 'ng:
Water Supply: Private: Public: Community:
Bedrooms: 3 Gazbage Disposal
Basement Basement Fixtures C
INFORMATION CERTIFIED BY
Environmental Health Specialist: r� rep�es u�e
REPAIR: REEV UATIO . '
--------------------- — —
Size of Septic Tank: ��� allons Size of Pump Tank:
Nitrification Line: � r �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump �
Remarks: �� � !
Date Well Approved: Well should be 100 f� from any sewer system
BY Environmental Health Specialist
Date Sewage System Appmved
gy Environmental Health Specialist
CERTIFICATE OF COMPLETION
Contractor.
--------------
Sewage System location, installation, and protection must meet state and lceal
regulations. Sepdc tank should be pumped out every 3 to 5 yeazs and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person County
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pernut is subject to revocation.
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
(1) (z)
■■■■■■■■■■■.■■ ■■■■■■■■■.�■
■■■■■■■■■■■■■. ..■■■■■■■■■■■
■■■■■■■■■■■.■. ■■■■■.■.■■■..
■■■■■■■■.■■■.. .■■■■■■■■.■■■
■■.■■..��■■■■. ■■■.■■■■■...■
■■■■■■■■■■■■■. ■■■■�■■■.■■.
■■■■■■.■■■■■�.■■■■■■■■■.■■
■■■■■■■■■■■■■..■■■■.■■■....
■■■■�■■■■■.■■■.■■■■■■�■..■.
■■■■■■■■.■■■■■ ■■■■■■■■■...■
■���■�■�■■���■■��������n�■
■����■■������■■�����������■
Site Evaluation Application
Date: ���� Z 3 � � / "/
Fee Collected YES J ,�-c �NO
pp.ks�'q3 4 ��,�3
3`�' 3�� �
��APPLICATION FOR IMPROVEMENTS PERHIT
`�'� 3"ro� - ---
l. Permit requested by: owner/prospective owner: ,S (� ����/�%F ` �
�<�t • �
Address: 06 ,it-cci-c�,cQz �- � � I �!.' _� Z / -
Home Phone ��: `>/�f G��3 -
2. Name and address of current owner:
Business Phone �i:�
���
/ .
3. Property Description: Lot size: ,j � J
4. Tax map 4�: j� 23 �� - Township: Cir,(y�) �lfi� �
Subdivision Name: � �— Lot �i�:
5. Directions to prop/e�rt,y: State Ro�d �� & RoIad Names, etc.
� r% .1� � �� AC I �-c .c � i�{ i ti�..h,� r V' `�-a . Fr� k�•,••
6. Permit requested for: New Installation: ✓ Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served:
� , � {
8. Dimensions of Proposed Structure: Width: 2� Depth: ��
�
10.
�
What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
�� " �
�
�
` w
Water supply private? �✓ public? community? spring? �
�
Other source? (Specify):
Are there any wells on adjoining property? ,.�� If so, identify location:
11, Type of structure or facility/: Proposed: � Existing:
Type of dwelling: House: V Mobile Home: Business: _
Type of business: �6y� - Number of Employees:
Number of bedrooms: �_ /� arbage Disposal? Yes ro ✓
Basement? Yes No ✓ If so, number of basement fixtures:
12. Clearly stake all corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system evaluation for the on-site sewage disposal system for.
the above described property. I agree that the contents of this application are true
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 invalid.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A-335(F) .
�� D � .
igned Ow er or Authoriz Agent
0
�
�
�
0
\
Permit Issued (,/ +l7
Permit Denied
Plat Observed v
l?ACTORS - SITE EVALUATION
1. SLOPE (X)
2 . SOLL TF.�cTUxE (i2-36 i.n. )
x
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTURE (12-36 in.
(Clayey soils)
4 . SOIL DEPTH (in. )
5. RESTRICTIVE HORIZONS (in.
(Impervious Strata� rock)
6. SOIL DRAIIQAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
r
��,,� �►
�i%i�/
`1�
/
AREA 1 AREA 2
S S .�
'F�S � P S
�3� , U
r
PS n n.c PS � . �
PS
P�
V�
PS
�
,�-�
PS
�
S
�
PS
�
S
PS
PS
�
S
PS
PS
U
S
PS
LL._
S
�
U
�
�
PS
P
PS
U
PS
�
U
S
ARF.A 3
S
PS
�T
/� s
/—. PS
U
S
P$
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
;�L�
$. OTHER (specify) PS PS PS PS '
U U U U
9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOMMEEAIDATIONS / COZ4IIIITS :
S1TE CLASSIFICATIoN DIAGRAM (Include: Soil a=eas, property lines, roads, streams, gulZies,
Wet areas, fill areas. wells, water bodies, slape patterns, etc.)
JUN-18-Z013 10:45A� FR�M-
�,plication Date: 6 a0'� 3
�moant Paid: 00 . U �
Receipt �: I 71 �
�,.��,sf �'�4���1�
������
L:. r.�•S 3�0lAAY]C�'t �e� II 1'HL oea 0 ti��
__ 4ePlication for Scrvices
; , Services Re3uested
i�lmproY�mcrtt Permit (Sit� Evaluation)
' S?Ut}_DU.S�(}0_00 if> 6t)J
-- t. - _.J.� ----
.= lio5ilc Homc 12cplacemcnt or Building l�ddiiicn
S i�0.�0 (i; sitz visit required}
� = Construc�
', (Fee is ��e
Permi� R
! S"r5.00
on �;e
T-9T0 P.001/002 F-685
Taz Map: 3
Parcel#: o
_ 1�'ell Permii ('rie�v/ReplacemenL�Itep:�irj �+~ � � Repair of �zistin� Septic System
� S300.aD.�5300.001S7�.OQ i Application: Tv'o Charge/ Cr� � I SO.QQ �r $3COA0
1) Applicaat Infa 'on: l �
Name: � e ( Phone {honie): � �
�ddress: �i -% � T (wark/ce11):
. ���rn%�
2) \s�e and adclress of c rrcnt owner i di erent ihan ap licant): .
\Iarne: � e2i � Phone:
Addre�s: _ f�o _. 0�(__�"�� _��
--�.��.�2Q��?�..11/G 2�3�
3) Propert�' Description: L�t Sirx: �_`5/Subdivisi�n: Q/l I� Lot �: /
.�"'� ��
Address and/q,r directions t� Pr�party: �_ �_1 ^ i � ._,_ ,�, .� �—����.�,r,
Q ycs ��n Doc:s ihe e contain any jurisdictional wetlands? " �
L� } es t�d�� �Dees �he site conli:in vi.� :xisting wasccwx��r sysc��ns'? (�%l ���
� Jes A�"n�- ts any w;:st�wl,e� rir.iro to re gen�rated en :hc site arher tzan domesric sewaDc?
C3 ���s t�3'r�.o 1s the sitc sabj;.ct r,� ap�roval by any ocher publi� a,enc��?
� y�� L�io Arr �h�rc an. eesemancs or righi of ways on this orogerry?
(i:� `yes' is chccked pl: asc provEde supportin� do�:umenrat;on)
.�} Proposed Cise and Type of Struc(ure:
❑Resi eatial
: e+�� Su��,le Family Residence �I3xirnLm num�er af bedrooms: ,� _.
❑�xpa�ui.�n ni Existing System If ex�ui5iori: Cuntnt num�t' uFbedruom�_
C Rzpair ca �la�t��nccionin� 5ystzrn �'iil tiiere 1� a ha.scment? ❑ yrs G ne V1�'ith p:umbing .�'ixtures? C7 yes ❑ no
i��u�-IZesident�al
'C;�e ot bus;ne:s: ____ __ _ _, , _ _ . , . »_ 7'o[a! Squzre faota�z of Buitding:
�farimum r:um'va: of :mployzts; ______ _ _. _ . ,_ , _ __ __ __. �Iaximum number of seats:
�} ��'ater Supply: ,�e« �vtll ❑ Existing �1�'ell ❑ Cc>mmuniry WeII ❑ Puhlic Water G Spring
.�re there aal}' existin� w•;:;1�, sprin;s, ur e;;is�ing tivaterlir,as on inis property? � yes no
6) If applyinb for �autburitation to Construct', p{ease incl;cate preferrcd system type(s): ��
'J Cor.�e►�:�ons! ❑Acc�pcad ❑ 1fln01dCi�`e L� Altcmati�t ❑ Uthtr_�� �'�ny
I c�rri,fi• that the ir.�ormatian pr-oi�i '�d bvti•c is can;pl�:rt� alyd curr:Cl. I G'ISi7 1[iTC�BYctand thcrc if lhe in1�rrnaliv�l provided is
irrac�rrral., r,r i t �ire % s�hs: �.tl}� a!tc�•ed, o� the inic�rd�c: �se clra;i��s, al! par�rit� �n�'approvals sl:aC�'bs it •ulid
6 �3
Signs (()wneri Le 1 epr entari���^` j Uat
* Supportin� documzara:ion requir,,d.
Ferm;t. sre valid for either 60 wontLs or are non-expiring when accomp�ied by stn �pproveci plat
� cotnpleted `Lot Preparatiox' form raust accompany anS� application reqtairin� a sitc evaluation.
(10.� 1 1) Yerson �ottnty Em�irflnmen[al Health. 32� S, Margan 5t., Suite C, Roxboro, NC 27573 (336-597-179Q)
���, sf ���.� ��
�� � � ����
lC�+e��a�r��rnT-n-T ��rn��.11 IL���.II.�I�n.
Applicant: CL`�o�, 1�t1,`�
Address/Location: 5n ►�o� --��
�
Tax Map: Z3 Parcel: Sl�
Subdivision K��-L.� Pa��.
Phase/Section/Lot # �
�
Improvement Permit
Permit Valid for: Five Years X Non-expiring �
Type of Facility: S,�c,� �,a�� �s�c»1c.E New � Addition _ Water Supply: PWv�_ wi�.�.
Number of: Bedrooms ,� / Occupants b"'� Employees / Seats: Projected Daily Flow: 3too gal(ons/day
Proposed Wastewater System: _AtJuq�;p��, ��p Type: �
Proposed Repair: _ /��.\q��,��� Q�1p Type: '�%
Permit Conditions: �►��r�►-i.E sn-E, q.s��.1�c� � s�y�� �„►� ����4 -� �, qtstie� g� q
: _- .-�-=-_ �-_=_
Authorized State Agent: /�� ate:
(X) Owner or Legal Representative: Date:
The issuance of this permit by the Health Department does n�guarantee the issuance o�ther required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
(mprovement 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 North Carolina `Laws
and Rules for SewaQe Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System:
New Repair _ Expansion _
Type of Facility:
(*)Type Design Flow gal./day
Soil LTAR: gal./day/ftZ
Basement: Yes No
(*) System Types Illb, Illbg, IV, und V, require periodic system inspections by the Person County Hea[th Department.
Wastewater System Requirements
Tank Size: Septic Tank gal. Pump Tank gal. Grease Trap gal.
Draintield: Total Area sq. ft. Total Length ft. Max. Trench Depth in.
Trench Width ft. Min.Soil Cover in. Min.Trench Separation
Distribution: Distribution Box / Serial Distribution / Pressure Manifold
Specifications:
Authorized State Agent: Issue Date:
Permit Expiration Date:
ft.
The system permitted is: Conventional /Accepted / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
���.s� I�:I�IIC�..���
`-''��`'�= c� � �TF� � �Y"
IE�.wasosa�c.v..�xa4�a.a1' 1F�a��m.1L�tIla
SI.T PLAN
Name C�-`� �- K��-Y Tax Map #�, Pascel #�
Sub�visio�� Y �o _ Sectiau/I.ot�)
d��.,,,1�,
Authorized State Agent D�te
Systua components repraent appmxinlare conrours nnly. T7re coatracmrmust llag the sysrem poor to begrnning rhe Installstion to
insute rhat propergnde is maintaiar.d.
_
� t�5'CE.'. S`�S�E1� w���, `�4�1Q�. A Qf.scb�. �Y� ���
, E�6��S�E.t� (3��e.E "�i�. C,oasr�wcc�v�j
At1zKc�W'tan��� CA� Qf. ►ssa.��.
-�K P�o��.�.-�Y �.nJ,�.s ►�v�r t5�. �..�aee� Q��. .s�.
�J (. �a(� r��� -
0
�/a� P�4.�C�� c. '�DR,� 4 5''d s"�Ec"� �'%P6�lR � S`;:s� C�vs': �
t�n�o o� a� C��.�-sc►�cz. P�,o�. -tv C-A . sss�Ar\c�.
�r. -s}t�-� 'B�:ot�ar� t'was�.
- 3bc 6P0 �
-- . \a �-t'AR
-� 1'»n1�tr��'t� S�. 4tis�tLbAt�c� wr�r� C�.Ab��t,�o.
-Z�-i ; �� �,� C�