A23 91The D�str�c� Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
� IMFROVEMENT� PERMIT N . � �
- Date �
Owner: `
Location: �
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Contractor: e- ' �� �' C° ` •
Water Supplp: Private � '"- Public
Sewage Disposal Faciliiies: No. bedrooms � Dishwasher, Disposal, ;'
washing machine, other a1utomatic appliances
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5ize o"�ank: �r��! �.f r� Nitrification line: � �
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Other diS,�osal facility:
Water supply and sewage disposal facilities location, installation and
piotection �inust meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owrier in such a manr�er• as not to create a public health hazard.
Septic tank aiid . nitrification line MUST BE INSPECTED AND AP-
PROVED BY A;�MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE: ANY PORTION OF THE INST LLATION IS COV-
ERED AND PUT'>INTO USE.
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Date approved• Signec� � `%t�����`�" � -"�%" '` ���
� . ' ; Sanitarian , .
Well:
Sewage Disposal:
BY.
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Counter- , ,`_�i
signe ' ` / �<':
ner o repre�tative)
Certificate of Completion
Date Approved: �� By-
Sa 'tarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
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Application Date:
Amount Paid: . D 0
Receipt #: 17 7 7
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.� Improvement Permit (Site Evaluation)
$200.00/$300.00 if> 600 d
.Mobile Home Replacement or Buitding Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
�� ) ���� �.f'1 V Taz Map: �� 3
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�:_.�. � ` �; �. � ���� Parcel#: ____�_�—
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)C�a�r..'ascv�'^ �^�'* �aa�mll 7C-7C�im.A+E�a
Services
for Services
❑ Construction Authorization
(Fee is dependent on the type
❑ Permit Revision
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Inf rmation: � i
Name: C' Gl v t h . l, LC Phone (home):
Address: (work/cell): _
2) Name and ad ress of urrf� owner (if different than applicant):
Name: N\ 6 0� Phone:
Address: � � a a � •
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ro er Descri tion: Lot Size: < < Subdivision: �O�IC �� Lot #: � r J
3) P P h' P —�–
Addres and/or directtions to Pro erty: � 100 'E' �
� c�ti �o �• O c��L '� S V' � c
❑ yes �`no Does the site contain any jurisdictional wetlan s?
�es b no Does the site contain any existing wastewater systems?
❑ yes P�no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes �'no Is the site subject to approval by any other public agency?
❑ yes �no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
�Residential �
t�'1Vew Single Family Residence Maximum number of bedrooms: �_� Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement7 �yes ❑ no With plumbing fixtures7 �-yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Squaze footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well �Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no
Please note any known ground .water resfictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
�Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other Any
1 certify that the information provided above is complete and correct. I also understand that if the information p ovided is
inaccu te the site is s equently altered, or the intended use changes, allpermits and approvals shall e in lid.
� �
gnature (Owner/ Legal Representative*) Da e
* Supporting documentation required.
• Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
. A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
Harold Kelly
From: Harold Kelly
Sent: Wednesday, February 15, 2017 4:38 PM
To: 'mduncan@legacy-building.com'
Subject: 111 Oak Cove/ Lot 11, Oak Pointe/ A23-91
Hello Mark,
You submitted an application on February 6, 2017, requesting that the existing septic system be modified to allow the
house to be shifted closer to the lake. The septic system was installed in 1986, and consists of a 1000 gallon septic tank
and 500 linear feet of drain line.
In order to abandon a portion of the existing drain field , an equivalent amount of drain lir�e would need to be added in
another area. Unfortunately, the available replacement area is not suitable for the installation of a septic system drain
line. �
Based on the these findings, we are unable to issue a permit to modify the existing system. Please feel free to contact
me if you have any questions.
Kelly
H. Kelly, LSS, REHS
Environmental Health Supervisor
Person County Health Department
325 S. Morgan St., Suite C
Roxboro, NC 27573
Ph: Sss-597-1790 Fax: 836-597-7808
hkelly@personcounty.net
Oak Pointe (Lot #11)
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