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A23 98� � 1� ' .. } .� �� z Person County Heaith Department � Sewage System Improvements Permit Date:J��This Permit Void After3 Years '�� Owner: '�P �Fr ��/ �-}-��i e Y�'�r� S R# � 322 Location/Directions: Subdivision Name: ��'—�0 1 �'1 fi-1_'- Lot Sizc: '� Type of Dwelling: Water Supply: Private: —� Public: Bedrooms: -� Garbage Disposal Basement Basement Fixtures INFORMAT�O�(%$RT�FITD BY „_, �Y�„� Lot # ��_ Community: REPAIR:`� ' REEVALUATION: � � � � � � � � � � � �; � � � � � � � � � � Size of Sepdc Tank: _11�S�g��lons Size of Pump Tank:.�S��G�/wJ.j Nitrificauon Line: f7�fB ��i 3� l 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 gy Sanitarian Date S pp��1� ' ' gy Sanitarian CERTI AZE OF COMPLETION l.VliLLQl.LU1. � �� . � �� Sewage System location, installation, and protection must meet stste and local '� regulations. Sepdc tanlc should be pumped out every 3 to 5 years and shalt be maintained ►��- by owner in such manner as not to create a public health hazard. Septic tank and'c� nitrif'ication line must be inspected and appcoved 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 permit is subject to revocation. (G.S. 130 A-335F) I.ocation of sewage disposal sewage system sketched on back. (OVER) Person County Well Date: �� This Permit Void A Owner: : �' Location/Directions: Subdivision Name: Drilling Contractor: _ I-iealth Permit Department � � otn �i SR# � I Lot # WELL CONSTRUCTION ►ti Distance from Nearest Property Line� /4 s Distance from Source of �' Pollution d u S � Total Depth: F� Yield: �GPM Stadc Water I.evel �_,�F� Water Bearing Zones: Depth �.� FG � Ft. Ft. � Ft. Casing: Depth: From �_ to �� F� Diame ��_ Inches TYPE: Steel � Galvanized Steel If Steel, does owner approve: Yes No Weighr. � Thiclmess:l� Height Above Ground: �� Inches Drive Shce: Yes ✓ No Were Problems Encoimtered in Setting the Casing? Yes No �" If "yes" give reason: `d Grout: Type: Neat `� Sand/Cement Concrete � Annular Space Width 3 Inches Water in Armular Space: Yes No `�' Method: Pumped Pressure Poured i— Depth: From �— co � FG Materi Used: No. Bags Portland Cement �_ Weight of 1 bag lbs. If mixture (sand, gravel, cuttings) - Ratio: �— to / ID Plates: Yes r✓' No ►d 4 x 4 slab Yes ✓ No � I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPAR'TMENT. � 1 _ �" � S' a�re o on c Date � �z� Sanitarians Si a e ate Issued Sanitarian's Signature Date Completed Sketch well locarion on reverse side. NOTE: Make �ke �ch��t�nst�ll�tion showing 1 t size and shape, location of house, septic tanks, privies, water suppliesj �tc. No�g`'�i r��pro,b�ks}s�9xisting on ot. Write in measurements in order that installations may be located at later d�te. Note' location df w��.er supplie on adjacent lots�;'=`+� Application Date: � � �' Amount Paid: Receipt #: _ �� ) f ��% ��A. V Tax Map: �� v,,; � � �� Parcel#: �"'.�cav*na-�TM* � �osn.ian.11 IHrm�.11�. tion for Services Services � Improvement Permit (Site Evaluation) / $200.00/$300.00 (if> 600 gpd) �� ° � ❑ Mobile Home Replacement or Building Addition � $150.00 (if site visit required) 0 Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 0 Construction Authorization (Fee is dependent on the type of 0 Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $ I50.00 or $300.00 1) Applicant Informa�on: Name: �«-Qi � �L Address: 6 2) Name and addregs�cur o �er (i� ifferent than applicant): Name: �%E:��%�'/t_-S C3�'i - Address: Phone (home): (work/cell): �j S� Z �ZZ� Phone: 3) Property Description: Lot Size: Subdivision: �� Lot #: l�1 Address and/or directions to Property: ❑ yes � no Does the site contain any jurisdictional wetlands? es ❑ no Does the site contain any existing wastewater systems? ❑ yes �-r�Is any wastewater going to be generated on the site other than domestic sewa e? ❑ yes �te— Is the site subject to approval by any other public agency? � G�� ,tp�? C- ❑ yes L3-tro Are there any easements or right of ways on this property? �/^ /�Jj�� (if `yes' is checked, please provide supporting documentation) �� . ��-('� � � 4) Proposed Use and Type of Structure: ❑Re identia! ew Single Family Residence Maximum number of bedrooms: O Expansion of Existing System tf expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement7 ❑ yes ❑ no With plumbing fixtures? ❑ yes 0 no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well xisting Well ❑ Community Well � Pub(ic Water ❑ Spring Are there any existing wells, springs, or exisring waterlines on this property? ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): �/� ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the information provided abo is complete and correct. I also understand that if the information provided is inaccurate, o�the sit�is subseqr�gntly alter d, or the intended use changes, all peYmits and approvals shall be invalid. Sig'�ra ure ((�wner/ Legal Representative*) '� Supporting documentation required. ate 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) � ��: �'''�� . : • .,�'. :�,�. 1 � � ��► �. : ,: ,.... .. ... .:. .;'.:r. . ' . :... . � .`' �� 1J �� • . .. ��n.�°n.��:srnn�nn�rn,i�m�.��.�.. �c��n.�.��n Building Additions/ Mobile Home Replacements Tax Map #: �3 Parcel#:�_ Address: � s' �k � �" ` � � . � Approval Requested for: Applicant Name: Address: Phone #'s: Mobile Home Replacement � Building Addition . �- � Q ��7 I1� (c�/e,� s, Pernut Located: � Yes No Installation Date: —1 ��Q v Design flow: �. (gpd) Current Contract with Certified Operator on file (if required): ti% Water Supply: _� Well Public or Community Wastewater s stem shows no visual evidence of failure on: s/�/1 date) Y (Applicant's signature if site visit is not required) Addition/Replacement Approved � Yli2.�% irorunental Health Specialist 5��—�� Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net S' � �a'�� Application Date• ��%�O� r �'7 Amount Paid: 0 . U Receipt #: ��—� C+ (��dl r '�- Cra�-� Ai1 ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 �pd) 0 Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (1�Tew/Replacement/Repair) $300.00/$200.00/$75.00 '�� ) f 11 �Ld��l � Tax Map: A� 3 , � � �� Parcet#: �� l�uavraa•��*+•+�*�.and�rn.Jl �)L�Im�.n4�. tion for Services Services Construction Authorization ee is dependent on the type of � Permit Revision Repair of Existing Septic System Application: No Chazge/ CA $150.00 or $300.00 1) Applicant Info mation: Name• � Gc '� v i L�/.� �. LC-C.- Address: D tz 2- � 7 2) Name and addres�Cur,rept oy� er (if iffer� an applicant): Name: f f' ��. Address: Phone (home): (work/cell): - S�1 Z- 3Zz`�- Phone: ^o � , ��;�;a ��.�.��/��Gl 3) Property Description: Lot Size: �3 Subdivision: Qm�/-'� Lot #: Address and/or directions to Property: ❑ yes � no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater systems? ❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ❑ no Is the site subject to approvat 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 ❑ 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? O yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Tota! Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well L�"Existing Well 0 Community Well O Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on � is properiy7 O yes 0 no � 6) I�f Pplying for `Authorization to Construct', please indicate preferred system type(s): L�l Conventional 4Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any w� �Gn�L I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, the site is sub ently tered, or the intended use changes, all permits and approvals shall be invalid. /,l� � l /�2 � Sigaature (Owner/ Legal Representative*) Dat * Supporting documentation required. 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. f 1 Q/111 Pers�n Countv F,nvironmental Hea(th. 325 S. Mor�an St.. Suite C. R�xhnrn N(: �757� ��_SU7_� �om ��, s� ��.� �� - - _ � � �� ?�s �-yn �- � ��.Il I�3I � �.11 �II� Taz Map: fl�3 Parcel: q$ Subdivision �� P�ot�, Phase/Section/Lot # I� Applicant; �'��Ac��t autuD.� Cu �L.C. Address/Location: �3 �AK Cav�Q'��'re S. _�__� Improvement Perre�it Permit Valid for: Five Years �_ Non-expiring Type of Facility: New _ Addition _ Number of: Bedrooms 3/ Occupants b`�/ Employees / Seats: Proposed Wastewater System: Proposed Repair: VVater Supply: �►�� W��, Projected Daily Flow: 3bv ga(lons/day Type: Type: Permit Conditions: �a4va� �a� -Yti� s�i�c, �' P+��P 'Y�a" '49�v�a�s -rra�� wt� r�v..1�� AS�ra,J.c�,r�.Q� _ Authorized State Agent: Q. Date: h-.�3-1�} (X) Owncr or Legal Representative: - Date: - _% `% � The issuan�e of :his permit by the Healt�h Department does not guarantee the issuance of other required permits. It is the responsibility of the applicanbproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocatioa if the site plan, plat or the intended use changes. The Improvemeni is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Luws a�td Rules for Setivag� Treatment and Dis�osal Svstems'(15A NCAC i8A .19U0). Neither Person Counky nor the Environmental Health Specialist warrants that :he segtie s}•stem �vill cvntinue to f�nciion satisfa�torily in the future, or ihat t�e water supply wi�l remair �ota�fe. Authorization to Construct Wast�water �ystem See site plan and additional attachmefzts �_). � Proposed Wastewater System: "Y'pillti�l 1�S�Lac:-r��'r (*)Type �$_ Design Flow 3�'6 _ gal./day New Repair � Expansion _ Soil LTriR: — gal_/day/ftz Type of Faci(it-�: 3-�q�o�� He�Se Bsse;�ent: � Yes _ No (*) System Types Illh, Illbg, IY, and G; re�uire periodic system inspections by the Ferson County Health Department. Wastewater System Requirements Tank Size: Septic Tark (�pp gal. Drainfield: Total Area � sq. ft. Trench Width �' ft. Pump Tank l�_ gal. 'fotal Length � _ ft. ilRiti.Soil Cover "" in. Grease Trap '—' gal. Max. Trench Depth '" _ in. Min.Trench Separation — ft. Distri6ution: Distribution Box / Seriai Distribution x/ Pressure Manifold __ .. _.. . - -� - �-- Specifications: Authoriz�d State Agent: .-.. -,ro ex�rn�t, a•, �*� �G Issue Date: 10-�3-1`t Permit Expiration Date: �a-�3-1 ��? T'he system permitted is: Conventionat �/A d / 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) � �.+.\S-s,r+c�►., T�tJ\LS Wt1Ei� Sth�w�, . �� AiEY�+A, tii�.. �•,1v., . � H�n a QF. �l�,Qu�4�E0 �� s�aE 8 � ��.-�c 4u,.A �s �t�:. oEtibweN ':O 'AQ�.v� � '�1�E EF�v�c,�T '�'C! S�ii�. ,� a�, � -� C�� Pe�� w) � o v��,�s C��e�s��-l��ti. J " � � � � "��6�►�iA'� �� c. � q:� �- ��a�� -�, g °'° 5 � Gx.s-�,� �w�.�c�,� q � � �� _ � u�'n h � � J � � ° � W � •° � o n � n sc1�c�� : � �� = �O t�� TOTAt AREA �1 LOi 5835b S.F. �os�o ��wais sur�� 7857 S.� OFt 13X. OF T07AL AREA �2 58255 S.F. 1.34 AG� ELEG ��5�� . �� i�� w � - . q'� u � fp 2p s � 3 '�i h � , 6 z cn �n S . 420�CONTOUR Z BEIP n ` . . �to � HYCO l.AKE �! W o �� BOAT DOClC 6 � 3 � z 0 � -a x z c� � v A M. dt E. OOGGETT OB 600. PG. 831 �� ,S.f ��.�� IC�n�v�iu-��rna,,.-n�o�radau.l� IF3C��.R�:I�a WELL PERMIT ��.5�� (New_ Repair_ ) Tax Map: �3 Parcel: q b Subdivision: /� Lot: � 2 Applicant's Name: 2 PH��v� � �'�� vS. Mailing Address: _ Phone Numbers: Q�'7- Z� _ Location of Property: �(� . S• �K � K� Permit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and County regzslations governing const�uction and setbacks applv. 3.) Permits expire S years, from ihe date of issue. 4.) Issuance of a permit does not guarantee a potable water supply Other Conditions/Comments: � , �i :.� . "��• / Permit issued by: �� ( �'�� [ 'Z-�Q� `� Date: —('Z� �l� �?e�s�^� Certificate of Completion QNew WeIL• OLiner: EHS/Date EHS/Date Location: _ �� • Depth: Grouting: G��,��5'�� Oq� Grout: Well Log: �J Well Tag: �_ Pump Tag: �1�t%9� DAbandonment: Air Vent: - -t� Date: �� Hose Bib: � Method/Materials: Casing Height: Concrete Slab: Well Driller: �/R �t S Pump Installer: ��'c� Approved by: r�. (1_ Additional Comments: �� c� � �.�Q Date Sample Collected: EH ;: Person County Environmental Health 325 S. Morgan St.,Suite C Roxboro, NC 27573 License #: License #: Date: 3-5- �S Date Results Mailed: % ' Phone:336-597-1790 Fax:336-597-7808 11/26/13 � ��'?� �f �� IE��m��.Il IHI��,.Il�II� Taz Map A�3 Parcel # �8 Subdivision ORK Pcr� Phase/Section/Lot # la # of Bedrooms 3 Apglicant: LE�Ac�t A��o►,�c� Ca. �LLC,.. -- Location: 83 oA1� c�ov�: �v� S;a� ��°ation Pe�rn�t -��'��-�` --�� System Type (From Table Va): i'iii3 Product (IIIg): '—" Type V& VI Expiration Date: -- Type V& VI Renewal Date: — This system has been irtstalled in compliance with applicable North �arolina General Statutes, Rules for Sewage Treatment and Disp�nsal, and aU co diti�ns of the Improvement P�rmit and Construction Authorization. �(� � w�� (.4uthorized Agent) �'►r�r�`e l�w►s b- S��S (Licensed Contractor) �1 �� " � cP��p e�� /�/"�� i�y — — � _ � _ `- -_ i I �� _ _-- � V� j/ � - � . �� - . p << � •�. � � �� '° .� �n a�,,� �, 1�' �� SL Scale ��'S '` PCFID, rev. 12/14/12 �1� � ��' _3��R l�� (i)ate) 1�0 3a i (Date) Line Length �c►s;,.�� 5010' Tax Map: � Parcel #: �� Septic Tank System Checklist (Type II-I� System Type: �Ti Q Sepiic Tank InifiaUDate State ID & Date; � scq_ ty.� � �c, •� -(b-1 Capacity: prs � ►oe Tee and filter Baffle Vent �Riser Outlet boot Perm. Marker DistributiQn D-box Ievels set) Serial Pressure Manifold � LPP Notes• � lYitrification Lines I�titiaUDate Trench Wid+h: � ft. Trench De th: in. Total LeYigth: ft. Minimum s acing: ft. Rock de th/ uality Dams/ste downs Grade < .25" in 10') Cover 6" minimum) Setbacks _ From we1_ls Pro erty lines Foundations;basements Sur.faceWater Other: Pump System Checklisi Pum Tank InitiaUDat� State ID & Date: � i -85 9-1`l-�`� Ca acity: p`� ��aO Riser (6" min.) v�s 3-►0 -� NEMA 4X Box Model: � R�►ohaus w�, P Piggy back plug Hard wired _ �RS 3 - �a --�5 . Alarm functioning °�+as 3-�a - �5 Mounted on ost Above grade (12") Conduit sealed Pressur� Manifold ' I�Turrtber of taps: Size and sch: � � Contracted Certified Operator (Type IV Systems): Notes• (c11rJ � j� `-tfNob� Ex,�scici�e Qg+`ter��F�c.'"� c�' N"�"S w' t"lA, wF�� "S'� !� 15 �T cs4�- W�..t� 5'S �P►\l,�c �� `'�4�5�) ��.1`�c �.�Y�F31c� ' 1'14. �,r��'LY�rti.C-. AL�v \��c� 1� �.�k�'�(� �� S'S''�" �4�1'►�� f�\�� 1 �� . � r�o.� i� " 2�" �� , �ce,�c��- ��,� � � ��k� Y� �