A24 61. _�`�. � I/��
•A�piic:�tion Date� i� ��
Amoun4 Paid: � . r�C�
RecEiut #• I� � / 2
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APPLICATION FOR SERVICES
❑ Improvements Permit - $150.00
(Mobile Home ReplacemenUAddition)
❑ RepaidReplace Existing System Pertnit
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Tax Map #: - G �
ParcEl #:
Well Pertnit (NewfReplacement) - $225.00
Construction Authorization for Sepdc Systems-
$150.00/$200.00
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFIED
CHAiVGED, OR THE SITE IS ALTERED, THEN THE IMPROVEiVIENT PERMIT AND AUTHORIZ4TION TO
CONSTRUCT SHALL BECOME INVALID. �
1)
2)
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Permit requested by: (Owner/agent/prospective owner : ��M IS `� �`1,
Home Phone: Address: � � � � S� �
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Business Phone: - ' — C,� � � , � � �
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Name and address of current owner: � .,�- �f G=
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�T-�1� :�' •� � • t C` � '7 �� t
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3) Property Description: Lot size: /i�� Townshi�iiN'�`I �'/ . ubdivision G '� � Lo
Directions to the property (�ncluding road n,ames and numbers):�:J ,J ;�}-1; ,� r G�r.l C` -.fcc �r�
4)
5)
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Proposed Use and ,tructure Description: answer each of the following questions: -�
a) Proposed _, Existing , Type of Structure: Width: �% � Depth: �'�
b) Number of Bedrooms: -� Number of occupants or people to be served: �
c) Basement: YesJ No Will there be plumbing in the basement?
d) 6arbage Disposal: Yes No ��--'
�
Water Supply Type: Private new _ or existing�, Public_, Community_, Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
'site plan.
�„_......
6) Does your property contain previously identfied jurisdictional wetlands? Yes_ No=�'`""�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. �
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAF(ED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby ma�� application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for�t e above-described property. I agree that the contents of this application are true and represent the maximum
facilitie$�;fo be placed on th property_ I understand if_the site„is altered or the intended use changes, the permit shall
beco �'in}�alid._-..-__.—:__-.-"-- �---:__..___ _ . .
1 a . . . .... .... .. /
;i/�� ' - , i � -
.% Ow r or Legal Representative Date y
PCND, rev. 06l27/02
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____::. �� � j� �� � ����
�7rIl.�11]I"�IriLa7YY]Lc��Y11��.J1 �«��l.��JY�
October 10, 2006
Tommy Winstead
1990 Long Store Rd.
Roxboro, NC 27574
nsuring a healthy environment
...:.. ..._ --._,.�_..____.... .
. _ >_..._ _. ..---- � --°._- .,-:_:.,
_ _. _:.: .. . �
Re: Lot 10 and part of Lot 11/ Roy Carver Subdivision / Person County, NC
Dear Mr. Winstead:
On August 17, 2006, I completed the evaluations of the properties referenced above. The
properties were evaluated to determine site suitability for the installation of an on-site
wastewater system (septic systems). The sites were evaluated in accordance with the
North Carolina Zaws and Rules for Sewag,e Treatment, And Disposal Systems' (15A
NCAC 18A .1900). The lots were evaluated by making a series of soil auger borings
across representative portions of the property.
Based on this evaluation, the lot must be classified as Unsuitable for the installation of
septic systems for the following reasons:
(Rule .1942) Soil Wetness
(Rule .1943) Soil Depth
(Rule .1945) Available Space
Sites must be classified as Unsuitable when soil characteristics indicate that a septic
system would not function properly.
You may request an informal review of our decision from the Regional Soil Scientist
with the North Carolina Department of Environment and Natural Resources. Please
contact our office if you would like to schedule an informal review.
You may also obtain the services of a qualified soil scientisticonsultant to evaluate the
property, review the data, and submit a proposal to the Health Department. The proposal
must be accompanied by data which shows that the system will properly treat the
wastewater, will not contaminate groundwater or surface water, and will not discharge
wastewater on the ground surface.
phone 336.597.1790
fax 336.597.7808
20-B Court Street, Roxboro, NC 27573
r
In addition, you have the right to formally appeal this decision to the Office of
Administrative Hearings. A formal appeal must be made within 30 davs from the date of
this letter. The proper paperwork must be submitted to the Office of Administrative
Hearings. A copy must also be sent to the North Carolina Department of Environment
and Natural Resources. Please cvntact our office to obtain the necessary paperwork and
mailing addresses. Once the required information has been submitted, a hearing will be
scheduled and held in Person County. '
Please contact our office (597-1790) if you have any questions or if we can be of further
assistance.
Sincerely,
Harold Kelly, LSS RS
Environmental Health Supervisor
c: Mildred H. Carver