A24 71�
The District I-i��lth Department�
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
.
Name of owner:
Name of contractor: �� b�1�� � u i n�t�
Address and Directions d��! U C-'�� � rC ►
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Person or firm doing installation: �
Address � -'. f -� �T-L+L`�X � � �O- �t G �
No. of persons to be served Bedrooms 1, 2, 3Q4.
Additional appliances to be used: Disposal, dishwasher, washing _
machine 1 `—L[���'�
Becommended: Septic ta /
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Nitrification line: �_ �11� I r
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line mus! be inspecied and
approved by a member of the Disirict Health Department sfaff before
any portion of the installation is covered.
Date Approved: 8,. y� - %�
By
Signed
Sanitarian
O. David Garvin, M.D., M.P.ii.
District Health Officer
Countersigned
(Over)
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Make sketch of, installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date. -
INSTALLATION -(Date )
(Road or Street) Y �,,,�,,,,,,,
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FINAL IN
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,Q Taz Map,l� 2 � Parcel # �
����� S� ���� �� �p 4i �, Subdivision
�--� � � � � � � � � Phase/Section/Lot #
IE�.�aa-��.�����.Il IE�L ��,Il�II�
# of Bedrooms �
Applicant: � 5���; � (�
Location: f�(
�peration Permit
System Type (From Table Va): �^ product {IIIg): L�Z �G�
Type V& VI Expiration Date: N Type V& VI Renewal Date: �
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
y+� � . �,�-�4�'
(A thorized Agent)
C, � � l; �
(Licensed Contracior)
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Scale �S
PCfiD, rev. 12/14/12
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(Date)
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(Uate)
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Line Length
I 5d`
d � SD`
Tax Map: Parcel #:
Septic Tank System Checklist (Type II-I�
Se tic Tank InitiaVDate
State ID & Date: >
f
Capacity:
Tee and filter -3 � (
Baffle
Vent
�Riser 6-- 3 - (
Outlet boot
Perm. Marker
Distribution
D-box evels set)
Serial
Pressure Manifold �
LPP
System Type: �� �'
iVutes: �
Pump System Checklist
Pum '�ank InitiaL�D�te
State ID & Date:
Ca acity:
R.iser (6" min.
NEMA 4X Box
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
No±es:
183�8
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Person
Printed April 26, 2016
See Belaw for Disclaimer
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SITE PLAN
Nam ��' '"�`� �` "' " Tax Map# 2 1 Parcel#�
Sub vi o _ Section/Lot#
� � �
`�^ Authorized State Agent Date
System components represent approximate contours only. The conlractor must flag �he systsm prior to beginning lhe
ir.sta!lalion :o insure tha! proper grade is maintained.
Note: An Accepted system may be used in place oja conventiona( system without permit au�horizotion or modificalion.
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Tag Map: �� f
Subdivision
Parcel:�
Phase/Section/Lot #
Applicant; � l(XY�'
Address/Location: _�___
---------- — -------�'-'�- ac'�s �`_�--- -- --
Permit Valid r: Five Years
Type of Facility:
Number of: Bedrooms
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Authorized-3� Agent:
(X) Owner or Legal Re
Improvement Permit
Non-expiring __
New Addition
/ Employees / Seats:
VVater
Daily Flow:
ga[(ons/day
Type:
Type:
Date: `(-
Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applic�ntJproperry owner to insure that all Person County Planning and Zoning and Building Inspections requirements aze 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
aird Rules for Se►vaF� Treatment and Disnnsal Svstems'(15A NCAC J8A .19U0). Neither Person County nor the Environmental
F3e�lth Specialist evarrants that �he septic sysiem will c�ntinue to fanciiort satisfa�torily in the future, or #hat tne water supply wii!
remair �otabfe.
Authorization to Coostruct Wast�water System
See site plan cnid additional attachn:ents (`).
il
Proposed Wastewater System: l�l�v, � r�pp�
New Repair � Expansion _
Type of Facilir�: ��� �S-
IY, and V,
(*)Typ���� Design Flow 3�0�_ gal./day
Soil L'ff�R: �' gal./day/ftz
Bsser�ent: � Yes _ No
r the Ferson County Health
� .�eP� �.' � �r � r � 5e � �'astewater Sy stem Requirements
� Tank Size: Septic Tar►k �_ gal. Pump Tank � � gal. Grease Trap `- gal• sR�,,.�� 4 S
Drainfield: Totai Area 2�� sq. ft. 'fotal Length � ft. Max. Trench Depth �. p�`s�'�
Trench Width � ft. iVlici.Soil Cover � in. Min:Trench Separation `� ft.
Disiribution: Distribution Box / Serial Distribution �/ Pressure Manifold
S�ecifications: _ vv� ST- n�� Ro�� �.2,.•� �-�'�� -h ��+-� -{- r� s-e ✓, e rA-P�,.� So ��C 3�
Authoriz�d 5tate �►gent:
��5,
IssueDate: �(-Z�-(
Permit Expiration Date: -Zf� � z
T'he system permitted is: Convention /Acczpted �/ Alte ' e / Innovative . I accept the co�iditions
and specifications of this permit.
(X) Ow°ner or Legal Representati e• Date: r
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
Application Date: � �1 G
Amount Paid: -- /��
Receipt #:
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$ I50.00 (if site visit required)
0 Weil Permit (New/Replacemer�t/Repair)
$300.00/$20G.00/$75.00
1) Applicant I
Name: ; ,
��,?,�� �lle���A. V Tax Map: �'2 �
,, � � ���� Parcel#: �
�".xnv nn�ans�itxaae�sn.d�..� IH�ae�.s..�i.�n.
for Services
Services Re uested
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
$�s.ou
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
2'' Phone (home : � .��r ' �j �J%— �� �%
(work/cell): -- '^V �
2) Name and addr se s� urr� ent ow��er (if different than appl�ica
Name: s ��%l��
Address:
3) Property Deseription: Lot Size: � Subdivision:
Phone:
Lot #:
��
��� ' �� � � . ^ oc, � t, �
❑ yes no Does the si e contain any jurisdictional wetlands? � nc.,( u� rn ,r-�
�yes ❑ no Does the site contain any existing wastewater systems?
�❑ yes � Is any wastewater going to be generated on the site other thar domestic sewage?
❑ yes � Is the site subject to approval by any other public agency?
❑ yes � Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Z'yge of Structure: .
❑Residentia!
❑ New Single Family Residence Maximum number of bedrooms:
—�❑ E. ansion of Existing System If expansion: Current number of bedrooms:
Zepau• to Malfunctioning System Will there be a basement? ❑ yzs � no Vb'ith plumbing fixtures? ❑ yes ❑ no
❑Nan-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well E�Existing �Vell ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
1 cerfi � that the info�•mation provide�l abov� �s complete and correct. I alsn und2rstand that if the information pf•ovi ed is
in c�ate, or if the. s' e is subse�en It red, or the intended use changes, all permits gnd approvals sh 11 be in� lid.
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Signature (Owner/ L epresentative*) Date
* Supporting documentation required.
• Permits are vatid for either 60 months or are non-expiring when accompanied by an approved �lat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 32� S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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