A24 85�1 02 � — � �3
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1''he Distric� He�l�h Department
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CASWELL - CHATHAM - LEE - PERSON COUNTIES
;-�. �'� Water 5upply-and Sewa e Dis� o
9 p :sal
IMPAOVE�uIEN`�g pERMI� No.�_
'�p � �''�' Owner: _
t i� 8 ��pq Locat;on:
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! � �,;�
Contractor: ��„������ �
Wd�e! Supplp: PPi.vat� __� �_ .�blic '• �
Sewage Disposal Facilities;
washing machine, other • at
Size..of tank: __y���
�
ooms �_ Dishvvasher, Disposal�
appliances ��! '�'
�, r��:-�_--T-
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.�'_t
�ther disposal faci 'ty: �1 ��' ^ �
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.> Water,`supply and `sewage disposal•- facilities cation, installatipn . and
protection must meet stafe and local regulations. •
' Septic tank should. be pumped: out every. 3'to 5 years .and shall be main- . �
•-: tained iiy owner in such a manner as not fo cr.eate. a public health hazard. �
Septic tank and nitrification line MUST. BE INSPECTED AND AP_ �
' PROVED BY A MEMgER OF THE DISTRICT�HEALTH DEPAFi,TMENT .
STAFF BEFORE ANY PORTION O�F THE INSTALI:ATIUN IS COV- .
ERED AND PUT INTO USE.
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Location nf well and sewage disposal facilities sketched on back.
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DocuSign Envelope ID: 30895C6F-D76B�3F19-BBCF-7B16A696E160
Application Date: �
Amount Paid:
Receipt #: I �( 34 9
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.��� ) f � � �.e�l`l�ii'`Y�'�T � Tax Map:_�
.r... .� • I Parcel#:
. :=-.r ;� 0-�-��-�'�'-Y I
:[ :aa�s-an-a�aaiz�a�z31a� �f�:�c-u7i��
Application for Services
Services Repuested
� Improvement Permit (Site Evaluation)
$200.00!$300.00 (if> 600 gpd)
� DZobile Home Replacement or Bullding Additioa
5150.00 (if site visit required)
❑ Construction Authorization
is
� Pcrmit Revision
$75.00
on the riae of
❑ Well Permit (New/Replacement/Repair) �Repair of Esistinb Septic System
$300.00!$200.00!$75.00 Appiication: No Charge! CA $150.00 or 5300.00
_ _ �eu.l ���'�� ���'= i7ow�.�. �uneJ� �� 3 � 6 --sv y - oS�Cn
1) Applicant Information:
Name: `I� ..w %-,v .� 1�/1 Ct.�` � � c�- C v v� �1 e r�
Address: i �f l P; r�-{-c�`��s�,-,.,� r-r� . D.tG
2�3� 3
2) Name and address of current a�r�ner (if differeut th�n ap�licant):
. _.. _.
Name:
Address:
Phone (bome): �°2 �" � y�' tfo 0�
(�vork/cell): �
Phone:
3) PropertyDescription:' LotSize: .��' �'L Subdivision: l+�l�e¢S{-cn� Lot#: Ph B�`�3
Address and/or duections to Property: 1� I t�,-.1 %�� ( 7r. . e�,��: �z . r�!'` �--1 �e�-3
❑ yes � no Does the site contain any jurisdictional wetlands7
I�'yes ❑ no Does the site contain any existing tvastewater systems7
❑ yes C no Is any was[e�vater going to be generated on the site other than domestic sewage?
� yes C�t'no Is the site subject to approvai by any other public agency?
� ycs Q"no Are there any cascmcnts or right of ways on this property?
(if `yes' is checkeci, plcase provide supporting documcntation)
__ . _ _ _ __
4) Proposcd Usc znd T}�pc of Structurec
❑Residential
❑ New Sinble Family Residcnce htaximum number of becirooms: � / Occupants:
_. „_._
❑ Expansion of Existing System If expansion: Current number of bedrooms: 3
�Repair ta Malfunctionin� System' Will there be a bascmenY? ❑ yes ❑ no With plumbing iixtures? 0 yes ❑ no
�Non-Residential
Type of busincss:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
_ ._
,�} Water Suppiy:, � New well C� Existing Well ❑ Community Well 0 Public Water O Spring
Are there any existing �vells, springs, or existin� waterlines on this properly? ❑ yes l� no
Piease note any known ground water restrictions or sources of contaminarion:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional 0 Accepted ❑ Innovativc ❑ Altemative ❑ Other 0 Any
I cert� that the informaiion provided above is camplete and correct. I also understand tltat if the information provided is
i�taccurate, the site is subs��uently altered, or dte intended :rse changes, all pernrits alid approvals shall be invalid.
—�.....�,....e
l�, 11�.a�l�G�
Signat�?rej���A�,�al Representative*)
* Supporting documentation required.
6/18/2017
Datc
• Permits are valid for either 60 months or are non-expiring tivhen accompanied by an approved plat.
• A completed `Lol Preparatioi:' 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)
�'/hr/tG /�G�G./f�„�j��/�'
Taz Map Z� Parcel #
����� S f ���� �� Subdivision
., �-� � � �-� � � rhase/Secti�n/L�t �
I��.�na-���.����.Il ���.Il�I� # ofBedrooms
Applicant:
Location:
Operation Pern�it ��.�
System Type (From Table Va): _�a Product (IIIg): � r�� ��
Type V& VI Expiration Date: , Z1 Type V& VI Renewal Date: C
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.
(Auth rized Age t)
�o i�,►�•r��
(Licensed Contractor)
Scale �T�✓"
PC�iD, rev. 12/14/12
o--Z��I���� �urJ '��-�/c
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'"�P�.► �.1 t"-'�- ��'t��
7 Ji 7
(Date
7 !/ / �
(Date'
Tax Map: ��;=i- Parcet #: �
Septic Tank System Checklist (Type II-I� System Type: �
Se tic Tank InitiaUDate
State ID & Date: j % � Gt
7�l�
Capacity: � ��
Tee and filter
Baffle
Vent
Riser
Outlet boot
Perm. Mazker
Distribution
D-box (levels set)
Serial
Pressure Manifold �
LPP
Notes•
� Nitrification Lines InitiaUDate
Trench Width: � ft.
Trench De th: in.
Tota1 Length: ft.
Minimum s acing: ft.
Rock de th/ uality
Dams/ste downs
Grade (< .25" in 10')
Cover (6" minimum)
Setbacks
From wells
Property lines
Foundations/basements
SurfaceWater
Other: �
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Capacity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Mani%Id
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
Tank Com onents InitiaVDate
Pum model:
Block (4")
Nylon retrieval ro e
Float tree and attachments
On/Off float swing: in.
Alarm float (6" separation)
Anti-si hon hole
Check valve
Threaded union
Gate valv�
Conduit sealed
Outlet sealed
A proved and secured riser
Su 1 Line
Size ancl material: in. sch.
Length: ft.
�`-1�, i , �� ���� ��
_� � � ����
):E�+���a-��� ��.��.:1 IE–IL��.Il�11�
Taz Map: _ Parcel• �
Su�divisic�� �%'S��
Phase/Section/Lot # '3
Applicant: �y�v� �loc�i�'C!�
Address/Location: _ _�
�
-------------- — - �'� ' —�''_'----- ----- —
Permit Valid for: Five Y�,*a�s
Type of Facility:
Number of: Bedrooms / i
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Authorized State Ageni:
(X) Owner or Legal R�
Improvement Permit
Non-expiring
New Addition Water
/ Employees / Seats: �
r�� �
Daily Flow: gallons/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 th:, responsibility of
the applicanUproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject tu 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
�uril Rules for Sewage Treatment and Lisposal Svstems'(15A 1�1CAC 18A .1900}. Neitber Person County nor the Environmental
Health Specialist warrants that t6e septic system will continu,, to function satisfacto;:iy in thc fature, or that the water suppfy will
remain potable.
Authori�ation to Construct Wastewater Sys#em
aee site plan and additional attachments (�.
i1
Proposed Wastewater System: G1�.1C �vt � (*)Type��, Design Flow 3� o gal./day
New Repair � EYpansion _ Soil GTAR: '— gal./day/ftz
Type of Facility: 3Y�� (,e,P �-. Basement: _Yes _No
(�k) System Types Illh, Ilfbg, Ii�, ctnd V, requireperioriic system inspections by the Person Coa�nty ilealth Department.
Wastewater System Requirements
Tank Size: Septic Tank i�OO gal.
Drainfield: 'Total Area sq. ft.
Trench `+Nidth — ft.
Pump Tank `— gal.
Total Lengtl� _ ft.
Min.Soil Cover —' in.
Grease ira� �
Max. "french Depth
Min.T�rench Separation � ft.
Distribution: Distrihution Box / Serial Distribution / Pressure Manifold __
Specifications: C{�.cSt� � %�� -e�i �� • �S�%�� 'ew
j ���� ✓1 r0. � . l� � C ( �'' Il �h �`Z � 1^
Authorized State Agent: �✓ fssue Date: "
Permi; Expiration Date:
�d�9�1 •
Tl�e system permitted is: ronventional �/Accepted / Alternati��e / Innovative . I accept the conditions
and specifications af this permit.
(R) Owner or Legal Representative: _ Date: �O `/��� 7
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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SITE PLAN
Name � Q '1"' 1 � �
Su6divi 'on
uthoriud State Ag t
Tax Map# �� Parcel# �r
Section/Lot#
. o — ^ ,�'
Date
System components represent approximate contours only. The contmctor must Jlag the sys�em prior to beginning the
ixstallation to fnsure lha� proper grade is maintained
Nole: An Accepled syslem may be used ir. place oja convsnticna! sysrem svith.out permi: auth.orizafion or mad fca�ion.