A24A 54, -� Appli�;ation Daie: �i 7
Amount Paid: 6. 0 0
Receipt #: „_j `1 �
❑�
(Site
$Z00.00/,�300.00 if> 600 gpd) --
e Replacement or Baitding
�150.00 (ifsite visit required) __
Permit {New/Replaeement/Repair)
$300.00/$200.00/$75.00
� ( j� �k�}�T Tax Map:�
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�"� 4•.. /J/��� Parcel#:
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V
l��m�vuar�r�**�!c�a���ll ���m�iiE$a
for Services
Services Re aested
��r- �� 0 ConstructionAuthorization
(Fee is de endcnt on the e of s stem ermitted)
lition ❑ Permit Revision
$�s.ao
Q Repair of Existing Septic Systecn
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Informa i :
Name: v
Address: �
c_` � O '
2} Name and address of current owner (if different than applicant):
Name: •
Address: _ �
3) Proper#y Description: Lot Size: Su division:
Address and/or direction� to Property: �� b. �ir,
Phone {home): �/����
(worklcell): ,�� f - l�,�s'l - �7� (p
Phone:
� Lot #: o�%��
p yes Does tiie site contain any,jurisdictional wetlands? �pf� � C✓�,�f�
❑ yes o Does the site oontain any existing wastewater systems? ,�'o t��
❑ yes no Is any wast$water going to be generated on the site other than domestic sewage
❑ yes o Is the site subject to approval by any other public agency? �
� yes i�no Are there aay easements or right of ways on this property?
{if `yes' is checked, piaase provide supporting documentation)
�'�u ve,/y
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a�'a✓e dZ� 2�/G�/ 3ia0..e
`�s�- ��%Y� d ��YY�;
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4) Proposed Use and Type of 5tructure: �,��/,�' �r� ? �
esideniial �
ew Single Family Residence Maximum number of bedrooms: �/ Occupants: �
❑ xpansion of Existing System If expansion: Current nvmber of b�drooms:
❑ Repair io MaIfunctioning System Will there be a basemeni? � yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type af business:
Maximum number of empIoyees:
Total Square iootage ofBuiiding:
Maximum number of seats:
5) Water Suppty: C! New well O Euisting Well ❑ Community Wel[ �ubIic Water O 5pring
Are there ariy existing wells, springs, or eacisting waterlines on this property? ❑ yes ❑ no
Please note any known ground .water restrictions or sources of contamination:
6) If apptying for `Authorizafion to Construct', please indicate preferred system type(s):
�onventional � Accepted � Innovative ❑ Altemative 0 Other ❑ Any
I cert fy that the infor�nation provided above is complete and correct. I also understand that if the information provided is
inac�rate, e site i ubsequently altered, or the intended use changes, all permits and approvals shall be invalid.
SignaEure (Owner/ Legal Representative*)
* Supporting documentation required.
� �
Date
• Permits are valid for either 64 months or are non-egpiring whea accompanied by an approved plat.
• A comnleted `Lot Preparation' form must accompany any application requiring a site evaluatiou.
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September 12, 2017
nsuring a healthy environment
Re: Application for Improvement Permit: Tax Map/Parcel: A24A; Parcel 54
Dear Mrs. Pausback:
The Person County Health Department, Environmental Health Division on 9/11/2017
evaluated the above referenced property at the site designated on the plat/site plan that
accompanied your improvement permit application. According to your application the
site is to serve a 4 bedroom residence with a design wastewater flow of 480 gallons per
day. The evaluation was done in accordance with the laws and rules governing
wastewater systems in North Carolina General Statute 130A-333 including related
statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rule
.1900 and related rules.
Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina
Administrative Code, Rule .1940 through .1948, the evaluation indicated that the site is
LTNSUITABLE for a sanitary system of sewage treatment and disposal. Therefore, we
must deny your request for an improvement permit. A copy of the site evaluation is
enclosed. The site is unsuitable based on the following:
X Unsuitable soil characteristics (structure or clay mineralogy) (Rule .1941)
X Unsuitable soil wetness condition (Rule .1942)
X Unsuitable soil depth (Rule .1943)
X Insufficient space for septic system and repair area (Rule .1945)
These severe soil or site limitations could cause premature system failure, leading to the
discharge of untreated sewage on the ground surface, into surface waters, directly to
ground water or inside your structure.
The site evaluation included consideration of possible site modifications, as well as use of
modified, innovative, or alternative systems. However, the Health Department has
determined that none of the above options will overcome the severe conditions on this
site. A possible option might be a system designed to dispose of sewage to another area
of suitable soil or off-site to additional property.
For the reasons set out above, the property is currently classified UNSUITABLE, and no
improvement permit shall be issued for this site in accordance with Rule .1948(c).
Note that a site classiiied as UNSUITABLE may be classified as PROVISIONALLY
SUITABLE if written documentation is provided that meets the requirements of Rule
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
.1948(d). A copy of this rule is enclosed. You may hire a consultant to assist you if you
wish to try to develop a plan under which your site could be reclassified as
PROVISIONALLY SUITABLE.
You have a right to an information review of this decision. You may request an informal
review by the soil scientist or environmental health supervisor at the local health
department. You may also request an information review by the North Carolina
Department of Health and Human Services regional soil scientist. A request for informal
review must be made in writing to the local health department.
You also have a right to a formal appeal of this decision. To pursue a formal appeal, you
must file a petition for a contested case hearing with the Office of Administrative
Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714. To get a copy of a
petition form, you may write the Office of Administrative Hearings or call the office at
(919) 431-3000 or download it from the OAH web site at
http://www.ncoah.com/forms.html . The petition for a contested case hearing must be
filed in accordance with the provision of North Carolina General Statutes 130A-24 and
150B-23 and all other applicable provisions of Chapter 150B. N.C. General Statute
130A-335 (g) provides that your hearing would be held in the county where your
property is located.
Please note: If you wish to pursue a formal appeal, you must file the petition form with
the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS
LETTER. The date of this letter is September 12, 2017. Meeting the 30 day deadline is
critical to your formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative
Hearings, you are required by law (N.G General Statute 150B-23) to serve a copy of
your petition on the Office of General Counsel, N.C. Department of Health and Human
Services, 2001 Mail Service Center, Raleigh, N.C. 27699-2001.
Do not serve the petition on your local health department. Sending a copy of your
petition to the local health department will not satisfy the legal requirement in N.C.
General Statute 150B-23 that you send a copy to the Office of General Counsel, N. C.
Department of Health and Human Services.
Please contact our office if you have any questions or need any additional information.
Sin e ely,�
y,� �C►,�/
Adam Sarver, REHS
Environmental Health Program Specialist
Person County Health Department
Enclosures: (Copy of site evaluation); (Copy of Rule .1948(d))