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� °The, Distr�ct Health Department
..,
Orange, Person, Caswell, Chatham, Lee Counties
� `� Water Supply and Sewoge Disposal
� IMPROVEMENTS PERMIT No.
� Date �� • � � �7;�
,
T.,2.:� F�.�(-��{-�� � � i � .
u Ownei: - ��"1 i�' 3 � t' �r': --�.-i�� r � ��. � � '£=$ � � >' �
. �;
' '"''�� 'iP4; Location: .. .� :. , . _ .
.•� �: ��� '�'. j; ' , ' `� '� 1, F' :::
� � `x t- `,,` r � _ •'� 'i_t �;"" .� ,;;
'��E�� ` Contractor�
G,,r
. �; _
�� Watei� Supplye Ffrivate j Public `
i � '� �,
� � ... . :. ' : : .
�; Sewage Disposal Facilifies: No. bedrooms Dishwasher, Disposal,
� � washing machin� jogther� automatic ;appliances � �
' ', Size of tan�: ��' j{���r ��;��-�_ Nitriftcation lirie: ��^+%�� �` k
t. ' r . " �^t�
� — - +"'l , ' '
; �-Other disposal•facility: �• - _ . , -
,. ,_..
� . � : i , ; ;.
° Water supply and sewage disposal facilities location, instaliation arid
': "�protection must meet sfate and local regulations:
i Septic tank�should be puriiped out every 3 to 5 years and shall be main-
� �tained by owner�in such a manner as not to create a public health hazard.
Septic t�n ! and riitrification; llrie„ MUST.rHE .INSPECTEB AND AP-
� ;PftOVEI3 B� A MEIVIBER. OF TEi� DISTRIGT HEALTH DEPA�i,TMENT
� `�T;AEF BEFORE ANY PORTION Ob` THE INS�ALLATION IS ",COV- !
I RED •AN73 PUT INTO ;USE. � i
1 � :% i i a � �
; , ,
j f/�� /i ,�
j Dat.e approved: %"�. - Signedl ��.:�'�"` i'�L•�.�Ut" tx �-'�� � t'• t f.
'� r.? S8ri1tSt'lAII � !
� Well: ' _ � • � F
• , o , . .,� v � .
� . Seivage Disposal; .; �` � . 4 ;,.�ounter °< , `� � E i �
' : g signe f ��M �
y: � .
i �:,. ' ' : (Owne"r o his'representatiSe) " � � . '
, . . t ,� (
�Certificaie of Com,,�e io � ,� i ,�Ft ' �
� %���,� �� �� Ir� ..
Date Approved: � g � �� '
� y�`{ ,
� �anitarian � � _
! (OVER) `. ...- _ �
Loeation of well and sewage dispo'sal facilities sketch��'on back:
i. .
Application Date: � " j 7'��
Au�.eunx Paid: o2b0. c�0 _
Receipt#: �} b �(3 _ _
���� S � ���.� ��
_ � � � � ����
T�: aa vn. zc-.r.a v-n.�ra�._.c� a-n �an.Il .IE�I a�.rn.11 �:Ea
Application for Services
(Set�tic Svstems and Wellsl
�
' +r � • N
Tax Map: ,_ � � /�
� Parcel #: ��
_ r
Services
L�mprovement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
G Well Permit (New/Replacement)
$225.00/$125.00
❑ Construction Authorization
(Fee is dependent on the type of sy:
❑ Permit Revision
$75.00
❑ Ytepair of Existing Septic System
No Charee
Important: If the information in the application for an Improvement Permit is incorrect, falsified, or the site is altered, then tlte
Improvement Permit and the Authorization ta Construct shall become invalid
1) Services Re u' ted b�
Name: � �5 �a �� ris-� / Phone # (home): '�'—� �
Address: c�'�� a or'v�t -}T�`!��(, (work/cell): � � �=�p�,—=�fljt'"j
-S ,As.�.�► / �- �� � ��3
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: 1 �� %2 Subdivision:
Addres� and/or direction,s to Properky: _ ti�t,.fr�� 1��k
4) Proposed �Jse and Type of Structure:
Residential _ ,� Business/Type: Other
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes _ No � Garbage disposal: Yes �No _
Approximate size of building foundation: I�ength Width
S� Water Supply:
Private Well t�(Proposed Existing _�
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes ✓(please show location on site plan)
Note: A comnleted apptication must also include:
➢ A plat/site plan of the properly thaP shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that tlae property is ready to be evaluated
I am submitting this application to request services from the Person County Health Department. The in%rmation
provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become
invalid.
Signature (Owner/Legal Representative): Date: � 7 ��
11/07 Person County Environmental Heal.th, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
�`�� ) �. ���� ��
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T�x M�p � ! Pa�rc�el #
Su�bdivision � � • • .. -
. '
Ph�s - Sect�ion Lot # :
� Improvement Permit
Permit Valid for ✓ Five Years No Expiration /
Type of Facility: �vn�e_ Z� �e�cP New V Addition _ Water Supply �
# of Occupants �# of Be�3'ooms Projected Daily Flow 3�, g.p.d.
Proposed Wastewater System: ' L' v ' Type: �
Proposed Repair: W Type:
.. �, .
Permit Conditions:
Owner or Legal Representative
Authorized State Agent: �
► --. -. .____��.___. - - � —
�
�e; Date:
� _ __ Date: �-1S—o�
�
The issuance of this pernut by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in stue that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit 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 and Rules %r Sewa,�e Treatment and Disvosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that
the water supply will remain potable.
Authorization to Construct Wastewater System (ltequired for Building Permit)
* See site plan and additional attachments (_).
Propose Wastewater System: C.on�ev,�,' e��_c, �/ Owr►�_
New � Repair_ Expansion _
Type ofFacility: priv„-�e .e��dPnce
Type 1�_ Wastewater Flow 3le b g.p.d.
Soil LTAR: • 3 g.p.d./ ft 2
Basement _ Yes _ No �
Wastewater System Requirements
Tank Size: Septic Tank: DDO gal Pump Tank: Doo gal Grease Trap:--��al
Drainfield: Total Area: �ZdO sq ft Total Length ! d it Malumum Trench Depth � in
o. C',
Trench Width � ft Minimum Soil Cover: �_ in Minimum Trench Separation: _� ft
Distribution: Distribution Box Serial Distribution ✓ Pressure Manifold
Specifications:
Authorized State A�
Permit
Date: �—/S—o8'
The type of system permitted is V Conventional �� r�ccepted Alternative. I accept the specifications of the
permit. --.�.._ . _.�. _` — — .
O�vner/Legal Representative: � � �z -a� . � 4—i - -` � Date: � _ _ _ _ _�
PCHD rev. 11/10/OS
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SITE 5%�TC�[
Na�me d"t � I�S 1 hmm�SSo� –
Sub n
uthorized Sta.te Agent
T� �d� #' n �'1��i"�.��:�el ��r. �' 1.
Section/Lot#____�
_' �o_ �.-d� .
Date
System cvmponents represent upproximate�confours o�r1y; The con�ractor must, fTag the system�irior to .
beginning the irutallrrtion to i�sure that propergrade is mdtrntained
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75% x gal =� g� per dose � gal per minute (gpm) = F'low �8aie
�rictivn �ead _ �_ �.
T..�ss: 3.03 ft per 100 ft of supply line x� ft of supply line =100 =��ft
. ft x 1.2 =_�� ft of friction head .�
I1�ianifodri Size: �_" �'orce 14�ain Siz�: _�_„ PVC . .
'�o�� 3)yn�ac Heaai =^- 3� ft of Elevation head +_�ft �of Pressure head +�ft of
Friction �Iead = �._TDH .
Pa�mQ i8equia�sYaent: 40 � GPAi1 @'^� SZv ft of He d.
�r�wd�wn: �..9�a1 per dose ;` 2l gal per inch =� inci� dra.wdown per dose
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� Tax Map 14� �' Parcel # � � _ Townshi :
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Applicanf: e .
Subdivision: ;� eSbo Yo v. � �� Lot #
Location: S -�. z.�a — o .
n_i _ _ . . .� . . . .
�yp� �f �a#er�5u�p�y: � Individual Communi Pub 'c
— — �!._._ h
�s�uia�e�aen�:
Site Approved By:
Grouting Approve3 By �
Well Log. �
Pump Tag: � •
Well Tag � '
.Air Venfi ` �
Hoae Bib: �
Casing Heigh� '
Concrete Slab: � � ` .
Well Driller•
Well Approved by:
����See.A�a��g�d �ite �k�#ch���*
Liner:
'Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
Wells must be 10 feet from property lines.
- Wells must be 100 feet from septic systems.
V�Tells must be at least 25 feet from any building founda,tion.
Other canditions:
Date:,
PCHD rev 01/�7I04