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Persor� County Health Dept
325 S. Morgan Stre�f
Roxboro, N.C. 275?��
Gq�srier -�;02-33-1fi
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Date
mprovements Permit. (Established/Recorded I,ot) _ Reinspection of Existing Sys[em (Loan Closing)
Imt�ovements Permi[ (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Welt
Improvements Permit (Addition)
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,_ Bacteria _ Chemical
1. Permit requested by: .
ownerlprospective ownec
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ome Phone #: �� �3 -D I v�
usiness Phone #: �0�-i� --1�7 �— lQ �
Name and address of.current owner:
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. Property Description: Lot size:
Tax Map#: � � �
Parcel#: �
Townshio: C' t. ,r. � �n :D��-(Y�
5. Directions to property: State Road n& Road
ames, tc.
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_ Replace Existing Well
Petroleum I Pesticide � _ Lead
7. Dimensions or Proposed Structure: �
Width: Z
- - c ...n � �.� F� �
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
�hat this sewage disposal system is intended to serve?
9. Water supply t}�pe:
private �blic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
10. Type of structurelfacility: Proposed: xtsting: Q�
Type of dwelling:
House: ❑ Mobile Home: C�usiness: ❑
Type of business:
Number of Employees:
Number of bedrooms: _�
Garbage Disposal? Yes ❑ No 0/
Basement? Yes ❑ Nofl�f'so, # of basement fixtures:
6 Number of occupants or people to be served: r- � �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'Son County Health Department for a site evaluation for the on-site
se�vage disposal system for the above described property. I agree tha[ the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the propecty to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signcc� Owner or Authorized Agent
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Control Corner
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PERSON COUNTY
PERSON COUNTY HEALTH DEPARTME:
ENVIRONMENTAL HEALTH PROGRAM
325 Sou�h Morgan Stree�
Roxboro, North Carolina 27573
(33G) 597-2371
Date: ��
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The above referenced lot has been evafuated by the Person County
Environmental Health Department. The resuits of the evaluation, a copy of which is
attached, indicate that the site is unsuitable for instaliation of a ground absorption
sewage system for the foilowing reasons:
Due to the limitations on your site, this Department is not aware of any
modifications or altemative measures that can be implemented to upgrade the
classification from °unsuitable° to "provisionally suitable.A Your application for an
improvement permit must, therefore, be denied.
You have the right to an informal review of this decision by the environmental
health supervisor of this health department and also by the regional staff of the
Department of Environment, Health, and Natural Resources. You should contact the
health department to aRange for this further review.
You may also wish to obtain the services of a private consultant to collect
site-specific data and submit such data and a system design to the health department
for technical review. A site may be reclassified to provisionally suitable provided
written documentation, including engineering, hydrogeologic, geologic, or soil studies
indicates to the local health department that a proposed septic tank system or a
�� proposed altemative system can reasonably be expected to function satisfactorily.
Page 2
The substantiating data from these studies must indicate that:
A. The effluent (wastewater) will receive adequate treatment;
B. The effluent (wastewater) will not contaminate any ground water.or
surface water; and
C. The effluent (wastewater) wili not be exposed on the ground
surface or be discharged to surface waters where it could come
into contact with people, animals, or vectors.
Finally, you have the right to a formal appeal of this decision if you file a petition
for a contested case hearing with the Office of Administrative Hearings, P. O. Drawer
27447, Raleigh, NC 27611-7447. A copy of a petition form will be provided to you
upon request. The petition must be received by the Office of Administrative hearings
within 60 days after the date of this notice. The hearing will be held in the county in
which your property is located.
If you file a petition for a hearing, you must send a copy of the petition to Mr.
John C. Hunter, OfFice of General Counsel, P. O. Box 27687, Raleigh, NC
27611-7687.
Please call or write this office if you have questions or need additional
assistance.
Sincerely,
. G� fU' ' .
Environmental Health Specialist
Environmental Health Division
Person County Health Department
Enclosure