A25 42The Disfrict Health Deporfinenf
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC TAI�lK PERMIT
- Date�h �3" � �
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Name of owner:
Name of contractor: r
Address and Directions .�"� ��10 ►�(� � +G '
G�17 1Q�F_�'.�t'FRo..Mc C�<3es M f II 2c� ,
p� y
Person or firm doing installation: !� e� d
Address
No. of persons to be serve� Bedrooms 1, 2,�4.
Additional appliances to be used: Disposai, dishwasher, washing
machine � �% �P
Recommended• Septic tan
Nitrification line: � �Q—A �i1 ,
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspected assd
approved by a member of !he District Health Department staff before
any portion of the installation is covered.
Date Approved: ,,,� -' .3 " G
By:
Signe�
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned .
(Over)
NOTE: 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. .
SUGGESTED INSTALLATION (Date ) � FINAL INSTAIS.ATION (Date )
y (Aoad or Street) . (Road or Street)
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ficrns Phon� - T.z.� , ,4ddre� � .�nc �� �- . i t � �
Bueiness Phan� e� n�- a �-3� `E' 3
.. sj i�ama anc! ��f c� ownar; C'� ��-�
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3) Praperf.y Qeec�tlon: Lct 9iza 7aw�h�: _._.
Dltedi�ns to th� P�P�Y (��9 road. nart�es and n�un6e�a): _
Lot�
4) Propa��d Llee utd 9�trs D�on: an�rer �d� ib�wi�g qttes�on� •
�i �l�d r. ��9 _, TYF� of �� Widtk. �ep�
b) Nurnher ot eedcaom� �. Wur� ot aauw� �' P�P� m be �rva� ' ,
c) Baaeaaen� Yes �o —V�III there ba �g in the �serre�C? � ._
� Ge�ge � Yes � Na _ . .
� �i� �P�P�l/'�IPa: P neiww _. ar �g..�, P+�ic_, �/...... �,.
Are•a�y vudb cm adjoin�g pr�operl�►? Yes,_ No � ityee, pf�ae i�0e a�ie laca�on cn �e s�a p�n.
� Dos tit. p�vp�rty c� p�vb�y 1da�d j�uin�omd �� Ye� _ No ,_
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Pt.FA9E NOTE TNE FOLLOWU�IG: , . � , • •' . � . , � :
'➢ A PLAT OF THE PROP�TY' OR St'�'E PLAN YUST HE 3178lIfTf� WIT�1 TN{S APPL1iCAT10[�L'
➢ P�i0PER7Y LINE9 �1ND � lIU9T 8E f�.LARLY YARl�. .
➢. THE L�OPC9� LOCATlON OF ALL 9iRUCTURES �T 8E �1'Al� OR FiAGt�. • .
�► THE St7E �AUST 8E READII.Y A�IBLE FOR AN EYALUAT�N BY T�lE HEALTH DEf�l1RT1�'i' SrTAFir.
1• � n�aioa �an fio the Person Cauniy 1�It� Oepa�trn�nt for a�a eveluation fbr 1he a�-eiie saWa6� �sP�
gY�n �r the attove-d�n'�ed p[ope�iy. 1 ag�ee #ttat the c�ntents' af this applic�on ar� tn� a�td re�r�sent the tzmotimucn
� ba b� plac�d an th� praperiy. 1�nder�and ti the s�s is ai�esed ar th� int�nd�d u� changes,lhe p�mui shall
become invalid. �-�-� r J_ '`� �
40
Ouix�e�r or L�al Reer�iativ � � Data
p(��p, tmr iN171D1
App�ication Date: �� o�� b� Tax Map:
Aznount Paid: _ Parcel #: - �y�J��
Receipt#:
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Application for Services (Septic Systems and Wells)
Services Re uested
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 g d) (Fee is de endent on the e of s stem ermitted)
❑ Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) I-' epair of Existing Septic System
$300.00/$200.00/$75.00 No Char�e
�C 1) Services Requested by:
Name: C �.J � Je a� H eS �'�' J`
Addres� b c C� ee ;1 \
� U e r�o a-a C Z'7y3y
Phone # (home): �i�' S�1cj ' 72�ag
(work/cell): 33 (� - S O 3- i`�I 3 G
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
4) Proposed Use 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
5) Water Supply:/
Private Well V (Proposed Existing �
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
Lot #:
(please show location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of the property that sliows property dimensions and tlie size a�d location of all
proposed structures.
➢ A signed copy of t/te `Lot Preparation' form verifying t/iat tlte property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid. � _ , ,�
Signature (Owner/Legal Representative
Date : � �/ " ���
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Location:
T�x M:p ;_ '�.rrel'
�u,� diiuis�ian
' .�.s �-S�ct�7on' � t �
/ �pra�effi�n� ��rrffiit -
���at �Jal'ad for ✓ ��`e/ �e�� �+To ��pn�iaon �
Type ofFacility: �{ed New Addition � i�laie� �up�iy 1✓1/y,C� .
# of Occupants # of Bedrooms 3� Proje�ted Daily Flow ��2�� �D g.p.d.
Proposed Wastewater System: � Tyge:
Proposed Repair: �2-i;�J�� I TyP�: ��� .
Permit Conditions:
�Owner or Legal Re�resenta.tive Si Date: __
Authorized State �Agen�t: . � ",�,.,� Date: �/ 3
The issuance of this peanit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the"
applicant/property owner to in sure that all Person County Plaiming and Zoning and. Bw7.ding Inspections req1;+�?m�++ts are me� This
Improveffi�nt ��er�it i� s�nlsject to re�o�a$ion if the si� ptan, plai or t9ie in��de� ta�� cbaaag�s. 'Tlne Yffig�r�ve�a�ent �'e� i� mot
af%e#�� by a cin�nge iaa ownerslaip of the property. �is per�it was issane� in co�pliaacs w�itii t9i� grovi�i4ns of th� i�`io�th C�lina
Z�ws ara�d Rules for S'ewage Tre�ts�e�u� �sssd I)ispmsad Svste�s' (15r� P1CA� 1�A .1900). l�ieithes� I'e�son �man�nty moY ��
Enviraaanaental �ealth Speeialist' warrayx� t�a�. the septis t,�ic sysieex� widl c�niin�ae ta func#ioa� sa�s�c#�a i�y ira tixe fta�rure or'tlaat
the wa#es� suppIy rvii! r�mazn�potai�le. - -_ ..
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Aa�t�oxi�ation �o Constraeci ��te�vatex Sys�e� (I2es�a�re�i for ���ag Peraanat)
* Ses site plan and additional attachments (_�.
Prop�sed Waste�vater Syst�m: <
New Repair� an
Type of Fac�ity: � �
Type � Was e�ratex• 7Flow,�g:p.d.
5�� I,T�. �_ g.p.d1 ft 2 �
Basement _ Yes _ No � � ,
�laste�va��� �ysteffi I�.�e�°e�ents
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'�a� Siz�: 5e�f�c �� LGc�n �� �m� 'Taa�c: � gal �G�r��'��p: —' ��l
��ai.�el�d: 'To�i �ea: � �q it �Tot:el Lemgth �q D fft � ' � Tit�nc�a I)eptla /� �
T�eaac3a °a�Vaai��a J7 �t 1l��I'i�� �oi1 Coeea : �v in I�Yi�aaffi� Tre�� Se�aaKaatioia: �, �
�is#a�ii��atnon: �3isiYib�ioaa �oz X Se�iai ��tribnii�n � Press�re M�mfld
s�te ���t• c
Permit Expiration
Date:
The type of system permitted is Canveniio � cepte�. Altexnative. I ac�ept tlie suecificatians of the
�,perxnit. �� ] JV � O'"� � � ?5
�vs��e/�.�� �3.�pg�sa���a�e: l/ �� Date:
' PCHD rev. 11/lfl/45
ConnectGIS
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Applicanl
Location:
T�x M�a�p � P��rc�el #
Subd�ivi�sion
Fhase, Sect�ion Lot #
Operation Permit
Sysfem Type (In Accordance With Table Va):
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.
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Autho ze tate Agent Date
Installed By:--O����lG ��u,Jis Date: /o�3d/o-53'
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PCHD, rev. 07/29/02
Tax Map #:
Zoning:
Parcel #:
Township:
Subdivision: Section: Lot:
Applicant:
Location:
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements
B) Distance from system to any welis
C) Distance from septic tank to foundation
D) Distance from system to property lines
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank
B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet
C) Date of tank manufacture
D) Tank serial number
E) Liquid capacity of tank gallons
3. SUPPLY LINE TO TRfFNCHES
A) Grade (1/8 inch per foot minimum)
B) Material supply line is'constructed from ✓
C) Diameter ✓ �
D) Length ✓ ✓
E) Distance from tank to drainfield/distribution device
4. DISTRIBUTION DEVICE(S)
A) Type �Jt.e , n.e
B) Is Device water tight
C) Distance from the distribution device(s) to the trenches
D) Is the device on a level foundation
E) Does the device perForm according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD �
A) Trench depth L G inches , -
B) Trench width 3� inches
C) Distance between trenches �+ (o �
D) Number of trenches
E) Length(s) of trenches 1 O
F) Aggregate depth /2� inches
G) Aggregate material and size �GGl�� � ' �
H) Record septic tank outlet elevation
I) Trench grade `1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth
b. Proper rise over step down
c. Solid pipe used / _
d. Elevations of step downs �/ (Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 07/29/02