A25 7BJu i -25-d2 11 : �2A
. _ �. �,
.�licatlon Dat� 7'3f��'
Arn4u��PaL: ��ZS�`.
I�.�coii?t.�� !
�� \
�3��
�� 2ZS .v�� �3-0�
�� �� ����
e��
..�.��--,� ��--- �'���`� ��
- —,.� ��' �� .��7 �'�. '�' �
� aavv.a-.a•a-aaa�.ca-s�,r�..11 ���c.e��L,t:i��..
APPLICATION FOR SERVICES
-�au nn��: /� �" %�
P�rcal #• �c�c� p��.,�.3
�Impravementa P�r V -,.F - — '
. .. Services' Requssted ,
mlt (Recorded LotJ -�96-69� fS0 ❑ Well i�ermit {NewlReplacement} - $225,04 -
❑ Improvements Pam,It -$150_00 _ Construction Authonzatlon for 3eptic Systems-
(Mo6118 Home ReplacemenVAdditlon} 5�50.001$200A0 •
Permit RevisiQn Fee • $75.00
IF TN� INFORMATI�t ,�l,�j�.7tj,�Ll�AT1(,�N_�QR AN IMPROVEMENT PERMIT IS INGORREC7'A. FAL5IFIED�
�}�►N�CED,_QR_THE R�ITE 18 ALTERED, THEN TH�E 1�,IAPROVEMEN'T P�RlVII'� AND AUTHORI7�►7'�N TO
Cc�NSTFtUC�' S�IAj,�, ���OME lN�l�_
1} parmit reguest�sd by: (Owne,r� /agentlprospective owner):_�1�LZ� �' �/
Fiome F'hone: _�,���Y Add�ess: ( �6 � •
Busine�s Phar,e: �i�- �r�'� .,.c._../� %!!S _ ,,.v • �'- 3 7�/
2f Name and addrass of curr�nt nwner: T �c� ;Jta.ili_Q� •
__—�_1_`� �E,�xr.�c �.s
3j Proporty Q�:�cri�tion:
Directians ;a the prope
_ .�,,�
Lot size: �� Township: ��d Subdlv
{I�n� luding ro d names and numt�ers}: ��_
'_J��� Cri Mr. '�'�� M.`�l raL- ��
�F w-'u 6� � 2,� 1�,a� �'c�r� p�.ss�j��
�
l.ak # ,�13�3
� c,�.�6 /�-kc�
�-�_3._ rr,; `/es
-sc..-.—..� r �. �—_ �—_,.......___...._
4} Pruposed Uuu and Structure Clascription: answer each of the fol owing questions: �y`� s'�2'�'
�) Propos�td ✓Exlsting _, Type of Structure� �� �����t.�' Width;lS-� � Depth: `��v_`
b) Number �f Eedrooms: � Number af �ccupants or people to be served: �;, M.�. /�7U
c) Basament: Yes� , No � WiH there be plumbing in the basement? /��.¢
� j Garbage uisposai: Yes _, No ✓
5) Water 3upp1, � yp�: Private �new � ar existing_�_,_), F'ublie , Community.,�,, Spring __
�ire any wells �n adjoining ptoperty? Y�s_ No � If yes, piease indicate �pproximate locstion on the
sitr� plr�n.
6) noe3 y�our property contain previously idc�ntlfied jurisdictiona) wetlands? Y�s,W_,_ No_�
��A3� hi�T� THE FCILLGW!_hJG:.
� A PLAT OF THE PROPEF2'�'Y OR SITE PLAN MUST BE SUgMITTED iNlTii THIS kPPLiCA71�N.
� PR(�P�RTY LIN�S AND CORNERS MUST 8E CLEARLY MARK�D.
� 7HE PROPOSED LOCA7'ION OF ALL STRUCtuRES MUST BE STAKED drz �t�iGr,�t�.
� THE SITE MUST BE READILY A�CESSIB�E FdR AIV EVALUAi1�N LY "CH� HFA.!_TH DwPt�R7��S�:fVT
����r.
I hereby make application to ihe Person County Health ❑ep�rtm�,nt fc,r � s't�: �:�.:,��i<;t�;,�7 'o� ;�� ,. .::,�: c�i�:nos�al
systQm for ti�e above-described prapetiy. I 2gree that 1ha conter�ts c�r ?t�;.� �:' �, :',: n�. :�, �., ; , ��:�::���
Tac,iities ta be placed on the property. I understand if ti�e �,�<.� ;::, ��:�r� ,; ,..: , � : r�;���
.l i.' L'r �� � 1 1 i-I�/�r l�I[�" ,
i-
� �! .
_ .� -- ------�_ ' � "3�'v'-
------,-�---- -- - -� - ------- - --
EJtivnar or Lec��l fti'aprpsc:nt�tive
�° n��n�^�n��n�n��n��.� �c��.���n.
August 15, 2002
Alene Pulliam
1107 Ephesus Church Road
Semora, NC 27343
Re: Application for Improvement Permit for wastewater system for property located
off McGhee's Mill Road approximately .2 mile on right past Munday Road.
Person County Health Department File: Tax Map #A25, Parcel #7B
Dear Ms. Pulliam:
The Person County Health Department, Environmental Health Division on August 13, 2002, evaluated the above-
referenced property at the site designated on the plaUsite plan that accompanied your improvement permit
application. According to your application the site is to serve a three-bedroom residence with a design wastewater
flow of 360 gallons per day. The evaluation was done in accordance with the laws and rules governing wastewater
systems in North Cazolina General Statute 130A-333 and related statutes and Tide 15A, Subchapter 18A, of North
Carolina Administrative Code, Rule .1900 and related rules.
Based on the criteria set out in Title 15A, Subchapter I SA, of the North Carolina Administr�tive Code, Rules .1940
through .1948, the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system.
Therefore, your request for an improvement permit is DE1vIED. The site is unsuitable based on the follawing:
1. Soil depths to saprolite unsuitable (Rule .1943).
2. Expansive Clay Mineralogy (Rule .1940).
3. Available Space (Rule.1945)
These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated
sewage on the ground surface, in surface waters, directly into ground water or inside your structure.
The site evaluation included consideration of possible site modifications, and 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 iJNSiJITABLE, and an improvement permit shall
not be issued for this site in accordance with Rule .19480.
However, the site classified as UNSUITABLE may be classified as PROVISIONALLY SUITABLE if written
documentation is provided that meets the requirements of Rule .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 informal 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 informal review by the
N.C. Department of Environment and Natural Resources regional soil specialist. A request for an informal review
must he made in writing to the local health department.
phone 336.597.1790
fax 336.597.7808
20-B Court Street, Roxboro, NC 27573
You also have a right fo 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 Center, Raleigh, N.C. 27699-6714.
To get a copy of a petition form, you may write the O�ce of Administrative Hearings or call the office a[ (9 ] 9) 733-
0926. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina
General Statutes 140A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C. General Statue
130A-335 (g) provides that your hearing would be held in the county where your property is (ocated.
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 LE'I IER. Meeting the 30 day deadline is critical to
your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review
that you might request. Do no[ wait for the outcome of any informal review if you wish to file a formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by
law (N.C. General Statute 150B-23) to send a copy of your petition to the North Carolina Department of
Environment and Natural Resources. Send the copy to: Office of General Counsel, N.C. Department of
Environment and Natural Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy
of the petition to 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, NCDENR.
You may call or write the Person County Environmental Health Department if you need any additianal information
or assistance.
Sincerely,
�� -
. n� -
Joel N. Hicks, RS
Environmental Health Specialist
Environmental Health Division
Person County Health Department
, , y.
.. .r.
�1� 7 .) ���� ��
1 J 4 �
! � � � ����
��.�aa-��.� ����.Il. I�33L��I1�I�n.
T��x M��F� � — P�rcel # �
S�uhcl'ivi�s•ion '
Ph•��s�e Sect,ion Lot #
Applicant: a� 1 cR c. P� � �� u M ,
Location: Cl�.ub LaKc P�d �(�'1c ►,ccs (Y1ill 2d. L�t on � '�ma �[ • m1 c
�.S t ��d
`/ Improvement Permit
Permit Valid for V Five Years _ No Ezpiration
' New �Addition Water Supply�r��a�c. Wc.l)
Type of Facility: I'Yl O h �� t �"c� m C
# of Occupants c�,x. # of Bedrooms 3 Projected Daily Flow � O g•p•d•
Proposed Wastewater System: (�' �n�c.fl-Ei ona� ra�i _ Type: �
Proposed Repair: Xt pt Type:
Pe�t Conditions: =�l
�Uc.rSiOn _ i c
cc.,o �lttLt� O
Owner or Legal Represe
Authorized State Agent:
�e m ,�� F Ic� f c.d
k�a ��I- P i o c, • Ck�--� l cts d- i n,Sta.l co �
`• a_�,n�c. Fin�slcd qrade.
c.r e_r�d
Date:
�Date: �c�o'�
The issuance of this permit by ti�e Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/properry owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met This
Improvement P.ermit 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 Zaws and
Rules for 5ewa�e Treatment and Disnosal 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 �Required for Building Permit)
* See site plan and additional attachments (�.
Yropos astewater System: C,onu cn�,i o�a-� ��u i�Y TYPe � w�tewater Flow c3�g•p•d•
New �� Repair Expansion _ Soil LTAR• • oZs g.p.d./ ft 2
Type of Facility: ,°n c. 1�.� i d c bi ic, �c. Basement _ Yes _ No
.�
Wastewater System Requirements
Tank Size: Septic Tank: �� gal Pump Tank: gal Grease Trap: � �� S�
Drainfield: Total Area: �}�,� sq ft Total Length �� ft Ma�imum Trench Depth
in
Trench Width � ft Minimum Soil Cover: �_ in Minimum Trench Separation:
9 ft
i�istribution: � Distribution Box Serial Distribution Pressure Manifold �
Specifications: (Y�Ct,t � W�S O
Tn Sfu. t (afi bn ,
Authorized State Agent:
Permit Expir 'on Date: _
The type of system permitted is V Con�
the permit. -- /
pwner/Legal Representative� ��✓
�
�
rc.
Date: 9 S—o�
Innovative Alternative. I accept the specifications of
Date:
PCHD7/30/2002
`-.���, s.�- ���.� ��
�.� � � ����
I� �� n � � � �. 2: � �.�. 11 IE-3L � �. Il � ]�
Applicant:
Location:
T��x M�C� P�rc�el �
S�c�ihci'ivi�s�ion
Fh��s�e Section Lot �
Improvement Permit
Permit Valid for _ Five Years _ No Ezpiration
Type of Facility: New
# of Occupants # of Bedrooms � Projected aily Flow
Proposed Wastewater System:
Proposed Repair: ,
Permit Conditions:
Owner or Legal Representative Signature:
Authorized State Agent:
The issuarice of this permit by the Health Department in d�
applicandproperty owner to in sure that all Person County
Improvement Permit is subject to revocation If the aite pl
6y a change in ownership of the property. This permit �
Authorization to
* See�site plan and additional attachments (_�
Proposed Wastewater System:
New Repair Expansion
Type of Facility:
1:i1
Size: Septic Tank: gal
W
_ Water Supply
g.p.d.
Type:
Type:
Date:
Date:
aot guarantee therissuance of other permits. It is the responsibility of the
nning and Zoning and Building Inspections requirements are met. This
or the intended us changes. The Improvement Permit is not affected
:ue in compliance ith the provisions of the North Carolina 'Laws and
18A . 00).
Drainfield: Total Area: sq ft Totr�l ength ft
Trench Width ft Minimu il i'Cover: in
Distribution: Distribution Box � Serial Distribution
Specifications: � �
Authorized State Agent:
Permit Expiration Date:
The type of system permitted is Conventional
the permit.
Owner/Legal Representative: �
�Required for Building Permit)
Type Wastewater Flow _g.p.d.
Soil LTAR: g.p.d./ ft 2
Basement _ Yes _ No
gal
Innovative
Grease Trap: gal
Mazimum Trench Depth . in
Minimum Trench Separation: ft
Pressure Manifold
Date:
Alternative. I accept the specifications of
Date:
1 •
fL��yi;�� . ������
' � '���V'l� ��
�" .avaa-�,r*,.-,.*ea�a�m.�. �77�mIl'�a
' SITE. S�7CG`l� � .
Name i� i`tr� � P�. t( i a m Taa M'ap #'R o25 Pazcel #�'�
n • � Section/Lot#
. '_ �S �
� Authorized State Agent - . � Date � . �
syste�m components r�pr�cses�t �rpproxi�xate�r�ntours or�ly. The �or must, flag the sys�e»��rio:-ta�
beg��s�sg the s�sstalla�ion to insra�s tJr�rpro�ergrade ss nr�t�ed �
— �`��a�� �Zq���CcP c�ivcrSl0r1
� ��d �`P�
d.;tc�.. �}' c.o�ru-r�c� P
�.olcs c,�.p�/Govcrc,s/c,(c.an5t�c,
�a�d (�;p � o,.�.-�;lcf t�?/ 3'' scl�,�'�
Pvc�-l-pru�ldc. C��Ls',
- 3c� '' d, c c.� 7rcncj,c�S .
.... Str�u.( d,iS,�.��bu��
- �(y�r-5ic��c� 51�ou.[�
kie, lo� cnow5 f� �d
�2.ncA�•p�sS s��� Tu"K�,ISo
�
Nc� L°�°�� �
���s'�
��
. � ,
s�
I "- 40 �
, -
, ,��s .
. �o �
� y • •
\\�;`
5�•'�? � ~y �
� �' I
.I i5� - - � - - �`o,
�,
. �
6 �',o
, /
0 � i (� �°' �
I1�C G— tiGt s� (n � I I �R�oC.�d
�
- � .�
� ..
�o E
c U
\��`� A
� �h
.� Y
, �
ss � ,
� � ��� °d utmti��
P6fiD, rev. 09/12/Ul
�
�� � ���� ��
��,.. , �
� � � ����
1��.�.s�-n-r ,�„-„ ��.�.]L IE IL��,IL�.
T��x M��p P�rc�el = • :
Su�hd!ivi�s�io��
Ph�,s�e Sec�t�iai� Lot �
Applicant: �1 • �
Location: �-, �o��e t� � l� rn�.Qo� rh:�� 2z � Cm� �, ����x,,�.Q�, ,a r.�45
CJ T I --�
F- 2oa� •
. Operation.: Permit . �
System Type (In Accordance With Table Va): _�0. �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
� CAROLINA GENERAL STATUTES, RULES .FOi� .SEWAGE �?REATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMP VEME T PERMIT . AND CONSTRUCTION
AUTHORIZa►TION. . ��ess,�,, d;.,�s, -. � ��=z��3 ..
. . �Q��n�a- �a��-c�,1u � ....:.1�a�-�3�: . � � . ..
Autl.oriz State Agent � � . � � � � : �Date � - �
Installed By: Ir%� � 1� 1�;5 . Date: �- a i-�
, McCfl►�acis IM:�� �` . . .. .
. . i ,�.. . . . . . ..
� , . ' . .
Zs'
i
i
,5��,. ,
i ��'��z b
�� �;5'Iz �
'�'3
�y
g g'/s �v'5��.. �°
.� .� �
, ' St�+H
_ ,
. . . .: .. . . 1�3� �. , . . .
s►' `.... ..�::.:._Tor�l� '�h�o" .�.. -.� .. .
• ._ . 12Z
i►-�3=�a 1�S
. zi' r�TS-►000 ► 35
= �''� �a+' y � so�' -b� I:r.,,
%�bs,�s �
,$g•l+, {►5
(07
� A dnb� �` � �,c� ��- ti-ar�-�+.
i�.s�.Q4� �� +:w.a oF ��iPQcl.ty..
'' �� 1.�.)� WCJ C*!'Zilf.C�. 4�' '�aw.�
oF �2p};� ��ru��c.�+�. �'�I�`
2
- �•v2lSion c�.:-1-ci� W�� nl�- '��aCs�c
Q,=- -1���1 0 � �p}.;� �tiSj�C�-.�
PCHD, rev. 07/29/02
a
S��TIC i'r4NK INSPECTI�N CHE��CI.IST �Type i[ - n�
Tax Map # Ao as Parcel # ooc�� 3 � System Type (Table Va) �i �
Owner/Applicant� A\te�..o. ��9���. . Subdivision
Address/Location (Y1c�� n�::t� iZ� SeclPhase Lot #
State ID/date s'�-�yo
Capacit�r�_�o� .
Tee and Flter
Baffle �
Sealant
Riser (if app(icable)
Tank Outlet�. Seai
Permanent Marker
Pump iank
/Sealant
Riser
Water Tight
Pump
Check Valve/Gate Vaive
- Anti-siphon o e
• Fioats/Switches � � � � �
Alarm (visable and audible
Electrical Components
Rate (gpm)
Approved Pump Model
Biocic Under Pump
Pum Removal RopeJChain
Distri6ution System
Serial Distribution '
ressure an' o
Low Pressure Pipe �
, Appr. Pipe Materiai and Grade
✓ _ , Trench Width 3 ft. ✓
,� ,_ ,.�, Trench. Depth rn. .�,
i Trench Length 5 � ft. ,�
� Trench Grade ,
/ �..a Trench S acing ,i
/ .-a�_ Rock Depth and Quality ✓�
. � �. Dams/Stepdowns etc. ✓
i ..a� Pressure Laterals
Hole Spacing
� o e ize �
� Pipe Sleeve . - �
Tum-upsfProtectors
ftequired Setbacks
From Wells �. a
, From Propertv lines �;
.. :�. . _: . ,r.
Surface� Waters � � -
Public Water Supplies
Vertical Cuts (>2 ft.).
Water Lines
Vehicle Traffic
Easements/Right of W�
Other
Easements Recorded .
ert perator ni
Tri-Partate Aareement
Comments
. I ✓r
: � ���i.'i�
■�
0
-a
�a
i-a�-�
c�e �r+i�►,��.
1•Z�^o3
pchd rev. 3/13/0'1
���' 7��� ���� �11. V
`� � � �J ���
IE��a-�,.-„ ,*���.��.Il IF3L � �.7L�IEa
WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax 11�dap #: aJ� Pazcel #�� Townsliip
Applit�n� A i� tnL Pi.�. I I i c�M
Subdivision: � � i�' Section: ��:
�non: 5t t Pe-rm i t
Ty.pe of Water Suvnlv: �Individual CommunitY Public
Re�uirements• � � � i5��
Site Approved bp CS� �-� - 03 ��'
Gtouting Appzoved bp C �'u'�-�
Well Log . /-�2�-0 ,���d� hbc�Q.
Well T a" �� � �°
Air Vent S� '? �'��_ �
Hose Bib yS H- 4'��'�
Concrete Sla.b ���' �' Z � 'a3
�'� - t � �...: � .,,: _ � 1 i �
Ir ,
��� - . � � - � : . ��I - ��� � . - , a
� , ��
—
'�°5ee Attached Site Sketch''°k
Wells must be 10 feet from property lines.
Wells must he 100 feet from septic systems.
Wells must be ax least 25 feet from any biulding foundation.
Other conditions: I�C �� (�-1 t l( i.P d� O��S -�o S� 0� L�' ��� �T� Ct mc �a-�y �S� �
TO Hc�rriE-
':'; "" PC�ID, rev 09/07/01
Barnette Well Drilling Inc 936 598 9275 01127t03 07:06P P.002
��� -• `i �� �l
���,5� ���� �� o ? ,, << . �
� " � � �CTI� �C � � �
, 2 ,
��,.�.����.���.�.Il IE��.�Il� � �� � %� ,
Graut�g .
Owncr. , ", Tax N�ap�q�,�_ �'arccl # ��'3
Lvcation: �� �
Subdivision: r,�� y � -
Well Cdnstractian
Distance Fxmm �earest Property T�ine (Mind�um 1 Q feet) .
Distance from Septic System (.Niinimum 60 fcct)
Total Uept]�: 3�n -- ft Yield: ,,� ' — G�'M Static Water T.eve1: ,� ft
Water Bearing Zoncs: Depth �� ft � ft,._--�— ft
�
Cssiag: ' �
Dcptli: Fs+�m _ �, t:o �._ ft. Diameter: �� �
Type: C3alvaniud Stcc1
� Weight: '�hickness: � Height aho�e Groun,d: � in
Drive Sha�:�-�. Yes No AnY Problcros cncauntered while setting c�s�n�? Y�a No
�f "yes" givc reasoa:
Grour
. Nea� SandlCemeut Concr�� GxavellCemeut �
An�ular Space Width iz�ches �Vater in ,Annular Spac� Yes No
Mcthod of Grout: Famped Pressure I'o�— Deptht -�--- t° ���
1VXat�erials Used:
I1o. Bags PortlAnd ccmcnt � t�� .�Veigb.t of 1 Bag y � Pound�s
� If mixture (sand, gravel, cutiings) —�tio L to � .
ID plates: � Xes � Na 4 x 4 slab X Ycs _ No
��� �� Location Drawin�
I hcrcby ceztify that the above infoYmation is corr�ct and that this well was constructed 'va accorciance with regulatio
set forth by thc Person County Health Department.
.--•, uy # Z `� � � ii�te / � � La �`�
Si�tta�re of Can�-ac#vz� i�' � . .
�x Il11�fa
g.,,, 4 - Z � -�3 � � ��.
� �
�,� �'`