Loading...
A26 1The District f��lfh Departmenf ,: Orange, Person, Caswell, Chatham, Lee Couaties SEPTIC TANK PERMIT Date /, ! � `— � � � � Name of owner: ��' i��G{ 'l 1'� `=� b�, ���► � f �% y� r � Name of contractor: � � � i � _' -� � � i��. � Address and Directions �,r ��� � � ('� /'� . �t ---� � /� ; 1 � — .-�., ., c Person or firm doing installation: ��% f-' �1, '� '� �,����, C�'% �� Address I`�`# I � �!'"y?�. Cs_r , S-"�_T�'7 b r� i No. of persons to be serve� Bedrooms 1;/'�3, 4. Additional appliances to be used: Disposal, dishwasher, washing machine ,� �'�.0 � Recommended: Septic ta i) 1/7 T� "/� f f �> ' . Nitrification line: �r t2.� � ��- Above recommendation based on information received and observed soil condition. Sentic tank and nitrification line must be inspected and approved by a member of the Disfrici Health Deparimeat sta.ff before any portion of the installation is covered. Date Approved: �I o� — �� By: Countersigned Sanitarian O. David Garvin, M.D., M.P.H. District Health Officer (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 INSTALLATION (Date ) (Road or 6treet) ? + (Road or Street) `; , i' '!. ` .,\ - ( - ;, ;-� . � ,� ;I .-� - /, t,� -- — y, �������� �����, �■■■■�� �� ��, ■■■■■����� ��, .■■���������� .■■■�������, .■■■��������, ����e�������� ������r � f :�pp!ication Date: �' �q � 7 Amount Paid: 0200.0 Receipt #: 3 �1 . �rec�. � ►� Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 1) Arrlicant In r �t�o�: ��� Name: j �� Address: ' 2) Name and ad Name: _ Address: 3) Property Description: Lot Sdze Address and/or directions to ❑ yes ❑ yes � yes ❑ yes � yes ❑ no ❑ no ❑ no ❑ no ❑ no . ��.?,3'�� 1�' ������ "� cC�1CTI��C�Y IE��na-�������.Il IE-]I ��.Il�l� for Services Tao Mag: I�� Y� Parcel#: � �a� �,n`,, � s n _ \.� K.C�� . Services Re uested ' e� ❑ Construction Authoriaation p Fee is de endent on the e of s stem ermitted ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 J o ���1 (� - C,�c � Phone (home): � " � 't'� �� I � (work/cell): ��7 - �1 I�Co � Phone: Q�� '� n,�v�. ��l `�� Does the site �'ontain any jurisdicti6nal wetlands'! ' Does the site contain any existing wastewater systems? Is any wastewater going to be generated on the site other than domestic sewage? Is the site subject to approval by any other public agency? Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: ❑Residential � � : � �lrsfi.c�'9 �� � � ����� ��v ��ru/ �� �v�GT ��cl K�� � ���4' ❑ New Single Family Residence Maximum number of bedrooms: 3 / Occupants: � ❑ Expansion of Existing System If expansion: Current number of be�dr oms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes m no With plumbing fixtures? ❑Non-Residential Type of business: Total Square footage of Building: Maximum number of employe� Maximum number of seats: ? 5) Water Supply: �New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring '- Are there any existing wells, springs, or existing waterlines on this property? D yes ❑ no �;. Please note any known ground water restrictions or sources of contamination: ❑ yes Q"no ',;, [f applying for `Authorization to Construct', please indicate preferred system type(s): � Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any the infor he sit� is 'll,G� above is complete and correct. I also understand that if the information provided is �red, or the intended use changes, all permits and approvals shall be invalid. -- r � � Signature (Owner/ Legal Representative*) Date * Supporting documentation required. Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) Person County � � � �"u�� �w ":�'��� �� ����� �l4a, ` ' �' � � � � � , _ ` , �, � R� � ,� � � � � � � �� wi fi? �,� J e � a � va � �� � §. - � � �r�;, �y �' . - ��.'A° � � �� � � � g t ��� 4 s .5 < � �'s � , P e .� ,�- � }�.��" �_ ,�bv, � °'` ; `�.� �� �" 3�, " u �� e _ � m� �`� � . ' Y��-'' ' ,�„� °�..� 9 �,�,z�°�' � �; � �,. �'�� .;� �' s � ��� �,, � ' �'s}�^ R i .a� � , , a �*k� ���r .�°.z� �'�a°� i ,t ? � �� . ,�.., � �. . - �.ro,�` . � s � '<`.� , ? �r , � . � �- ,�, � . E� � ". ,p`, `�� 3 �, � . ^-q �. �.. . � �w �};' � � €, �s# # "�, � ��- . C�'� ,..: a k t�p � �'� � ,.a � � '°i'�g aq f `� v � _'. y.� � #R � } � �C � t 3.i� �, R � � °^� d '�F �F Y t � h ; .�r .� � 4� t� �, 3 � R� �1,� z.� � � �. s $ � � � �a,�. .r��'�i^�`w � b T � �� � ��� �..�` : }� F . �' 4 a��j e � � � � �,� ✓�.,�! i� ",�,�r� p . < *% �16Y d - � a p�'� '( �� r.. �;� �.� �,t %m � �� �. . t� Y„ �. ��,,�� � z.. �5�� e� � .. 2y � � #�''� ������� ��a ��Rp� ���� `. ^'��� � 4 q�� e� # "'�'M � �v } � � � x.�.� �E g� M . . u�� 15 � a �y5�,�"� : `+.� ����'q;Ri <�:�„ �a. . ���` '�C..r+. - ,a°°t" � .�w:'. "3� � �, ,5 a �+, ..�r� �.. p� R�� � p .. : ,� � 9 .��. �a ^"•,� a� �fyy.'� ;= � ` '� ka # „ �k � i'�.��, .. . <Y;^ e� � � , �1 � �g� � � � � �' . � .t' ' � k .s �, , x �� "'�° �* �r�., � �'� *qEm� i#�"�.� v� 3'� { � �� �'� �'�� � "� � € r � � � ,� � , �r�� � � � .� ` � ,�. -; '"'" so-,: ,� �g �, � � ,. �Y� � � �a.�. � r�� � � : � »�,,.. �r '� � , � �.k ,, � ... ,� if ,�{ � �* � , g�,g � �` a �ryc �' � � ,q q � � . � � �Y �,� ^7p� � a�. � ,-i��9" 4 � �'*� , ��'. �°'+.`H ... '"�� +. . � Er'"` �,. - � .� +� �� ��%�a� � ��s� ���` gF � �� �D � ,k . � 3 „� '� .. ?3 a > � � � '� � .. �. �.T `h,. � ° v �-, � '� }.M� 6 � � a�,y '� .� c �' �4 � � w�.s 3 ,� ?'�„ ��" 4 ��' ��,� � � � �: . ' � �4 °��� .� � ��� �� �` ��, ,� � _ ���_,� �� '� � ' � 4 � � � . �.�`,�s � �<:, � �. � = z �,�°'� �. � ��� � F �� � ��� � ��a,�'" � �1 . � � �' , R f , �� '����r- �;, �. a� . , � .. . ��a �. ,,.� �t a'� r ��� �'� f q�` . . r � . � + �`� a � d � aP.^4 �� { � . . � , . ��� r � � � � � _ �� � � �: . .� < �� �' �• €-'at � a.� 'rek v>�. � s '� � �, � � "� � ;��,, � � i 4 ��. . .. . �, � � � *2 � '� � � . a ` � �' ,',�� .. . 4'Y 6.J �. �� � : y. .�� ,� ♦ � e ,� . N � . " ;€." 'dr� � �� ;"�w° � �`� � � +r � �i %� • y � '� �� SV p �y� . � � b� • xY�. � . f �: ^�J'+` �' - `T W % , - 3 . t � �' � , _ ���� s. � `� 'S � �" rj-; � , , � �'! � x . . � Il ; , t . �`"� �, 1..z�` S �F . 'b � I �+', {'�2 . � � �''" e . � � Y� � • �. � �F � ��M�r�.A,k �c � � � , . . _ � 'sz,� �� � r � �A , ''�_ � # - °: �t.� r �� � �« s " , ,. C� ¢ � _.. , . _ "�,.� � � � � � ' � y �� l � � � � qs� 3�3 � �'61 A_ ' . , � =� � �Il� ♦ .. ..o�.�r+` . . .. . . . M + s �'j �A� °�^¢� :��°,�° i � ' � � . � . , J �1 . , , a. �' t mL�"4�„k . � �°`� r, . . '.`�i,' . �' ���. �3,., �y � '�' .�,: � i� �� � rl . k � 9 � � }� �' � � � '"d� .. � �� . � �, t . "i :6 , �w. r : °^ � bt 4.,� . . :- 4 _:..t . .. , � � : St" .k _'�° '�- i ' � t t t e .,t a* ` d�,�,��" � - � i x,�=,�:. � .� � f _ �. �,�� y . .�.�.�'�1 Ki €� � . ,. � '� S'�� l}it ,.it,& . . .. f � �}y, �. .,_ ��W.� p��, June 19, 2017 TaxParcelPublishing ,� n i < �:" q� � ,¢ �.,a�'a,G:. � .: �� k „ +{6 � a» x . � � D ~i � � '�•� `�.��� � � + � � � � s�=^�`� � �'p ` ° � i , � �• r � `..� -a� °' . �,, ' n � � Rt.• "S`�'a �� �a �•'�+� �� '�� � °�'a � � � � "� r � f � ,�4e. 4�,� .� �:� � ;� k� �` �:� � n ;. � ' � �,� � �;>. _ � ' � �,. �� � � � �'' � � � �y� � � �� � �`' � s�;, ��� � r�, � � �� f � � _ �" �4� c� �� � ¢y, �m � � � 'Pa4 E,� '4 i . , � �' •ty2'� �4 "� � � ��4 ��� �^ ���h y y .. 5 �ic'� , .."� _ ` � �tk��,� � ;`� <�, � �, ��� � � � C`' � ��, "� ��° �w ..,�� � : � � �"� � `- ,� � `� �e P ' � Ka . Y;iv&_ �Sy�. . . � �s.. � � � � � r �� �� x � . ar � ... � «`:; t �" �. � � � � � m.. ,n.� � w �= ��; , �.��� �� � E 'C�•:� J�����'x��'{�%� fi :. �p"�'�' � ' �'., ��� ��i. �.. ., . ��� v� 'Ra'a"� � "$_. -�� � �� x �," , ' ; �� 4 ,` � �"' �� ; °� �_. � ' , a x�g� � �,� � � � ` � � �. :��°� �� .. � i �.i yt� �'� �' � � 0 *� ",� * � � �� yr ,; r �� &#� �' � � � }T K f �� t � E ���� a g , �. R S ,. � � ��� � Y � � � � � A � 'o- � .s �� ��� �� �� . <aa M�3� F.g � , 3 { +i �' � - � * �£`'e' +Y yfi � � A 2�. > E .!� g &�. 4 f$�' .'. � �A �. � �, s j� ��� �-� �& � . � � t � �� ; �� � � ����. � � , � �� q., � b � . -`� �� .�''" �� d'� A , �y F,� �;$� � �, * �, � �� �� � � ���� . �� ��; �� � �� ��;,.�� 1:2,257 0 0.0175 0.035 0.07 mi ��Tr�—� � ��� 0 0.03 0.06 0.12 km Esri, Ina, Person Counry GIS For Reference Ony -Always referto the original source. ���, �� ���� ��T ������ �.f-"e irn�a �r- � 3ra�*-R-� � �n��.:l �� � �. � ��n Applicant: �P i �-ti Address/Location: 9 Permit Valid for: Five Years � Type of Facility: !2 �. Number of Bedrooms �/ Oc � Proposed Wastewat System: Proposed Repair: Permit Conditi Auth�rized State Ageni: _ (X) Owner or Legal Rep Improvement Permit Non-expiring New � Addition �Employees / Seats: Ta� Map: Z�P Pareel: Sub�ivision Phase/Section/Lot # Water Supp;y: ��� l Projected Daily Flow: '3l0o gall �s/day Type: c� Type: �r� t,�,' l� � r s St� �_, Date: ��-(Z� �y— Date: —�- The issuance of this permit b;; the Health Department does not guarantee the issuance �f other r�quired permits. It is th� responsibility of the applicant/property owner ±o insure that all Person County Planning and Zoning and Building Insgections requirements are met. This Improvement Perniit is subject to revocation if the site plan, plat or the intended use changes. The Improvement 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 �uri! Rules fo� Sewaee Treatment and Disnosal Svstems'(15A 1�iCAC 18A .1900). Neitber Person Couaty nor the Environmental Health Specialist warrants t�at tEe septic system wiil continu•. to f�nction satisfacto;:iy in thc fature, or that the water s�pply wiIl remain potable. Authorization to Construct Wastewater System ��`ee site plan and additional attachments (�. a PropQ�s�d Wastewater System: C �.- �' , (*)Type � Design Flow 3� � gal./day New l� Repair_ EYpansion _ Soil LTA�2: ,�S gal./day/ft2 Type of Faci lity: �� {Q�e S. Basement: _ Yes � No (�k) System Types Illb, Ilibg, Ii�, «nd V, require periodic system inspections by the Person County Health De�artment. Wastewater System Requirements Tank Size: Septic Tank � e3c� gal. Pump Tank �— gal. Grease Trap '� gal. Drainfield: 'Total Area � �� sq. ft. Tota.l Lengtl� 3� c7 ft. Max. "french Depth � in. Trench Width 3 ft. Min.Soil Cover _� in. Min.TYench Separation � ft. Distribution: Distribution Box / Serial Distribution� / Pressure Manifold _�_ � � �'e-41 ���ar�ik4 � So i � < n,.. . l���os-�,'�,,., s_ �33(o SQ?�l Authorized State Agent: Z " -{�-Q�ce� Issue Date: '��i'`!'7 Permit Expiration Date: ?-a 7� 2Z The system permitted is: Conventional /Accepted �i Alternati�e / Innovative . I acaept the conditions and specifications of this permit. (7ti) Owner or Legal Representative: Date: Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) m �� S� ���1C��1�T Name: �i ~ "' �� l� Subdivison: �;����� lE��sm��em�mIl ]E�emIl¢fln � Site Plar. � �,{�►"PYt � Address: Lot: EHS: Date: Tax Map: 2-�P Parcel: � � -a ---- ---- .s � �,,.,� '�, . �, - . 9a---• , :, _ � ;' N �,' a, '\` ���,P�� r} t� i, � �b ` 4 6 . ��11 \ / 1 4 c�� � ^� � � �1/ � � � 1, , . \ ,• \ '�, ��n�n�^��na�c�na.��n.� ���.��� ,�,, � ,� ,; \ , �•. ': ', o ' �� �', �� �'�� � l �� . ��, - � ; •' ' " . � �'�, �'� '� �'�, ', � .. \ ', - � , , �',, i ' i `\\ , � , ��1 ',' ''' � � � '� � '� , � � , , , . , � • � - � , � , . , � , � � , � � � � � � � ; , � � � � , � , , � � � � - --------------• � � , ,,`� _ � � � � � �t � ; _ , � ��� ', "�^�\ � { i � \ ,', ' Q1 ' ' � ; � � , / I ' O 1, ,� soil corner soil corner �� � � , ; � • / ' . �I � � � � '� � N ,, ` �� ' �, ' �'� � - ; " \� b(�e(� ' �� ', � �'� 25�i / ��i� �eq' • /1C 6•t�;����,o� ' �'� ���, o ��'�, ' , ' x.drainiine � � '�� �� ''� � � � � ,' ;,` \ , ,STO � \ , �� 1 ` .•,, \ . ex ex drainline 6'j? �•, � � �� \ ----- S il or -__•ti\ �ip ',� `\` ,. `9� S88 . � ouse � 6+�, \ \� . ,. • \ •�a�, �,Q ,' `'��,1' `\• , ,�j� house oM �� � '�\ �---. ' "''''C� s�o ,���5�� ' `��` �'\ � . � �, ,\ � ; ;. , �,, � , \ �o weus. '�\ ,. Ol �, \L�'' � . � �', . . wyl,�"�e`l .�� '\ , --- �� � �� �,%Cl�j '6,j �.� �.\ ------- � � � �., ��� •.,, . �` '� � �\ . ' \ �� � . �,?Q ` : \ ' \ �' -------- '`, ---� ' \ ,, ; , '� � -------------- .'• •'• �,, ��, Legend ---- ___ p_�_ '', � l;S�. `� �$-Q� 9 Point_ge � , ' � \ � Tax Parcels � 50 0 .-' 20 �'� 3 0; 400 N �`, ,, �, s�s, '�, 0 0� Feet ����' '��, •�1 inc =�1 0'�e t'� o� i `° .. '� � System Type: C Septic Tank: `� gallons Pump Tank: � gallons Total Linear Feet: 3�0 Max.Trench Depth: 2� " � S�In� C.Or�►�r� �� JJ� `�� D��ii� / Itl�Q�D� `�R� . WI _ _ . ---- - � / - �: Dc�Q lto�se s� I� 0�01� S�� � �.ec�m�-,�..�P aba��n;�� .��'�s4�� SeP�� �a���-1��� �c� ,,�.e,us. — ��+'M� -1- �L� �"� a��a� ��Pi�� � � �1W��1 Tqi^ s�. SPP-er0.'��Ur-� W�'I�'Q,.� �2�`S�'�.r �✓Q�vlllY2S J A �.�� !/(-P�J ��r .�l � % �t.2 S , Scale• � � l �� Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prio� to installation. 2) Contact Person County Environmental Heaith with any questions (336) 597-1790. Additional Comments: � :�t Tax Map: � Subdivision: `��` 7� )� ���� �� � � � ���� I� ��n,� � �.,� m,� � �.Il IE3C � �. ll. �1� Parcel: �_ WE�L PERMIT (New Repadr_) Lot: Applicant's Name: �Qv�� SQ WvP,�,,,� %��,_ J�a%Q�-� Mailing Address: Phone Numbers: Location of Property: � 3�('2, o,•�c� /' �t llr 4�__�� Permit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and County regulations governing construction and setbacks apply. 3.) Permits expire S years from the date of issue. 4.) Issuance of a permit does not guarantee a potable water supply � Other Conditions/Comments: Permit issued by: wt � �ew Well: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Installer: Approved by: Additional Comments: Date Sample Collected: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C Roxboro, NC 27573 Date: rl a-`�' c Certificate of Completion OLiner: • EHS/Date Depth: � Grout: DAbandonment: Date: Method/Materials: License #: License #: Date: Date Results Mailed: Phone:336-597-1790 fax:336-597-7808 li/26/13