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--=Person Courrty Health Depi OB v
325 S. Morgan Stre�t �, ,6
Roxboro, N.C. 275�� a°� �.IO
Gqtirier �02-?5-15 �
- ✓ ^ �� �,�
Date
Improvements Permit.(Established/Recorded I.ot) _ Reinspection of Exis[ing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Permit (Mobile Home Replace)
Improvements Permit (Addition)
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_ Bacteria
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Permit for New Well
_ Replace Existing Well
_ Chemical � _ Petroleum I Pesticide � _ Lead
1. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospective owner/agent: Width: 1 ? �.� �'
. . . / �,. _ , . _ . .-, � �'l "T _ i ,= �' TlPnth • � �
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Home Phone #: � �"J :S� %�/
Business Phone #: �
I�Iame and addre&s of:current owner:
. Property D
. Tax Map#:
Parcel#: _
Township:_
on: Lot size:
8. What type (if any, additions, expansions, or
- replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
Directions to p,roperty: State Road #& Road
ames,gtc. LU� _
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6. Number of occupants or
9. Water suppl y pe:
private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes No �.
If so, identify location:
10. Type of structure/facility: Proposed: �Existing: Q I
Type of dwelli . �
House: Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: _ __ __
Garbage Disposal? Yes ❑ No Cl
Basement? Yes ❑ No�1 If so, # of basement fixtures:
CLEARLY S L CORNER I�E PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I he y make application to the Pet'Son COunty Health Department for a site evaluation for the on-site
s vage disposal system for the above described property. I agree that the con[ents of [his application are true
nd 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 proper[y to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. wichin 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall beco� void and all fees paid forfeited.
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SignccyOw�r or Authorized Agent
NOV-20-20� 16=02 FLEXTRONICS
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shalt be issued until Authorization for waste water system construction
has been issued.
T� Map # �- �. � Parcel # � "7 �
Zoning rre� Mc.�r ► J Township ` ���
�Contractor ` Date '7 2 I— 9 9
Location/Address 5''? �V• — � .l9 �-�r� � --�
ivision Name
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S.R.# % 3 D �
Lot#
SEWAGE SYSTEM SPECIFICATIONS ` Q�
Lot Area /• t-F ��C� Size of Tank 1 d-�-� � '�'
Mobile Home Size of Pump Tank --"
# of Bedrooms 3 Nitrification Line � 6�k 3�
Max Depth Trenches 1 � `.��. ��
Permits may 6e voided if site is altered or intended use changed.
Well and S tic Layout by ` .
rCommen ..-� G� �� ..19,
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Da�e���✓1— Installed y c). �t�,UtS Approved by
eli Permit Paid
SYSTEM SPECIFICATIONS
Individual �/� Semi-Public Required Slab
Public Re lacement Air Vent ,�
Site Approved Required Well
Well Head Approved Well Ta��
Grouting Approved ' ' �,p,QQ, j�
Comments:
Date - Installed by
Approved by
0
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This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisf�ctorily in the future or that the water supply will remain potable.
c:\am�pro\permit.sam O1/95 rev.l.l
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Person County Health Department
Environmental Health Section
Tax Map #: �%� Parcel #• �%�
Zoning: Township: �.�.(�{%� —
Subdivision: ������5% Section: Lot: '?
Applicant: ���� ��`�'�
Location: �� �tl �"/� �a��5 Da,�_� s/� �v� r�'
O eration Perm it
System 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.
, � 5-31-D�
thorized State Agent Date
Tax Map #: ��P Parcel #: �%�
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section
Zoning: Township: �lll 1 �P � ,�,� _
Subdivision: JQ� I����� _ Section: Lot: _.�L_
Applicant: l,Gt,Y l� � �� Y 1 i� —
�ocation: J�7 /v `�(� fi✓1 i�MQ�� ���i Kk� •�D DV2 �.
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements �,,�_.
B) Distance from system to any wells �_
C) Distance from septic tank to foundation
D) Distance from system to property lines /D'
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank ✓
B) Visually inspect the interior walis, 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 TRENCHES
A) Grad��Pl��lQ� i1/8 inch per foot minimum)
B) Material su pty line-�s constructed from �i
C) Diameter ��
D) Length � �
E) Distance from tank to drainfieldldistribution device 2
4. DISTRIBUTION DEVICE(S)
A) Type
���B) Is Device water tight
C) Distance from the distribution device(s) to the trenches
D) is the device on a leve{ foundation
E) Does the device pertorm according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth mches
B) Trench width inches
C) Distance between trenches �� lI!/1 (,('�_I/l��i�
D} Number of trenches
E) Length(s) of trenches
F} Aggregate depth ��_ inches
G) Aggregate material and size
H) Record septic tank uttet elevation
I} Trench grade (< 1/4" per ')
. J) Step downs
a. Minimum of 2' of undisturbed earth �_
b. Proper rise over step own �_
c. Solid pipe used
d. Elevations of step downs (Record elevations and show on as built)
See "as buil pfanl� attached sheet.
PCHD, rev. 10/12/99
- --- PERSON COUNTY ENVIRONMENTAL MEALTH
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SifSTEiIA LAYOUT
Tax lllap #: �d`(o Pared f � I -
Zoning Township ` 2 ��I
,�ua„� L � sa ►�aYfi � � ..
�nwuon: � 7 N
� yCArt�s ���
s��: I/V�.ld ►Qose � ,,� g'
Improveme�t Penr�it
A buildinq aermit cannot be issued with onlv an Imarovement Permit
New Repair ✓ AAddit[[on Type of Struc�ue � Water Supply �" � ry .
� of o«x,� �.��� e�� 3 on,�
sasemer�r �, easen,errt F'c�s? �l�
Projected Daily. Flow: � g.p.d. Pertnii Vaiid Fa: C1 Fnre Years 0 No Expiratton
Proposed Wastewater System Type:
Pump Required? es . o
Propased Repair : � � � � � � �_,_.q, ��u
Peimit Conddlons: ' ( ft
��
Owner o� Legal RepreseMative SigAature• : Date:
Authorfzed State ABecrt: Date:
The issuance of this permit by the Heaith Depa�hment in no tees the issuance qf other pprmits. The permit
hoider is �espct�sibfe for checicing wiih , appropriate goveming bodies in meetlng thei� requirements. This site is
subject to revocation if the site plan, piat, or tfie i�rtended use cl�anges. The Improvement Permit shatl not be
affected by a change in ownership of the site. Thls peRnit is subject bo compiiance with the provisions of the�
Laws and RWes fo� Sewage Treatrnent and Disposal Syste�ns of the North Caroiina Administrative Cade.
Authorization To Ccnstruct Wastewater Svstem (Reauired for Buitdina Permitl
Type of Wastewater System CAYt �`�'�� �� wastewate�r Flaw: 36� Q.�.d.
Fac�liiy Type: � �'�� �.S .
Basement? 0 Yes �No
Wastswater System Reauiremerrts
:Septic Tank Size• �° 6 a gaqons
New 0 Rep 0
8asement F 0 Yes j�'No
Pump Tank Size: �— gaitons
Total Trench Le�gth: �/'y'� feet Maximum Trendt Depth: � iruhes p+99� �P��� �-
Maximum Sai Cover: G inches Trench Separatton: �( Feet on Center -
Other: .
Permit Expiratio�t Date: yL?� �ivP,i,G �I�r�, . .
Autho�ized stace Agen� Oate: ' `1J"22 --Da .
The type uf syst�eem pertnitted Cl daes � 0 oes not differ from the type specifled on the appiicatIo�. 1 accept
the spedftcattons of thts pernitt
OvmeNLegal Represantative Slgnatiue: Datie:
PCHD, rev.11/18199
. .--�---- _ ... . ._.... __....._ _. _._..._._. ... �
Person County Health. Departrnent
Environmental Health 3ection T�x Map #; a�O �
_ � Parcel #: -� � �
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-- ---- -'� � 5 a � �►�a�'r
Ap Ucant' Name
. Autho ' tate Agent
S1TE S14ETCH
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Subdivisi NSectioNLot#
!(- �-a- �o�
Date
System com�pone�ds npresent appraur3mate cnntnr�rs only. Ths contractor must flag the systern
prior to be � the installation to insure lhat pmpergrode is malntuined �
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