A26 174Application Date: �-�g - � � � �' Tax Ma ,� '
Amount Paid: 0. O C i'ec� �'i- �a ��.:.��J�, ���� �� P� �
Receipt #: � �3 70 ��u`""� (�; � ���(°� Parcel#i � `jT
1-�"".un-s-an-aD,•r,.,�,� � ana:,m.Jl 7��I�.a.]L�,l�n
C�
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 if> 600 d)
obile Home Replacement or Building Addition
�15G.00 (if site visit requiredj
0 'Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
for Services ,.
0 Construction Authorization
(Fee is dependent on the type of system permitted)
� Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Chazge/ CA $150.00 or $300.00
1) Applicant Information:
Name: 2l�i1G >��,�5
Address: 2 wi �, r, i.,�-
�%�'�_
2) Name and address of current owner (if different than applicant):
Name:
Address
Phone (home): J?i�o �1�'� �6 5,3
(worWcell): 33� 58 !�'l'O'7
Phnr.e:
3) Property Description: Lot Size: �i910/�Subdiv;sion: Lot #:
Address and/or directions to Property: Z$�.Z L�%in i"/! G r'c�
❑ yes rd'no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes � no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
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4) Proposed Use and Type of Structure:
❑Residential
❑ New Singie Family Residence Maximum number of bedrooms:
0 Expznsio*► of Existing System If expansion: Cu;rzrt r•�mber of bedrooms:
❑ Repair to :�:lalfun�t:oning System Will there be a basement? � yes �7 iio 'vVith piumbing fixtures? ❑ yes ❑ no
❑Non-Residential ?�7� ��d�
Type of business: Total Square footage of Building: .7 C��
M�ac:mum number of emplayees: i�zximum numb�r of seats:
5) Water Supply: ❑ New well ❑ Existing Well ❑ Comrnunity Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is subsequently alt�red, or the intended use changes, all permits and approvals shall be invalid
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
��S'-I Z
Date
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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Building Additions/ Mobile Home Replacements
Tax Map #:�� Parcel#:�_ Address: r•
_ �ox� 7
Approval Requested for: obile Home Replacement
__�uilding Addition .
Applicant Name: �
Address: 2�5 Z� ' '� � •
Phone #'s: 2�[� -S9�I - �1�53 33� - �8 2- �0707
Permit Located: �/ Yes No
Installation Date: -- 0o Design flow: $D (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: V Well Public or Community
Wastewater system shows no visual evidence of failure on: �- 3 D-1 Z (date)
(Applicant's signature if site visit is not required)
Comments:
Addition/Replacement Approved
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Envir nmental Health Specialist
S -30 -�Z
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 wwv✓.personcounty.net
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Name � ��
Subdivision
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`Autho�ized Sta.te Agent
SI'I'E ��TCI�-I
Tag Ma.p # ?!� Patcel #��_
Section/Lot#
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Date
System cvmponents re�resent u�iprmxirnate�contours only. The contractor »aust flag the syste�vra�irior to
beginning the installation to ansure thut pnopergrwcde is maintained
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Amount paid 3%�.
Receipt f� ' �p�o�
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Improvements Permit.(Established/Recorded L,ot) _. Reinspection of Existing System (Loan Closing)
Imp.Fovements Permit (Unrecorded Loc) _ Repair/Replace existing Sepcic System
improvements Permit (Mobile Home Replace) /FSermit for New Well
Improvements Pecmit (Addition) _ Replace Existing Well
i s � :: �i t ¢.� r �ire. `y � t _i'"i � r � ::y, � '� ,'7; i� �x.�'Y`�.�r ^oty;
, : F,� „ � , � �WaEer Sample to.:be Collecied '��' ` �` � , � �` ���"y�'
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`s Bacteria 2�� Chemical PetroleumN _ Pesticide _ Lead
ermit requested by: . 7. Dimensions or Proposed Structure:
ner prospective owner/agent:�chn a-�Inn �rrard. Width: �o ��
3ress: S3 ,�ad�er �rr.�e _ Depth:� _
ome Phone #: 59�- �ln�1S
usiness Phone n: 597- frlo9S
Name and address of,current owner:
o h r► d-
Property
✓
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n: Lot size: a o• d$ Ac.vtS �
Tax Map#: �ar'Eion o� d�;
Parcel�: i� - o2S?
Directions to property: State Road #& Road
ames,gtc.
Lt. on
Number of occupants or people to be served:
What type (if any, additions, expansions, or
lacement is an[icipated co the structure or facitity
t this sewage disposal system is incended to serve?
9 Watersupply tSPe:
rivate t�. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes � No [�.
If so, identify location: Snark� p�Ae.rr��_ ar a-
1. Type of structurelfacility: Proposed: �Existing: Q�
Type of dwelling:
House:'� Mobite Home: Q Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �—
Garbage Disposal? Yes m No 0
Basement? Yes ❑ Nofl If so, # of bas�ment fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTIJRES•
I hereby make apptication to the PersOn County He31th Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the conten[s of this application are true
and represent the maximum facilities to be placed on the property. I understand if the si[e 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 even[ I have not
deiivered a survey piat 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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REGISTER OF DEEDS
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B 3087
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # �}' - �"� Parcel # /�
Zoning Township 4/iv� � � �u-
Date � o '30 -��,
Owner/Contractor
Location/Address 5S(��,,��r�'�Q�.���G �'/��73 .
� � � S.R.# /3�2
Subdivision Name Lot# oL �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area 0•O� us Size ofTank (��e �.�nY�
SFD ✓ Mobile Home Size of Pump Tank N A
Business # of Bedrooms�_ Nitrification Line ��X /f,t.jb
Max Depth Trenches a 6`�
Permits may be voided if
Well and Septic
Comments: �
by.
is altered or intended use changed.
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Date - '"� Installed by �),(�P,,jA9 ��j Approved by.
Well Permit Paid � WELL SYSTEM SPECIFICATIONS
Individual ,� Semi-Public Required Slab �-
Public Replacement Air Vent
Site Approved � Required Well Log -
Well Head Approved � Well Tag h�
Grouting Approved �/ ( �� � os ; b �'
Comments:
Date cl� o Installed by L(CL Approved by ,
This report is based in part on i�formation 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 applicatio�. Neither Person Cou�ty 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.
c:\amipro\permit.sam O1/95 rev.l.l
Person County Health Department
Environmental Health Sec,t--iro�n
Tax Map #: � � Parcel #: � J-1
Zoning: Township: alr� l�l'� G I(�tii
Subdivision: , �I �I�ee Section: Lot: ��
Applicant: �j�c�t
�ocation: G✓ I1% ' (� � �"� G ��,(,�. �Ul���1 I�t •
� �e �) v�-a.� -ro r-t tot � oYI V't�.
�-[� w�v�� Ta,U 1�;C�tvt� �1 ,
peration Permit
System Type (In Accordance With Table Va): i
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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Tax Map #: ,�}� �
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Date
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2 (d�'
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Parcel #• � �� -�
PCHD, rev. 10/12/99
Person County Health Department
Environmentai Health Section
Zoning: Township: Q�( h° �( � � _
Subdivision: �l �1��� _ Section: Lot: 2�_
AppUcant.
Location:
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requiremer�,ts ✓
B) Distance from system to any wells llt
C) Distance from septic tank to foundation �Z
D) Distance from system to property lines z I n`
2. SEPTIC TANK
A) Visually inspect the exterior walis 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 - a
D) Tank seriai number - - Z
E) Liquid capacity of tank ��D� gallons
3. SUPPLY L1NE TO TR NCHES
A) Grade �1/8 inch per foot minimum
B) Material sup �y line i constructed from
C) Diameter
D) Length ,.,,(p � �
E) Distance from tank to drainfieldldistribution device �_
4. DISTRIBUTION DEVICE(S)
A} Type .
ttt B) Is Device water tight
N��C) Distance from the distribution device(s) to the trenches
D) is the device on a level foundation
E) �oes the device pertorm according to its design specifications
F) Record the inlet and outlet etevations
5. NITRIFICATION FIELD
A) Trench depth mches
� B) Trench width inche�s�� �� L�,�/l�t'ir
C) Distance between trenches
D) Number of trenches 1
E) Length(s) of trenches �_ -
'F) Aggregate depth J� �' inches
G) Aggregate material and size
H) Record septic tank o tlet elevation
I) Trench grade )ll/I�/1 (< 1/4" per
. J) Step downs J ✓
a. Minimum of 2' of undisturbed earth
b. Proper rise over step down
c. Solid pipe used i/
d. Elevations of step downs �(R cord elevations and show on as built)
°i ' ' - lan�on attached sheet.
See as bui�p
PCHD, rev. 10/12/99
D a t e : �..'_�.�.=.��il
Owne�.�----
Locauon/Directions;
Subdivision Namc: .
C � tractor•
Y�RSUN COUNTY ENVTRONM�NTAL H�ALTH
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SR# ,
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Dnll�ng on • �,�Y � �QNSTRt?�I'iQN
Distancc from Ncarest Properry Linc _ Distancc from Source of
P�llution �p GPM
Total,Depzh: QO F� Yield: . FI
Water $earing Zones: Depth _Ft�_.
C De th•
Static Water Level Ft.
Diametcr:
asLng. p ,• - - ----____._---- — � .
'I'YPE; Stcel ' �Galvanized Steel
If �Steel, does owner approve: Y�s No____:___.
1�eight: _'1'hickness: • ` Heighc Above Ground:__._____ I:�ches
Drivc Shoe: Ycs No _ . __._.�--
Werc Prot�lcros Encountercd in Setting the Casing? Ycs - No_______
;i "ycs" givc rca.�on:
Gmuc: Type: Neat _ Sand%Cement Concrete
Aruzular. Space Width I2.___�nchcs
Water in Annular Spacc: Yes _ No______
_ Mzthod: Pumped � Pressure____.__ Poured ��_
Depth: From O,_ to O Ft. �
Materials Used: No. Bags Portland Cementa. Weight of 1 bag_r____1bs.
xf mixture (sand, gravel; cuttings) -12atio: _ to _ .
Tl� P]�tcs: Ycs � . No _ � �
4 x 4 slab Yes _✓ No
I HEREBY CERTIFY THAT THE ABOVE TNFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULA'TIONS SET
FOR't`H By�THE PERSON COUNTY HEALTH DEPARTMENT.
,
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Signat�irc of Contract � Datc