A26 183Application Date: ( � ����'
Amount Paid: .UO
Receipt #:
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Person Countv Health Department
Environmental Health Section
APPLICATION FOR SERVICES
Tax Map #:
Parcel #:
IF THE INFORMATION IN THE APPLIC�TION FOR AN IMPROVEMENT PERMIT IS FALSIFIED, CHANGED, OR THE SITE IS
ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested� by•(Owner/agenUprospective owner): /Co��i f/Yd "`'���
Home Phone: c5�55'S�rS�/� Address: 223 �'aa('s %�1Y2 2c%
Business Phone: �S'S'�—�v77 nXs�,['v �/1!C. 27�'��
2) Name and address of current owner: �O/(/�/�✓ �'� /Y� "�'����
ZZ,s' /3/�ov/<s /�i5(Z/2i/ /�c%
?e�.+'�5a/7�. �l/.�• ?7 '73
3) Property Description: Lot size: �c.�' Township: O/I�'�< <
Directions to the property (Including road names and numbers):
T.�/k� 1��' i
�s i Pil.S/
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed �!!Existing �
b) Stick Buiit �:� odular C, Single Wide ❑, Double Wide ❑ �
c) Number of Bedroom� :� d) Number of occupants or people to be served: _
e) Basement: Yes _t/No ❑ If yes, # of basement fixtures: �
f) Garbage Disposal: Yes ❑, No �
g) Dimensions of Proposed Structure: Width: Depth:
5) Water Supply Type: Private�w �xisting ❑), Public ❑, Community ❑, Spring ❑
Are any wells on adjoining property7 Yes ;�o � I f yes, location
6) Piease Indicate Desired System Type: (systems can be ranked in order of your preference)
�Conventional _Modified Conventional _ Alternative _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for
the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be
piaced on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand
that as applicant, I am responsible for identifying and marking property lines, corners and making the site accessible for the
personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the
Health De ent if my property contai any wetlands as designated by the Army Corps of Engineers.
' � �Z`yf�f
Owner or Legal Representative Date
PCHD, rev. 10/12/99
Application Date: — � I.J
Amount Paid:
Receipt #:
n
❑ Improvement Permit (Site Evaluation)
$200.Q0/$300.00 (if> 600 end)
� Mobilc Home Re�lacement ar Building Additiun
$150.00 (if site visit reguired)__
❑ Wetl Permit (New/Reptacement/Repair)
$300.00/$200.00/$75.00
��� ) ` ���� ��. V Tax Map: 2- �
.__,. .• • � Parcel#s
�� ������
�E�.mawnn-cnanaanc3�m.d�..2 7HIv.m.]Li.sLa.
�lication for Services
Services Re uested
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revisiou
$75.00
pair of Existiag Septic System
Application: No Charge! CA $150.Q0 or $300.00
1) Applicant Information: ��
Name: �o �e.. j /%a `^k .^ �1
Address: 333 ,(3n, o/<s n ,'�.i ��1.
/2c� .ibo.�o � /Y� .
2) Name and address of current owner (if different than appiicant):
Name:
Address:
Phone (home): 336 —s� y�— 4'Z 7 6
(work/cell): 33 6� S� 3— Z 8 7s � p„� I �
U.! (
�1e.�-�
Phone: � h,� c�aTi(�
I,.�i 1[ h�e ,�; �,
3) Yroperty Description: Lot Sizz: % t� Subdivision: Lot #:
Address and/or directions to Property: �,_'�,s r�/.Jr�—e .�,1 �2,� ��sn �/,'�� �,�// /��i/ f�i
3 �Io��� o� /�',�"� � �
❑ yes Cil.ue Does the site contain any jurisdictional wetlands?
❑ yes C�J-no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any �vastewater going to be generated cn the sitc ot:�eT than domestic sewage?
❑ yes CJ no Is the site subject to approval by any other Fubli:, agencv?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting docw-ner,tation)
�4) �P• p�sed L'se and Type oi Structure:
BRe�ide��tial 2
�7 iVew Single Family Residence Maximum number of bedrooms: v
�❑ xpansian of E�isting System If �xpansion: Current number af bedrooms: �
epair to Ma(functioning System W'iil there be a basement? (7 yes ❑ no With plumbing fixtures? L� yes 0 no
❑Non-Residential
Typc of business: __
i�iaximmum number of employees:
Total Square fuotage of Building:
Maximum number of seats:
5} Water Supply: ❑ New well Ly'Existing Well CI Community VVell ❑ Public `Vater ❑ Spring
Are there any existing �vells, springs, or existing w�aterlincs on this property? O yes ❑ no
G) If applying for `Authorization tu Construct', please indicate pre%rred system type(sj:
❑ Conventional ❑ Accepted f� Innovative ❑ Altemative ❑ Other ❑ Any
I ceri�
the information provided a�ove is comp�eie and eorreet. I also urtdef�stand that if tlie infortrtation provided is
�r if t e site i� bse rentl}� altes•ed, or the inlended use chafsges, all pe�•mits and approvals shall be :n-�uli��
_ � G��z� d (� D(�
Date
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
Permits are valid for either 60 months or are non-expiriug 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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HAMLETT-JENNINGS
k ASSOCIATES, P.A. •�"•
PROFESSIOwu. LAND SURVEYORS �
212 5 LA►IAR STREET - PO 80X 1266 .
ROX80R0 NORTN CJ�ROUNA 27573
(336) 599-87t2
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PROPOSED
SITE PLAN
ROBERT E. HOWARD
SCALE 1" = 40'
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ZE�.�a-��mm.� ���.11 �33L��,1L�
AQpiicant:
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T3�x fvl�p • � pa,r�,-�� � �
S��i h ef�i �� i�5�i a►,i
Ph�,�se�Sec�tioia`Lot ;�
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� C����rati�n Per��t � . �
System Type (in Accordance Wiih Table Va): .
TF11S SYS'fE91A HAS BEEiV INSTALLED IN COMPtlANCE lNITH APPLICABLE NORTFi
CAR L1Ni4 GE�IERAL STATUTES, RUI�ES FOI� SEWAGE T�tEATMEAIT AND DiSPOSAL�,
�►►ND L CONDITIOPIS OF' THE� �:`INiPROt/EMENT PEFiANIT �1N1D CONS�RUCTION
AU R17� N: .. . ,... ... . .' . . . . . .
� . ��..�._ ,. . - ' -. . . � .�� � i��.�.:.. . .� . .. :
. � � Authorized State Agent � ::: � .Da#e �
. . . �a �=����. .... � : .... . .
Instailed By: � I� S . . � Date: � ��-� ( �� ��
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PCHD, rev. 07/29/02
��D S���iC �NK aNS���TI��I ��iE�B�.lS�' (Ty�se il ' ��
Tax Map #� Parc�! # 3 Systern Type {Table Va)
OwneNA�piicant ' Subdivision
Address/Location Se�lPt�ase Lot #
State ID/da#e
Capaciiy.
Tee .and Fiter
Baffle
c�,.,.t...,s .
. . .,..,.... .. ..t.,+.............
� Tank Ou�et: Seai � � � �
� Permanent Marker � � �.
, Pump Tank
_ _. tate ate � � �,
- Eapac�.y gai: �
. . � � Waterproof ISealarrt .
� � Riser .
Water Tigtrt
� . . Purnp
,.. . . � _:� .> Cl�ecic Valve/Gate. Valve: �. �. . ...
.. - : Ant�-s� on o e .
_: . . � Floats/Switches . `. � _ .. . � � - �- � . : _
`� Alarm visable and audibte
� Electrical Components
� Rate m
Approved Pump Modei
Blodc Under Pum
Pum Removal RopelChain
� Distri6ution S�/stem
Seriai Distribution '
ressure an
Low Pressure Pipe �
Appr. Pipe Material and Grade
—
a
a
Width
Trench Grade
Trench S�acing
Rodc Depth and Quaii
Dams/Stepdowns etc.
Pressure-. Laterals
Hole Saacina
Pipe Steeve :. �
Tum-ups%Protectors
' Required Setbac�Cs
Fram Wells �.
From Property lines
S#ruGtur�s/�asem�nis
�ic . es rama�e ays
Surface Waters � �
Public Water Supplies
Vertica! Cu#s (>2 ft)
Water Lines �
Vehide Trafftc
Easemerrts/Right of W<
Other
Easements Recorded .
Comments�
pcf3d rev. 3N 3/01
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I���aa �������.IL IL--3L�;�.Il�]�
Applicant:
Location:
Permit Valid for F've ars
Type of Facility: � .
# of Occupants of edr
Proposed Wastewater System:
Proposed Repair: �c2p�/�t�iV�2,
T�x M�� " Parc�el # •
S�ihciivi�s•ioi�
Ph��s�e Sec�t�ioi� Lot #
Improvement Permit
_ No Ezpiration �
New�ddition Water Supply �_
oom Pf ojected Daily Flow 3� g.p.d. ��Q
+�t� d��Ik l Type: �1�=f-`�
Type:
Owner or Legal Represe
Authorized State Agent:
Date:
Date: � �
The issuance of this permit by the Health Department in does not guarantee the issuance of other pennits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation If the site plan, plat or the intended use changes. The Lnprovement Permit is not affected
by a change in ownersh3p of the property. Thls permit was issued in compliance with the provisions of the North Carolina Zaws and
Ru[es for Seivage Treatment and Disposal Systems' (15A NCAC 18A .1900).
�% Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (�.
Proposed astewater System: ,-{�`�l�t ( Typ� Wastewater Flow ��Og.p.d.
New � Repair x ansio _ Soil LTAR: � 3�� g.p.d./ ft 2
Type of Facility: . Basement _ Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: � gal Pump Tank: �� gal Grease Trap: gal
Drainfield: Total Area: sq ft Total Length � ft Maximum Trench Depth � Z "
� �
Minimum Soil Cover: � in Minimum Trench Separation: �_ ft �
�
Distribution:
Specifications:
Distribution Box Serial Distribution Pressure Manifold
Authorized State Agent: ,/�G,t�h L-t �l✓L
Permit Expiration Date: _�
The type of system permitted is �I/ Conventional
the pernut.
Owner/Legal Representative:
c
Date: G� �� � �
Innovative Alternative. I accept the specifications of
Date:
_ ...__ ... _.
PERSON COUfVTY ENVIRONMENTAL HEALTH �
pLEASE SEE ATTACHED PLAN FOR WELL StTE LAYOUT
Tas Map il:
�-�6� � �.,. 1 ��3 � �
�� TownstdP
�
subaivhlotc -
s.�o� '-°�
Weli P@rmit
�ae of Water Suaaiv: Individuai Commun'i#y Pubiic
Reauirements:
Site Approved by : '�(`� `�a� ✓Da
Groutin9 APProved y. S-��- S N .
Well Log �tk 5-.� �-oa
Well Tag _
Air Vent �—
Hose Bib -
Concrete Slab
Weil Driller: ��t �
� . ,� l.�
Wetl Appcoved By.
_ N � �o�s � Dn � �.k,c; �r
� -��.K.�d c�`� .�r'" ` � � .
5
. .�rou�'^� �
nate: ��� 3 �'v °�.
**See Atffiched Site Sketch''"k
Weils must be 10 feet from property lines.
iQlells must be 100 feet from septic systems.
Wells must be �at least 25 feet from any building foundation.
Other conditions:
G
PCHD, rev.11129l99
_��.s� .���.�c�.�
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�' arn�n�-�mi.aaa��rn�.rn.Jl
����.���a
D�6�[k�[i' OD � _____ �- 0 3 /
D` ° [� w� �J fl"K s 1�l-1...�L? r,, I%.� S
D�o Dc��[lo�l - S� �-S� a a— '
Well Lo ;
Owner: J�, � ,�r'�-- �,�-.,.� <t–r�
Location. Tax 1�Iap �-� parcel # _�
Subdivision: Lot #
—_
Distance From nearest Pro e Line �'�'ell Construc "on
P rh' (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet) ✓
Total Depth: ,'6 Y$ yield: �PM Static Water Level: __
Water Bearing Zones: Depth �� d ft ft ft
�� ft
Casing;
Depth: From D to _� Z ft, Diameter: 6� �
Type: Galvanized Steel •� �—
Weight: �_ ���ess: /� Height above Ground: � in
Drive Shoe: �/yes No An roblems encountered while settin = casin �
If "yes" give reason: ~ Y p � � • _Y� ��Vo
Grout:
Neat: SandlCement ✓ Concretc Gravel/Cement
A.nnular Space Width � inches Watcr in Annular Space Ycs ✓ No
Method of Grout: Pumped Pressure Poured ✓
Materials Used: � DeP� O to a-o Ft.
No. Bags Portland cement �_ Weight of 1 Bag �_ po�ds
If mixture (sand, gravel, cuttings) – Ratio Zo _L
ID plates: �Tes _ No 4 x 4 slab �-- Yes No
> DriLlin� Lo� . .. _
1 hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person County Health Depart�nent.
Signature of Contractor �� � •
-�. #_ 0 1 I)ate , S .� na.
— -
PC'�ID rev O1/16102