A26 38Application Date: �v �a ��
Amount Paid:
Receipt#:
��`�� ���$� ��
+ _� � � ����Y
7£ ��rn.vn zr-a.a �rn �ra-n_.e> na. cG.en.Il. IHL .+c�.zn_ Il. cL-.Il-n.
Application for Services
(Sentic Svstems and Wells)
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
O Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
Tax Map: A z�
Parcel #: 3g
❑ Construction Authorization
(Fee is dependent on the type of sys
❑ Permit Revision
$75.00
C�—�pair of Existing Septic System
No Char�e
Important: If the information in tl:e app[ication for a�t Improvement Permit is incorrect, falsified, or t/re site is altered, then tl:e
Improvement Permit and the Authorization to Construct sha[I become invalid
1) Services Requested by: ,
Name• /la� � �.e � o
Addre s��. t�. Z��$.�. a,� ��
�� -�. ,.-, � �
Phone # (home):
(work/cell): � ��7 ���.1�
2) Name and address of current owner (if different than applicant):
Name: ��'� � I,JO,,�/,vC k3 � rJS��ct�
Address:
3) Property Description: Lot Size: 2 0.�Subdivision:
Address and/or directions to Property:
Lot #:
4) Proposed Use and Type of Structure:
Residential !� Business/Type: Other
Number of bedrooms a� / Number of people served (seats/employees): !�
Basement: Yes Na�c (with plumbing: Yes _ No � Garbage disposal: Yes _ No �
Approximate size of building foundation: Length �b }� Width � L(�
5) Water Supply:
Private Well �Proposed Existing _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No � Yes
(please show location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing t/zat tl:e property is ready to be evaluated
I am submitting this application to request services from the Person County Health Department. The information
provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become
invalid.
Signature (Owner/Legal Representative): � Date: 5' ��' e�
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
��� l �� ���� ��
� * � � � ����
I���.��o�����.�.11 R33L��.11�11-�
• � � l7!!!�G�IG��. � � .
... ,
' ���'f� � �� � � :
T�x M�p ! Pa�rcel � .
Subd�ivision
Phase Sect�iom Lot #
Improveme�t �ermit
Permit Valid for �'ive Yea s No �apiration ' �}fiS�i%
Type of Facility: ,��p � S i�Ph , New _ Addition _ Water Supply __ ��JB.(�
# of Occupants �� # of Bedrooms �_ Projected Daily Flow 3(O Q g.p.d.
Proposed Wastewater System: Type:
Proposed Repair: Q [Y'?,l1.1-P Type: ��
Permit Conditions:
/�d ` �''oN�
Owner or Legal ]
Authorized State
Date:
Date: � /4<—D P
9L
The issuance of this pernut by the Health Department in does not guarantee the issuance of other pemuts. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoni.ng and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affe�ted by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`iaws and Rules fbr SewaQe Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
�nvironmeutal d�ealth Specialist warrants that the septic tank system will continue to function sacisfactorily in the future or that
the water supply will remain potable. •
Authorization to Construc� �Vasteyvater Systean (Required %r Building Pe�mii)
* See site plan and additional attachments (_�.
Proposed Wastewater S stem: Z �,/� Type�_ Wastewater Flow 3Go g.p.d.
New _ Repai � Ex ansf o Soil LT�: • 3 g.p.d./ ft 2
Type of Facility: �r �'va�2 �SI ,n . Basement _ Yes _ o
'6�astewa�er System �equirements
Tank Size: Septic Tank: ��al Pump Tank: ---gal Grease Trap:------ gal
I)rainfield: Total Area: �7 6 � sq ft Total Lengt D 0 ft Maximum Trench Depth �_ in
p.C.
Trench Width c3 ft 1Vlinimum Soil Cover: �_ in Minimum Trench Separation: � ft
/ 1V
Distribution: �% D stribution Box Serial Distribution Pressure Manifold
.
Specifications:
Authorized State Agell�_
Date: .��/ �%"L�'
Pernut Espiration�ate: � ►:i—f �
, � .
'The type of system permitted is entional '~� ccepted %�ltemative. I accept the specifications of the
permit.
�wner/i.eg�l Repr�sentative: Date:
PCHD rev. 11/10/OS
•�`��,./ / ����./ V �'�
t
' _L� �/ � �� 1L .1L
1� �.-�y-�D �.�.�a�.��.11 7HI���7�.
�ITE �7�'I'C� �
�
Na.�me �n �/j� �t4�P,� Ta,g Ma #-.,�.�_ Pa�r�el r�'t- g
� P �.
Subdivisio Section/Lot#
% _ �, : _ _
�' ,, • ., — �-_..�•' _�
-�—�'-� - _��,�-°..��,�-r�
A�tho�ized State Agent Date
System cdmponen�ts nepresent upproximate�contours only: The contmctor mustflag the system prior to
beginnis3g the install��'ion to insure that pmpergmde as maintained
� t�e��r -�'anK f id �
5ui��C�, L�a�r �-t�i-or�
e►����ng -rQ�1 K
� �Qin�al� �� �l'orvt Q�� rv�er� ��i�e5 1 /'" � -�,>r�;
vu►�ia�on5 ond (�D` �m w��5 ?�.
Kee� .
-- ,�� � C� (? �}�p( � -���:,cy v � �; .'% J
/ �
— �g �� �renc�, �oftnw► �max�
�
����� ��' ���( ' � �'��
- - e ' �:=---�-- � . � � ��
���. �������'�s
i�� � ��` �s ��1 � �
��. � '�a�
�������� N
' �e �-s��- �o --�, -r-�--� ��. �a�.� �1� �. �.���z N� � o � u1 a o Cv �'
, �,
�npiicani: � W►n�� � � .
Lo ca�ic n: � �
. � ��—
_ : � : . �. �� � ��, . .
. S�st�m Type (in Accardancn Wiih Ta�le Va): )�- CZ
THiS �YS;'�i1� k��'+� �3r�� 1N� s..�L.L�s7 1� Ct3I�f1PLL4FlC� ��Vti'�-i �P�L1CA��.E . t1tOR7'H
GAf�dLIN.4 G�s'1{E�L S i}�'tilTcS, ��3i1��� �OR Sc'�il.AC� T��TiVI��? ��di� D1S�OSAL, �
A�dD •�Ll. COli�93[7'1C3�lS C�� � T;-3E lI�iFROli��lE�3T ��r'�illi' d�ND G�i�STR11CTlOf�
�13T�-l�� . .
�, -
. . � . � ��.�s� � � � .
� Au orized Stat� Agerrt � Date .
lns#a11ed.Bf .��r'e� — -0 � �
� . � � �
� � � . . . . �
. l�
� � . � . � ,
.to l��o
% _ .
, D
v . .
. �
,. . �
�'�a .
. 'o � �o �
J `
�y �5�
,
��
,-
�o� joo'
S� WLO�iQ � `�' � ?C�-���, r���. G7(?�t'r,,�
�
��:�' ; 3ed �,�c�P� ��Ss����'�O� �°°�E��°��� � � � ��� l9 > ���'�j
: c: �/1c,t7 ���c�C2� :� 3�_ s'�S�E?P3 T�7� � I 2��� �/2� EZ
0����;-lA�plic�nt � � Subd�visios�
�:ddresslLocatior� Se�; Phas� Lct � �
d����. �°�rs� �ni�a�'��� �oi�a�����oa� ��� �ni�� �� �
� State�[D/da�e � re�cfi �d#h � 3 �. . -►�
Capaci aal. �,� � Trer�ct� �es�� �2 in.
Tee a�d Fi1ie� " � n T.re�c�t Lsr� �.
� Baffle � Tr��ct� C�asie � �
Seal�nt � Tr�s�cf� S acsn �
. � � Ris�r ir" a��licable � � � �oc�. De an� Qu�!' �k . .
� ��=ank Outfet Seal L}atns/S't� do�s e#c. rl �
Permanecrt ►Uia�ker IPr�s�ure Lai��s � . .
. i�um� �'anEs • � Hale S�acing � �
S$aie /date - o e �ze
- � Capaci al. � Pg �. Sieeve
. Wate roo� /Se�la�t � Tum-u slProt�tors ' �
Riszr F�qui��' S��a��
Water�Ti ht �� Frorn� �Ie1ls � S S'Q
� � ��a�� From Prope�}I fines � .
Che�ic ValvelGate �afve . Structuresl�as��e�zs � �
�� Anti-si on o e � atc. es / raana e Wa s
Fioats/Svuitc�es � � • � �Surfa� Waters .
�iarm visable and audible � Fublic 1�atef Su lies - •�
��ectrical Com onents • 1/.erticai C�is >2 i�. .
� Rate m .. 1l�a�r.Lines .
A rove� Pum iVdode! Ve�acl��Traf�ic �� '
Bioc� Unde� Pum � Ad'a��t sietns � -
� Purri� Removaa �Ro elCt�ain • ��asesne��i h� af V1la
. = D'a.s�ibu�aon.: S���a . Other
� Serial Distnbution �ba -o� �as�mer�s Recard�d
��ress�re iV�annoa e' e erator r�tra�
Lnw Pressure Pi � � Tri-�'�ri�#e A re�men�
A �. Pi�� iVlafesia� �nd G�ad� � " � . .
Valves - • , . � ,
��ma���ats . . .
rc:�c �r.311�/G':
� � \
-��� ��f �-'� �����1�
__... ,�^�- `� {� 1�J��,�,��,_
.�.1_'..,,..�r.'7i.�:r�:i.::r��CS,�t::i_n_tt:1t��.N,Ca YL.zn..11. !L. Jf �t � I
!G`:.27L ll ?rt_.1�':�.
�1�� �$'ep�H'�t�Olfl
T1ie applicant is respo�:sible for prepn.-•iszg proper•ty fcr a site ei�aluutior� by atl ,�;tviros:mental Henitle Speeialist.
Tlie applicant niust address each of tl�.e items listed below prior to tlle evaluation. (Note: A separate appIication and
site plan must be submitted for each proposed septic system/lot. An individual evaluation may encompass an area up
to 3 acres in size.)
1. Site �lan: A site plan must be submitted tivith your application. T1ie site plan must show property
dimensions, ihe location and size of proposed strucriues, and jurisdictional wetlands (if applicable). A
sample site plan woricsheet is available upon request. �
2. �roperty Lines: All property tines and corners must he clearly marked and readily identifiable, If you are
proposing to subdivide property, the proposed property lines must'�e cleariy marked.
3. �Clearing: In order to conduct a sife evaluation, tl�e lot must be easily accessible. If fallen trees, underbxush,
or otlier obstacies prevent free movement across die property, then ciearuig will be required. Soil
lIISfItPbQFYC2 iitllSt b� iD2lflZSIiL7,el� fdL,iPl1t�' PjtP, CIE(YP1i2 nror.ess in o�'fIEP PO (1VOIlI Y2IPtOVZT1� )t1818[d'ClI SOII (d31CI
adverselv affectin� site/soil c��aracieristics .
4. �ouse/struc#ure: The proposed location af a I�ouse or any otl�er structure rnust be marked on the property.
5. �range 8ign: Piease post the orange sign provided by tlie Health Deparhnent in a location easily visible
from the road in order to help ideutify the properiy to be evaluated.
6. Con�a�matimn: .Once all the items 3isted above have been completed, please sign below and ret�un this
form to tlie Person County Health Deparhnent. Once the (1) Application for Services, (2) a site p]an, and
(3) this form have been subnutted to our office, the application can be processed.
I�a�npoa�taa�i:
9 If an Environmental Health Specialist arrives at the properly and a site evaluatian cannot be
coiiducted because the site has not been prepared as requued, the applicant will be notified and the
application placed in `Inactive' status.
➢ When an `Inactive' application is reaciivated, the application will Ue processed based on the re-
activation date.
9 A revisit fee ($30.00) may be assessed prior to scheduling another visit to the property.
9 Applications which are in `Inactive' status for more than 60 days are considered void and ali fees
paid by the applicant are forfeited.
5� If you have any questions regarding the infonnation listed ai�ove, please feel free to contact our
office at 597-1790. Ottr office l�outs are 11�Ionday through Frida.y, from 8:30 to 5:00.
�7y signatrtre below iaidicates thut I J:ave read tlse i�, forrnntia,�z listed r�bove and ZhaP tlae�sroperty ifas bes�Y
pr•epal•ed for a�s evalucatia�z ist accorda�sce 2vitlt tJsese i�astructivns. ,I u�sderstnnd i�Zat if the canditio�es outlined
above have not been met, tJse appiicaateo� will be,�laced m�� °I�suctive' stafics.
Property locatinn:
Sigftuture:
M,C
tZate: —�Z— O�
Person County Environmental HealtL
, 32� S- =Vlorgan St., Suite C
Roxi�oro, NC 27�73
6i0? Pl;one: (336) �97-1790 Fax: {336j 597-7808