A27 155. .. _ ,. , - .
Nov-03-99 01:04P , � ,
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R�cslnt �k: __
Psrs Coun H� kh D� artmen
E vi� menta! safth !o�
PP O FOR ERVIC
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�) �rmtc r+�uasad by: (Owner/a ant/ rotpscUvs awn�rj:_�NE,FGY �FFcuEN? ,�ous i N Cr
Home Pt�e: Addresb: 37 i.ci Q,�{:g�n� ,s�.p
8usiness Phone: q,'3�5 - f�{00 2a n N � 3
2) Nam� and pddnss of currerrt own�r.
�) Pro�ertl► DesCriptlon: tot,�: • o/ Townthip: �( uE ,tf i c �
DifsCt10�131G th8 DroDeltv (Indudine ms.� nnrna. a...r ......����.
��x�a Ro
4) Propossd Use ond Stn,cture peacNpdon: ancwer oach of the foqowing questions:
a) Proposed �(, ExisHnQ u
b) Stidc Built u, Modular U, Sinqk Wkte !.:, Double Wide �
c) Numbe� ot Bedrpom�: 3 d) Number of oca,pants o� people to be sen�ed: 2•
e) Bas�rnent: Yes 0, No tf yes, # ot basement fixtures:�i
� Garbage Dlaposai: Yss U, No �
9) Dimenaial3 of Propoaed StruCture: Width: � Oopth: �
� WaE�r 3uppiy Type: priyat�� (neyy � or exisbny n), Public u, Community �, Spring �
Are a we1ls on �Idjoining prcperty? Yes� NQ r. If yes, location
6) P���ss (ndkab Distrod System Typ�: (systems can be �nked In ord�r of your prefaiynce)
.,�,Conv�ntlonsl �M�� Convsntional `Altemstive ,Innovative
oth�r (=p�c(ty);
CLEAfitY STAKE ALL CORNERS AND UNES OF THE PROPERTY.
8TAKE THE CORNFRS OF ALL Pi�OPOSED STRUCTURE3.
pLEA8E ATTACN SURVEY Pl„AT OR SITE PL.AN TO THIS ApPLICATION
I her�eby make applioeqp� to the penOn County Heatth Oepartment for a aite evaluation for the on-site sewaye diaposal systam for
�� ���b� prOA�+�Y• �°9�ee that tho contents of this epp�icat;on arv true and reprose�t the maximum factlities to b•
P�eC�d on the propertyr. I ur�deratand if thv aitg Js eltered vr the inlendsd use chartAes, ihe pertnit shall become invaNd. I undersland
that as app�c�nt, I am respo�slb�e fpr be��{y�Q and markin
personnN of fhe Pe� COunty Heelth pepartme�t to conduct thBeK eval��iatlons�l u��atand thet ( a�m respp �tij��io ��,, 9�e
Heahh �epartrnant if.�y� a(ns any wstfenda aa designatad by lhe Army Corps ot Engine�ra,
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Owner or l.sQal Reptesentativs
Date
PCHD, rsv. t011?199
PERSON COUNTY -"
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SITE EVALUATIONS �
DATE: '��-5- �`% /
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5
F�S�H COUN('t
PERSON COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH PROGRAM
325 South Morgan Street
Roxboro, North Carolina 27573 �
(910) 597-23'�.1
OWNER: �S� C�►'1 �1 Wir�'(��,r�'L.i
, � Cl � )
ADDRESS: � �, Im�i. �t/}�� �►v� �ey� � /Vr C.
LOCATION: Lp� I � �P,CVe,{� l�V�\ �v��%.t�/.f'Fa�/
DESCRIPTION OF PROPERTY: TAX MAP#: �/ LOT#: l ss
THIS SITE EVALUATION REPORT IS PROVIDED TO YOU IN COMPLIANCE WITH
(130A - 335G) N.C. ADMIHISTRATIVE CODE TITLE 10 SECTION .1900. DUE
TO THE SOIL OR OTHER FACTORS ON THIS SITE NOT MEETING THE
REQUIREMENTS OF THE FOLLOWING RULES:
.1941 (a) (3) (B) Expansive clay mineroloqv: Predominantly 2:1
clav which is unsuitable
.1942 (a) Soil wetness conditi'on: Color of Chroma 2 or less in
mottles are unsuitable as well as sites where soil wetness con-
ditions are less than 36" beloW the naturallv occurrinq soil
surface are unsuitable with respect to soil wetness_
YOUR SITE CLASSIFICATION IS UNSUITABLE. YOU HAVE THE RIGHT TO AN
INFORHAL REVIEW BY THE DEPARTMENT, THE RIGHT TO APPEAL UNDER G.S.
130A - 24. APPEALS MUST BE FILED WITHIN THIRTY DAYS IN ACCORDANCE
WITH G.S. 150B - 23(F).
y � G��'iv`�;�
Environmental Health Specialist
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PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: 1T o� 1 Parcei # ��
Zoning Township ( J� i� C�- T-� 1' �
Appllcant:
����
LocaUon: � 7 I I v/T' L�—��S ��'
Subdivision:�VQ� (�-`�'.� Sectlon:
e, �5s�u�rCa�eK t°K��
Lot: �,�,_
Improvement Permit
A building permit cannot be issued with onlv an Improvement Permit
Ne Repair _ Addition _ Type of Structure �(-�' Water Supply �{1 �Ocit�
# of Occupants vS # of Bedrooms � Other .
Basement? �Basement Fixtures?�D
Projected Daily Flow:�� g.p.d. Permit Valid For: 8'Five Years ❑ No Expiration
Proposed Wastewater System Type: �O (1 � Q�(1'� ��Cl� '��r�l PP,--�—
Pump Required? Yes _►_/No
Permit Conditions: �=. � ��g���-� -
Owner or Legal Representative Signature: Date: – 1
� 1
Authorized State Agent: Date: 1 �� �� J
The issuance of this permit by th Health Department in no way guarantees the issuance of other permits. The permit
holder is responsible for checking with appropriate governing bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
T
Type of Wastewater System
Facility Type: b �('� b�L�--
Basement? 0 Yes ��
Wastewater Svstem Requirements
Septic Tank Size: � gallons
�rater Svstem (Required for
�Wastewater Flow: ,�g.p.d.
New �/f�epair DExpansion ❑
Basement Fixtures? C� Yes C3�Pd�
Pump Tank Size: �_ gallons
Pe
Total Trench Length: �_ feet Maximum Trench Depth: � inches Aggregate Depth:� in.
Maximum Soil Cover: �_ inches Trench Separation: � Feet on Center
Other: u� v
Permit Expiration Date: – � ��
Authorized State Agent: Date: ��Q– . q
The type of system permitted ❑ does ❑ does not differ from the type specified on the application. I accept
the specifications of this permit. `�� r r � I–� I_� /�'
Owner/Legal Representative Signat e• � IDate: � I
PCHD, rev/ 10/12/99
, � ;�
Appiication #:
Tax Map #: ,�1��� ���
Parcel #: SS
Person County Health Department
Environmental Health Section
SITE SKETCH
� ll 1� ;11 � c�, s �e��e�C.�ee�k I..���o
licant's Name Subdivision/Section/Lot#
PP
�
. Il-Ib-qq.
uthorized State Age Date
System components represent approximate contours only.
Tlte contractor �nust flag the system
de is maintained.
�
Scale: � � � IGU�
PCHD, rev. 10/12/99
,,� L� Person County Health Department
. Environmental Health Section �
Tax Map #: � 01 � Parcel #: �Jr-�
Zonin Township: 0% ve I`���
9�
Subdivision: �-Eati�('/� � - Section: Lot: � 0
Applicant: � � � � m S
Location: S% N �l� �oh �, 5 .5 ��C_ �
Operation Permit
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.
- 1�-15-�?9
Authorized St e Agen Date
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Tax Map #: � =���
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Parcel #: � �S
PCHD, rev. 10/12/99
Person County Health Department
Environmental Heaith Section /
Zoning: Township: � (iuP �%
Subdivision: �a��� ��ef� Section: Lot: �_
Appiicant: �J i �v ' ��'a /�'/ S
-=,-+
Location: .�7 � �'�� � - ��
Operation Permit
1. LOCATION AND SEPARATION DISTANCES ��
A) System meets .1950 setback requirements
B) Distance from system to any welis �_�
C) Distance from septic tank to foundation
D) Distance from system to property lines
2. SEPTIC TANK ,,�
A) Visually inspect the exterior walls and top of the tank
B) Visually inspect the interior wa11s, 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 TREN�IiES
A) Grade �+� (1/8 inch per foot minimu ) �
B) Material supply,line is constructed from .��� �� ��
C) Diameter '`f "
D) Length .�' ,
E) Distance from tank to drainfield/distribution device �_
4. DISTRIBUTION DEVICE(S}-�Nft"
A) Type
B) Is Device water tight
C) Distance from the distribution device(s) to the trenches
D) Is the device on a levef foundation
E) Does the device perform according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD ���
A) Trench depth � �i inches
B) Trench width � inches /
C) Distance between trenches �
D) Number of trenches ,
E) Length(s) of trenches �al 99 �%d� ik� �
F) Aggregate depth —�,— inches
G) Aggregate matenal and size .� %
H) Record septic tank outlet elevation 7'�/�-�-
I) Trench grade See �%� „, � (< 1/4" per 10')
J) Step downs '�
a. Minimum of 2' of undisturbed earth ��
b. Proper rise over step down �
c. Solid pipe used �
d. Elevations of step downs '� !� a(Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
�" • .
�. - � � . . . ..
Date: 2
Owner. `� �
L,ocation/Directions: .
_ ...... _ _. _ . . .,.. .
PERSON COUNTY ENVIROIIMEKTAL HEALTH
WELL LOG
SR#
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Subdivision NZrne: ��� e Lot # 1 C�
Drilling Contractor: � S
WELL CONSTRUCTION —
Distance from Nearest Properry L�s� 1 C� Distance from Source of
Pollution L� � '
�
Total Dep.th: l�� Ft. Yield: S_____ GPM Static Water Level Z� _t-�.
Water $earing Zones: Depth �_rt._ Ft� Ft �t.
Casing: Dept}i: From C� to�� Ft. Diameter: (��— Inches
TYPE: Steel � Galvanized Steel �
If Steel, does owner app:ove: Yes No
� Weight: Thicla-iess: ,�18� Height�Above Ground: � � Inches
Drive Shoe: Yes �N"o
Were Problems Encountered in Setting the Casing? Yes No ��"
If "yes" give reason:
Grout: Type: Neat Sand/Cement � Concrete
Annular Space Width Inches
Water in Annular Space: Yes No
_ .. Me[hod: Pumped � - Pr�ssure � Poured ��. - � �. -
Depth: From C� co ZC� Ft. � -
Materials Used: No. Bags Ponland Cement Weight of .1 ba�_lbs.
If mixture (sand, gravel cuttings) - Ratio: to
�ID Plates: Yes� No � � •� �
� 4 x 4 slab Yes No
u
I HEREBY.CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONS�'RUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH By�THE PERSO�i C�Li�'I'Y HEALTH DEPARTMENT.
� --
ignaturc of Contractor Datc
►..
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: �� �� Parcel # ���
Zoning
Applicant: �I ( U LL�IIIIIlA li �i I�
Location:
Tow�shlp,�I � � �� -
�
Subdivision:' " ���'r�Y� S�On:
Type of Water Supply:
Requirements:
Site Approved by
Grouting ApprovE
Well Log
Weli Tag
Air Vent � �
Hose Bib
Concrete Slab i/
lol �
Well Permit
�ndividual Community Public
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. . . . - . : ar �-...,iL .il/. ���
Date: ) 7i r� �— � �
**See Attached Site Sketch'`'`
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD, rev. 11/29199