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A27 174... �Person ��County H,ealth��Department - �� S'ewage� System-Improvements �Permit Date �"�fi�'�Th�s Permit-V�o�d'Affer,5 Years � ' ' . . , Owner.' . . . _. .. `i ._ SR# � i.ncation/D'ueCtions:.s�i � . , ; — Subdivision 1�T e: � i.oc # ��--_ L"ot�Size: Type of�Dwelling:. �. . Water Supply: Private: — G'� Ptiblic: _ �ommurucyK� -- E. ,'. Bedrooms:—�— Garbage Disposal Basement ------- B�ement F'ixtures � INFORMA _ ��. D BX owner or representauve •.: S�l]1C8t18I1' ' ; • ..._ . . REPAIIt: __ _ . _ . kEEVALUATION..� � _ ::; .— . • �� .� �� "w•��r ��' �� r ^ Size of Septic Tank: __t�l�-- o� S3 � f Pump. Tazilc: � Nitrif'ication Line: Depth of Stone: , l2 inches _ . . Max Depth of Trenches: Altiemative System: Conv. Pump �P �mP Remarks: . .. Date Well Approved: � Well 'should lie 100 ft from any sewer system BY_ Sanifaiian � � • .., � 'Date Se e s ro� • �_ _ . _ . BY Sanitarian CATE OF COMPLETION Contracwr. _ � 2,�.�� -. —.----------------------- � Sewage System location, installation; and �p�rotection must":meet state and� local'� _ regulations. Septic tank should be pumped out every 3 to S years and shall be maintained � by;owner in such'manner as not.to. create a public health haZard. Septic. tank and � �iutrificatian line must- be inspectP.,d and approved � by a member-of .the Person County Health Departcnent before any pordon of ttie installacion is covered and put into use. If : the site plans or intended� use chaiige this pemut is subject to revocation. (G:S. 130 A-335F�.- , . . . . _. _: _ . ].,oca$on of sewage disposal sewage system sketched on-back.' . �OVER) . Peraon County HealEh Department Nell Permit �ISSOEOi�—_pATE DRILLED� OWNER:� � , �� _t� :��COUNTY e L/"S �- ADDRESS� R011D/STREET� '01''�.2� n � � th- i -� CPs DRILLTNC CONTRI►CTOR� � NAME ADDRESS t'1ELL CONSTRUCTION Diatance from Neareat Property Lina Pollutlon��_ S Distence fran Source ot Total Depthr Ft. Yieldr d CPH` Static Nater Level �/� Water Bearing Zones� Depth pt C�� F!. Casingr DePth: From�_ "-"-=�-Ft• Ft. Pt. TYpE: Steel tO--�_.Ft. Diameteri ( Galve�ized Steel l/ Inchas If Steel, does owner approvea Yes Meight:��_Thicknesa:/� No Drive Shoe: Yea ✓`�'—Neight Above Groun i�ylnches Nere prablems Encountered inNSetti— nq the Casingl 7aa�p � If •yea' g1�e fason� v� Grout� Typee Neat �� Sand/Cement 1lnnular Space Midth � Concret =� Neter in Annuler Spacee Yas Inche� Method� p�ed No L� Depthr From p=eaaure—� poured (� MaterieL Usad, N�a po=t1an��t�T 1 b°g�_lbs. Neight of If mixture (aend, qravel, cuttinqa) - Ratio� ID Plntes: Yea ✓ po �_to % � x � sleb Yaa�— po a neREBY CERTIFY T!!xT THE ABpVE INFpRyqTION IS CORRECT 11Np T�T ZHIS FtELL NRS CONSTRUCTED IH 11CCORDANCE KJTH REf�y�rlphS SE1' F�(�,H BY THS PERSOH COUNTy BpARD UF HEALTH. pERMIT VOID 1►ETEg TyREE YP,ARg, ��! /0� � �� d Signatuze of Contractor Date Sanitarian'a Signatuze Date Issued Sanitazian's Signatuze Date Complated Sketch well location on reverae aide. A�plication Date: 3" � ��"I Amount Paid: _� Receipt #: ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit reauiredl ❑ Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 �� Tax Map: ,� �2 7 �,.; � • �� ,�� Parcel#: I 7 � ��mwna-c.�anaxna�aa.�an..n. ��i�,.�d�in. tion for Services Services 1) Applican�t ormation• Name: `�[�5�� l�af �'�� Address: L23 S chu � I.dr S t�O i �� -F— �D r. ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision _. $75.00 pair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 Phone (home : (work/cel I): �33 Co , �' 83 - � 9 � �I 2) Name and address of current owner (if different than applicant): Name: � Phone: Address: 3) Property Description: Lot Size: Subdivision:�$es�-Vt� Cre�l�- Lot #: Address and/or directions to Property: !Z 3 SG �u 1 lp� S�o i��-- �f_ ❑ yes �o Does the site contain any jurisdictional wetlands? Ca yes ❑ no Does the site contain any existing wastewater systems? ❑ yes E�� Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes C�� Is the site subject to approval by any other public agency? ❑ yes � Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: ❑Residential 3 ❑ New Single Family Residence Maximum number of bedrooms: ❑� E�x ansion of Existing System If expansion: Current number of bedrooms: C9'Repair to Malfunctioning System Will there be a basement? ❑ yes Ca no With plumbing fixtures? ❑ yes � ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well xisting Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? �❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ 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 altered, or the intended use changes, all permits and approvals shall be invalid. � �-- 3 I � ��l Signature (Owner/ Legal Representative*) Date * Supporting documentation required. 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) �� ; �� `_.__^ � � � � � � � JE-�e��.�g-��-�,.,Y„ m�.��.:1 IE��.]l�l�. Applicant: �f'' Address/Location: Tag Map: �� Parcel: �� Subdivision d�►vEQ- C4.�11 Phase/Section/Lot # 0�9 Improvemeni Permit Permit Valid for: Five Years � Non-expiring Type of Facility: t'�1c��.E �%t�, _ New _ Addition _ Number of: Bedrooms 3/ Occupants ''"�5� Employees / Seats: Proposed Wastewater System: Proposed Repair: ACc�P�D Water Supp�y: �Q�vA�'E W E �5.. Projected Daily Flow: 3b4 gallons/day Type: - Type: Z11� Permit Conditions: �` R'�,� A��.� �Owow `�ss£ P�.AIa 51f�Et�� Authorized State Agenr � �. (X) �wner or Lega! Representafive: Date: � Date: � The issuance of this permit by the Health Department does not guarantee the issuance of other r:.quired permits. It is th:, responsibility of the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This improvement Permit is subject tu revocation if the site plan, plat or the intended use changes. The Improvement is not affected by a change in ownership of the property. This permit w$s issaed in compliance with the provisions of the North Carolina �Laws and Rules !or Sewa�e Treatrnent and L�sposa! Svstems'(15A NCAC 18A .1900). Neitber Persoo County nor the Eavironmental Health S�ecialist warrants that t�e septic system witl cantinue to function satisfacto::ly in thc future, or that the water s�gpfy wifl remain potable. _ — _ Authorization to Construct Wastewater System a"ee site plarc and additional attachments (�. x i'roposed «/astewater System: �c�cPcED �.2 5�� (*)Type 'IIT C� Design Flow 3b0 gal./day New Repair � Espansion Soil LTA:Z: . o�S gal./day/ftz Type of Facility: 3-ii6Q4� �1cA�� _ Basement: _ Yes _Pdo ('') System Types IIIL�, Ilibg, iY, cr�:d v, require perioriic systQm inspections by the Person County Health Department. Wastewater Sys#em Requirements Tank Size: Septic Tank�r►�b gal. Drainfield: 'I'otal Area 1'08fl sq. ft. Trench �Vidth � ft. Pump Tank �"' gal. Total Lengtl� 3�� _ ft. Min.Soil Cover �o in. Grease Trap "—" gal. Max. 'french Depth 3� in. Niin.T'rench Separation _� ft. Distribution: Distribution Box / Serial Distribution� / Pressure Manifold �_ Specifications: 't�.� dr ��.'TEI Ai.�thorized State Agent: (.ssue Date.: Permi; Exo 1.� ��S ' �,J►.s�aLl �fl The system permitted is: Conventional /Accepted �/ Alternatire / Innovative . I accept the conditions and specifications af this permit. (7ti) Owner or Legal Representative��` Date: ��lo �� Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) m s•�y ��n �o B b°e �� a^ �b 9$ �' � 4 �. 0 a � h t� � 0 a � � 4 tr9 � � b $� 0 P A �• s' n $' a y�' o' 5 a � H �i b � ��, s� ��.� �� I� ��n a- � �. �. � � � �, Il IFIL � �. Il. �h�. Applicant: YP�.� Location: �( ia3 �r Ott.�v�. Taz Map �`� Parcel # �`1'� Subdivision RKnnv�0. C3�E1t- Phase/Section/Lot # a9 # of Bedrooms 3 - O�eration Perrnii � �E��-� System Type (From Table Va): 3�i 6 Product �IIIg): �-'t- �`� Type V& VI Expiration Date: -- Type V& VI Renewal Date: �— 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. 'QE�t.cc�` A - �� (Authorized Agent) J�t�c�`t l-EwtS c3r Sa�1►5 (Licensed Contractor) Scale �S PCHD, rev. 12/14/12 t� b 1'� (Date) b 5 1y (Date) s�.�,�.�� eo„� a�►�E Q = d.iw Ra�a VA�.� l 3�o FY C�.�r. 'SK.Qs`c.-t�s�Y.� � _ = E,x�Sz►r:c�o �o'�►F1. Q�LA�.�ual6 __. � a'E�W Q�A��.le� I.F..2 ({'►1.�. SAv�r i�.�evs�� i�o �r�� Line Length t 3b�o' Tax Map: ot`l Parcel #: ��`� Septic Tank System Checklist (Type II-I� System Type: '� �c, Notes• Pump System Checklist Contracted Certified Operator (Type IV Systems): Notes•