A27 190_.
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Application Date: �ri � l08 ��
P�nount Paid: �o. � ck�'
:�eceipt#: � 03�`�5
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Application for Services
(Sentic Svstems and Wellsl
�.,�mprovement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
Tax Map: �} Z 7
Parcel #: ! q o
Services Re uested
❑ Construction Authorization
(Fee is de endent on the e of s:
G Permit Revision
$75.00
❑ Repair of Existing Septic System
" No Charge
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Important: If tlie information in t/:e application for an Improvement Permit is incorrect, falsified, or t/se site is altered, then t/ie
Imnrovement Permit and the Authorization to Construct sliall become invalid.
1) Services Regl}ested by: �
Name: /S�� � � LtJG� �
Address: o? o� � 7, VJ -Fs 2,cf
�,��b� �, ,� � ��s�
Phone # (home):
(work/cell): 3 3Cn- S 9�- l ��
2)Name and address of current owner (if different than applicant):
Name: � � .-�� , �--,—, I .
Address: �— • -�-
3) Property Description: Lot Size: Subdivision: Lot #:
.A/)ddress and/or directions to Property: /�',r.� x� AJ 1�u w � w�c/ .ti- c� v%� /t .
/ ) � �/ � � i%%� S b 1'(.N � � I /l.�i � 1 �'{'T' �i%'l 0 r.%T -� � L� � ��1 Q u..i'� �!%�1 Yi
4) Proposed Use and Type of Structure:
Residential ✓ Business/Type: Other
Number of bedrooms a�r 3/ Number of people served (seats/employees):
Basement: Yes No ✓(with plumbing: Yes �No � Garbage disposal: Yes _No /
Approzimate size of building foundation: Length Width
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 rreust also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of a[l
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the 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): �s Date: di ���/�
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Date: February 21, 2008
Brad Wesley
3721 Burlington Rd.
Roxboro, NC 27574
Re: Application for improvement permit for Tax Map: A27 Parcel: 190 & 254
Dear Mr. Wesley:
nsuring a healthy enviromncnt
The Person County Health Department, Environmental Health Division, on Februarv 20,2008,
evaluated the above-referenced property at the site designated on the plat/site plan that
accompanied your improvement permit application. According to your application, the site is to
serve a 2-3 bedroom residence with a design wastewater flow of 240-360 gallons per day. The
evaluation was done in accordance with the laws and rules governing wastewater systems in
North Carolina General Statute 130A-333 and related statutes and Title 15A, Subchapter 18A, of
the North Carolina Administrative Code, Rule .1900 and related rules.
Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina Administrative
Code, Rules .1940-.1948, and the evaluation indicated that the site is LTNSUTTABLE for a ground
absorption sewage system. Therefore, your request for an improvement permit is denied. A copy
of the site evaluation is attached. The site is unsuitable based on the following:
Unsuitable soil topography and/or landscape position. (Rule.1940)
X Unsuitable soil characteristics (structure or clay mineralogy) (Rule .1941)
X Unsuitable soil wetness condition (Rule .1942)
X Unsuitable soil depth (Rule.1943)
Presence of restrictive horizon (Rule .1943)
X Insufficient space for septic system and repair area (Rule .1945)
Unsuitable for meeting required setbacks (Rule.1950)
Other rule:
These severe soil and site limitations could cause premature system failure, leading to the
discharge of untreated sewage on the ground surface, in surface waters, directly into ground water
or inside your structure.
The site evaluation included consideration of possible site modiiications, and modified innovative
or alternative systems. However, the Health Department has determined that none of the above
options will overcome the severe conditions on this site. A possible option might be a system
designed to dispose of sewage to another area of suitable soil or off-site to additional property.
For the reasons set out above, the property is currently classiiied UNSUITABLE and an
improvement permit shall not be issued for this site in accordance with Rule .1948(c).
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
However, a site classified as UNSUITABLE may be reclassified as PROVISIONALLY
SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d).
A copy of this rule is attached. You may hire a consultant to assist you if you wish to try to
develop a plan under which your site could be reclassified as PROVISIONALLY SUITABLE.
You have a right to an informal review of this decision. You may request an informal review by
the soil scientist or environmental health supervisor at the local health department. You may also
request an informal review by the N.C. Department of Environment and Natural Resources
regional soil scientist. A request for informal review must be made in writing to the local health
department.
You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must
file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, N.C. 27699-6714. To get a copy of the petition form, you may write the
Office of Administrative Hearings or call the office at (919) – 733 – 0926. The petition for a
contested case hearing must be filed in accordance with the provisions of North Carolina General
Statutes 130A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C.
General Statute 130A-335(g) provides that your hearing would be held in the county where your
property is located.
PLEASE NOTE: If you wish to pursue a formal appeal, you must file the petition form with the
Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The
date of this letter is Februarv 21, 2008. Meeting the 30-day deadline is critical to your right to a
formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal
review that you might request. Do not wait for the outcome of any informal review if you wish to
file a formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative Hearings, you
are required by law (N.C. General Statute 150B-23) to send a copy of your petition to the North
Carolina Department of Environment and Natural Resources. You must send the copy to: Office
of General Counsel, N.C. Department of Environment and Natural Resources, 1601 Mail Service
Center, Raleigh, N.C. 27699-1601. Do NOT send the copy of your petition to your local health
departrnent. Sending a copy to the local health department will NOT satisfy the local requirement
in N.C. Gen. Stat. 150B-23 that you send a copy to the Office of General Counsel, NCDENR.
You may call or write the local health department if you need any additional information or
assistance.
Sincerely,
�
_ t�—
Justin B. Smith
Environmental Health Specialist
Person County Health Department
Attachments (copy of Rule.l948 (d)).
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( ) Improvement Permit
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1. Permit req�eostey} by: �i
Address. r�'�� �>i)�L %��i
APPLICATION FOR:
( ) Subdivision
Date Received:
( ) Other
Home Phone,��`'�
Business Phone
2. Name and address of current owner:� ��(Ja/ %���{�Y)
3. Property Description: Lot size � �(�-�j� Dimensions:
Front Left ight Rear �•-
4. Tax map No. Township: � t �� Block No. Lot No.
5. Directions_to property: St�te E�oad;No.� Road Names, etc.
I
6. Permit requested for: New Installation � Repaired
Additional Renovation re-using present system
7. Number of occupants of people served
8. Dimensions of Proposed Structure: Width Depth
9. What tyge (if any) additions, expansions, or�replacement is an�cicipated
te the structure or facility that this sewage disposal sys�em as intended
to serve?
10. Type of water supply: Well � yes no: If r.o, name source of water
supply: Are there any wells on adjoining
;properfy?�'� If so, identify location. /
il. ` Type of structure or facilit . Proposed Existing
Type of dwelling: Honse Mobile Home Business
�Type of business Number of Employees
Number of Bedrooms Number of automatic appliances
Basement Number of basement fixtures
12. Clearly stake all c�rners of the property snd the corners of all
structures.
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I hereby make application to the Person County Health Department for �
a site evaluation or existing system evaluation for the on-site sewage
disposal system for the above described property. I agree that the conten
of this application are true and represent the maximum facilities to be .d
placed on the property. I understand that if any changes are made without �
approval from the Person County Health De rtme t, the permit will be void. N.
Any permit for a system is non-transfer e wit out prior approval of the �
Person County H�alth Department. Perm' s are v lid for 60 months from dat �
of issue.
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FACTORS - SITE EVALUATION AREA 1 AREA 2 __ AREA 3 AREA 4';
1. SLOPE (X)
. SOIL TEXTURE (12-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
. SOIL STRUCTURE (12-36 in.
(Clayey soils) �
4. SOIL DEPTH (in.)
S. RESTRICTIVE HORIZONS (in.
(Impervious Strata, rock)
6. SOIL DRAINAGE/GROUNDWATER
(External & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
8. OTHER (specify)
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9. SITE CLASSIFICATION
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(See below) '
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitab�e
RECOr@SENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas,.fill.areas, wells, water bodies, slope patterns, etc.)
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i� �y�?a=g• ,�� 'i�q 3..�"'u r� ;w� kt" q��ti'3 v "i n��O uE$ t� � 3�» ae�. rv: ��'+< r y: e �c ;'�; - 'is �
E���'y� : .'�r «a.i^'s`����,"_ Q.�" �AVW� � wy . ,.. .a ..cY � �t. ,�R"..i:iyw� .. �. ..�. . .... '' �»:
ts Permtt� (Establ�shed/Recorded Lot) _ Reinspection of Existing System (Loan Closin
ImpFovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Repair/Replace existing Septic System
�ermit for New Well
_ Improvements Perrrtit (Addition) I Replace Existing Well �
1. Permit requested by: . - 7. Dimensions or Proposed Structure:
owner/prospective owner/agent:,�Qa�4�!/G cG�R��� Width: 'i �
Address: z. � z � a�i,� /L T��'a �! /�'d Depth: 3/' _
Phone #: � 9 4 r.� � y
;ss Phone #: �'`19 � � � �
Name and addre&s of current owner: .s� ��
Description: Lot size: ��� 7 9�' �
Tax Map#: A 2. 7
Parcel#: 1 9' D _
Directions to property: State Road #& Road
_ Number of
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
P�tOPOSED STRUCTURES.
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 prope�ty. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be
issued, I mus[ present a survey pla[ of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property 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.
o , /�a6 0 ,�.� !� T. ,rd s �'
or neople to be seNed:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
G�R.�G� ��xz`f,
9. Water sup ly ty�pe:
private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [.�.
If so, identify location:
l0. Type of structurelfacility: Proposed: �Existing: Q
Type of dwelling:
House: �viobile Home: C�'�usiness: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3 _
Garbage Disposal? Yes C'No �
Basement? Yes❑ Nofl�fso, # of basement fixtures:
I
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Z Signc� Owner or Authorized Agent
pertnit I,�suec�0
permit Denied t�
Plat Observed ❑
Signature � Date
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RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, welis, water bodies, slope pattems, etc.) C:MM[PRO�DOCS�APPSEC.SMFWANCE-P�
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B 1247
, PERSON COUNTY HEALTH DEPARTMENT
� , WELL AND SEWAGE �ITE, LOCATION IlV�ROVEMENT PERNIIT
N�t iar waste water system co;�struc�ion. ivu per�nit(s� for ionstruc�io,� i,ocat�ion or
..�elocation Activity shall be issued until Autha; ization for waste water system construction
has been issued.
Tax Map # � .� �% � Parcel #
Zoning � Township ' ;
Owner/Contractor o hi � (-. CGt rA �� 11 Date /(� - 23-r-�'�
Location/Address /�5.�1 �.1 -1,� Sitt.� /2n 7�, �/ftt /30� ��,,.�.�..� �n vi�.�
5ubdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ��, r% JG�y�s Size of Tank
SFD ` Mobile Home_� Size of Pump Tank_
Business # of Bedrooms�_ Nitrification Line
Max Depth Trenches
Permits may be voided if site is altered
Well and Septic Layout by i
use c�anged.
� G ,�
�
Date
Comments:
Date � g 9� Installed by ���, yy�� Approved
This report is based in part an information provided the homeowner or his/her
representative in the applic:ation submitted for this permit. The environmental
health specialist is not responsible for ialse or misleading information
contained in the application. The enviro�mental 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 application. Neither Person County 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
SUBSURFACE WASTEWATER SYSTEM MO1vITORING REPORT
`� � � 2 � � �� 1 �`D
Date of Ins ection Sy em I tallation ate Type ax Map Parcel #
�Z � s� y��.o�U//f��-fl ll� r�'7S'2 �
Property Address
Ins�uctions: Chzck yes or no for appropriate items and explain in space provided for remarks and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in the permit are to be cazried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks 7
Tank risers accessible, free of
infiltration and surface water diverted ?
Septic tank needs pumping ?
Inches of solids:
Septic tank filter cleaned 7
EFFLUENT DOSING SYSTEM:
Require3 nur.:ps present & function2! ?
High water alarm operating properly ?
Floats, valves, etc. in good condidon ?
Control panel & components in good
condition ?
Efiluent free of excess solids ? I1
Inches of solids(pump/dose t c):�
Elapsed time readings ?
Counter readings ?
Drawdown rate:
YES / NO
o,o
❑ � ❑ �
❑ � -
��� ■
� ■
►: ■
, `� �
■ ►
DISPOSAL FIELD:
Evidence of effluent surfacing 7 ❑
Evidence of effluent ponding in trenches ?❑
Surface water effecdvely diverted ?
Diversions/swales properly maintained ?
Vegetarve .over m�±ntained ? ❑
Protected from traffic/unauthorized uses ? �
DisQibution devices in good condition ?�.
Field free of settled or low areas ? �
/
/
/
/
/
/
/
/
li
►:
■
►:
■
■
■
PRESSURE DISTRIBUTION SYSTEYI:
Tumups/cleanouts/valves/taps intact &
accessible ? ❑ � ❑��
Pressure head properly adjusted ? ❑ / ❑ �
COMPLIANCE:
Compliant '�
Non-compliant ❑
,.T.._a.. ,,,�..:_�,.......,.,, n
REMARKS
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. _ . .. .._-�- --
a[ion/Dixcctions: ___ `�����r-�SA,� c�c�_ �
---...... . .
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��.:�'�visiol-� N�vric: . _._
----___ ... .. . Lot #
Drillin� Contrac[or: __...,� ... . _ ..._ ._.._._.__—
_.�,� ,� s __ . �1 � /1 _� _ �.. ---. _....----._. - �--��-- -----�.
Wl;l,l..C:C)Nti"I'IZf1C1'f(��f � . �
Distance from Ncarest Pro1�crty Lin��.__ �,S'�/� _� lliti�;ln�� �'zOm Source of '
Pollution_ � e a p %�,s .
To[a1.�Dep.th:. / Ft. �'icicl:---�,� � M
�� ' S tatic Water Level 'F�;'_
WaterB�earingLones: Dep�l��__�.�a ._1�t.._,�.J,Z__�'�• F[. ���,
Casing: llepcli:� Froin____��___`to._..S3y I��. Ui�unctcr: �. � Ynches
TXPE: S[eel � �� _G�i1V:1J11ICCI SICC� � � . '�
Z,f Stec;l, docs owncr .i��prov�:: �.'c;; No . �. ;
Weight:__ /3 Thick��ess:_��� I-�cight�Abovc und. ,_ � . : �
Gro �
Drive Shoc: �'cs_ � N�� .:--.�-�._._`�ches � �
Werc Problcros EJ�coti�ltcrccl i��jSc:ttiilt; �lc Cc,siri�;'? Xcs �� No �_
�f "ycs" give rcasoii: .`�
Grout: Neat .5:�� - ��-i--- :,j,���,,
T�� ` �cl/Cc,nc,�� � Coricrete •;�'�.
Annular. Spacc Wie1t1� _ � . . -----1� ichcs . ',�'�
Watcr in ,A,nnul�r Sp.icc: 1�'c;; No �.-- � �
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ctho.ci: � --_.._ ,
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Dcptli: From � .-t�� ---� _.____ __.__�- . .
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Z HEREBX CERTIFY TH�'1"1'I-IL 11,I30VL 1NrORM11'1'ION IS CORRECT AND
T�S WELL WAS CONS"1'�:UCI'�D 1N ACCORDA,NCE WITI-i REGULATTOr
FORT� � y.T�-I � P�RS ON C�0 U:N��Y [�I l;n 1.,TE-1 DL'• P� 1:TM ENi�. �
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�I�Ila�urc c�('Cont�;�.:[or
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Dat�-- � --,-,-.
� PERSON COUNTY HEALTH DEPA�2TNIENT
__ _ __ _ —
35�:� SOUTH 1�I.ADISON BLVD.
_
ROYBORO, NORTH CAROLIN:� 27�
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant Bv� �a��► ��
Address �LZ-- I�o�Zr�3on ��, County Q�r�c�1
Collected By '��
Date Collected�� l t-6� _ Time Collected �(��S
Source: ell ❑ Spring O Other
Location: � House Tap
pNo Charge harge
OWell Tap Other
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Total Coliform
FecaUE. Coli
Results
Present Absent
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❑ L�
Reported By ����Cy-y ��E'��� �T
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