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�A C�urier #02-33-15 n a t
1LO` ��'`� � APPLICATION FOR SERVICES
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i_ Improvemen[s PeRnit-(Established/RecordedyLot) W._ Reinspection of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot)
lmprovements Permit (Mobile Home Repiace)
_ Improvements Permit (Addition)
Repair/Replace existing Septic System
Permi[ for New Well
_ Replace Existing Well
l. Permit requested by: _
owner/prospective owner/
Address: __/_�� : fl �
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v E-iome Phone tt: —
¢ usiness Phone #:��
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� 2.�Nar�e and address of,cur
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7. Dimensions or Proposed Structure:
nt: � i NS � Width: ..� O
9 Depth: �- �
,�J� ,C ,`Z S'?�' g. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
_� that this sewage disposal system is intended to serre?
�,SSv 1 1 V`� A� D �t �'
t ow er: 9. Water supply [}pe:
'�-� private �. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �,
If so, identify location:
. Property Description: Lo[ size: �
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Tax Map#: ,�"-, ✓7
ParceI#: - �--
Townshio: D�,�pll_ .
. Directions to property: State Road #& Road
[ames,gtc. _ _ / � „
2�r
Number of occupants or people to be served:
10. Type of structure/facility: Proposed�Existing: Q
Type of dwe Iing:
House: Mobile Home: Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �
Garbage Disposal? Yes ❑ No
Basement? Yes ❑ No�F€so, # of basement fixtur�s:
� CLEARLY STAKE ALL CORNERS OF THE PROPERTY AI�ID TI3E CORNERS OF ALL
� PROPOSED STRUCTURES.
,� hereby make application to the Pet'SOn COunty Health Department for a site evaluation for the on-site
sewage disposal syscem for the above described property. I agree that the con�ents 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 shaIl become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the proper[y to the Health Dept. I undecstand that in the event I have not
delivered a survey plat of the property to the HeaIth Dept. within 60 DAYS after [he date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signcc� Owner or Authorized Agent
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PERSON COUNTY HEALTH DEPARTMENT
ENVII�tONMENTAL HEALTH PROGRAM
20-B C�urt Street
Roxbor.o, North Carolina 27573
(336) 597-1790
July 2, 2001
To: Ms. Mia Winstead
1883 Morton-Pulliam Rd.
� Roxboro, NC 27573
Ref: Improvement Permit # B2779 issued on February 10, 1999
Tax Map #: A027 Parcel #: 332
Located at: Jackson Farm Road
Dear Ms. Winstead: �
This is to notify you of our intent to revoke the improvement permit referenced
above in accordance with NC General Statute 130A-23 (Suspension and
revocation of permits). We are issuing this letter of intent to revoke for the
following reasons:
In accordance with the findings during my May 8, 2001 visit with Charles
Davis, the site indicated for a septic tank system drainfield on the existing
permit has been determin�d to be unsuitable for the installation of such a
system due to unsuitable soil depttis*(Rule.1943), topography
*(Rule.1940), unsuitable depths to restrictive horizons* (Rule.1944), and
available space (Rule.1945). *(denot�s reference to 15A North Carolina
Administrative Code 18A .1900) �
We have identified possible altemative(s) as follows:
1. Evaluation of this site by a qualified soil scientisdconsultant may
identify an area of suitable soils that may be considered usable for other
possible system alternatives. Such a proposal may be submitted to the
Environmental Health Section of the Person County Health Department
and all proposals will be thoroughly reviewed and considered.
2. Permits may be obtained for surface or other types of discharge systems
from the North Carolina Department of Environment and Natural
Resources, Division of Water Quality, with some limitations. For more
PCHD, rev. 10/12/99
�
information on these systems and permitting procedures, contact the
agency directly.
Please contact me at the number listed above for further information regarding
these option(s).
You have the right to a formal appeal of this decision if you file a petition for a
contested case hearing. A copy of a petition form will be provided to you upon
request. The petition must be received by the Office of Administrative Hearings
within 30 days after the date of this notice. The hearing will bc held in the county
in which your property is located.
If you file a petition for a hearing, you must send a copy of the petition to Office of
General Counsel, P.O. Box 27687, Raleigh, NC 27611-7687.
Please be assured that this office considers and investigates all alternatives that
could allow use of this site. Feel free to contact this office if you have any
questions or if we can be of further assistance.
Sincerely,
� • �-
�� _
1
J et O. Clayton, R. S.
Environmental Health Supervisor
Person County Health Department
Cc: Marc Kolman, Health Director
File
PCHD, rev. 10/12/99