A27 333Application Date:
Amount Paid:
Receipt#: _
�V-.�•�_S.� ���..���
` � � � 1������Y
I.�.y'na.4v-iisa-a:asrn.irn-n_a..,RT.'�:.L1�..�1. J��.�LQi.tR.11.'Q::I�.
. Application for Services
(Seatic Svstems and Wells)
Services
L Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
C Mobile Home Replacement or lBuilding Addition
$150.00 (if site visit required) �
❑ Well Permit (New/Repiacement)
$225.00/$125.00
Tax Map:
Parcel #:
C Construction Authorization
(Fee is dependent on the type of sys
❑ Permit Revision
$75.00
� Repair of Existing 5eptic System
No Charge
Important: If the information in tlie application for an Improvement Permit is incorrect, falstfied, or the site is altered, tlie�i the
Improven�ent Permit and tfieAuthorization to Construct shall become invalid
1') Services Re uested b�� ��� �
Name: �� h �
Address: � O'Z $ � O� S�f'
�.,��r� � � Z7 S?
Phone # (home):
(worlJcell): _
2)Name and address of current owner (if dif%rent than applicant):
Name: a�o)d �ictu��s T!
Address:
3) Property Description: Lot Size: Subdivision:
Address and/or directions.to Property:
Lot #:
4) Proposed Use and Type of Structure: � �� G�rd�
Residential Business/Type: Other ` >-�'GjQ �
Number of bedrooms / Number of people served (seats/employees): ��
Basement: Yes No (with plumbing: Yes No _�
Garbage disposal: Yes No
5) Water Supply: �
Private Well (Proposed Existing _�
Community Well: Public Water System:
Are there on the adjoining properties? No Yes
(please show location on site plan)
Note: A completed application must also i�tclude:
➢ A plat/site plan of the property that sho►vs property dimensions and tlze size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluatecf.
I am submitting this application to request services fpom 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 :
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
�
;
5
�� �
� • �
w �
�-� ,� ^.� �J � � �. `� � �
.l! :�ml.'�.7r"�CD�]r31C�.c�7rn.�.�.J1 ���.Jl��
lBualding Additions/ Mobile �ome Replacements
Tax Map #:��
Approval Requested for:
Parcel#: c3
Mobile Home Replacement
� Building Addition
Applicant Name: i Y1 C/ 4f� ld
Address: " S .
�Gl���, r.l�' c3-�5�3
Phone #'s: �',�-�5�3
Perinit Located: � Yes No
Installation Date: y- i O-� Design �flow: �_ (gpd)
Current Contract with Certified Operator on file (if required): �_
Water Supply: �_ Well Public or Community
_,.
�
Wastewater system shows no visual evidence of failure on: �-, �
(Applicant's signature if site visit is not required) a
Comments:
�
Addition/�2eplacem�nt Approved
��!r��lvk.�� �Y�.�
Environmental Health Specialist
11/15/OS
���8��
Date
TOWN d COUNTRY
BUILDERS OF ROXBORO
o.e. so�, P. 174
O �
�N
:� N
� N
1.32
ACRES
D.B. 550, P. 516
P.C. 11. P. 60-A
3Q s � �1 1�
SS,p, PA�SEp �
�'i
N
0
n
'3:5 ,
/��
/
M
, h
DANNY W. YOUNG I o
D.B. 289. P. 886 � �
�
�o
N�5 35,2� �7
/ / /
/ �
i r
� /i
/ �
l
� /n� , ,
�
2s.00, ,
/IF NF
/
�
�
/ I
�
, //
/
� �ps, � 1
' U I
1 �
' 'EXISTING 60'
I / PRIVATE ROAD
� � D.B. 148, P. 134
1 �
� � i
� � o �
� � I
l ��
o �
� �
�F Izs.00,
' NF � � �
' ` �
MIA DANIELLE WINSTEAD � � �
D.B. 367, P. 725 ' �. /�
I I ./
� �� `
I I1 I
�
__ _ � U�
100. �
Amaunt paid �j,p� � �,��j,"� ,
' i R e'c e i p t � , �C' �,�� -��✓ .
.• ' � vj .� j Q o2
���— APPLiCATION FOR SERVTC'rS
,�.•
� l `�'
ate
1. Permit requested by: . '-I _I 7. Dimensions or Proposed Structure:
owner/prospective owne:/agent: GU� c�l Width: i5-4
Address: � _ Depth: ��
�
�
V Home Phone n: r,��f—� d
� usiness Phone n:
a
z
2. I�Iame and a�dress of,current owne::
, ►. . �
8. What type (if any, additions, expansions, or
cepiacement is anticipated to the structure or tacility
that this sewage disposaI system is in[ended to secve?
.� 9. Water supply t}•pe:
private�. pubIic ❑ cortmunity ❑ spring ❑
� Are any wells on adjoining propecty?Yes� No [�
If so, identify location: �T� � �` 5
. Property Description: Lot size: /� 3 Z
Tax Mag�: /d `. Z
Parceln: _ ✓� 2 P
Township: D iu
. Directions to property: State Road �& Road
i�l� �`/ �_ � ���r
d
e
Number of occupants or people to be servcd:
1(�. Type of structurelfacility: Proposed: �Existing: Q
Type of dw,�e,l�l' �'.
House:l(d"Mobile Home: Q Business: ❑
Type of business:
Number of Employees:
�� Number of bedrooms: .�._
Garbage Disposal? Yes ❑ No
'— Basement? Yes ❑ No so, n of basement fixtures:
CLEARLY STA�E ALL CORNERS OF THE PROPERTY AI�ID THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'Son COUIIty Health Department for a site evaluation foc the on-site
sewage disposal system far the above described property. I agree that tfie 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 shaIl become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a sucvey plat of the property the Health Dept. wichin 60 DAYS af[er che date of the evaluation of
the site by the Health Dept., this apg�ation shall become void and all fees paid forfeited.
t
Signee� C�Gvner or Auttiorized Agen�
�
B 2881
� PERSON COUNTY HEALTH DEPARTMENT
� � WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
. has been issued.
Tax Map # 2 Parcel # � ��
Zoning Township {� i '�'L � �
Owner/Contractor �,�:�,� � �vu,�, {-r-y �1.�.� �OL �'S _Date L-I .
Location/Address
Subdivision Name Lot#
/� SEWAGE SYSTEM SPECIFICATIONS
� Repair Lot Area 1. 3a�4L Size of Tank `�
SFD L� Mobile Home Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line 4 g0 `�C �+
Max Depth Trenches o�b ��
�
a
w
�
a
Permits may be voided if site is
Well and Septic Layout by
Comments: ���-.4
Date�-'(d ��d Installed by
Well Permit Paid WEL
Individual 1� Semi-Public
Public Replacement
Site Approved '
Well Head Approved
Grouting Approved (, ;
� Comments:_�v_o ��. ,� .
� �
Date
red or intend d use changed.
, Approved by
0 _ _Q
SYSTEM SPECIFICATIONS
Required Slab � '
Air Vent .�
Required Well�.og i/' S
� _ Well Ta� �/ �
Installed by�JQnS Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information -
contained in the application. The environmental 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
Environmental Health Section
� Tax Map #: ,�, %� Parcel #: ���
Zoning: Township: (/l.� � � `�
Subdivision• Section: Lot:
Applicant: �D�ii%�'���% � l r lA
Location•
57 , fi i � �/� ���� ��v�/'� �'
�� �" l� � , � �t ` .
Operation Perm it
System Type (In Accordance With Tabie Va): �GL�
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.
�!UL : � .� - % La,l ��
./ . -. - �.-
�-��-0�
Date
Tax Map #: � %i� Parcel #: ��7�
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section
Zoning: Township: �� � (1� �I � �
Subdivision• Section: Lot:
Applicant: �81� 7 -��� �l ��5. fi
Location: 'J� � L ' � e , �C � vG�E���l
, `D r � �j''�l �
O eration �ermit
1. LOCATION AND SEPARATION DISTANCES /
A) System meets .1950 setback requirements V
B) Distance from system to any welis �
C) Distance from septic tank to foundatian � 1�-
D) Distance from system to property lines 'z/�'
2. SEPTIC TANK
A) Visuaily inspect the exterior waiis and top of the tank ✓
B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet _��
C) Date of tank manufacture ]—� I— U
D) Tank serial number — —i4Z
E) Liquid capacity of tank �,f�00 9allons
3. SUPPLY LiNE TO TRENCHES
A) Grade � 1 c / 118 inch per foot minimum
B) Material suppl lin ' constructed from �G
C) Diameter ,���
D) Length � �
E) Distance irom tank to drainfield/distribution device %
�Y6�Y1 !� -
��,
4. DISTRIBUTION DEVICE(S)
A) Type -
� B) Is Device water tight
n� C) Distance from the distribution device(s) to the trenches
B U D) is the device on a level foundation
E) Does the device pertorm according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth=�� inches
Bj Trench width �' inch�s9 � a� ���,t��
C Distance between trenches
D) Number of trenches
E) Length(s) of trenches �� r ��
F) Aggregate depth J�_ inches
G) Aggregate material and size
H) Record septic tank ou et elevation (�
1) Trench grade (< 1/4" per 1'
J) Step downs
a. Minimum of 2' of undisturbed earth t/
b. Proper rise over step down �—
c. Solid pipe used ✓
d. Elevations of step downs (Record elevations and show on as built)
See "as built �p�an� attached sheet.
PCHD, rev. 10/12/99
�
,
�r
ri:i;:,urr r.�,��r��ri� i:rvv.i.icoNr,::N•t•r�i. iu:n�.•r.ii
IJI•:I.I. i.()I;
Date:����eJ
Ownei:-i;,' ,,N
L.ocation%� t• �`�'�'���rr/�. �'�, /��'�' (� �
/ u��.CL�Uj��. --�-�! G//�S O n r i.J�� .
� .. _,.. _...__
Lu,,� �� �1!- ryr� . . .�. ._ d� _ ---_
.�i u U;! � v����L�._� .. .
s, ori Nan-, �: .
Drillin ConC�- _.___ - ----__ ot ,
• . _..... . ... _., #
� actor. .._ ..______L
. ..y� s ..._ . � � - J/_ ---
��... ._... �.._ __�. %�--
VVI ;l .[ ..C�'C)N ti`I'1� 11 . �_.--------- -�-__._.
-- _..._.. CI'( (�N
isca��cc fxom Nc�u-cs� 1'ra��cr�y I_,ir��:_. .-.__ .__..___.�.___.
Pollution �
� �S�/.��. .____ llist;���c� �i-o1n Source o.f '
u-5
To[aI Dep[h:. Ft. �'icicl: _ �' .
Water $earing ;Lones: De th ------ �-- ----... __ C�1'M .Static Water Level
C '� P / �-.�_.Z�- 1 t •...-/-.`� .. �'�• � ��Fc:
asing: ,Uep�l: � Frorn ' ---rt.`_�t.
TXPE: S[eel . � __.t<>.__.. ...�..__I'�. Ui.ui�c�cl-: � �
• � Inches
� . ,.�lv:u�izcd S[ccl ��
Z.f Stccl, docs ownci- :1����cov�:: �'�:; —`-... . '
� Weight�. 'lhic ... Nc� .
�_ �icss: --- .
Drive Shoc: �� �.IIcight'A(�ovc Ground: .
�'cs �_ No .._.,L�� `Znches � �.
Werc Problc�l�s E�icountcrccl iri .�c:ttinl; t11c C:,si.J� �'� Xcs �
., .,
�C ycs bive • so�i: ,�. .. :---
I•c•i -______._. No
Grout: Typc: Nea[ -------- ,S;�iicl/C'c:nlcn� t�" , �
A.r�nular.Spacc Wi�]�J� — �- �Coricrete � • ::s�;�
Watcr ' . -- �..--.. _ . ____]a�chcs ���.f:.
� Annt�l�u- Sp.�cc: y�•.. . �'��'
Mct�iod: I'w�i x:c ;._ ,�•�: --. . ....----- ��.---� � .
Dcpt�i: From I _ �� - . _ _.. y� ! r c.. :.� ��:��._ . _.___. 1 'c, urccl__ � �.�. . . . � . , ,
. ,,,
' � ..__ I�t.
Matez-ials Uscd: --- ' " i
No. .�3a�;s 1'c�c�t:uid Cc�ncnt ��'
.IFmi;;turc (sZncl, �;rr���c:l, CUI.IIiI;�ti) - lZ•�cio: '_�... --- Wci�ht of.l�ba�� G�.� lbs: ��
Il� �']:itcs: Xcs � . < ----� �� .,�-.�,,�
1� -- �---- N��_. . _ --- . � � .. • .. � �;
x �� �,lab Xcs__�_..__ Nc> .... .... .... . ..- . •.
�------_....___....._ .._.��l�I l.I .I IVCr 7_.�X►_- .
�Cp[�l �
�I=— ,�,o — ----------�--....._..-----.._._ . ----_..._�_
- -___ .._..._ l:orrnataon Dcticri �ion
-,�.� _ � �� _� -
—�_ --�--- _ _—__ ��'i d � �L �
-��__ . c.,
- — ------ S�-�CI ��U 1��-�-----_
- - ---.--- _��� � � _...._______-
i � � �, . - . _ m �,r�..--�'�
- --- - ..�:
Z �EREBX CERTIFX Tf-I,l1'��.I,IIL �.13()VL' 1NFUR . .•,..
,.`�
T�S WE�,L W AS CONS"1'I� UCrI'LI:) (��� -. M�1'1'ION ZS CORRECT AND TN% '�
. ��RTH BY�T�-i� PERSON c":n(1.N 1'1' [�I1;AJ:.�ORDA,NCL- W�TI-I IZEGULATTONS�`S�
I-I ,
.. .. DCP�1l,.TMEi�1-I- , :,,,,�
,:.
... _. . ��=_—�w�--�,_ _
,�1��11;11UIc t�( (~p��f,,;�:IC,r �
Datc
�
IS
� ` .
;
;
CONTROL �
CORNER /
IF1
°' o
0 0
� �
.n N
� N
JOSEPH A. HICK
0.8. 195, P. 8
„'� • 4
�� S7g.35 TOT�
�� f,� �
��.,� ,
�
��
� �� `�
� --
�� I
1.32
ACRES
4
- To
N�5 •35 �2�,�W.
L. DAN WINSTEAD, JR.
D.B. 137, P. 13
�t1 �. M � P � � Z ?
Lo�- 333
PLOT PLAN
J. D. WALLACE BUILDER
SCALE 1" = 60'
N0. DELTA RADIUS ARC 7AN CHD. BRC. CHORD
C- 1 04'39'33 1,826.04 148.49 74.29' S12'04'46"W 148.45