A27 368Application Date: � ��� `1-3 �0
Amount Paid: o2G0 �O� �_ �� '�
��- �3
Receipt #: ) % %,�5� �
.
LJ`��� �DQI
J�Impruvement Per�nit (Site Eva!aation)
$200.U0!$300.00 (if> 600 �d) ____A___
J Mobile Iiorr.e Replacea�ent or Buitding Addition
$150.00 (if site risit recluired)
❑ VVeil Permit (l�iew/Replacement/Itepair)
$300.00; $2Q0.00/$75.00
��� ) f 11 1l,dJl�.��.�. V Tax Map: � 1`�
.,....: •' � � Parcel#: '�b �
�_ ������
IE:,�a�n$-xsn* � ��rn.a:�.11 7I 3C�e�..lt�
Services
for Services
L� Construction Authorizatioa
(Fee is de endeat on the e of system permitted j
� Permi� Revision
$75.00 _
G Repair of E�isting Septic System '
AppIicarion: No Chargz/ CA $150.00 or $3d0.00
/1) Applicant Information:
Name: J ,50 �( ��1 LIC�R 6l�
Address: l8 "7 � /Y�,�L L HZ"L�, � �
0 C
2) Narne and address of :,urren owner (if different than appli�ant):
Name: 1U<�2soN HO�1�.zN6S LT D,
Address: ,�j�._Sp H 6�1--�1nLz � s�'� ►4 � Q�,
RO X�3�r� ��u L,; Z7 '� y _
3) Property Description: Lot Size: � 3�-�_ Subdivision:
Address and/or directions to Property:
Phone (hamz): _ j,3 �p ` . 'rj q q ' Z %Zj>
(worklcell): ,�3(p -= 5R 3 � 3G� 27
Phone:
Lot #:
❑ yes '�'� Does the site contai.� any jurisdictional wetlands?
O yes 0���� Does the site contain a��y existu�g wastewater systems?
❑ yes �'g� Is any wastewater gcino io be ge7e�•ated on the site other than domestic sewage?
❑ yes G{p� Ts the site sutsject to approvat by ar:� ciher public ag�ncy? �,.___----..�
❑ yes Q'no Are ihere any easements or right of ways on this property? - " �_
(if `yes' is checked, please provide supporting documentation) .,,. `� �!1 . N �1 e� �
4) Proposed Use and Type of Structure: '��t '� e e��, ,,� ���-���-�� �
❑Residential 4--...________..... __'�''-�� _- -"'l-
❑ I�,'e�v Single Farriily Residence lYlaximum uumb$: of �edrooms:
❑ cxpansion of Existing Systeni If expansion: Cureiit num�er of bedrooms:
❑ Repair to Malfunc;tioning System Will tl�ere be a basement? ❑ yes ❑ no With plumbing fixt�u-es? O yes �7 ne
❑Non-Residential
1�pe ofbusiness: Q��yGLd��_ ��'�1�%� � Total Square footage ofBuilding: ZOO SF
Nlaxinium number of ern�3ayees: , ` _ Msximum namber of seats:
5) Water Supply: ❑ New �vetl ❑ Existing Well ❑ Community Well ��ublic Water ❑ Spring _�
Are there any existing �vells, springs, ur existing waterlines on tttis property? ❑ yes E� no
�f applying far `Authori�ation to Construct', please indicate preferred system type(s): �
❑ Com�en±ional � Accepted ❑ lr�novative ❑ Alternative ❑ Other H Any
I cert� that the information provided above is complete and cofrect. I also una'erstand tl2�zt f the inforrnation prUvic�ed i.r
inaccurate, or if �the site is subsequsntly alte•red, or the �ntendad �se chafzges, all �errn�its and approvals slkxli be irrvalic�
Signature (Owner/ Legal Representative*)
� Supporting documentation rcquired.
�— /v—/
Date
Permits are valid for either GO months or are non-egpiring when accompanied by an approved pla�
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)
.-���.s� ���..��.�
� � ����
�C�an_�n�s.��n.�*-+•-�+� ��rn��a.�_ ���.mI��I�n
rlpplicatrt: :1 Aser1 1nf r�Y,�.RSot�
AddressiLocation: �y,�� 158 WSST
� �g�----�''�v_..�►��. _ & _o_ �--
Improvement Permit
Permit Valid for: Five Years �� I`ion-expiring
Type of Pacility: Mp�t.W�,s �t,�w�b New � Additian _
Number of: Bedrooms / Occupants / Employees / Seats:
Proposed Wastewater System: (s,ave -��aA
Proposed Repair: C,�,�.1v�a�,�,�. Q�m�P �,ave�rn��.
Permit Conditions:
Authorized State Agent: _��j ,__
(Y) Owner or Legal Representative:
Tax Map: Aa'l Parcel: 3�0`�
Subdivision
Phase/Section/Lot #
Water Supply: E�.►sz►.�1�b �wvr�� W�v�
Projected Daily Flow: ��c., gallons/day
Type:
TYPe� � �I a
-t'1�� •
Date: '7 3� 13
- 30-/3 Date: `7/ ��)i
The issuance of this permit by the Health Dep�rtment does not guarantee the issuance of other req��ired permits. It is the responsibility of
the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a�hange in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina 6Laws
airr! Rules for Sewage Treatment �nd Disposa[ Svstems'(ISA NCAC 18A .1900}. 1�Teither Persi�n County nor the Environmental
Health Sp�cialist warr:�nfs tt=at tn� ::;,�tic system v�ill continue to iunction satisfactoriiy in t�e futurE, or that t6e water supply will
rcmain potable.
Authorization to Construct Wastew ater Sys�em
See site plan and additional attachments (�.
�.
Proposed Wastewater System: (�av�a�.yt�iAti. (*)Type �a Design Flow 1��_ gal./day
New � Repair _ �xpansion _ Soil LTAR: .,�' gai./day/ftz
Type of Facility: i"1,�Et�i�� 1?,�.c,Yc��it� Basement: Yes � I4o
(*) System Types IIIb, Illbn, IT�, and V, require periodic system inspect�ons by the Person County Health Dep�rtment. _�
Wastewater System Requirements
Tank Size: Septic Tank � a�� gal.
Drainfield: Total P,rea 4Do sq. i't.
Trench ���idth .3 ft.
Pump Tank —' gal
Total Length 13S _ ft.
Min.Soil Cover �o in.
Grease Trap ""' gal.
Max.1'rench Depth _Z-� iii.
VIin.Trencl� Separation � ft.
Distribution: Distribution Box iC / Serial Distributian.� / Pressure Manifold
Specifications: I LSo
l-E.� 6'rta L t 5:
1Uti.N As Poss�v�
Authorized State Agent:
�E9L►t4L bY�.Yl1� ' ��
[ssue Datc:
Perrt�it Exx
The system permitted is: Con�•entional �/Accepted / Alternativa / Innovative . I accept the conditioTis
and specifications of this permit. �
(X) Owner or Legal Representative: Date: � /
Person County Environmentcrl Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573% ph: 336-597-1790 (rev 5/12)
.' ,� . p � ` 20 40 � � � . .
BAR GRAPHI inch = 4� ft.
IW
�C �DO N� 1h�STf�V•• W�'C� w�
�, 1''1\T�\hiti S�� 0�'s'L1'(Z.�1,C.�
� � � i'��° . `�a'•�i»<s�-o
��.\��.`.
l'A�� ���o �, 33�- 5�1�t- ��t°I'a
�Y v�C"� S'l 5�.'�'� e�cil. �
�
� � 5�,.'14'�0�
WILKERSON HOLDIIVGS,
� IIMITED PATRNERSHIP
� D.B. 273, P. 658
\
\ ZONIN6:.RC
RESIOENTIAL/AGRICULTURE LAND USE
� IS _ �^�. = . -
• ,
�
�
�
. ` 6
1Q .
\
�
�
\
� ; a�, �
� �
� \\\ ,�, � � � WIL ERSON HOLDINGS,
. � ,�h �i `.�` 3 � LIMITED PATRNERSHIP
� � � �o �, •�` D.B. 273, P. 658
�
� 6' h ��� % ��, s 1
�� . z."' � �: �, ��o ��. 1
� . , �,� ,��
.'� ,' � � •� ,
\ � ,- �P,q��p ��-� \ �' �'�°�sF 1
\ � � '` / '9
.�% ' ,' � �f
,,, �\ ,,� � , 1 . 0 6 �
� `� f� DRAINFIELD , �' `
��\ \` ,�� AREA � C R E S �
`� �� i . �
EXISTING �.` �.\ �� � � �
GRAVEI � , , � � � — —' — —
DR I VE ��NS �\�'� \ • 8' x 30' �
� �� � ; � ' RECYCLING EXISTING �
. �\\ �\` `•,\ \ �,�T � BINS BARN IS ' �
. `�` ��` �\ 1 iy i
`� \� \� � � . �� �� /
�� � �. � }� ' ��, '
� �� �♦ �., .' `�+�Q'
� . �� ..� � � :
� . � NS
� `�\ � EXISTING • / '
� � � BUILDING A � �IGN � �
� /
�� � � e � ,a
� \�� ��6' I 90 ` �.�°� � .
I��'poo , 9� �, �� �'` � �
�� \� � �
\� T�j� PAYEO QRIVES \ r� � � /
���6+�4�\` . AND PARKING ,�. �
i� . �
' .� � � .
. /
. �.
� �
� \��. `\�� � �rtoPoSEn ��;ti�' � •
\ \ '�i 18 • J
��` ��\ � ��� � ��� RCP pp, �.� le .
�� �� �� �� ' � 1�` � '
� ♦ , �1 �O i
����� )� ���� �b �J �� ♦ . �'j i
� `� �� Z � /
`_'' � �—.1— cC � jC.T�T�C�Y . , .
. � / '�,;, � ' ,
���s���.��.��.n ���..u¢� � , , Gj� /
,� ,
SITE PLA1�T � NS '
�
�
Name .iAS�'� W��-iL1oT� Tax Map #��, Parcel # 3b�S
Su divisi n Secrion/Lo #
• �, � 7Tr13
.Suthorized State Agent Date
Sysrem compoaents tepraent zpproaQmate conrours only. The contraaormusttlag t6e sysrem ptror to begianing the inszallarion ro
insure thatpmpergnde is maintained.
LEGEND
NF � NAIL FOUND
NS o NAIL SET
•IF • IRON.FOUND
o IRON SET
�/ ONE WAY FULL ACCESS DRIVEWAYS:
� PAVEMENT SCHEOULE WITHIN DQT R/4Y
/' $" CABC'$:2° 59.58 ASPHAL�T SURFACE COURSE
OR 6" CONCRETE 0 3000 PSI
i � •
i �
.' 6a' / _
/ 1O �6 �
g..� � ,��y �
. ob h � 5� � .
�h6 , .�o � ,
i � / ,
���, sf ���.� ��
� � � ����
� sa�aa-��a.�*�„-„ ���an.� �'�¢3�.Il��a
Applicant:
Location:
W � 1.\�,�-�5.71`�.
� ;v �t 1 �1'1
t��...`. H►v�.- �
O�eration Permit
Taz Map a`1 Parcel # 3b$
Subdivision
Phase/Section/Lot #
# of Bedrooms
System Type (From Table Va): � 6___ Product (IIIg): �. �
Type V& VI Expiration Date: �1 A Type V& VI Renewal Date: _�L
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.
t'J�.� ��� A . St�r�N
(Authorized Agent)
�iY1M`t �w�s � s�as
(Licensed Contractor)
PI�
�� �
p� �.
Scale 1�'S
PCHD, rev. 12/14/12
q�b��
�
i'��`L �•I��� s����t
�
�
0
g 7. i3
(Date)
�Z �3
(Date)
� > i'O� '� Av... �Za?�-Ll.'�`t I.�i��5
�i. ('c�.-`t +-c�u� �F�.�E�c t���
.� 1�i ��- �'l�f�� �S1�ol,► FWtaP
Line Len
� 40
Z 7�
Tntal { 1 O
Tax Map: /�1�`1 Parcel #: �31a�
Septic Tank System Checklist (Type II-I� System Type: � 6
Se tic Tank InitiaUDate
State Ip & Date: ��-t�{�. �c�,� g�. 1�
'� L3
Capacity: �p-C 5- i oa Q
Tee and filter
Baffle
Vent
Riser
Outlet boot
Perm. Mazker
Distribution
D-box levels set) q
Serial Da5 s �t t�y
Pressure Manifold y,�Jp,�
LPP
Notes: '(3u��J��,6 w«L �i�FCT "�"o c��-�sct� �.�.1.�..
Pump System Checklist
Pum Tank InitiaVDate
State ID & Date:
Ca acity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure NTanifold
I�'umber of taps:
Size «nd sch:
Contracted Certified Operator (Type IV Systems):
Notes•
Tank Com onents InitiaUDate
Pump model:
Block {4"
Nylon retrieval ro e
Float tree and attachments
On/Off float swing: in.
Alarm float (6" separation)
Anti-si hon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
Approved and secured riser
Su 1 Line
Size and material: in. sch.
Length: ft.
to� W��3 C�..��x�� sr� �vH�. . A�o ��c��� ��c�.rl��.
�a��a�,� � �� `�g... s��.v �.�cv2, � �,�, �-c'E .
�,A�.�.cc� MR. �,s��.��CLsa�, d' -tv�0 H�t1 't`p �E.
St�Q�.i�;�, Wt.�� �I.�t�,F��LU hr�0 S�%Cw Z�' �'
� at�\ t�'��,a �' � C3��� a�MnS C m uvq �
� 5 s u,�o • -�.' t�l 0.�
�j3'� 13 1�-c.��V� 'p�+�rii �j� Sai.a1�`(p(�. � QE-'�1,�'C"C IiS►�'�,a
�-�o-�� � `��- �. c
C
�-z—� � � � Q� c� c�t�
�Vr `Q�`,v`