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A35 136Person County Health Department � �-�.� Well Permit .- � Date:�/T� P it V' Afte 3 ears l 33� '� Owner SR# •� Locaaon/Directions: � 3 Subdivision Name: L'°� # Drilling Contractor: '= �; �„ � I,,�� f/ �� WELL CONSTRUCTION � Distance &om Nearest Property. Line � u�' Distance from Source of � Pollution D w s . Total Depth: �.FG Yield: �r�GPM . Static Water Level �Ft. � Water Bearing Zones: Depth a-- FG y� Ft FG � G Casing: Depth From D to � FG Diamet� rnches TYPE: Steel � Galvanized Steel If Steel, does owner approve: Yes No WeighC �..— "C�c��s: -�-�Height Above Crround: �� Inches Drive Shoe: Yes `� No ,� Were Problems Encoimtered in Setting the Casing? Yes No ro If "yes" give reaso�. � Grou� Type: Neat SandlCement Concrete p,nnular Space Width 3 Inches Water in Atmular Space: Yes No �. Method: Pumped,�_ P�SS��_� Poured � Depth: From _l1-- Macerials Used: No. Bags Portland Cement �._ Weight of 1 bag � Ibs. If mixture (sand, gravel, cuttings) - Ratio: ��_ ��__ ID Plates: Yes i/ No � d: d slab Yes �� No `�' I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. /��- ��/�`� • �--� ' Signature of Contractor Date � '��%—� S' i s Signamre Date Issued Sanitarians Signature Date Completed Sketch well location on reverse side. U � , J�-�3 � � Person County Heaith Department Sewage System Improvements Permit Date:,�� "I'his ermit Vo'd Afte Years- � 3�3 `j � Owncr. 5 c� f:� SR# `�..-- - • �. . .cti •/J-- -` n .a_>_ h� . .._ _ C � «�.r.0� Subdivision ame: "'�— Lot Size: � T o Dwelli g: �� Water Supply: Private: ��c: �� Bedrooms: � Garbage Disposal �-- Basement ---- Basement Fixt s T-- TNFnRMATION C�R'�IFIED BY � _ # REPAIK�1 � lZ��VALUA"11UN: Size of Septic Tank: � d� gallons Size of Pump Tank: '--' Nitrification Line: � (� D �� Depth of Stone: 12 inches Max Depth of Trenches: Altemative Sys . on Pum L P Pu Remazks: z Date Well Approveci: Well should be 100 ft, from any sewer system BY S�� Da Sewag Syste�n Approved:,�s – � BY T�''� Sanitarian CERTIFTCATE OF COMPLETION • , . Conuactor. _ _ L � T ,q/.�i._ �, .Son s _ _ _ _ _ ►-� Sewage System location, installation, and protecrion must meet state and local � regulations. Septic tanlc should be pumped out every 3 to 5 years and shall be maintainecl � by owner in such manner as not to create a public health hazard. Septic tank and'd nitrif'ication line must be inspected and approved by a member of the Person Counry � Health Department before any portion of the installation is covered and put into use. If the site plans or intended use change this petmit is subject to revocation. (G.S. 130 A-335F) � �� Locauon of sewage disposal sewage system sketched on back. � W (OVER) � � _____.. ._.,._ .. . ..._ � �. v � � y �i M Ir �. l% P'1� � � ;, . y y . a w ;� � ° �' � o � � o fD ': N A R �' � °: �• °, . w o�' .7 "(� y °, � w � � �i w �! � o ., A n F N� '.T b �* o � � �. o� y O Oq o � � � � w • y w � � � �D � �• a 41 � y fD `� w °' G � M fD n+ �R � � � a O M a m � K � � m w er y � b � � � � �: � o x y y � � � e' fD y o � A w y '. � � M Application Date: �'T Amount Paid: Receipt #: ��1 0 Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) obile Home Replacement or Building Addition $I50.00 (if site visit required) ❑ Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 'o�� 1'��LJ� '�'a�s IVV�ap: � � �J "� I'arcel#: ___[�� `�'''��- ��. � �p7��(,_,7� i�p�1 ��r, ][.Il S IlII`KD7I?LII.7C�.2-:339:,L4..il J.L 1��G.aS1.��'',L'.11. tion for Service� Services Re uested ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision $75.00 0 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: � 1 , � �� Address: '� � �(' �y � � 2) Name and addr s of current owner (if dif erent than applicant): � Name: 0 u P 1"�-�- i C �� Address: 0 c c'� � � � 3) Property Description: Lot Size: �� 0.0 Address and/or directions to Property: Phone (home): ,� � ��'$ (work/cell): Phone:_ 3� -sq q- a y� � ❑ yes ❑ no Does the site contain any jurisdictional wetlands? � yes ❑ no Does the site contain any existing wastewater systems? ❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage? � yes ❑ no Is the site subject to approval by any other public agency? ❑ yes ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4�roposed U§e and 'I'ype of Structure: Residential ❑ New .Single Family Residence Maximum number of bedrooms: ❑ Ex�ansion of Existing System If expansion: Current number of bed�r ms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes Q no With plumbing fxtures? ❑ yes ❑ rio ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) V6'ater Supply: ❑ New well t� �xisting Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If applying for `Authorization to Construct', pleasQ indicate preferred �ysfem type(�): ❑ Conventional 0 Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the inforntation provided above is complete and correct. I also understand that if the infornzation provided is inaccz�rate, or if the site is sarbsequently altered, or the�te.nded a�se changes, all permits and approvals shall be invalicl. �, ,,. w «- Signature (Owner/ Legal epresentative*) '� Supporting documentation required. Y-3-�`{ Date Permits are valid for either 60 months or are non-expiring ti�hen 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) ConnectGIS Feature Report ��i��IE��C�MS 1YEB NC35TiNG �i9 �O ZA965 ��1948D 1S4 19479 - Gv ,i �a—•--•� 1877d 18T � � � 19d7B 1948Q i6t 550 187.8 R Page 1 of 2 Person Printed April 03, 2014 See Below for Disclaimer Parcels a PfQgf�55 J4C225 (1� i I pf0�f255 /4t'�25 (2) 79.7 ft ; Rarcel �4ddress Points � Parcel Camer Paint� 0 Parcel Line E7imer►sions Lakes ! � Roads Gity c�f Raxbaro � � 1� Voluntary Agric�ltural DiStricts � � �[!� C S N � 1 �T � ' .� aflve LqN� ` � ' : tl7 Feet http://gis.personcounty.net/ConnectGIS_v6/DownloadFile.ashx?i=_ags_map 1 b 1682e 1 bc58... 4/3/2014 � � � � �- , ) �' )- � i j � ,� � . �� , �; �, �� .:�.� , � � .� S a d' �� `�-�'� y �� c�� ' �� ,�!�z�-�i��_rz�r.n�eA�.�L=<�,�i. 'I�,��.�n.71�:1� �a��d�� m��/ ly��nfl� ��a�� fl�a��a��n�5 � Ta� Nlap #: �135 Parcel#: �310 Address: 45 0�+� t,.�►a� � �t1o�o_, tJc. �`►5`1'i Approval Requested for: x. Mobile Home Replacement Building <Addition Applicant Name: C�`�a ��'�S Address: 3`1`l0 i�Ua�+� P.� R�a�a..Q r�c. � a�?s��} Phone #'s: 33b- 5 9�1 - S53g Permii Located: X Yes No Installation Date: a-5- �yq\ Design flow: 3b4 (gpd) Current Cantract with Certified Operator on file (if required): �_ Water Supply: X, Well Public or Community Wastewater system shows no visual evidence of failure on: � 9 � (date) (Applicant's signature if site visit is not required) Comments: Ac�Qa�� 'o �eu�c� �.xu�� 3-(�-��r S��t�.��oE. w� A - "i'y'�rc. Q�UR�or� Q�Q� w��C.. • t�E w�us� a�E.O 'i� "6�c. t O�T oc'r� — sEeric. , �a�. a �►a�aF - �x,�,�� o�� .��A�S �,.\ -r�a�v. � 5��..� �QE �rcv F o� i3ac� a� c%w ��s� c,a��T �� Asc- cv� -�o.�s�. �c�,c�� . ��r1��/��a�aai ��p��e�l �1.�.,..�. Q. �.1� Envirorunental Health Sneciaiist I Da e Person Coun�� Environme:�tai :�ealth; 3�5 S. tiiorQan St., Suite C, RoYboro, NC 2 i�; 3 Fhone: ��6-597-??9C/ ra;:: ��5-�9�'-7�0� � �.v�:�-�v.,:ersoncoun�t��.i;et ConnectGIS Feature Report �� rYE� k�S14�#C+ �S'_. u^ '5�i8 "G' A � ;'>5G .5 fi �:2.7 ft ,s��9 N �T � �''� � �� q35 � i3c� Petson CouMwy Environmental Hea�tt � M� � �� t,r�?.3 ft �c iJEw Qo�,wrp� taa�o c ��10 T.�►`, �A� -� �a�, s��.W,�, l.� t.,ar�i�. � �.x�mc�b t�C.c� Ca.1�,�,�ir`�s �tJ "�%. �r�a�. � S�� c��. � = �saen — — - ^! � — �� 1 � _ _ — — — — — — � � — ^ _ � � � . % 1''111SZ � ` _..r�� v �� "1 W� An►181.� w►�E � 2p. ( ay � •��, >?a � w u ��3.� � � J � Page 1 of 1 Printed April 09, 2014 See Below for Disclaimer ='a.? f3 184 21965 � �� • 1 : 5D Feet � � , . � �,>�,�,�� OTICE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who hav �cently upgraded to the Windows 8 operating system or a new version of Internet Explorer. We were able to resolve this issue by directing users to the Internet Explore ompatibility View tool. This link is io Microsoft's "How To" for the tool: http✓/windows.microsoft.com/en-USlnternet-explorer/products�e-9/features/compatibility-vie� this does not solve the problem feel free to contad us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGLS has bee repared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system ar �tified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectG] �sume no leqal responsibility for the information in this system. Grid is based on the NC state plane coordinate system, 1983 NAD. http://gis.personcounty.net/ConnectGIS_v6/DownloadFile.ash�c?i= ags_map563bd96e2f4c4... 4/9/2014