A35 144PERSON C�UNTYy HEALTH DEPARTMENT
SEWAGE DISPOSAL
ZHPROVEHENTS PERMIT NO.
Issue Date: .� ^ ? ? .�,� `�
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Owner: L�� � 1� C.."'r, j�t' �.
Location:
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Septic Tank Contractor:
Building Con��actor: � �v� �
Water Supply. Private Public 1'�y`ti�•
All wells should be 100 ft. from sewer system.
Lot S�Zg: f, U c, c v �
Sewage Disposal Facilities: /No. bedrooms
Size of tank: ����J�� lp,G�f'� Nitrification line: !
Other disposal facili
Water supply and sewage disposal facilities location, installation and
protectiion must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be
maintained by owner in such a manner as not to create a public health
hazard. Septic tank and nitrification line t4UST BE INSPECTED AND
APPROVED BY A MEMBER OF THE PERSON CO. HEALTH DEPARTMENT STAFF BEFORE
ANY PORTION OF THE INSTALLATZON IS COVERED AND PUT TO USE. THIS
PERMIT VOID AFTER 3 YEARS.
Date Well Approved:
By: (�._
Date Sewage D'spos�a/l A roved:_
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BY=
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Signe � � �
Sanitarian
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Counter- �
signed ) � � ,,. C'� �} ':� ��
(Owner or his�'s�presentative)
Certificate of Completion
Date Approved: �� �� (�y By:
� Sani ian
(Ovez)
Location of well and sewage disposal facilities sketched on back.
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n ounty ealth Department ,
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DATE ISSUyE�D: • DATE DRZLLED:-� �� o� COUNTY: �c r d
OWNER:�/—G q ��/ �'y r.��. ROAD/STREET:
ADDRESS:
DRILLING CONTRACTOR: �/Qwr %,[���� �j .
NAME ADDRESS
WELL CONSTRUCTION
Distance fr m Nearest Property Line/,S /y,.i Distance from Source of
Pollution (� d �('
Total Depth:_ �' Ft. Yie1d:��GPM Static Water Level Ft.
Water Hearing Zones: De�th��Ft�y�Ft. Ft. Ft.
Casing: Depth: From to�.�Ft. Diameter:_�Inches
TYPE: Steel Galvanized Steel t�
if Steel, does owner approve: Yes No
Weight:�Thickness:��Height Above Ground:�Inches
Drive Shoe: Yes C o w� ��No
Were Problems Encountered in Setting the Casing? Yes_No_
If 'yes' give reason:
Grout: Type: Neat � Sand/Cement Concrete
Annular Space Width 3 Inches
Water in Annular Space: Yes No '��
Hathod: Pumped Pressuze Poured L�
Depth: From �to �� Ft.
Materials Used: No. Sags Poztland Cement�Weight of
1 bag��lbs.
If mixture (sand� gravel, cuttings) - Ratio:�to_�_
ID Plates: Yes �� No
4 x 4 slab Yes� No
DRILLZNG LOG
De th
From To Formation Descri tion
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I HEREBY CERTIFY THAT THE AHOVE IN£ORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W7TH REGULATIONS SET FORTH BY THE
PERSON COUNTY BOARD UF HEALTH. PERM T VOID AFTER THREE YEARS.
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ignatura of Contractor Date
Sanitarian's Signature Date Issued
Sanitarian's Signature Date Completed
Sketch well location oa reverse side.
Application Date: �- I a' d� � Tax iVlap: � 3�
Am�unt Paid: 1� �. U� Parcel #: �i- �
Receipt#: � `) 0� `� � � 02 � � �
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Applie�tion for Sery�e�s (Septic Systems and Wells)
Sea-aic�s Re uested '
e mit (Site Evaluation) ❑ Construction Authorization
./$ 0.00 (if> 600 g d) (Fee is dependent on the ty e of sy;
iViobi eplacement or Building Addition ❑ Permit Revision
$150.00 site visit re uired) $75.00
C�J I rt(New/Replacement/�iepair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Char�e
Services Requested by:
Name: Cx � �T�" Phone # (home):3 ;� �— � nj �1' 3 � � 3
Address: 0 p - T r(�d , (work/cell):
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2)Name and ae�dress of current owner (if differ�nt #han applicant):
Name:
Address:
3) �roperdy �escriptnon: Lot Size: �� Subdivision:
Address and/o�directions to Properly: ��b ��g. _ mc (�\�� �
�A K L... 1 = � � � �' � � ��. �e`c�t:�s �`, \\ ��J , � � � e Y ;�
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4) I'roposed Use and Type of Structure: l��F �' - S�+���C w: ae h�ob
Residential ✓ Business/Type: Other _
Number of bedrooms �� / Number of people served (seats/employees): _
Basement: Yes No �(with plumbing: Yes .V No _�
Garba e disposal: Yes No ��
Water Supply:
Private Well (Proposed Existing �
Community Well: Public Water System:
',ot #:
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Are there wells on the adjoining properties? No Yes (please show location on site plan)
1°Iote: �4 completed aD�lication musi also include:
� A pladsite plan of 1he propepty tlzat sliow� pro�erty dimen.sions and tl�e size an�l locntioaz nf �ll
proposed structures.
9 A signed capy of �lie `.�ot Prepczration',�'o�m ver�ing that tlae praperty is reac�y �o �ie evalstuPe�l
i am submitting #has application to request servic�s irom the P�rson Cou�aiy $e�lth �epartme�at. � understand tha�
�f the info�anation provide�l is �ncorr�et or if ��e site is subsec�ues�tly altered, or if the intended use c�anges, a�9
permits and approvais shall become invalid. -
Sig�a$aa�-� (�wner/Legal Repr�sentative
� ► �
10%08 Person County �nvironmental Health, �25 S. �iior�an St.; Suite C, Roxboro, NC 27573 (336-SQ7-1790}
or
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Tax iVlap #: A�
A_pproval ReqLested for:
Parcel#:
�/ 1�lobile Home �eplacement
Building Addition
Applicant Name: A
Address: e �-• �. '
Rox�onro. !JC 2757�- __
Pi�one #'s: 331�� $qq _ 35�}3
�Per�.it Locate�: �'es No
Installation Date: �- Design floyv: o� (gpd)
Current Contract with Certi�ied Operator on file (if required):
VJater Supply: J Well Public flr Cammunity
Wastevaater system shows no visual evidence of faidure on: Z.- fg-Oq (date)
(Applicant's signature if sit� visit is not required)
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Environm tal Health S�eci�list Date
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Subdivisi.'� � _ � Section/Lot#
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Autho�ized State Agent . � Date _
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Iaegaagniaa� the �aa�l&a�zosa i� �aa�e t3aat�i�n�erg� ss a�scasa�tussa�d
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Lot Preuaration
The upplicant is responsible for preparing property for a site evaluation by an Environmental hCealtl: Specialfst.
The applicant must address each of the iTems listed below prior to the evaluation. (Note: A separate application and
site plan must be submitted for each proposed septic system/lot. An individual evaluation may encompass an area up
to 3 acres in size.)
l. Site Plan: A site plan must be submitted with your application. The site pian must show property
dimensions, the location and size of proposed structures, and jurisdictional wetlands (if applicable). A
sample site plan worksheet is available upon request.
2. Property Lines: All property lines and corners within Z50 feet of the proposed house site must be clearly
marked and readily identifiable. If you are proposing to subdivide property, the proposed property lines
must be clearly marked.
3. Clearing: In order to conduct a site evaluation, the lot must be easily accessible. If fallen trees, underbrush,
or other obstacles prevent free movement across the properiy, then clearing will be required. Soil
disturbance must he minimi�ed durinQ the clearing process in order to avoid removin� natural soil and
adverselv af'fectinQ site/soil characteristics .
4. House/strueture: The proposed location of a house or any other siructure must be marked on the property.
5. Orange Sign: Please post the orange sign provided by the Health Deparhnent in a location easily .visible
from the road in order to help identify the property to be evaluated. �
6. Confirmation: .Once all the items listed above have been completed, please sign below and return this
form to the Person County Health Department. Once the (1) Application for Services, (2) a site plan, and
(3) this form have been submitted to our office, the application can be processed.
Important: '
➢ lf an Environmental Health Specialist arrives at the property and a site evaluation cannot be
conducted because the site has not been prepared as required, the applicant will be notified and the
application placed in `Inactive' staius.
➢ When an `Inactive' application is reactivated, the application will be processed based on the re-
activation date.
➢ A revisit fee ($30.00) may be accessed prior to scheduling another visit to the property.
➢ Applications which are in `Inactive' status for more than 60 days are considered void and all fees
paid by the applicant are forfeited.
➢ If you have any questions regarding the information listed above, please feel free to contact our
office at 597-1790. Our office hours are Monday through Friday, from 8:30 to 5:00.
NIy signature below indicates that I have read the informaiion listed above and that the property has been
prepared for an evaCuation in accordance with these instructions. I understand tltat if the conditions outlined
above have not 8een met, the application wiQ be placed on `Inactive' status.
Property location: _L� 6 S D � K (��. ,� �� J��'r �� 6 � � � ����, � , (' ,
Signaiure: ��� ��� Date: — �� � l
Person County Environmental Health
325 S. Morgan St., Suite C
' Roxboro, NC 27573 �
6/07 Phone: (336) 597-1790 Fax: (3;6) 597-7808