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A35 183'�) ` i)' � ( � • i�x Nla�� P�r�cMel I�;I�. ��` , S��ihdivis��oi� + Pia:�se"Sec�tioii lot � :� �c�� \"1�� •1 � ��r� `— t r .�r �rr �ar�� e_. r�� I �. ' I �_. �-. 1 ��. Applicant: � - � Location: Ma 9►�.�� Yh 1t '1� �(�; ..�,�.,, [�(. (:..,�,e C'1,,,J.�. �%` lY�a. ?�L.. l2.2 � e�r►�,h� s�.��- � n k �-• f�—,r,c.S 1- C�� Cs�� (1,hw�.� � v—T— . . � era�� o : er � lt . System Type (In Accordance With Table Va): � C� � THtS �YSiEiW hlAS BE�iV iNSTAd.LED IN COi1�PL.lANCE 1I�ITH �PLICA�L� �IORT�-9 CAROL9R9A GENER�►1. STATUTi ES, FtULES .FOR .$EW�4GE��T�►�'AlIEN'i AI►JD �DISPOSA►L., �ND �L CONDlTIONS O� THE IflAPf�O!(E�A�IVT � PE6�MIT .�D CONSTRUCTION - � . . .. AUTHO��'i'!ORl... . � � -�. � .. , ..... _�. 1.�^�.^�3 . .. � . .. Autho zed S te �Agent . � � � � . . � - � � ` : � Daie • • � � Installed By: � S� a-A., . . Date: 1 � �5 -�''� � , . — . . . c: 4 . • �. . . � . . • � ��.i'.�a � .'/o'/ •.� .' _.a: .. • .. • _ � . • . __:.._„�----.... ..._... .. ._ _:. ,... : • . . : . • � . . , �' )�, � - � _. _ : . . :. .... . :_ . . ' . . . ,,�_ �5�:.. .. �_ :. V_. . . ... . . . .. � . L ,s� v V_ s .. C: � J �7� 1 l,U' �� m �� - r CHD, rev. 07/29/02 e � s��c �-�� «��c-�o� ��.1��- {z}/�� [ - n� Tax MaQ # A�� Parce! # ��3 System Type (Table Va) _�; a OwmertApQlicant� �M .�.�-�oc.� Subdi�rision AddresslLocation ('�,�� C�,v�_ (�� ?z. Ser./rPhase Lo# # � Sepi�c" T'ank na ate� etsa �ataon tnes na� a#� . St�ie ID/date :� r�--�� r� „_�.�z Tranch Width ,�. fr. � �� „_,�.� Capaciiy. �-� Tee and Fiter Baf�e • Sealant Riser if ap iicable) Tank Outiet: Seai Permanerrt Marker � Pt.ca�a�o Tank /Sealarrt � I Riser • a �aaupr � �heck Vatve/Gate Valve . - � Anti-siphon o � Fioats/�wiiches �: : � � . � . . .. . Alarm (visable and audible) Rate (gpm) Approved Pump Modei Bloc� Under Purnp Pump Removal RopelChain Dis�b�a#�on Syst�m Seriat Distribution ' ressure ani o Low Pressure Pipe • Appr. Pipe fUateriai and Grade Valves _ .� Trenct� Length �I �S ft. ✓c�z ,rs^�- �+ �s�.o� Trench Grade ^ .u� � ,_ 3 Trenct� S acing ��,� ,� �o� Rocic De th and Qualiiy rr. v- , _ � Dams/Ste dovms etc. � ��_ -,, � „� .�; Pressure Laterals � Hole Spacing . � o e � �ze .. . . � . . . Pipe Sleeve . � - - � � � � � Tum-i�psfProtectors . . . �Requi�s9 Se�ack� � � From Wells �. � � � C� � ��-s�3 � Frnrn Properly lirtes � s� i �5-�3 . _ � StructureslBasements.:: � �. � c�s � .-s-o . rtc es � ramage ays � � .s�o �SurFace` Waters . _ C� . . �i�T� � Public Water Su�plies s� . i�-��, Vertical Cuts (>2 ft. . s �,�s- Water Lines � i ►,.5-�� Vehicle Traffic Ss �►..�-�-� Ad�acent�Systems S ��. Easements/Ri � ht of Wa � � �_. O�e� Easements Recorded . perator ntract � . Co¢nit�en�s� - � _ pct�� rev. 3113/01 �� c� � � �qv�"� bet � 9 L�M � l� l�" �� uY ea Coo 9uo � J �'/ p� �9s e �et pqt� ��9 ev�� `i��t�9 tot 4� �0 9,�v : • �� t e ?`�tycc`�J > � l'� �= v'�`e ;.: , � �u��, l(��• � �� '� � � ��-- _--- s��e� ------ -- �� P �j�� (/� �� " �� " ( 1334 �, � U SR d � tS ( � ��rcN"� _ — l � __ —.- � ��s' ► �j� ► G�� ` G\,��G�� o P �NOn�' ME� �� SC� �� ` = �D �� 1 � � �, �` � �O _ ---------- ---- . _ _ _______ __ -- S81'02' 44"E • 2?t3.2�#� .��-�6� _-----'_' _ _ _ ..------ — -- . e�� , ��,'� �o� '�`��'� �� e � �� ia �� _ � �, . ; N � Q u> r ) ! ' .� rn � N ;v `. � N81'3Q'44.. 249.49' . �� _ — ' s �� .�•��e-n �r''r" C7"'.��.JL ��a�.�� r'�''�� . �� s�� .��1�� N ��I�'s��. Syi� ��o�T�' �� : .3 s �� # / �'-� �� ,,� i "'.W.�.�1.. , �� S1113�1V1�310�: .�l�OSI: , . �'�e af W�.�r Saa��: �—Indiv�.dua1 Community Public R.�ta��s�a�n%�• Site Approv+ed bp ✓ �--s� io -z�-�� Gmuting Approved by✓ c-s � �� - z� �� Well Log r� �-a�-��- �ell T Air Vent � ✓ ' "�� 1 � - 5-�"� Hose Bib Concrete Slab � - �ir �;�� Weli Dri�s: c�•�:�+� .c�� 1-L � W�1 �pproved. �g: D�te• \�-S-a�b '�Seel�xtac,aaerfl 5iie S�e�a�` Wells must be 10 feet from gropertp Iiaes. WeIls must be 100 feet from septic systems. Wells must be at least 25 feet from aup building foundahion. Qther conditions: h�'�,� pCf�, rev. 09/07/01 � ..�. �- Apolication Date: � � � 7�� ax �lap #: Amount Paid: �00.0 0 Receipt #• 2,7�4 G � �arcei �• � � Z �� .� �� c� _ ' ` � � � �TZ� �" �Y � a-awaa-��aaa-�-� o��_JL 7�-a��.71.�I�a APPLICATION FOR SERVIC�S IF TFIE INFORMATiON IN THE APPLICATION FOR AN IMPROVEMEiVT PERMIT IS INCORRECT, FAL51FlED, CHi4NGED OR THE SITE IS ALTERED THEN THE IMPftOVEMENT PERMIT AWD AUTHORIZ�►TION TO CONSTRUCT SHAL� BECOME INVALID. 1) Permit requested by: (Ownedagent/prospective owner): �DA/J7 G�?ENN /REY Home Phone:,.�3L- s99 • a �sy Address: %/.t3 �cG�« if �%ii.�d Business Phane: i/s-SGa-qf�.t� . �okb,�e � �l/� a�s7q 2) Plame and address of. ca�rreni owner: Ao/�M c.h�� niN /.c',e3Y � _ G/► �t �s A�%i%/ � oxbo.-c, . NC �?7S7f/ 3) Property Description: Lot size: /. G/ Township: Subdivision: Lot # Directions to the property (lnctuding road names and numbers): T k� f��L Ga.� � tD ��. �_�_t 2..�.i�rs � Oa k-G�evt -/��_ �• e� fZd fa Ite ��e% 1 and a o ab.+�t' ��_�n: k s, �iopt/fy •n i;tAi �� Oe.l� 6rp✓t G�/../ei.. 4) Pro�osed Use and Structure Description: answer each of the following questions: a) Proposed �, Existing _, Type of Structure: /�'lo�/�id. r Width: � Depth: b) Number of Bedrooms: _ j_ Number of occupants or people�to be served: I c) Basement: Yes , No � Wiil there be plumbing in the basement? d) Garbage Disposal: Yes � No � 5) Water Supply Type: Private (new _ or existing�, Public , Community , Spring _ . Are any wells on adjoining property? Yes_ No _ If yes, please indicate a�proximate location on the site plan. 6) Does your property contain previously identified jurisdictionai wettands? Yes_ Alo_ PLEASE NO'T'E THE FOLLOWING: ➢ A Pf.AT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢� PROPERTY L1NES AMD CORNERS MUST BE CLEARLY MARKED. � ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE SITE-MUST BE READILY ACCESSIBLE F�R AiV EVALUATION BY THE HEALTH DEPARTMEiVT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for.the above-described property. I agree that the contents"of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is alteresi or the intended use changes, ttie permit shall become invalid. _ Representative �-/7- �3 Date PCHD, rev. 06l27/02 �� j�� t��y��\\ . � � . .�s � � i�3 ��.y * y t_,.� 1i � 1SL! 1S. �L� �.�� 0 0 � � � �� ^�ry��,,�,�,�,�,,�{ �� ^ U'IAt�I��X�W-WI�UI�L`-14115 � �"_ ��na`a'��a�'++'T �aa'��.� �1��.��. . � Iffiproi�effie�lt P��ffii$ Peaffiit Valicl for �F+"v Yea � IVo E�iration Type of Facility: �� - New Q�Addition # of Occupants � # of drooms Projected Daily Flow �� Proposed Wastewater System: Proposed Repair: '(/L �i� Permit Conditions: ��_�v� ��rP�-6� ' Owner or Legal�Represe� Authorized State Agent: ��ter SnPply 1/l/ � "( Type: �`� Type: R Date: ---Zv --o Date: `�v The. issuance of this permit by the Health Department in does not guar�ntee the issuance of other pemuts. It is the responsibility of the applicant/property owner to in sure 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 Permit is not affected by a change m ownership of the property. This permit was issued in compliance with the provisions of the North Carolina Zaws and Rules,�or Sew�e Treabnent and Disposal Svstems' (15A NCAC 1�A .1900). I�Teither Person County nor the Environmental �ealth Specialist warrants that the septic tank system. will continue to function satisfactorily in the future or that the water snpply will remain potable. � Autlaor�ation to Cons�uct'Wa�te�vater Syste�a �Requirecd for Building Permit) * See site plan and additional a#achrnents (_). p y ��1,�,'�vy��j�C� t _ Type a Wastewater Flow �f1� d. Pro os d Wastewater S stem: , -�•p• New �� Repair Expansion p p Soal I� AR: ► � g.p.d./ ft 2 Type of Facility: �%17� ,[�E7� Basement Yes �No VYastewater ��stem Atequirements � Tank Size: Septic'�ank: �� gal 1'ummp T�: � gaA Grease Trap: gal I?rainfield: Total Area: i� sq ft T'otal Length � ft 1VV�aximum 'I'rench Dep�a a a� '��eaach �Vid#h � ft l0�inimuffi �oil Cover: � iai Minimum Trench Separation: ft��• Distrilm�tion: � Distribution Bax � Serial Distri 'on Pressure Manifold � . �pecifications• � � � � L'�G� Aaa#horia�cd State Agent: ��5i Permit Expiration Date: Date: �—��v3 The type of system permitt�d is _�£onventional Innovative Alternative. I acc�pt the specifications of thz permit i�waeerlg„egal ig�pr�se�t�tive: Date: - �/-D ' PCHD 1/17/2003 Barnette Well Drilling Inc �36 598 9275 10/28t03 03:56P P.001 �� S ��%�.� �� a�°c� oo � . �/`� g � y y A � � � /..�.-�+ p � `�-' - '�^ �C �D ��"�' � � �yzP � � � < <l (��,.. ��-�.:.�; �-�,-��.�-��.�u ��.�.��.,� a� ao� i� .�� c�� _ __ - -- Owner: � Locztion: _ Subdivision: r�..__a Y „�. Lot # Tax Map�l� Parcel # � Well �ons#xvction Distance �ram n�arest Prvperty Line (Minimunn IO feet) lt� Distance from Septic System (Minimum 60 feet) l�-'U Tot�l Depth: "� ft Yield: � GPM Static Wat�r Level: c�� ft Water Be�ring Zones: Depth � ft ft f''t _ ft /t�c: �� i ��" ' ..��- l� Q�� L. � Casing: Degth: From _ � _ . to /C `f ft• Diametex: �_ sn . Type: Galvanized Stee! f Weight• Thickness: �� Height above Ground: /� in Drive Shoe: Yes No • E1ny problems en�ountered while setting casing? Xes-�-�No If "yes" give roason: �. Grout: �1eat: SandlCement Concrete GraveUCement �� Anm�lar Space Width inche.s Water in Annular Space Ycs No Method of Grout: Pumped. Pressure Poured / D�pth __�___ to •�C1 _, Ft• 1V�aterials Used: I�o. l3ags Fortland cement VYeight of 1 Bag Pounds If mixture (sand, gravel, cuttings) — Ratio to ID plates: �es _ No 4 x 4 s11b �' Ycs � No Drilling Lo� Location Drawin�g k rom To �ormation � � .�G'>_�.��.��-L. � � _� .� �' � c� � . � � � �c,.�-`Crv.�.e �c � �� . � O � � . � I hereby certify that the above infornnation is eorreet and that this well was eonsmteted in aeeordance with regulations set forth by the Person County �J'ealth Departmcnt. , Signature of Con ctor ' �� D # r � Aate f� -� � � � , ' PCHA rev {19/.;f}! ' � '� PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant �� h L�e. Address � ��t �AK �rov� 1"l-� � Z�oh �rl• County P�r56n Collected By 1 S Date Collected 5� l�l -i� Time Collected /D ; I� Source: C�ell ❑ Spring ❑ Other Location: C�Iouse Tap ❑ Well Tap ❑ Other ❑ No Charge �arge ........................................................................� ****�********************************************�********************** Total Coliform FecaUE. Coli Results Presen Absent ❑ ❑ `1d' Reported By • Date Reported �( Z� � ( � � PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant �i�,,�,-)-t,n LQ� Address g(��p Vq� lxt�0✓�. f• �►ay� County��_ Collected By �s Date Collected � -,� % � /� Time Collected /�%�5� Source: (9'Well ❑ Spring ❑ Other Location: �iouse Tap � � -sc� r �� C�]"No harge �❑ Charge 0 Well Tap ❑ Other ........................................................................� ***�**********************************�*******************�**�x�********* Total Coliform FecaVE. Coli Results Present Abs nt 0 ❑ � Reported By Date Reported � � � � � �