A36 5ir ¢.w
Application Date: -� � / � Tax Map: �_
Amount Paid: �00 . d � Parcel #: ��
Receipt#: p ?i �
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Application for Services (Septic Systems and Wells)
Services Re uested -
O Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 if> 600 d Fee is de endent on the e of s�stem ermitted)
D Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uued $75.00
Well Permit ( lacement/Repair) CJ Repair of Existing Septic System
$300.00 200.00 75.00 No Char�e
1) Services Re a by: �S so 3� ����
Name: ,J �4 � �Phone # (home): ��� . ��}— '
Address: .3 u ,,� (work/cell): _��� ,SDL/— /z S /
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2)Name and address of current ow�ner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: Subdivision: �
Address and/or directions to Property:
J � �
4) Proposed Use and Type of Structure:
Residential � Business/Type: Other _
Number of bedrooms / Number of people served (seats/employees): _
Basement: Yes No (with plumbing: Yes No �
Garbage disposal: �Yes No
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6��5
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Lot #: —
S � /l
rPr � Ja-4C� i` i J�
5) Water Supply: �
Private Well (Proposed Existing �
Community Well: Public Water System: '
Are there wells on the adjoining properties? No Yes �-� (please show location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of the properly that slzows property dimensions and the si�e and locatio�: of all
proposed structures.
➢ A signed copy of ihe `Lot Preparation' form verifying tlzat tlze property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Depai•tment. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become in��alid.
Signature (Owner/Legal Representative): � l,vJ Date : , /
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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WELL PERMIT (New�„Repair�
Taz Map: � Parcel: �
Subdivisionc
Applicant's Name: ���b� �� S
Mailing Address:
Phone Numbers: �� ��
Location of Property:
Lot:
b ����e �� �
Permit Conditions:
�) See attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply. �
3) Permits expire S years from the date of issue.
Other Conditions/Comments:
Permit issued by: ►� �
Date: $ Z�O �(
CERTIFICATE OF COMPLETION
New Well Inspection: � Y�"�"` �Liner Inspection:
� HS/Da � Bve� EHS/Date
Location: �1 C� // �� Installer:
(� Grouting: q Q�i Y�+w`-e'� �'^ Depth:
W� t�-f'�� -- Well Log: o� Grout:
Well Tag: �
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller• ���� �
Pump Installer:
Well Approved by:
Date Sample Collected:
� PS � "�
� Well Abandonment:
EHS/Date
Completed:
Method/Material(s):
License #:
License#:
Date:
Date Results Mailed:
Person County Environmental Health
325 S. Morgan St., Suite C Phone: 336-597-1790 Fax: 336-597-7808
Roxboro, NC 27573
8/1/08
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STTE PLAN
Name / � � Taz Map # �1" Parcel # �
Subdi ' � Section/Lot#
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Authosized State Agent D� '
System compmeais mprrsenr appiaxim�re coamurs only. Tfie coatracmrmust9ag tbe system prior m b� 'b �nj Do �e iasra!latioa io
lasurr thatpmpergndeismaiatained
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PCFID, rev. 09/12/Ol
Barnette Well Drilling
336-598-9275
l\ESID�NT.%1QL WELL CONSTRUCTION RECORD
2+lorrh Carolina Depar�en: ofEnvironment andNatzual Resources- Division of Water Quality
R�LL C01�1RACTOR CERTIFICATION# .�� �%– �
Z. WELLCaNTRACT03;, ..
,
� � �iJ� 7 �Cl.�•�'�
WeR Cpnlractor (Indiv�dual) Name
Ba e e elI D' Ii (nc.
WeA Contracior Company Name
S1'1 Bamette Tnoet� Rd
Sb'eet Add25s ...
Roxboro NC 27 74
City or Tawn Siafe Zip Code
3t 36 � 599-001 �
�rea code Phone number
2 VYELL 13�IFQRMqi7pN:
+ �. n�
WEILCONSTRl1CT10MPERMIT� `+�i.'.1:�' J•:�,,, :!7 �
OTrfERASSOC(ATFD PERMITn�.{ifappRicabte) ✓.1.-: �; � �j
SITE WE�L 1D K(�f app;cab►e)
3• YYELL tJSE (Check qpplicable Box}- Residentiai Water 5uppty �
DATE DR1itED � – ;; . ,- �.
TlME COMPL�TEp ���• � qM � PM Q/
4. WELL L�CA7lON:
CfIY: ^� a;�� . �. COUNTY�� • S � �y
- ,ti � : " '
� . :� �t , _ - _ �,y •�'Y:; , , ,r .: 75
{Sireet Nams, Numbers, rbmmwdy, Subdivisiaa, Lot No., Pz�e1, Zip ��j
TOPOGRAPHIC / �A�lQ�SEf71t�G: (c�e�c approeriate hox)
�Slupe pVafley �flat �Ridge pptl��
�'��� �' �� � "DMS aR 3X.X�CX)OC)OCX pp
LONGfTllDE �_•Q� '2 S�- - Dh�ES OR 7X.lOCXl000CXX QD
La6tudeJiongitude source: [GPS Cji'opograpfuc map
(locab'a7 of_we!lmusi be shown on a USGS topo map andaftached to
this fam rfmt using GPS)
5. WELLQWNER •�
� J �: C. L�C :.y- i
�Yi1Ef �1diFi2
i� �� r, � i ; I� L I,� .: y �,,0.
street Address r -
��%�:r> ;ii: f _ : �57�/
r,City or Totixi Sfate Z.ip Code
� �S� ^7 '�� 7
anea coae Pnone rn,mber
b. WF1L DETAFLS:
a. TOTAL DEPTH: L : ..� ' =
b. DOES 1M1IELL REPLACE DClST3hIC WELL? Y�S C3 NQp/
c. WA1"ER �E1fgL Befaw Tap of Casing: Z 1 �-_
Nse '+� if Above Top of Casin9)
ct. TOP OF CASING IS ' l FT_ Above Land S�face'
'�aP ot �asirs9 terrnirtated aUor betow land surtace may requ'�e
a v2riance in ac�ardanoe with 1bA NCAC 2C .o� 18.
=- �� (9FM'+): ��i - METHOD OF 7EST BIOWII ZOf11
f o�sa��crioH: � HTH AmouM CCE
I
� g. WATER ZONES (depih):
� 1'op %`' 6attam 1�� Top 8ottom
• T°p__ � 5> gottpm � 5� ioP Bottom
: Top 2.l� BoKom 2��5' ToP Battom
� Tb{cknessl
7. CASING: D�pth Diameter Welght Materiai
. �
Top V Bottam� Ft ^�. �Y .yi1� r.� ,� .
: Top 8ottom Ft_
Top BQttom FI. ��
: e. GROt1T: Depth Maferial ��d
= Top c� �ottom 2� Ft. Sand/Cement Poured
. 7op Bottam Ft.
Top Bo�am Ft
9. SCREEN; pepth Diameter S1otSiza Nfaterial
top Bottom Ft. in_ in_
Top 8attom FL in. ir�.
—_--
Top 6ottom Ft. in. �.
10. SAN DIGRAYEL PACi(:
Depth Stze Maieriat
Top Bottom Ft.
Top Botiom FL
7op Bottom Ft.
1�. DRILUNG LOG
Tap Boltom
�_/ 2
�! =��
�a � � �_�
/
f
i
I
/
I
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12. REMARKS:
Format�nn Description
_ r �� yvs,,r !
�.�� r^'� �1 �`'P
-�—
� IDOHEREBYCEE271FYTHATTHlSWELLWASCOiJS'iRUCTEDIM
: ACCORDANCE WlTti 15A NCAC 2C. WELL CONSTRiJCTION
: STANpA,RDa, qIVD TNAT A COPYOF 7NIS RFCORD HAS B�EN c�
� PRQVID�D TO THE WELL OWNER. '
/ �Y .� r
.:
n �
( �;, .�... �� ��-�-_ y _ �L _ r
� SiGM1lI%Tl1RE OF CER77FIED ELL CONTRqCTOR DATE
T,-r, ��5 r - ��,^P �
: PRINiED f�AME OF PERSON CONSTRI,iCTTNG THE WELL
Submif witfiin 30 days of comple�ion to: Divisiort of Water Qua(ity - ir�farmation Prooessing,
�6'I T Ma7 Service Center, Raleigh, HC 27599 i6'f, Phone :{819) 8Q7-63t30
Farm GW-1a
Rev. 2/t)9