A36 91'he District Heal�h Department
Orange, Person, Caswell, Chatham, Lee Counties
SEPI'IC iANK PERI�IT
Date �� 1 � s'' !
Name of owner � +S � �"-� � �'� r r � ��` r �,•"�i;
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Address and Directions ��� ��� '� '� � r� l�� � Ta•
Person or firm doing installation: �� ���
Address
No. of persons to be served bedrooms 1, 2,�.�+�.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Minimum Requirements: Septic tank / ���
Nitrification line: _l�'�"d ���� � � � ���� � � ��
Septic tank and nitrification line mus! be inspecfed and approved by
a member of the Health Department staff before any portion of the
installation is covered. !
Date Approved:�._�g,� / " � j��
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�^ Sanitarian �
By:
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date.
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Building Additions/ Mobile Home Replacements
Tax Map #: K3� Parcel#:�_ Address: 315 sea�c►tis�r IQd..
Approval Requested for: Mobile Home Replacement
� Building Addition
Applicant Name: J b e s y
Address: � 15 S�a�wS'�(Y
Phone #'s: �D �( � �j $ 3!�
Permit Located: � Yes No 3�O
Installation Date: �{—�g—(� � Design flow. (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: �/ Well Public or Community
Wastewater system shows no visual evidence of failure on:
(Applicant's signature if site visit is not required)
Comments:
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Addition/Replacement Approved
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Enviro ental Health pecialist
/o -IS- aS
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 w�vw.personcounty.net
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�uilding Addiiions/ l�obile Home �2eplacements
Ta�c Map #:_���� Parcel#: % Address:
Approval Requested for: Mobile Home Replacement
✓ Building Addition
Applicant Name: ,.i 0�. � �a�.�-��.1r'
Address: � i-� -� N �.. ��� �r
�c,�boir� 3•l C � is 7
Phone #'s: �0� �4 �' a 6
Permit Located: ✓ Yes No
Installation Date: !- 4; - / Design flow: ,�� (gpd)
Current Contract with Certified Operator on file (if required): ��
Water Supply: ✓ Well Public or Community
Wastewater system shows no visual evidence of failure on: �o O (date)
(Applicant's signature if site visit is not required)
Comments:
Adc�ition/�2eplacement Approved
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Environmental eal pecialist
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Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 �vti��v.personcount��.net
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�aiiration Date:
�mfaunt �aid:
Ret�i �:
Tax Mae #' �`�
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IF'i�lE INFORMATfO(d IN THE �,PP�CATIOAI F�R AN IMPRO�/EAIIENT PEi�MIT 15 INCORREC'i'. F�ILSIFiE�. � e'�oSS��
CHAPIGED OR THE SITE IS ALTEi2ED THE�t THE 1MPROVE�IAENT PERMR AND AUTHORIZ�1"�90N TO . ��- P
CONSTRIJCT SHALL BECOME IN1/ALID. �
1) Permit requested by: (Ownedager�tlprospective owi
Hame Phone: „� �_�'�- 33yZ Address:
Business Phone:
2) Name and �ddress ai cvrrent ov+mer:
3) Properly Description: Lot size: j'� Q T wn.ship:
Directians to the arooertv (lndudins� mad names-and
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4) Proposed lDse and Stnacture Desaaiption: answer eact� of the fQllowing questians:
a) Proposed . Existing � Type of Structure: �r ��/c h�c� ��— �dth: � Depth:
b) Number af Bedrooms: _��� Number of occupants or peopie to be served: Y �
c) Basement YesT,";- No _ Wiil there be plumbing in the•basement? �+'S
d) 6arbage Disposal: Yes . No si _
5) Water Supply Type: Private �ew _ or e�isting� j, Puhiic , Cammisr�ity� , Spring � .
Are any wells on adjoining property? Yes No _ tf yes, piease indtcate appro�cimate location on the
�site pi�n. �
6� Does your properiy cantain_p�viousiy ideMifted �ur[sdic�ional wetlands? Yes_ IVo�
QI�ASE NO'TE Ti-lE FaLL01MNG:
7 A Pl.AT OF THE PROPE3ZTY OR SiTE PLAN MUST BE SUBMITTE� WtTH YHIS �►PPLICATION.
➢ PROP�2TY UNES :4iVD CORNERS MUST BE CLEARLY MAR4�. •,
9 THE PROPOSE� L�CATION OF �1L1. STRUCTURES iWUST BE STA�D OR FLAGGEi).
➢ THE SITE dAUST �E €tE�4DIL`r A�CESS16l.� FflR AN EVALUATION BY THE liE4LTH DE�ARTMEiVT
STAFF.
I heret�y make appiication ta the Person County Health Department far a site evaivation fior the an-site sewage disposal
system for the above-descrihed property. 1 agree that the cantents �f this applicatto� are true and re�resent the maximum
faciii�es to be plac�d on the property, i understand iF the site is aitered or the intended use changes, the Pe�mit shall
become irnalid. _ „
Cwner or Lega! Representative
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Qate
PC�ID. rev. 06127/02
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SIfiE. �]�TC�][ � .
e�� �- J� ��, Stc-� Tag lYla.p #�Pascel # /
ub I � • � Secrion/I�ot#�
10 aa -��.
Authorized St�te Agent � . � D� . .
sy� �o�o� �� �pro�� ��� �ty. Z he �iractor must, flag the system prior to�
beginning the installation to irrsure that�iropergrade is maintarned
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Scale• � � I SC�
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1'G�ID, rev. 09/12/01
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WELL PERMIT
PLEASE SEE ATTACHEI) PLAN FOR WELL SITE LAYOUT
Tax Map #: f� C3 tc Pazcel #� Township w U�S c� � ��
Appli.can� �� e, � �a m �-�c-r'
Subdivision:
T nr�tinn� � r�. �l � LCI. �� t. ���
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Section: - Lot
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� L Gt 5`� � aC,c $ c.
�n ri U� �dx � ��I� -
T e of er �Individual Community Public
Re,�uirements•
Site Approved by G�S � d- W- J �
GtoutYng A zoved bpC'.�� ��-2 Y-°�
ng
We]l, I,,pg� lc� -Z8^�2
Well T�,' =5S ,3-�-Y-�Z
Ait �%Brit�� 1v-Z.Y-�,Z
Hose BibC�S +�-Z`/-�z
Concrete Slab
1-4,,,� k
,l S�"�
Well Drille ^e �� `�Q 1 �� ��. . .
Well Approved By: Date:
'�°5ee Attached Site Skexch'�°k
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp bu�ding foundation.
Other conditions•
PC�ID, rev. 09/07/01
Barnette uell Drilling Inc 336 598 92:5 10/ZS/Gi2 11:�3A P.b01
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Qwner.
Location:
Subdivisi
GQ'�a���fi
_ �,f�,. Tax Map -3,��- Parccl # �
Lot �
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Well Constraction
Distaace From n�rest Prapezty Line (Minimum 14 fcet) �
Distancc firom septic 3ystem (Minimum 60 fcct)
Total Deptli:.4 o v ft Yieid: �� _ GPM Static Watcr Level: �3 �_ ft
Water Beaz�i�o,g 7�on�: Depth //a ft,�� ft i� �
-- - �Ui.. Q +�,.
Casi�nt�:
Dcpth: From �,p to 6_3 i�. Diam.ctrr: �_ �
Type: Galvanized�Stee1
Weight� Thickness: �� Height above Gcound: � j��_ in
Drivc Shoc;,�,_� Yes No Any probl��ms encouatered while setting casing? Ycs� No
Yf `�es" give rea.5on- __
Grout: .
Ne�t: SancUG�ment�. Concrctc Gra�veUCcmcnt
Annulat Space Widt�t inches Watcr is� A�sanular Space Yes No
Metiiod of Grrout: Pumpccl .,__� Pressure roured _,... DePth � ta ______ Fc.
Matecisls [Jccd:
No. �ags Portlancl ccmcnt V�Teigrit of 1 Bag Pounds •
If mixturc (saad, �vel, cuttings} — itatia to
ID plates_ _ Ycs � No 4 x 4 slab _ Yc� �,,;� No �
Urilliug Log � LocatioA Arawing
I hereby certify thaL the above in�forrnation is coLzect and chat this well was constiucted in accnrdance witix regulatians
set furthby the Pcrsou C�unty H�aith Uep�rtrnent.
$i�u�plre of CoatraClor ��-��'� ID # Z `l Datc lU � j D Z-