A39 35�PPltc:ation Date: 9 -16 -0 '� Tax 1VIaQ �: /'1" 3 �
Amount �aid• �
Recai�t #: l�arca! #:
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APP�ICATION FaR SER1/1C�S
�� - s�zao.ao
uf�ts Permit - $150.00
Home Replac:eme�UAddihlan)
�P� ��9 �m Pertnit
w�t �rma �n��p�e�t�
canstrudion A�m
5150.0W5200.00
Pemut Reviston i
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�IF THE INFaRMAT1OM IN THE APPl:1C�►TION F�R AN lMPRO�/EEMEPIT PERMIT 1S INCORRE�', FAtSiFiED.
C9-IANGED �R THE SiTE IS AL'T�FtED THEAI THE IAAPROVE�IIENT PERAAIT AND AUTNORIZA"i101d TO .
CONSTRUCT SHALL BE�OME INVALID,
'1) Permit requested by: (Ownedagent/prospective owner):�
Home Phone: Address:
Business Phone•
2)
3)
4)
5)
Idame and �ddress cf current owner.
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Property Description: Lot size: Townshlp: Subdivision:_
DireE4ons to ttre property (lndudin road�ames�and numb ): �•
� Lot #
r
proposed Use and Shucture DescripHo�: answer eacl� of e fo lowing ques ons: � i
a) Proposed , Existin9lGTYPe of Structure: ,�r1r � �n n/C�j Width:� Qepth:�_
b) Number af Bedrooms�� _� Number of occupants or peopie to be served: � -
c) Basement Yes 1� No Witl there be plumbing in the�basement? !Yj
d} 6arbage Disposal: Yes No � _
Water Supply Type: Private �(new _ or existin , Publyi . Community� , Spring ,_
Are any wells on adjoining property? Yes No �tF yes, please indicate approximate locatiari on the
'site pfan.
6)� Daes your property cantain_pr+eviouslb identified �urisdic�ionai wetlands? Yes No �
PI�ASE NOTE Ti-IE FOLLOIMNG:
9 A Pl.i�T OF THE PROPERTY OR SITE PLA�V iVIUST SE SUBMITTE� WITH THIS APPLICA'�ION.
➢ PROPEi�TY UNES AWD CORNERS MUST BE CLEARLY MARd�D. •,
9 THE PROPOSED LOCATtON OF ALL STRUCTURES MUST BE STAKE� OR FLAGGEI3.
➢ THE SITE MUST �E �iE,�►DILY ACCESSIBL� FOR API EVALUATION BY THE HEE�►►LLTi-� DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposal
system for the above-described property. i agree that the contents of this application are true and represent the maximum
faciiities to be piac�d on the property. I understand if the site is altered or the ir�tendes! use changes, the permii shali
�
Cwner or Legal Representative
o'�- /e - U�
Date
PCIiD, rev. �6127/02
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Owner: �
Location:
Subdivision:
Drilller ID .# , .,� � - � � f�
Com��ny N�me .
D�t�e Drilled �� r _
Well Log
Ta.Y Map �� P arcel # � � �
Lot #
Well Construction
Distance From neazest Property Li.ne (Minimum 10 feet) (a
Distance from Septic System (Minimum 60 feet) (o D
Total Depth: �� ft Yield: GPM Static Water Level:
Water Bearing Zones: Depth io ft S 5� ���,ft f�
Casing:
Depth: From �_ to ��_ ft. �'-iDiameter: �� in
[i�
Type: Galvaiuzed Steel i�
Weight: Thic�ess: o�C� Height above Ground: �_ in
Drive Shoe: Yes r/ No Any problems encountered while setting casing? Yes �No
If "yes" give reason:
Grout:
Neat: Sand/Ceme t� Concrete GraveUCement
Annular Space Width � inches Water in Annular Space Yes �No
Method of Grout: Pumped Pressure Poured c� Depth to
Materials Used:
No. Bags Portland cement J� Weight of 1 ag � Pounds
If mixture (sand, gravel, cuttings) — Ratio � to �
ID plates: ✓Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log
I.ocation Drawing
From To Formation
a k �
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I hereby certify 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 ��� o��_ ID# O� / llate i oZ
PCHD rev O1/16/02
The� D'istrict Health Department�
�range, Person, CasweA, Chaiham, Lee Counties .
Woter Supply and S�ewage D�i�sposal
,
nat? �,2�-2�
owner:
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T�ocation: ��
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hK,; . � ��•
Contractor: ���{�/ ; ^�
Weier Supply: Private b�' pubIic
---���� ._
Sewa e IIisposal FacilitFes: No. bedrooms � L
washi machine. otfter aut atic appiiances �
Sizo f tank: Nltrification tine:
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9� �-'lA'l<2.c � l�1'�S�ic� d c� v�pa�-�,/� v► e� /�%e
Wnte�r supp y an sewage dispasa�i fac�li�ies loc'ai�fi, installatio a
prote+ction must meet state and local regulations. .
Abo�: o recommendatians based on information received and ob'��
:tuil condition. Sep tic tnnk and nitrification liiie •MUST BE I•1�TSPECTED
ANI) APPROVED $Y A MEMBER„�OF THE'• �.STRICT .HE�ALTH DE-
PAATMENT STAFF before any portion of the� � ristallation, is covered
und put into use. ..
, : '`� ,
Dnl�� upproved: ^ � � ,^ �
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Wcit: ' '
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SL'N'L�B Disp S l; ~� �� S �
Ay :
ani ar�an
(OVER)
t,oc�itfo�� o[ well and Gewnre disposul facilities rt�cctched on bock.
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The IJisfrict Hlealth Depar�ment
Oraage, Person, Caswell, Cha#ham, Lee Couaties �
S.EPTIC �`fANK PERIVIIT �
� Dat ra . .
Name of owner � . � ` ,���,��� . . � .
Address and Directions ` •
. �
PPrson or firm 'ng fnst ation• �'
Addrmss ___�Q_ � -
No. u.4 persons to • be serverl bedraoms 1, 2, �4.
Additidnal appTiances to be used: Disposal, dishwasher. wasl�ing
machine
Niiniynum Ii,equirements: Septic tank
Nii,ci�ication liae: _�e�Q___ i��� �.t�% : 0� a .
scptic tank and nttrillcation line must be 9aspecied anci approved by
n momber oi tho �-Ionlsh Dopars,m;ent siaff befare any portion of the
Instnilation is eovered.
Cuunlcrxlgned
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Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer '
(Ovrr)
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
3 .�
Tax Map #: � 3� Pazcel #��'� Township .
Applicant
Subdivision• Section• - Lot'
Tvoe of Water Suvnlv:
Reguirements•
�dividual Communitp Public
Site Approved by ✓�� "j -o
Grouting Approve by 3 �t `�� ��
Well Log
Well Tag
Air Vent
Hose Bib �
Concrete Slab
Well Driller.
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Well Approved Bp: Date:
'�°5ee Attached Site Sketch'�
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 building foundation.
Other conditions:
PCF-ID, rev. 09/07/01
\���.i C� �j ` 1
The Dist�rict Heafth Depar�ment
Orange, Pe=son, Caswell: Cha3ham. Lee Counties
Wat�er Supply and Sewage Disposal
D`at� J —"3 � b
Owner: � w
L.acation� ^
Contractor: �
Water Supply:�`�rivate —� / Public
SewaRe Disposal Facilities: No. bedrooms ��. Dishwasher, Disgosal,
washing machine, other automatic appliances � �
Size of tank: .��---- Nitr9f�cation line:
. ���
�
Othe� disposnl facility:
Water supply and sewage disposal facilities location, installation and
protectiUn must meet state and local regulations. '' �,__
Abo���a recommendations based on information received and observed
soil condition. Septic tank and nitrification line MU5T BE INSPECTF�.D
AND AI'PHUV�D BY A MEMBER OF THE DISTRICT HEALTH DE-
PAii.TM�NT STAFF before any portion of the instaliation is covered
and ;�ut into uac.
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