The URL can be used to link to this page

A39 37ANo. �� be�� B�� , 2,�4 Additional appliances to be used: Disposal, , dishwasher, washing machine xecammenaea• septi� +�� b C� C� �'C�' I, Nitrificatinn line: Above recommendation based on information mceived and observed soil condition. Septic tank and nitrification line must be inspected and. appro�ed by a member of the Disirid Health Deparlmeai staff before any portion of the installation is covered. nate nppmoea: ! 2� 1�— � � - Si�� , Sanitanaa By. Countersigned O. David Garvin, M�., M.P.H. District Health Oificer (Over) � NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on ,�0 adjacent property, etc. Write in measurements in order that installations may be located at later � date. �O SUGGESTED INSTAI.LATION (Date ) � FINAL INSTALLATION (Date ) (Road or street) (Road or Street) No. of persons to be serve� Bedrooms 1 2 3, 4. Additional appliances to be used: Disposal, dishwasher, ashin arwf hinP 1 ftecommended: Septic ta �'"- � Nitrification line: � � Above recommendation based on information received and observed soil condition. Septic tank and nitrification line must be inspecfed and approved by a member of ihe Disfrict Health Deparfinent slaff before any portion of the installation is covered. Date Approved: —�' �� . ^ Signed ' �y� 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 tank�., privies, water supplies on adjacent property, etc. Write in measuremerits iri order that installations may be located at later date. - - . ,, SUGGESTED INSTALLATION (Date `) FINAL INSTALZATION (Date'r � ) (Road or Street) (Road or Street) Application Date: �D /Z �� S(' ��T Tag Map: Amount Paid: /SD • � ._..,.�'� •l � �� Parcel#: -�� Receipt #: y,37/ D g � � �� .un� nu-rcxa,,,.TM„aeantian.11 IC�L�o�.11�,lin 0 Improvement Permit (Site Evaluation) $200.00/$300.00 if> 600 d) obile Home Replacement or Building Addition $iSO.O�i �ifsite visit requiredj O Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 for Services Services Re uested ❑ Construction Authorization Fee is de endent on the e of s stem ermitted) 0 Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant In r ation:�� Name: Address: y � � . c �� S' � �i 2) Name and address of current wner (if different than applicant): Name: Address — D - ��.�... � c �� r� �T Phone (home): 3 3�- J�� $ O/� (worWcell): 3 3 !�- j c7 �/- /G �j Phor.e:33G, - ��SS' g l� 2. 3) Froper�ty Description: Lot Size: ��,� Subdiv;sion: � L�t #: Address and/or directions to Property: ❑ y.e�s ❑ no Does the site contain any jurisdictional wetlands? C�yes ❑ n� Does the site contain any existing wastewater systems? 0 yes EI'no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency? ❑ yes ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: O sidential New Single Family Residence Maximum number of bedrooms: � Expansion of Existing System If expansion: Curc'er�t r•�mber of bedrooms: 0 Rcpair to :�1zlfunctEoning System Will there be a basement? � yes �7 no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum 7umber of employees: Total Square footage of Building: i�zximum num.be; o: scats: �) Water Sup�ly: ❑ New well �Existing Well ❑ Community Well ❑ Public Water � Spring Are there any existing wells, springs, or existing waterlines on this property? �es 0 no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted � Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Legal Representative*) �` Supporting documentation required. S—/O-/2. Date • Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � � � �� . � . �� ` 1 ' '` � � �1J �� s . .. � n ¶ ��II.�ILIC'�Il9.]��Cll(�_.7111.¢��il.� � .(Z'i�i1.11.��Il. Suilding Additions/ Mobile Home Replacements Tax Map #:� Parcel#:_��_ Address: �� n � G 27 Approval Requested for: Mobile Home Replacement � Building Addition Applicant Name: .�S , x t, C-%r� r,-, � 2 r� - Address: .� ri �a lQoic�ro hl�, 2�57� Phone #'s: �� q—� 1 q 2 Permit Located: 1/ Yes No Installation Date: - - ' Design flow: � (.�0 (gpd) Current Contract with Certified Operator on file (if required): 1: Well �/ Public or Community Water Supp y Wastewater system shows no visual evidence of failure on: �� / Z'� Z (date) �Applicant's signature if site visii is not required) Addition/Replacement Approved \ Enviro ental Health Specialist �—/2 /Z Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.nersoncounty.net .. .��J~ � �� .. �_ ' ^� � � v 1 V � .11. I��y�,r,,,,.,.,,��.�.11 ]HC�.�.fl�. .. . ., � SiTE S�TCH � . Name �, W s 1�11�vV1�12�'� Ta,z Map #_.�.Patcel # =9� Sub ' ' ' n . � Section/Lot# � 9,1�,�z . . Authorized State Agent . - Date . System cumponen�ts re�resent u�i�iroxsmate�contours only.� The coniractor must flag the system prior to , begins�ing the installation to insure thatprolbergrade is maintained � t�p�� :s � �- M � �� — �' � A lir.ation Date: b'� 0� Amount �aid. • Q_ Rec�ipt #: �� a �--�__� _ _ � � — . cC � ��.T1�T� �Y ��-�a-�--•- --�-^- •e�� I��.IL�� Tax iViaa �: j��, Parcz! �: �� APPUCATI�N Ft3R SE3iVIC�S � �IF T'HE INFaRMAT10N W T9�lE APPl:fC�►T10P1 F�R AN IMf�RO�lEAAEiVT PERAAIT iS INCORREi:T. FALSt�iE�. C�-IANGED OR THE SITE IS ALITRED THEA1 THE iRAPROVE�iAENT PEiZl1A1T ATID AUTHORfZAilOfd TO . COHISTRUCT SHALL BECOME INVALID. - � 1� Permit requested by • (�wne�/ager�tlprospective cwnerj: �h,v.� .� � G � , � i1 /a-n► �,�rs- Hame Phone: �YQ ��7 9 Z. Address: �o c� �.�r �� 1s I2 �� Business Phone: ra.�-, � �.• M�,,Q,/To, 2) Alame and �ddress cf current ovmer. S�l M� � , �_ 3) Pro�xerty Descsiption: Lat size: I �f �% Tawnshlp: Dire�tions to the aroaertv Undudinq ro�d r�arrtes-and_ ! ot # �� 4) proposed Use and Structure Description: answer eact� af the folfowing questions: Fo r G'p �vf a) Proposed _, Existing . Type of Structure: Width: � De{�th: b) Number of Bedrooms: Number of occupants oc peopie to be served: - c) Basement Yes . No Will there be plumbing in the�basement? d) 6arbage Dispasal: Yes No _ 5) Water Supply T�e: Private 1�(new or existin , Pubiic_, Cammuniiy� . Spring � . Are any weils on adjoining property? Yes�o _ tf yes, please indtcate approximate locatian on the .site pian. � 6) Does your property car�tain_previousfy ideMirRed jurisdtctional wetlands? Yes IVo� PLEASE NOTE Ti�IE FOLLOVNING: 9 A Pl.AT OF THE PROPEiZTY OR SiT'� PLAN NIUST �E SUBMRTE� WITH '4'i-111S APQ�ICA'TION. ➢ PROP�TY UNES ATID CORNERS MUST BE CLE�►RLY MAR4��. •, 9 THE PROPOSE� Li�C1�i1ON aF ALi. STRUCTURES flAUST BE STA�C�ED OR Fi.AGGEi). 9 THE SITE MUST BE RE�►DILY A�CESSI6LE FZ)R 1�A1 EVALUATlON �Y THE liF,41.TH DE�ARTMFa�IT STAFF. I hereby maice appiication to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. 1 agree that the contents af this appl'�cation are true and re�resent the maximum facilities to be placad on the proQerty. I understand i�F the site is altered or the ir�tended use changes, the permii shall become irnalid. Cwner or Lega! Representative �a-3—az Qate Pc�n, rev. astz7�oz t�1��+�� • ��1L �1�� • � ,f� ''�\��T � `t�.J �p/' �Z�, V` JL JL �]m�]r�aS'^''� B��rmJL 1C7L�� ... - � . . . • 1 � Y � • �� •� ► , u � . - . r �- ' � :.■ SITE �SE.TC�7[ Tag lY1ap # �3� Parcel # �1 � . • � Section/Lot# . Ip-� _oa - - Date . � System co»sponents r�rrsent appmacimate�contouss only. The co�mctor mrest, flag the systesn j�rior to. beg�g tlis i��aA�on to �rnsure thatproperg�de is ��rnt�ed - � M E �/ � (,� �LC, Q �� r _ ��' � ��-��rJ.� - �j�" : Tft�1K �„��L — 10��` F2o�''' t��%E3 7�. � �o� ��c,tr�? s�s s�: i� l� �''�C � �� P�v,s EQu�c�mEa r SN�p PGi�, sev. 09/12/01 �1�i )�� .�.. V �.... (� � �� IC��a-��*-��^�^ ��¢.e:.71 �ZL�.�.IL�IEa WELL PERMIT P]LFASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: � 3 R Parcel #�� Township APP�� lr� � C�ct w` b�t.�"�S . Subdivision: r � � T ,,,•�.;.,.;• � { � ( ,� � _ � �I , , � . R�uirements• �n Section: Lo� i'� C�.cs-ass f r8 M l-� i`y�Wa� �a-�ra � Zndividual Communitp Public ✓� N (0'a3� o,� Site Approved by Grouting Approved bp 1 W� D'�' 'D a' Well Log ✓7�-f Id a 8- o�z. Well T� . 1�1r Verit Hose Bih Concrete Slab Well I)riller. Well .Approved By: Date: ��LL G�Z�-L � • �S �n F� � Fw L r�- ► S°� uo t I� � J '�°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 bu�ding foundation. �� LI U CS T�Lf� Other conditions• �� (�.O�J �� t-k[ ai�.S a/1 s��- P ��c✓1. . `:'•; '" PCfID, rev. 09/07/01 ��, s f �I��.� �� '' —�— C� c� ZCT�� Il��aa-�� .��. IL-��.Il�1� Owner: • �,.� � Location: Subdivision: 9�� ' � �'�� D�[l� �D � � C�o�p� a�o I-I i l I� ��cl l�' ��.� L L� � a�o� /� -��-�� Well Log Tax Map �J'�%Parcel # � r%� �YY�C_C V"Y1C�%Yl Ninl�ijdlb�� A�i�l (�-� �Q��(`� Lot # Well Construction Distance From nearest Property Line (Minimum 10 feet) / d tiC.f • Distance from Septic System (Minimum 60 feet) d � Total Depth: / ll' ft Yield: /� C�M Static Water Level: Water Bearing Zones: Depth i�0 5 ft�-�ft ft ft � Casing: �' � Depth: From �_ to ! ft. Diameter: -� in Type: Galvanized Steel � Weight: r �� g� Thiclrness: � 0��`5 Height above Ground: �;� in Drive Shoe: � Yes No Any problems encountered while setting casing? Yes If "yes" give reason: Grout: Neat: Sand/Cement Annular Space Width Method of Grout: Pumped _ Materials Used: Concrete GraveUCement inches Water in Annular Space Yes Pressure _ Poured Depth No. Bags Portland cement Weight of 1 Bag If mixture (sand, gravel, cuttings) - Ratio to ID plates: _ Yes _ No 4 x 4 slab _ Yes _ No Drilling Log Pounds _ No _ No to Ft. Location Drawing From To Formation r1 I - � -� � � ,-�f��• . �t�. � _ U �_ �� . !�- � � � y � �Ct-�i J o �� a z � � i �,: �_� . 7 � C� -13ur1ihtCv461d :� �a �at-1 �� ii�a r �� r�'r '�� r �b 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 t ID # -.��yi �. � Date . /C� �.-•Z�' �Z PCHD rev O1/16/02