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A40 15B, 1���t,�v �'�.%'r'�-+-`� Z Person County Health Department � a�wage System Improvements Permit Date: � ��' � This Permit Void ter 5 Years Pe it # Owner: � �' �tiskr'�,� � � � sR# �•� Location/Directions: � --��� � Subdivision Name: Lot # Lot Size: Type of Dwelling: Water Supply: Private: Public: Community: Bedrooms: Gazbage Disposal � Basement Basement Fix es - INFORMATION CERTIFIED BY % " - Environmental Health Specialist: , er «,�uve REPAIR: � REEV ATI N: ------- --z-------------- Size of Septic Tacil�,�. .gallons Si�ze of Pump Tank: Nitrification Line�a' � Depth of Stone: 12 inches Max Depih of Trenches: � Altemative System: Conv. Pump LPP Pump n,...,.,._i_,.. _ �__�����_��_�_��_�_��_�_� Date Well Appmved: Well should be 100 f� from any sewer system gy Environmental Health Specialist Date S age y m pprov • ?—.3– g� By Environmental Health Specialist �TI�CATFypF CO I.,�TION ,,.� Contractor. oa �K /1 /. , it. rr�l1Jl � � ------------------------- � � Sewage System location, installation, and protection must meet state and local � regulations. Septic tanic should be pumped out every 3 to 5 yeazs and shall be maintained by owner in such manner as not to create a public health hazarci. Septic tank and nitrif'ication line must be inspected and approved by a member of the Person County Health Department before any portion of the installation is covered and put into use. If the site plans or intended use change this permit is subject to revocation (G.S. 130 A-335F) L.ocation of sewage disposal sewage system sketched on back. (OVER) NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Write in measurements in order that installations m1y be located at later date. Note location of water supplies on adjacent lots. ' (1) (2) v l CJ�`% �/ " \ h ,4��ltcahon Oat�; ,�maunt �aid: Re�iQt #: 1 PG � �'A �/ �! � �/= Z7 �/ v1.; dl'� � r `/j'-" n n/.. +vt i ;�-""` /l Q �'� ��/v l ' ��; 7ax Maq #• � -T�� ---� Parcal��: � � � �-1�1�.._ � �,��r--���� �s-����y- — -- _ � `LJ � .1L .1L ���..aa-.m-.-.. -�--�- ..��,.�. �r��s�. APPl.1CAT10N Ft3R SEiiVIC�B • �i� TH� INFORMATION IN THE APPl:1CATlOiV FaR AN IMPR�VEAAENT P�RMIT 18� iNCORRECT P!#L,S1Fi� : CHANGE9 OR THE SILTF,IS AL7'ERED iHE�I "iHE iRAP1iOVEiNE�IT PERMlT APID AUTHORIZ�►T1�JPl 70 .. CON9TRLlCT 3HALL B�Ct��AIE lP�l�Lll�, � -� � 1) Pemlit reque�ted by: (Ownr�rlagentlprospectiva owner�: Hame Phone: ��_ 6��.7 j j Address: �. � e ' Bu,sinness Phone: ,,, �U - /q ;�, • c ,�;i../, C.. �-7_s7 �f 2) 3) Name and �dde�ss af cw�rent c�rwe►ee: 12„K �5 4- 1.� v�a /� ' SS.�.( ,�c� rclle �1 JIIt ��'.�.— � � ' � ��u�,..-��atJ.�, ?--�'s7tF 1Propsrty De�cripti�n: t�t size: �� Townshlp: 1� �a ��' ,Subdivisic Dire.�fians to the property (lndudln�Q�name9•and numb�ers): L� �,�., �L,e /1„�f/a A.t:II< /?.��'IS-11 �r,�.�1-�n �i Lot 'S/�.��/�z wic:(�� D'I� /6-f' /!vc'i 4) Pro�a�d Us� and Structurs Description: answer eact� of the #oll�ing que.s�ans: ,, � � a) Propo�ed Exlsting Typ� of Strudure: /,�nc��/.P �i>•'� P Width: ��i i tiepth: �(� �____ b) Numher of�droams: � Number of occ�pants or peoQle to be� served: _ Z�, . c) Basemen� Yes , No � WW there he plumbing in #he•5asement7 � d) 6arhage �Isposat: Ye� � , No ,� � W� �P�7� TYP�: Prfirate,�C (new� ar exlstin � Public,_,, Cammw�ity�, SP�9 � . mm Are any wells on adjalning property? Yes No _(f yes, piease ind(cata apprnxtmata lacation on th� .si6e p1�rt. • � Does ycur propepiy contalra_prevlously Ident�ted Juri�dictlonai w�#lands? Ye� Rlo� � � �_ �� . • ➢ A PLAT OF TWE PROP�RTY OR SITE PLAN 08U3T HE SUBMITTED WITH THtS AP�R.ICJ�►TION. ➢ PltOPEi�TY LlNES AND CORNERB MU�I' 8E CLEARLY MARKED. •, 9 THE AROPOSED L�CATION QE ALL STRUCTURES i1dUST BE STAk�E� Oii FiAGGEi]. 9 THE 91TE MU�T BE REP►DILY ACCESSIBI.E EOR AN EVALtlAT10N BY THE HEALTH DEPARTMEi�T STAFF. � � � I hereby make appllca�on to the Person C�unty Health Department for a site avaluatIon fior the on-site sewaga �ispasai. system for the abave-described prop�rty. 1 agree that the coritents of this appiicatlon are true and represe� the maximu�. facili�es to be placed on the properiy. I understand i� the site is altered or the intended use cllanges, the perm� shalY hecame irnalid. � Cvuner or Lega! Representa�ve - - �� Date PC'rlQ. [ev. 061271D2 .�... -� i 8 ' '0` y ' ,^/ � ..�. c 'r+ �° z i o. o• �s'7 �. r L. � • � ..._.�.�. t � `�' , ,p�` �p 'v. � '` ry � , � e � f � � ,,� ` N � � � "1 o a • h Q w N � � �� � ti r c. �°. ,�,,,/ ,,,, .� � o ��. �. � � i l�'��',�, �� _ e 9•? • ,_ � � � • ; � � �•-- . �. . . . � ,,�,,..�:si�:� . � , � _ ��:5��:-�:�� - ���PK� . .. �...ac...iY'�..:�._.,.� :,i. � .-::.w... . . ..::u.nea�.�.:�..:.,.�w,c�.9�vJ�.:'.-..� �a4..,.�.... .r1.i..'.:^r..s.� ..:c.<'. r>_.,F„�'�..v. e.�....c. ,...... .��., ..+... . _ . _...a.._. _i._ .._ a,rv.. <,i .. . . �, ': ?:.^ ' �i.i�.. kkt.rcv,.vu..... sn.�t;rrc....� .,v.i � . . . . � � •�•�',:,.,�-,.'a`""".r.P7'�:�v'�"e'""'-'�.'ey�rrc,.,..."*� M^w!�te�n� � �er.t.-�..�+.�fx7x, . . :.,�mzY!STtv„�nt t.?f.�!..+:"'"",�'� � (nii�n�.�tu ,.�! �l�l�� I t � , i I �: 1 �. � I 1 I i 1 � � �� I I I� I �� � � � I �� � � � I i � � � � 1. I I I � � � AQQlir.ation Dat�: z-5-�3 /� �t � Tax Nla� #: la `� � �lmoutnt �gid: ,Y 'Z 25 . v� �� �j . Re�iQi#: a7u�R' �arcal.�. �S-(� a �/ � ��,� C or�� o� � �� �l� ���Z � � .____.��� �� �I�I�..� �1� = � � ��--�— ��.��-.�. _-.�-,- ��.�.a. ���..�. AP�..1CA710t� Ft3R S�1HC�8 . � I� THE INP�RAAATI�N IN i'4�E APAl�1CA't'IOPI �+l]R �►N IIId�R��fEBAENT P�RlIIIIIT 1S� INGORRE�i' P�,LS�FlEfl C�ip►NGE� OR THE SITE 19 ALT'E��D. i1�i��! i'HE 1�API�CJi1EiU1�TiT PEiZ11AR AND AUTiiORI�►i1ON 7O . CON9i'F2U�"i 3H�LL BE��YIE IP�VA�LID. . 9) [�emeit requ�d('Oby� `1�-0��/(�p���qddl�s� �� � � � ,' o • ' Hame Phnne: 6usieteas Phone: ,�� /927 o X r ; C. 7S d) 3) I+�� ae� ��s �f t o�ee; ��, o/� ' Gr r � S ' � . dr(7 ,� �7 . P�p�► De�cri{ptiorr: t�t s1ze: � llcd� Townshl�: ���1%i: Subdivision: Lnt# " Dtr�fians to the prapertSoc (lnduciing,��ad names•and numb�ws)', .. 4) Y�rO� U� ae�d S�cactuur� ���i{�n: ansvwer ea�i af�e #aliowingq�estinns: � i � � a) Propo�ed !� Existing Typ� �F Struc�uro:� ��i � lr ' G(/Gv� Width: � 7 De�th:,� b) Num�er af Hedroam�: � Number of accupants or peoQla tn be�servved: �- • c� 8as�ment Yes . No � Wlll th�ere be plumbing in #he•basem�ni?�O d) sarbage Oispasat: Ye9 • . IVo ,�,_C 5) l��r �pl� 7'yps: Priva6a �(nerw ;�, ar exlstln . Public� , Community , Spdng ' . Are any welis on adjainin9 ProP�Y� Yes� a_ lf yes, pl�ase 1ndlcate app�mdmate i�atiari on th� 's�e pi�rt. - ' 61 tl�� you�� pro� conta�n..��wiou�iy id�e�fided Jur�sdict�n�t �#land�? l�es �fo,,� PI.�aASE M� THE FOLLOUIi1NG: ➢ ai �►T OF TW� Pl3�P�TP �ft �CfE PL�! i�LB�T �E SU�N!['Cf�� 119i!'iii Y6iIS ��.1�►i101V. 9 PiZOPEi�'tY LlNES �P1D CORNERS i1�tlJi' 9E CLF�IRLY 9aAR�. •, 9 THE PROPO�ED LOC�4T10l1 aF ALL 97RUCTURES �lJ9T BE STAf�B OR Fl..AGG�. 9 THE SITE QAU�i B1E R�►DI�Y ACCFSSI�L� Ft'�i� AN EV�►LUA71OA1 Bi' TT�IE ME�1L.Tiri DEPA[Z'i'tNE3dT STAF�. � . . 1 h�reby make applic�tian to the P�rson Caunty Health Department fnr a site avaluatIon fior the on-sii� sewage dispasai. system for the ab¢�ve-described prop�rty. l agree that th� cantenf� of this appi'u�tian ae�e true and represent the maximu�. faciii�es to be placed an the pro��rty. I understand ii the site is aitered nr the intendad use clzanges, tY►e Ferrr►i� sha� became invaiid. � Cwner or L�gal Repres�t�iir�e �` -� D3 Date PC'r�Q, rev. D6i271D2 _ .�� 1'`� .f � T .. .l � � � � � S � �, ���� � - c (�� l � I �- ,: ,_, . _, , ., .�_. .! � . , _ � ,: ,; _ _. � ,: , . �� � #� g��� # � � ��Rting Sewage System Iteport For. 1Vgobile g$ome Replacement . . • Ad&tion Type- Requester: Original Permit Located: Home Phone# � � �/ Business # � � li� �ater Snppl� �,�ll Septic System Designed For. �,�.Residential Business Other # Beslrooms � # Employees ��� � 0 'Tank Size: ��� Nitrification I.ine: �C� f�� f System Type:� 4 .in +• � . I�ate Installed: �� �j��� Certified Operator Required: �'7 � �n site wastewater disposal system shows no visual signs of malfunction on `— ��? 1'eunassion is granted to• �� � � �� � � ` r `^' •" ` ` � �iealth S ecialist Date• ` �`� Env�ronmental p � � ��� �Q : � �`,�,,,,t,�-1 � '��c�-- � Oti��- 5��,�.� � S� �M ���.c� �a�� - � W�� �1��+�� � ����� �� �,•' � � � �� 1i Ji ��.�.a���R^If'T}1Y7L �'tf ..��L�L�L� �Q�i�.�� �� ��� . PL�SE SEE �'1'I'A�EI) P�1V F�It WEg.�. SI'1'� Lt���� Tax Map #: � I'arcel # ;� '�ownshap suba�����: s�o�: �t �'�e of Water Saa�t�%: l�e��ffiea��• Site .Approved by Grouting Approv Well Log�— 1 Well Ta� '✓ , .� v�t � v 1 Hose B� �/_ Concrete Slab � �� ..•.i . �: -. .� i�;�► � � Communitp Public �- ���e �'�'�� �/ �l� �� �d � �� � � � `., ,i _ C , . : .. ���/ .�. ::.. , . ,�,.-' ,:,;,.,.,-.. .., '�°5ee 1�ttacflaed Sit� Sketc��` Wells must be 10 feet from property liues. 3,�C' � Wells must be 100 feet from septic systems. �r� Wells must be at ieast 25 feet from anp building £ounda.tion. Ot3�er conditions: PC.�ID, rev. 09/07/01 . ��--��. s..� �������� �..�__� � . � � � ��-�--� ��a�--as� �-*�-T► �.-,.--+�-��.-���.1L 1�'� � a�11.-��..-a. Tax Map # F� �l c7 Pazcel # I�� F�xisting Sewage Spstem Report For. "Mob�e Home Replacement - / Addition Type: �o�c.t, Requester. ') � r,�,u �1 �. � Home Phone# ��l --�+ i4/y9 S�o'1$ H�.t� �.1\s � Business # ��/ -! 92� d�hk�,z� ��c a����i . Location: Ptc-ras� !�-r�--. � �� �S 'l��k,� v����s � Original Permit Located �� � VPater Supplp: w Q� I Septic Spstem Desi�med For. �Itesidential Business Other # Bedrooms 3 # Employees Othex Spstem Tppe: ���w�D.�- Tat�k Size: � o� u Nitrification Liae: �� k 3' Date Installed: Z- 3-� 3 Cerdfied Qperator Requued: n L'- � On-site wastewater disposal aystem shows no visual signa of malfunction o� �-8 -� Permission is granted to: �t�.\c �x-cA�, ' � '�� � `� Zv' ( o �-�- �- �-� �z . J� �Q,�� . , f� . . , Envixonmental H th Specialist fs Date: `f - 8-�S � . �-a�,�c . D � � � `g io' g. ,�.U, � � � �- V . E � . l . .. � � i � � � � � � � �' � � �� �� �� � 4� j�� `�4 . s � � �D � � � �, � � � � `�� � �� � � � ` � �� �� � � � � � - � � "_ � � � s � �b • � � - .��---.--�--�---� �, - � :- � � ��`�, 4 � ��rn...�+y�k � . �. �a�.,✓: _.. - :r�. �� � 5r ��''' - � '�D � � �i � , � �` r� v � � .• 1 %`'�; . . � ` � � � �'`� , '� ,�'' � � % � � -� s�'�- �a a �_ � � � � �� � � �/ � Application Date: � � ��� l�� • Tax Map: �D Amount Paid: NC Parcel #: I S,g Receipt#: ����� I���� ��� - _- � � ��� -�- ,c�- �.�: �� a .�n u3�.�_ � �...�. ll �r «-.�. n ���. Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) lJ Construction Authorization $200.00/$300.00 (if> 600 d) (Fee is de endent on the e of s stem ermitted) � Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired) $75.00 ❑ Well Permit (New/Replacement/Repair) L Repair of Existing Septic System $300.00/$200.00/$75.00 No CharQe 1) Services Requested by: Name: 'r�nr�n�r NtJ�� Address: �a� 1�,yc,`,o � �\�6 ,.d �oxh�� rs ��S7� Phone # (home): (work/cell): �`�"1- I ^79� 2)Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: 4) Proposed Use and Type of Structure: Residential Business/Type: � P Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No � Garbage disposal: Yes No Lot #: 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 property tliat s/iows property dimensioizs and tlie size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. 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 invalid. Signature (Owner/Legal Representative): `���JM2.�n ��" Date : II �!7 i48 10/08 Person County Environmental Heaith, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ` �� �� � � �� � � � �, � � '�, ; � � � �� . .�. � �:.� ; .�.. , � b � � ; �,� .� �� �� �� �.\? I �� s� ��:�-.�.7r�<�:�Y'�.:rrs.�.{�:�..?�.�t.�� �.��:�.i�.'�.�. ��u��a���� ��������1 I`l������ ���n� ���i1������n�� Ta� Vlap #:��Q_ Approval i�eqLested for: Parcel#: S ti�lobile Home �eplac�ment �Building Adclition Applicant �ta�ne: � Address: o C 5 Phone #'s:�W � .� �7-l79a Perr�it Located: ✓ ��es No Installatioa� Date: 2-�- �� �esign �o�,v: 3[ep (gpd) Current Contract tivith Certified Operator on file (if required): Water Supply: �Well Public or Community Wastewaier system shows na visual evidence oifai�ure on: - �Og (date) (Applicant's signature if sit� visit is not required) ��,�,�_j-��' ���I��o�al�3 ��a������� �q���°n��� �-- /l-l4 �� Enviro ntal Health pecialist Date 1?/151�� SAMMY B. N�ti�K I NS D.B. 14�> P. 613 AXLE POLE I �. '� � ��F r�C��� I �� � CURNEi r � ; / ! %. � % � � l ! J � /; / J � r J � r / .\ �� � � � �� , . � t ' � _ �— `�_�! 47 N � / / �\\```/ O � 4�c/ ! N � cb / , � , �o / 3 / �u / / ; � i� �� � � � i � / / � � i � � � � r / � � .� r � � j / � `�, �J i � NF� � z �� � �l / I � , � � � � , ; � / � % � / , � / � . o , r� , �� � Report To: ��o - i�-� North Carolina State Laboratory of Public Health 306 N. W Im�ngton St. Environmental Sciences Raleigh, NC 27611-8047 htta://siph. ncqublichealth. com lnorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: BONNIE HOLT 5428 HURDLE MILLS RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES022212-0006001 Date Collected: 02/21/12 Date Received: 02/22/12 Sample Type: Sampling Point: Sample Source: Other Temp. at Receipt: Sample Description: Comment: Purchased Time Collected: 07:17 AM Collected By: B. Holt Well Permit #: GPS #: Inorganic Chemical I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Calcium 5 mg/L Chloride 8.70 250 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.39 4.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium < 1.0 mg/L Manganese < 0.03 0.05 mg/L pH 6.7 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium < 1 A mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 9 mg/L Total Hardness 14 mg/L Zinc < 0.05 5.00 mg/L Report Date: 03/08/2012 �.�; : �,,�; a � , �.��� MAR � 3 2012 - �. ' _-- J Page 1 of 1 Reported By: �e�ic �%loKcol � ,s.. Report To: North Carolina State Laboratory of Public Health 06 N. W?m� gton St. Environmental Sciences Raleigh, NC 27611-8047 htta://siph.ncaublichealth.com Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET Name of System: BONNIE HOLT 5428 HURDLE MILLS RD ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES022212-0007001 Date Collected: 02/21/12 Date Received: 02/22/12 Sample Type: Raw Sampling Point: Kitchen sink Sample Source: Ground Temp. at Receipt: Sample Description: Comment: Time Collected: 07:16 AM Collected By: B. Holt Well Permit #: GPS #: Inorganic Chemical I (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Calcium 7 mg/L Chloride < 5.00 250 mg/L Chromium < 0.01 0.10 mg/L Copper 0.11 1.3 mg/L Fluoride < 0.20 4.00 mg/L Iron < 0.10 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 1 mg/L Manganese < 0.03 0.05 mg/L pH 6.2 N/A Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 6.30 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 26 mg/L Total Hardness 23 mg/L Zinc 0.11 5.00 mg/L Report Date: 03/08/2012 — .. , — � Reported By: �e�ic 7%LoKeol -- _ �_ �, — , ---. , . :_�..:�. '.� 1' �=-'' p,1,4R �. J ZO12 �..,�� : Page 1 of 1 PERSON COUNTY HEALTH DEPARTMENT 355A S. MADISON BLVD. ROXBORO, NC 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant � r,�u ��� Address �-la� 1��rc1�o ���\IS� County p�� Collected By�P�- Date Collected ��a1��a Time Collected �l: a0an� Source: � Well l.�'No Charge 0 Spring ❑ Well Tap ❑ Other ❑ Charge �����*�*�**������xX�:�������*���x**��**�x��*��*:�*����������������*��*���* ����***�*�**��*������������**���**�����t���*��*��������*�����***��������* Total Coliform FecaUE. Coli. Reported By, Results Present Absent ❑ � o � /� //� . � �1��1, Date Z � ZZ 170� � v � r�pplication Date: �l� � Tax 1�Iap: t�`-tu Amount Paid: ���. �' Parcel #: 15(� Receipt#: I-E- 90477 c� # �a37 ��� � �-- ���� �'�� - - -`�'_ {� {� ��.`�� �' `�� I�� �za,s-.i � �v =za •,—•-„ .L:.. �z:i �f.,.-_a 11 I �L�� :c�.�� � n��a �,���ic��flt�n �o�' �e�'v���s (Septic Systems and Wells� 5es-vic�s �e uested � �mprove�ent ��,rmit (Site �valuation) � Constpuction Authorization �200.00/�300.00 (if> 600 � d) (Fee is de endent on the ty e of system ermitted) L l�obiie �ome �eplaceanent or �uilding .�ddition ❑ Permit Revision $1�0.00 (if site visit re uired) �75.00 �eii �ermit (i�evv/Yteplacement//�22eP�ir) (� itepair of �xis#ing Septic System $300.00/$200.00/�75.00 No CharQe �� �� Servic�s �te eae�teml �y: Name: r, ��Zm� Address: � a� �..,_�� R� ��� ,� a-�s-��-F Phone # (home): (work/ceil): _ Z�l�t�in� amd a�3dres� oi sa�r��nt a�vnea- (a�' c�iiffe���t t�an ap�iica�►g): Name: Address: 3) �rog��s-� �escra�a�nosi: Lot Size: �Subdivision: Address and/or directions to Property: 4) �'r�posed �7se anc� 'Type off Sta-uc�ure: Residential Business/Type: Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No _� Garbage disposal: Yes No 5) VV�ter Supply: � Private Well ✓ (Proposed� Existing _) Community WeIL• Public Water System: Are there wells on the adjoining properties? Tio Yes �ot #: (please show location on site plan) I�T�te: �4 care�pleterd tsn�lacation ,�nu�� r�lso inelasde: ���Zat/si�e�l�zac of ih�,�raperty tdaat s/aows�� ��e� �di�aaen$ion� aa�rf the siz� r��trl �ocntioaa �f ra�'1 p�oposerl st�uctures. � � �ig�e�i cnpy �f t,�ze `,�a2 �r�pc�rut�on'.f'��na v�ri,�'yi�ag tha� ��ae,�a���e�ty as �a�cd,y �o a5e ev�al�arated � am �ub�aait#ing thas ��piicatian to reqaae�i �ervacEs �roan �h� �'�rson Cou�aty �eaith �e�a�an��i. � unde�staaaa� tl��� �i #he infoa���tion �roviderl as incoa-i �e�t or i�f t�e �a#e :� sud�s�ea�aae�n��v alt�re�, or i�' t�e intende� aa�e cfi�a�g�es, �dfl per�nnts and approva�s si�aHl became �nval'aci. _ �ag���hu�-Q (Owner/Legal Representative): �j�c �- ���� : 3 3v��� _ 10iO3 Person County �,nviroiunentaI Health, �?S S. �iior`an St.; 5uite C, RoYboro, NG Z i 57� (336-�Q i-1 � 90) ; `�-.`�,,;.��.� ����.���� � `�= �-�=: � �o ����� I�',.���:�-�a-ffi� ��.�.11 I�iC �.�.1 ��. �/���� �����1� ���°ai'_���D�IlE'�LJ �'��Z i�✓��q9: �0 ��13'�E�: %�� �iIl�➢(�3�Il3nOfifl: 1�1�9i�B�IlC�Yfl��S i���'S�: r `J' cJ�C ���I��T L��Q��'�SS: r o bd,-o c 2� �'�c�n� t�uam�es�: ��g: �,�c��io�a o��'a���e�: ,[�r�/r /��`/�S �%. 7 Lot o� (,� af � 5Y28� ��r$aaa# �'vn�di�a�n�: �) See attached sire plan for pr oposed well Zocation. 2) All cr�plicable State and Caunty rebulatians governing construction and setbacks capply.� 3) Permits expire S years from the date of issue. d�t3�ar ��nda�ors�/�'�s�a��senPs: ���-�aat ;s�a�ed by: ���e: 3— ?,�o� � ��+ i��'�����'� ��'+ ��I�/���+'�'��1� 1��� ���� ��n�g����n�an: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: 'b���l �a-���er• Pump Installer: '�"��1� �p�ar��ve� �w: Date 5a.�mp?e Collect�d: Pe:son County Enviro:imental ��ealt,'� _::� S. yiorgan St.; Suite C Qoxboro. NC 275i3 �,a��� ��ns����n��: EHS/Date Installer: ,�Arn.tf� Depth: Grout: ��� �������mm�ae��: EHS/Date Completed: Nlethod/1�Iaterial(s): _ �,i��s��e #: Lic�nse#: �ate: Date Results Ylaileri: Phone: 330-�97-1 �90 : it: ��0-=97-7803 3/1/08