A40 16Application Date: �3�61� Tax Map: �%1c�
Amount Paid: au� •ov Parcel #: j(�
Receipt#: S-� 2,i{�IS
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Application for Services (Septic Systems and Wells) �1`� �
�rvices Requested by:
Name: �/,(�er'�f" Ji�—�i�.kl,:i �►Ck�,s Phone # (home): 3(o�i-- � ('73
Address: ?� 5jr So h�s S-fo r� `R oa o( (work/cell): �D �-`�� �(
f'�OX�1�Yn �C d�%S %�
2)Name and address of current o��ner (if different than applicant):
Name:
Address: �'77 In/Doc��/ t�ri ✓�
�I i m�i e,r l Q ICe f�/ L �% 5� il �
3) Property Description: Lot Size: Subdivision: i,ot #:
Address and/or directions to Property:
�� ���� s S-}v�ce R�1
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
�Water Supply: , �
Private Well � (Proposed �. Existmg _)
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 ptat/site plan of the property that shows property dimensions and the 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 su6mitting 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)• Date : a5' �v0
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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I� �.�a�� �a-� ��.�.�.Il I�3I � �.11 �1�a
W�+ �I, P�Rli/II�' (New � Repair�
Tas Map: � Parcel•
Subdivision:
Applicant'� Name: /�f d�ir� �� C
1Vlailing Address:
Phone Numbers:
Lot:
Location oi Property: �� � �� �vJE' � J�e lt�-
Permit Conditions:
l) See attached site plan for proposed well location.
2) All applicable State and County regzclations governing construction and setbacks apply. �
3) Permits expire � years from the date of issue.
Other Conditions/Comments:
Permit issued bg�:
Date• 8 Z 6/o_q
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dC�R�'�FICA'I'E OI+' COMPLETI�l�
New Well Inspection:
EHS/Date
Location: ��� q ,_ ���
Grouting: ��� �la I�i
Well Log: TS R- l 3-D�i
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
I,iner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: ��C�t'ZS License #:
Pump Installer: License#:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
32� S. �Iorgan St., Suite C
Roxboro, NC 27573
Date:
Date Results Mailed:
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
08/09/2009 16:46 336-388-5940 EVANS WELL DRILLING PAGE 02
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I.ocatiqn:
Gr�ut Log
Tax A�ap � 1'arcol � �
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5ubdivis�on: �t �
� • Wep Cortttr�ui,diDp
riistanco From ncarc.�i F'ropeaty Line (Minimum' IO foct) _�_ 1�
Di�Uuloe �o tic Sy� (,M' 60f�et� ��
'xatAl Dopth:� R Yiald: GPM tatic Wxttr T..avel: �„ �L
'Watcr Searin� �onoa: Dopth fl R ft.��7 1 tt '
Ca�iaSs � .
Ucptlt: �'rom „�,,�, ta � ft. Di��; ��� � . � .
'�j+po: G�lvaaizcd Ste�! __��___ .
'VVtri�L� Thiclmr.sa• � �oi�ht �bovc Cirntqtid; ;�„� � ip
Dciva.9bac; Ye� � No � Atsy p�rpblcan� anr.ouaterod wtrile eat�it�g oasin�7 Yec �, I�v
1£ "yes" give raa�oa; '
(yrout:�
Noat: S�JCamnnt.`�/ Cw�crew C�ravqUCo�vnt �,�
Annular Sps�ce Width ,,„„f„�, in�chae Water ia Speae Yosr � N -
~Moti�od of araut P�mpod .�sau�e Pournd� �paptb ,�, tc � I�c,
iMIAteMA1t Uaed: �
Na. Ha�s Portlt�d ce�ncat - u�,�,,� Waight qt 1 Bt� ,,,� potuu�a
If �,ixtu� (�qd, �rs�vel, cuttin�a} — ��o ,,,_(,�,r to �
� I? � l ates: i-- Yos _,_, No 4, x 4�lab � o s ,,,,_ No
lUacr: . .
Dcptb: , baW inrtslled: _,__�_,�� Grout: � by:
Drllllp� Lag
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I hercby vtrd�y tt�t t�o a6ove infnraset�cm ia �orrect An�d that ttus wa11 wae constructcci im accard�ncc with rc�ula�«� sai fori t
by thc Pr�rson Cou�nty Hoa�tt� cp t. � � f
Sl�wre oiCa�atr�cto � t�a�� Date � '1
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lurnp Ymstnlienont
Punsp lnctail�tian ohu�atnr: 5tataR.egi,traLloaN�us�bar:
F'ump Deptk�: d �k Static V�'�iar Lovesl: ,�C-�_.,..� � �
�ump Malcx & Modct: Pump Siza �nd �attng: hp gpm
L hrreby aertify tlsat this puulp was i�etalied arcd the woll liead oorapl�d eacordin� to the Pcrson Gaunty Well Reilrsj in aPfeat
an this date and tl�at a eepy af this n:cord ha� been prav€dccl to �hc wa11 awaer.
Pump �nstYller Slgnature _,,, D�ta: PC�ib rov O1127/04
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SITE PLAN
Name , s Taa Map #,�Parcel #�
Subdi 'si Section/Lot#
Authorized State Ageat D �
Sysrem cnmponeau xpirseat spplv�matc coamurs on1y. The coau7cmrmusr Sag r6e sysum pdor m h�giz n1 � L�v the iasrallatioa ta
' iasute �arpmpergnde ia msmt�wed
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.ea� �or�
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PCHD, rev. 09/12/01