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A40 113Application Date: �'� q- � � �,2-'Za� �� AmountPaid: a00 �DU � � Receipt#: q O �C �S� �� S, f" �� 3q3� �:,.. ��T�i�` I��v��....d..--,-em� 7E�Lo�.]L�71s. Application for Services (5e�tic Svstems and Wells) Services �improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building AddItion $150.00 (if site visit required) � Well Permit (New/Replacement) $225.00/$125.00 Tax Map: _ Parcel #: _ 0 Construcfion Authorization (Fee is dependent on the type of sy; ❑ Permit Revision �$75.00 ❑ Repair of Ezisting Septic System o e Important: If ihe infnrmation in the application for an Improvement Permit i Improv,ement Permlt and theAuthorization to Construd shall become invalld Service_s Re� �uested b�y: . F � Name: ` vOC2�st-�f' 1 F'7�� i 1 t C�.�'1 S Address: 2 `�' ''t . (� � a,s � v ac�2--. fals�, or the slte is a[iered, then Phone # (home)• �5`��' �� (work/cell): o2Cs�-��J�� 2 2)Name and address of current owner (if different than applicant): Name• � Address: 3) Property Description: Lot Size: (�`''� �Subdi�i.sio Lot #: 1� Address and/or directions to Property: '�7 � o�� C�S � � i` l ls .�� g-�L} j 4) Proposed Use and Type of Structare: Residential %� Business/Type: Other Number of bedrooms �_ / Number of people served (seats/employees): Basement: Yes No X, (with plumbing: Yes _ No � Garbage disposal: Yes '� No ,_ Apprnaimate size of building foundation: Length� Width � Z' � Water S�pply: . 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 comnleted apnlication must aLso include: ➢ A plat/site plan of the property that shows properly dimensions and the size and location of all proposed structures � ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated I am submitting this application to request services from the Person Connty Health Department The informatioE provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. � , , Signatnre (Qwner/Legal Representative): � Date: yffl / 11/07 Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573 (336-597-1790) ' �� i � 1K �� ...-. � y ` � � � � � �� m,,.,, ,�„-�:, ��.�.Il I�33L��.Il� ApPlican� � i ��in ✓t 'F �'��mi#'�alid for /� Type of Facility: �j ## of Oc�upants �c� � Proposed Wastewater Proposed Repair: � ;,,� c�Q �► I I �GY.-, T�x Map I ' �rc�el A Su�bd:ivi.s�ian � ► � ' �' Fh�s�e S�chion Lat � Improve�nent �ermit - �`ive �e�s 1�To ��piration / � P g New �Addition �ater Supgiy ��l( . � of Be�rooms ,T�_ Projected Daily Flow � g.p.d. Type: Type: . r Permit Conditions: ti�� Si � S�'e'� �-, Owner or Legal Representative i Authorized State �Agen� Date: The issuanca of this pe�rit by the Health Departinent in does not guarantee the issuance of other permits. It is the responsi`bility of the � applicant/property owner to in sure tha# all Person County Plauni.ng and Zomng and Building Inspectioas requirements are met 3'his IffiQrovement �ermit i� subject to revocation if the site plan, piat or the intended use changes. The Improvement ]Permit is not affecte� by a change in ownership of the property. Tl�is permit was issued in compliance.with the provisions of the North �arolina `Laws and Rules for Sewage Trerrtment and �isnosal Svstems' (15A NCAC 18A .1900). Neither Person �ounty nor the Environment�l �ealth Specialist�warrants Wat.the septic tank system will continue ta function satisfacton7y in the future or�that the water supply will rema.in:potable. - -- .- . � Authori�ation to Constr�ct Wastewater SysEem (Reqnired for Bu�ding Perm�it) * See site plan and additional attachments� (_�• �"Z /��i�7 Proposed Wastewatei System: d-e� �� r Typ��. Wastewater Flow �8 �g:p.d. New � Repair Expansion _ f� � Soil LTAR: . ? S g.p.dJ ft 2 Type of Facility: � =l �� % %�S • Basement _ Yes ,�No � � , _ � ; _ . ` �aste�atea� Systeffi ]�es�uireimea►ts '�ank Size: • Septic '�ank: � 0�D � gai Pnmp Tank: '— gal �Grease Trap: '� gal �rain�field: 'Total Area: j 32� se� ft �Total Yrength �Eo ft � M[a�ffinm Trench Depth 21 m 7Cremc3� �idth � ft Ngiaiffinua Soi1 Cover: _� in 10�linimnm Trench Separation: ( it �isiribntaon: �, �istrihu#ion �oz Senial I2istribntion Pressure Manifold Speciffications: c� �9 C� S�IS�/L, o v► C°i'� �'� • �nthorizeai State A.gQnt Permit Eam: 2 Date: The type of system permitted is �nventional � Acce�ted Alternative. I accept the spe�ifications of the P�� // ` i�w�e�/��gal ��presentalive: � �ZZ�s�J' Date: / D � PG'� rev. 11/10/OS a pamclmam sr aper�.ndordtarp amsm aa uoua//slsur arp �uamdaq os soud mrassLs aq� �'egzsn�sos�euuon aq,t �/Qo suiatum ate�cvdda amaardar srv�mod�a� m�rsS�r a3�Q i��T a�Ets pazuo�n� f� Z Z � J #�o-yuou�ag S� � 5 Q i. 4nS � �l # �� # � �� S �'�,( � � a�N � � � � 1�iV'Id IS U�i Q (' �� ;,�.e.,.----�-- ------�- -- - . . � �`'''~�--�� ' �� _ �'•�s• �t �IC3`1C��1L • 1(�;��.as��.a-aa�ca� �sIL.1��1 � � ..:�..-� ,_�� .�� -j� �� r a��,,T:��JS --- � �—.-- y __._ _ _ _ _ �� _ �t� t �, � ._ ... • � •- . . (��'"� �Is 1��,�� . - --�------- s��, j l �» �'�, y-t: �^ �P� -Q ��i� �'�� 4�� .�.s .1�6' ar�Ql �� h �� ;sZ � , � � ,nl �D ,tQ ol � � � ba �� o) �S�N �� nn a � � � ,�� / .; p4'O�z�'`'°�-�--'�---� � �� '1•� ' - . . .' � 'r� � ""`i""'1` ,� v� • .�-- � � � . � � • �s � -- � "---- ...-:' �'� -$� - � � �- oo , . - -- � �—' �� -r � � _._ � , � . � .� r' r � :.`)°., : . . �� 1�. 7t.)� �� .. �� i � �� I��.�.��.,� ��.��.11 I�II�.�.I1�I�a. Operation 1'ermit Applicant: �`^�'Y ""� �� c�(r ¢� S Location: _ __� „ , , ,Q/I TaxMap `�� Parce #� Subdivision ,'� S� Phase/Sectoin/Lot # 3 # of Bedrooms This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. System Type: (In Accordance with Table Va): Product: �""`�'"`'� Ex ansio—� Initial: � Repau: p ._.. . . .... ... ._.._ . �- -- -� � - ._. _....-�-�---- . ... _ _ .. . . /�-r .. _ . . . . � �� .- - . . . REH /�EHSI Date � Licensed �. 2( � � P�L Scale p � ov�� 7 �, _ ��.,,� ��- ; �,, s,�� 2 << � J 2'1 .i � / �{ � ( ( Date �� x� �� s � �� e � � Tax Map: 7`� Parcel #: �13 Septic Tank System Checklist (Type II-VI) System Typ�-f�' � Notes: Pump System Cliecklist Pum Tank InitiaUDate State ID & Date: Capacity: Riser (6" min.) NEMA 4X Box Model: Piggy back plug Hard wired Alarm functioning Mounted on post Above grade (12") Conduit sealed Pressure Manifold Number of taps: Size and sch: Contracted Certified Operator (if applicable): Notes: Tank Com onents InitiaUDate Pum model: Block (4") Nylon retrieval rope Float tree and attachments On/Off float swing: in. Alarm float (6" separation) Anti-siphon hole Check valve Threaded union Gate valve Conduit sealed Outlet sealed Approved and secured riser Su ly Line Size and material: in. sch. Length: ft. ' �� " 1 ��/^� �11lJ �� „�,� � `YJ � � � � � 7�" n��n�t^ammi.n��n��.�. ��ai.11.-�.�n W�LL PERMIT (New �tepair� Taz Map: � �arcel: jl � Subdivision: ZdA S Lot: �� Applicant's Name: � l.� (q� l,�%� � �� ar� S Mailing Address: Phone Numbers: Location of Property: '� Il� ►� —� ��u: 4 � f.c�� s 1� --�- Permit Conditions: 1) See attached siie plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply. � 3) Permzts expire S years from the date of issue. Other Conditions/Comments: - Permit issued by: I�ate• t Z Z lv � CERB'�'�CATE OIF C�1d�LE'Y'IIOI�T New Well inspection: � � /�ate /' � Location: / bl N�, � � � Grouting: t oa� Well Log: ,�1 y/2�Ii� Well Tag: / Pump Tag: ✓ Air Vent: f/ � a�1�1 Hose Bib: ✓ Casing Height: v ,�� Concrete Slab: ✓ Liner Inspection: EHS/Date Installer: Depth: Grout: Well t�bandonment: EHSlDate Completed: MethodlMaterial(s}: _ Well Driller: �/2//�t'j 772,��_,[� License #: Pump Installer: License#: Well Approved by: �� -�$ Date• �%�� (► Date Sample Collected: Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Date Results Mailed: " N � 6 �-1� P �� Phone: 336-597-1790 Fax: 336-597-7808 siiios 04/27I2011 08:46 3364215085 TRIAD DRILLERS .�LG'SII�ENTI,AL wEi� eoNST�ucTtorv �t��o�t� Narth Caroli�a pepa�tment of Environmcnt and Natural Resourc-�s- Divisiun of Water Quality WEL�, COJYTRACTOR CE�iTYFICATtUN # � �_ 2. W�I.L. INFORMATION: � WELL GONSTRUCTION PERMIT# � OTNERASSOGIATEDPERMIT#("dapplicable) Lr!' S17E YVELL ti7 �(1f BPPncahte� ^,��^ 1� . PAGE 01/01 g. WATER ZONES (iiepth): � iop,�� Bottor►�� 7op Battom__._ Top �ottom,� Top Bottpm� 7ap 8atiom�_ Top eottom • . Thicknessl. 7. CA51NG: Depth •Dlamet6i � Welght MatoAal Topr;,� Bottom�,_ Fi.� �_ Top_____ BoRom Ft.,� ,�_�/ �i� Tap Bottom Ft. ' ' 8. GROUT; qepih Matariat � rop Bottom "� Ft. Top� Bottom �4__ . . Ft Tep Bottom . _ Ft. � � 8. 9CR£EN: Oepih Cliamater 5to2 Si=e Mstorlal '�. 4VELL USE (Chedc Applicable Box): Residential Water 5upply;$' Tup,� 8ottom Ft. in. DATE DR1LL�0 � �oA � Botiom Ft. In. Top Bottom Pt in. TIMECOMPLET�D�._ AMC] Ptv{�. ' . 4. YVSLL LO TION: �,/I ' . 10. SAt�10lGRAVEL PACK: C#TY: (..d�D�l r� f T"��IY�COUiJTY TOP 8ott m _... �t. Slze � �� Top eottom� Ft,� fSireet Name, Numbers, Ganmurity. Subdivision, tol t�to., Paroei, Z�p Code) . Top �OKom ' Ft. TOPOGRAPHIC / LAND SETTtNG; (check sppropriate box� ' dSlope ❑Valiey �flat ORid@e pOther LATI7UDE _� �°�' a i�" PM9 OR 3X_XXXXXXxxX pp • LONGITUDE ��' G�' �►r�` DMS OR 7X.XxXXXXXXX DD LatitudeAongitude saurce: �GPS I�fopoqraphic map (Jocat�on of weU must be shawn On a US�S topa map andaHacAed ta this form it rrot using GPS) b. WELt OYYNER /V C Cus1�/l� %%%D li�rs �wner idame ' /9,31� r..l,� filll��s�- . Suest Add ss • ' _s i'D �� f�� C ot Town Stat� Zip Code � �0%� — .r? �%�� Area cade P�one number R.VYELL QE7A1L3: � a. '�OYAf. DfiPiH:---%Sr_ b. DOES WELL REPLACE EXISTINc3 wEi1,� Y�S p N0� a WATER LEV�L Beiow Top. of Cs�ing: FT. ' (Use •+- if Above 7ap of Casing) d. T�P dP CA$ltiG IS ,,,� F'f. Above Land Sur(ace" 'Top o! CaSirlg ler+ninated at/or 6alow land surfBCe may require fl y�riBntB ir1 dCtotdanCe With 15A NCAC 2C .0 S 18. e. YIELD (gpm): � BTii D �F TEST 1 ir' t DI8INFECTi0N:7ype ArrtOuM�,_ 42, REMARKS: in. (n. (n. Ntstertal `Formation Descilption !a i DQ 11ER�BY CERTIFY THAT iHIS WELL WAS CONSiRUCTEp IN ACCORDANCE wlTH 15A NCAC 2C, WE�L CONSYRUCnON STANDARDS, AND TFlA'C A��P'�F Tf-►IS RECORD HAS BEEN PROVIDEO TO THE WELL NER/ � . D� $�t�tti��i8� a�'i�q�r��l:�o t�e �Jtvi�ton:af'{Na��r QWa;it'Gy wiC#iin 30 days. Attn: lr,formation Mgti, Form GW-1a ?[:�`I?7`:�l�?�r11'1{C@�C+eil;t�t['� E�I�#gh, N�.2T:S8:8,1'51,7 Rhone tVo. (8T8.) SO7-63'Otl ' R8v,11108 l,� �'� ;r�i;satin� �q�e: Z: S � '�Amount Paid: Receipt #: � � 0 Improvement Permit (Site Evaluation) $200.00/$300.00 if> 600 d Mobile Home Repl$cement or Bnilding Addition $150.00 (if site visit required) ❑ Wel! Permit (1�Tew/Replacement/Repair) $300.00/$200.00/$�75.00 r-� ��.� ��`� ! : �� . � �� J Parcel#: �� ... � � �� 1E��s�mm��.Il IE33[��Il� Services for 3ervices ❑ Cunstruction Aut6orization (Fee is dependent on the type ❑ Permit Revision ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant ormation: � Name: C ' ' Address: 'a a � � 2) Name and address of current owner (if d' erent than applicant): Name: Address: Phone (home�l'� � — �3 (work/cell): �=3q--pLs'a Phone: 3) Property Description: Lot Size: Subdivision: Lot #: Address and/or directions to Properiy: ��/ /i, ,� ; ��'S ��—�� or� UC_ Z75 7� ❑ yes ❑ no Does the site contain any jurisdictional wetIands7 ❑ yes ❑ no Does the site contain any exisdng wastewater systems? O yes �fio Is any wastewater goiag to be generated on the site other than domestic sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency 7 � 1G� � ❑ yes �'no Are there any easements or right of ways on this property. /L (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: r OResidential ' . � New Single Family Residence Maximum number of bedrooms: �/ Occu ants: � ❑ Expansion of Existing System If expansion: Current number of bedrooms: � ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes �no With plumbing fixtures? ❑ yes ❑ no �ion-Residentiat � Type of business: /� Total Square footage of Building: ,�� Maximum number of emp oyees: Maximum number of seats: 5) Water Supply: ❑ New well � Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? �yes ❑ no � Please note any known ground water restrictions or sources of contamination: _ (� �6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted � Innovative � Alternative ❑ Other ❑ Any 1 certify that the information provided above is complete and correct. I also understand that if the information provided is in urate, the site is su equent altered, or the interrded use changes, all permits and approvals shall be invalid. t ,,�GZ��..�Y Z ignature (Owner/ Legal Representative*) Dat * Supporting documentation required. o Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat. a A completed �Lot Preparation' form must accompany any application requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N�27573 (336-�97-1790) �� . . � `•►., ~ , � �./ `L.1� � � � � �L..�.�7YIl.'�"71Ir"<CD7Y71.IC]C71.t�7YIl.lLd;i1.� .��L�Ii.��:�']L Building Additions/ Mobile Home Replacements Tax Map #: /��o Parcel#: 1��, Address: 2K 1 Cbl4n �a I sfakc �. Approval Requested for: Mobile Home Replacement �� Building Addition ( Garc�e � Applicant Name: � Address: 2 � . P,ex6ere 1� G 27 S"j� Phone #'s: 33(n- 3 22- 3-1s3 ��- Co39 -St ( 50_ Permit Located: ✓ Yes No Installation Date: u-$-� � Design flow: �BD (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: ?- ��{- (� _(date) (Applicant's signature if site visit is not required) Comments: a; �►,; � a I I se �-bacKs Addition/Replacement Approved Enviro ental Health Specialist 2-l5-18 Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcounty.net ��,)f 1111e��1� �� lE��sm��¢mfl IE��mIl� Site Plar. Tax Map: A y� Parcel: 1 l3 Name: ��Id j�; (�i �S Address: 2�{ 1 Csl�.�� t��rks Qd . Subdivison: Lot• • EHS: �ate: Z-15- I 8 Note: 1� Drain lines represent approximate contours. Drain line locations must be flagged prior to installation. 2) Contact Person County Environmental Health with any questions (336) 597-1790. Additional Comments: