A40 127The District Heaf�h Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
Date �
} �� �� n , �� �`" ` v' � J
Owner: • � � +
�— -�'�� � r� �
Location: �
�, t �„ 1� � ., '� � �
r � ,
L i".�r ; t*-.� "�� � ; -;r�^�—�� �, � ; �,
� - �: �
Contractor: �'1�C� ��
Waler Supplp: Private �— Public
�^ _. '�
� r; (�,`..1 , .7
Sewage Disposal Facilities: No. bedre �cos �_. Uishwasher, Disposal,
washing machine, other automatic aF �liar' `_: _
l ., !
Size of tank: �(Z�� r,Fe NitriBcation line: �� ,`
,�,
�ther disposal facility: `��
� S' S��
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPAR.TMENT
STAFF BEFORE ANY PORTION OF THE IN,,,STALLATION IS COV-
ERED AND PUT INTO USE. / t
� J1 �� r �� 1-
Date approved: Signe �' `� " �� � � � � � �•�?�
j :%Se�tii ri�n J : �
Well: ! �' .
r' ,.I -
Sewage Disposal: Counter- ��.�;{,st ��- j,n��,, v'f
BY_ 9igned ?
(Owner or his representative) _
Certiticate of Completion
Date Approved: �J ��� Y � By:
Sanitarian
(OVER)
Location of weli and sewage disposal facilities sketched on back.
NOTE: 1'T�sketch of installation showing lot size shape, location of house, septic tanks, �s, water
supplies, e�c. ote special problems existing on lot. Wrste in� easurements in order that installations may be located
at later date. Note location of water supplies onx,adjacen �ts� < <
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; �1
Person C'ounty Health Department
Existing Sewage System Report For: Mobile Home Replacement
_�Addition(�����
R e q u e s t e e: �i,� i�/�-�—e
���yt,,��� H ome P h o n e# � q_ D�q 2, �
13D ��-� ��_ Business#
'�F,E� . `P ax M a p# Zf- D���" n%
- — ._ �, c _. _
Location/Uirections:
Original Permit Located !�
Septic System Uesigned r'or: �
itesidential li Business Other (speciEy)
# f3edrooms � # Employees Other _
�
Uate lnstalled �%-2b�'�3 Water supply �
'Pype ot System
Nitrificatiott Line I�Ui�.3/� 15����(�a ��y��`+�`^`-�' ��
Tank Size � �
Certified Operator Required /1/�
On site wasLewater disposal system showes no visually apparent
malfunction on J`^— s''� �
Yermission is granted to: �� r �'�
G� �"n��'
ccor ing to the attached site plan.�
Comments:
� � �
Environmental Health .$�C.. !/(J ����
DATE
Amount paia ��0.00
Receipt �� � � � �{SO
�-%
�
H
O
�
3 -as =5 �`
Date
APP�.ICA'�'ION �OR SERVIC�.S
�
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rmit requested by:
ner/prospective owner/agent
r�rPcc' .��C� �tJ��.<.!IA�.) .
,. � imensions or Proposed tru���e� �o
1 I c�����' Width: �-_ �` �/
1JJP`� � /
1� , Denth: "� /� � �o
fC�.+:,�.�c�it� �. f --a7.�'� 3 8. What type (if any, additions, expansions, or I
- replacement is anticipated to the structure or facility .
that ihis sewage disposal system is intended to serve?
ome Phone #: -�"?`� - c�� � ��� �A.L� �ou� 5;����`�
usiness Phone #:
. Name and address of current owner: 9. Watec supply ty pe: '
� . .� L � �C ��, �," private �ublic ❑ community ❑ spring ❑
' � Are any wells on adjoining property?Yes � No �
If so, identify location:
Description: Lot size:
Tax Map##: �- 4 d
Parcel#: � 1 � %
Township: ..�" I�fi�-�*.-�. .i�; �a���.�
. Directions to property: State Road #& Road
'.1
/o ,v;
�
c n,�
Number of occupants or people to be served: _..�.
10. Type of structurelfacility: Proposed: DExistirig: Q
Type of dwelling:
House: 0 Mobile Home: usiness: ❑
Type of business: '
Number of Employees: � _ : ::.
Number of bedrooms: �_ �
Garbage Disposal? Yes ❑ No �� ��.
Basement? Yes ❑ No�-if so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF..ALL
� �PROPOSED STRUC"�URES. - .-
I hereby make application to the PerSOn_COun�y �ealth Department foc a site evaluation for the:on-sit�
sewage disposal system for the above described propecty. I agree that the concents of this application ;are true
and represent the maximum facilities to be placed on the property., I understand if the site is alteced or the
intended�use changes, the permit shall become invalid. I understand tfiat before an Improvements Perini�E can 1
issued, I must present a survey plat of the property to�the Health Dept. I understand that in the event I have nc�
deIivered a survey plat of the property to.the:Health;Dept. within 6 0_ D A Y S a fter t he da te of the evaluation of �
the site by the Health Dep[., this application shall�become void and all:fees paid forfei[ed. �
R ,: U ..
� .. .
z Signc� Owner or Authorized Agent ��
�ermit Issued ❑
Permit Denied ❑
plat Observed ❑
Signature
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Apalication Date: V °� � �6 � Tax Map �: � �
Amount Paid: l .d O • ' Z 7
RecQipt #• � q 33 � Parcal #:
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7� aa�aa-oaa�*-�-� mss�m71. ����,11.�7�a.
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APPLICATIOM FOR SERVIC�S � W� 1 i
Pertnit (Recorded
❑ Improvements Permit - $150.00
(Mobile Home ReplacemenUAddition)
❑ RepaidReplace Existing System Pem
stetl ;' :> O
,,. _. ___
Welt Permit (New/Repiacement) - 5225.00
�2 .
Construction Authorizatian for Septic Syste
$150.00/$2U0.00
Permit Revision Fee - $75.00
IF THE IMFORMATIOId IN TiiE AIPPLICATION FOR �Afd IMPR�VEMENT PERMIT IS INCORRECT, F�►LSIFiED,
CHANGE!D OR THE SITE IS ALTERED. Ti-!E� THE IMPROVE�fiENT PERIViIT AND AUTHORIZ�►TION TO
COIVSTFtUCT SHALL. BE�OME INVALID. �
1 Permit requested by: (Ownerlagentlprospective owner): �$ l 2�-�ev )--� 0 W�
Home Phone: 3�� SS �.�[/ 0 2 Address: H �c, s S o r���
Business Phone: S1 S�-,'S'6 cl ots 6 0 v� D� �' �-� S''? L�
, 2) Name and address of current owner: �q M C
3) Property Descri�tion: Lot size:
Directions to the property (Includ
GbLnt��
� o� Township:
CO(vuie)
Subdivision:_
�a.�e �
G�- zo.�
_ Lof #
4) �roposed Use and Structure Description: answer each o the follow ng A�estions:
a) Proposed _, Existing x, Type of Structure: p� � A d� t t�� Q� Width: a� Depth: ��
b) Number of Bedrooms: � Number of occupants or people to be served: _,�
c) Basement: Yes_, No _ Will there be plumbing in the basement?
d) �arbage Disposal: Yes , No �
5) lnlater Supply Type: Private x(new _ or existing�, Public_, Community_, Spring _
Are any wells on adjoining properiy? Yes�' No _ If yes, please indicate approximate location on the
�site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No�1',
PLE,ASE NOTE THE FOLLOWING:
➢ A PLAT OF Ti;E PROPE�tTY OR SITE PL4N flflUST BE SUBMITTED WITH THIS �►PPLICATIOfV.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STA4CED OR �LAGGED.
9 Tl-IE SITE MUST BE READILY ACCESSIBLE FOR �4Id EVALUATION BY THE liEALTH'DEPARTiViEiVT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the macimum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid.
�,.� o� I��
Owner or Legal Representative
�-ac � � S
Date
PCHD, rev. 06/27/02
P.
. ,. ._. . .. . _. . . .. ,�: . . . _.
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S�'1'�. ��.'�•`��.
l�Tame �a l tP. r I'1 DuJ� . Ta.g Ma # 0�� Pa�ce]. # 12 7
P
Su ' ' ion ' �S � Se�tion/Lo 20-
� 8 DO
Authorized State Agent . � Date .
`� System components represent ap�iraxiriaate�contours only. Thc cantractor �aarsst, flag the systesrr prior to
beginning the installatzora to irasur�e that�r+oj�erg�rade is »aaantai�ed
i•
• � �f in: l . .
� � I�� �
1�'rfG �
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Scale: Ca
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I'G�, rev. 09/L/01
�'��� S� ���..� �� : � aD � 3 � 6 � , �
�`.,. . '� �nl�i`i�K`� �� r� e��c W e d l�r II i y
; :. ; ������;_ a
���n���;.-�„ ��.��:Il: ���.a�� D� o D� 1 1 1- q- o r.
Owner: �[
Location:
Subdivision:
UItP� �owC
G
o n•.0
Grout Log
Tax Map �0N 0 p�el # ���7
� � v3�'S
Lot # �O-
- Well Constraction
Distance From nearest Property Line (Minimum 10 feet) I n
Distance from Septic Systern. (Minimum 60 feet) (, �
Total Depth: ��'1� ft Yield�: GPM Static Water Level: 2� ft
Water Bearing Zones: Depth �15 R ft ft ft
�'q�l
Casing: � �
Depth: From _� to Q ft. Diameter. �� in
Type: Galvanized Steel
Weight: Thickness: ,��_ Height above Ground: � Z in ;
Drive Shoe: Yes No Any problems encountered while setting casing`? Yes �No
If "yes" give reason:
Grout: "
Neat: Sand/Cement Concrete GraveUCement �
�. Annular Space Width � inches Water in Annulaz Space ✓ Yes No
Method of Grout: Pumped Pressure Poured �✓ Depth to
Materials Used:
No. Bags Portland cement � Weight of 1 Bag �% Pounds
If mixture (sand, gravel, cuttings) - Ratio to
ID plates:�/ Yes _ No 4 x 4 slab � Yes _ No
Liner:
Depth:
_ ,v
Date Installed:
Drilling Log
Ft.
Grou� Installed by:
Location Drawing
From To Formation c�
(J QV r r'�,, �J�n '
;. k p .
n ►w� � �
��p le OG � �
_ „�
� N�tle� M��IS ��
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 Depariment. �
Signature of Contractor � �� ID # � ` 7 Date . � ��- 9 "� �
Pump Installment
Pump Installation Conlractor: �G� n-e�'tG 1�G �) ��;1)� n y State Registration Number: 3Z �7
Pump Depth: /�� ft Static Water Level: � ft
Pump Make & Model: e� Cc.� �e� Pump Size and Rating: %IZ hp � � gpm
I hereby certify that ttris pump was installed and the well head completed according to the Person County Well Rules in effe�t
on this date and that a copy of this record has been provided to the well owner.
Pump Installer Signature
� l�""� Date: ��'y�5 PCHDrev01/27/04
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- WELL PERMIT
�LEASE SEE ATTACH�D PLAN FOR WELL SITE LAYOLTT
. � �' o
'Pype of Water Supply: _ Individual _ C mrnunity Pubhc
�tequlrements:
Site Approved By: `�S� $' 3� - a5 Liner:
Grouting Approved By: ��� !!� �v-a5 � �Installed by: �
Well Log: � l(-! cS-c� Depth set:
Pump Tag: � Grouted:
Well Tag: ✓ � Date• •
Air Vent• C;S - �o- �5 ��
Hose Bib: �/CS � Water Sample: �
Casing Height: �/CsS �
Concrete Slab: � CaS
. � ,
Well Driller• ��� �'��` �
Well Approved by. � Date:��� _�
****See Attached Site 5ketch****
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
,
Other conditions:
�
PCHD rev O1/27/04
Application Date: 3 % 1 =�� � (' ������ Tax Map: � � �
Amount Paid: d v.. ."� � Parcel#: �
��— ' �� c�. � 1LT��IC� ��
Receipt #: � t� �. 65 d
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❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
� Mobile Home Replacement or Building Addition
$150.00 (if site visit re uired)
Welt Permit (New/Re nt/Repair)
$300.00/$200. /$75.0�
�lication for Services
Services Requested
D Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: Qo,�� � f p� t,� ���- Phone (home): 33 f� S� °i '� D 1 S
Address: (work/cell): 33 6 S 03 - y/ 7�7
2) Name and address of current owner (if different than applicant):
Name: � c. V , -r (� �c� __ Phone:
Address: f 3Q C o/o✓I i�, l� s� �
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: Sa I�o� �1-L, I/ / l�,r�-,il` il s i�.
T��a1n��;� t �s�-� ��, �
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes C� no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes G]-fio Is the site subject to approval by any other public agency?� /�t I ���
❑ yes C�fio Are there any easements or right of ways on this property. ��'`� � 6� �/� �j%
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
� E}cpansion of Existing System If expansion: Current number of bedrooms:
C�'�tepair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: � New well �Existing Weil ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properly? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative � 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.
��1� � � � �
Signature (Owner/ Legal Representative*)
'� Supporting documentation required.
3 -� 7�
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)
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WELL PERMIT
(New _ Repair �
Tax Map: j1�0 Parcel: /Z�j .
Subdivision: Lot:
Applicant's Name: y
Mailing Address: � �/�� llii�%�
Phone Numbers:
Location of Property:
Permit Condiiions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing const�uction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments: �„lit�-f�•0
Permit issued by:
Certificate of Completion
�Tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller: W q��/ W t�-0.�lC�S .
Pump Installer: �
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date: -�=����
- -`
iner:
EHS/Date
Depth: 0 �
Grout: 5 -17-(�
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: -
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13