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A PPI,ICATION FOR SERVICES
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Permit requested by:
ome Phone #: ��1- ��I ( �
usiness Phone #: �( 3-� IQ��
Name and address
�.� �✓il �.
Cc-�-?
�, �QhY1b�'n 7. Dimensions or Proposed Structure:
�NS e Width: CqcS � '
'I rgs 2�/� Denth: `�� �
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
arr nt o ner: 9. Water su ply type:
j-�1'�� � private �. public ❑ community ❑ spring ❑
" Are any wells on adjoining property?Yes ❑ No �.
,t-r'y _ e E���"�"e5 If so, identify location:
. Property Description: Lot size: 2-(o � CtCI eS
. Tax Map#: �}ya
Parcel#: � SH -� / SS
Township: - -
. Directions to property: State Road #& Road
iames. �tc.
'S
-�u.j'n 1�-�- b�r�-i� /'���I ��IC� t,9�ave1
Number of occupants or people to be served: �
10. Type of structure/facility: Proposed: �xisting: L�
Type of dwelli :
House: Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms:� 3--
Garbage Disposal? Yes CJ 0
Basement? Yes ❑ No f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'son COunty Health Depal'tment 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 maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be
issueci, I must present a survey plat of,the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the prop y. to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this a��lication sha�ecor�e void and all fees paid forfeited.
Si�nec� Ow�c or Authorized Agent
Permit Issued l� ,
Permit Denied ❑
Plat Observed ❑
. --
. � , � D�te
Signature
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_.:: _ , S s s _ s
1. SLOPE (%)
PS �_� a/O D U U
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2. SOIl.7'DCTURE(12-36INJ S ��� 7'� S S S
(SANDY. LOAMY. CLAYEY, NOTE 2:1 CLA� PS PS PS
u g GiA u u u
3. SOII.SIStUCTURE(t2-161N.) S S S
(CI.AYEY SOfLS) PS PS PS PS
U � � U U U
4. SOILDEPT}i(IN.) � P S S S
PS �'��L�L,:) PS PS PS
�� U U U
S. RESIRIC77VE HORIZONS (iN.) S S S
(AIPERVIOUS STRATA. ROCK) S ��-' � PS PS PS
U U U
6. SOILDRAINAGF/GROUNDWATER � � S S S
(FXfERNAL R Q�ifERNALI PS *� PS PS PS
t% 1T��,/ U U U
7. SOILPEAMEABILTIY S S S S
(PERCO[AA770N RAT� U � L�T'� PS U U
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8. AVAtLABLE SPACE S � • S S S
PS �� C PS PS PS
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9. STIECLASSiF1CAT70N(SEEBELOW) _ �
SOIL SERiES
S-SUITADLE PS-PROVISIONALLYSUITA6LE U-UNSUiTABLE
RECOMMENDATI ONS/COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:WMIPROIDOCSWPPSEC.Sh1FiNANCE.PC
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B1128
PERSON COUNTY HEALTH DEPAR'!'ML�NT
WELL ANL' SEWAGE SITE, LOCATION IMPROVEMEN'T PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Reia�ation Activity shall t�e issu�d until Authoriz�tion fo� waste water system construction
has been i�sued.
Tax Map # � LjD Parcel # ���
Zoning Township v.5 N y�a �k
Owner/Contractor '/.{ M� �,� � v,�,1 nl so a./ Date C'/�/9�
Location/Address yw y� �� y_S T/� a �.e �I G.a �� o,q ur c��
,T/L cyn/ G� �n.r T�t/ Bi2 � o icF' �>> S.R.# I I q �
Subdivision Name G'c� �,�. rrz y B,e ��,�c� �s r,4 �t#_ � t 7 � �;.,� �,,,, c�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �.�� a L Size of Tank fo �� i�:,� L
SFD Mobile Home Size of Pump Tank �/A
Business # of Bedrooms�_ Nitrification Line tft�c� ��r3 '
Max Depth Trenches z� °�- z�''
Permits may be voided if site is altered or intended use ch nged.
Well and Septic Layout by r
Comments: / � �� �v c= s a 47 n�
.� —
Date D/0 6 Installed by TiM NI y C� �-' i S Approved by
'r=y��ir r��� � � � � � -T - -1 lO - �1�i �' _
Well Permit Paid Q' �WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent ✓�
Site Approved � Required Well Log
Well Head Approved Well Tag
Grouting Approved
Comments:
� Date !I/�
�
!Installed by � V'r41v � �✓�c,I Approved by.
a•_ �u+.
This report is based in part on information provided the homeowner or his/he�
representative in the applic��ion submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
�. ' :.A:�i:�L'>'s. ,
.. .. ....:....:i:��c...... ......
� � � LOT 15 ��
p�• � ��, i� PCOT PL=AN FOF
� d y �� � .PAMEL A `JOH.�
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a C. a' �� ' /�/ ec o �'ao eo' `�zo',
� � ��` \` CONTROL/' `, LOT 16
� CORNER � \
� , � / ' - � , eut t t�en - 60 }-�t.
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.�i` . . .FA pA�
� � LOTS 6 d 7 *'
"� "COUNTRY BROOKE ESTATES" ; ��
\ / P.C. 4, P. 17 ;: r�. � -
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LOT 5
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Nss, 51, 9S �
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Application Date: � � � 3 "����
Amount Paid: 7�.C�i—
Receipt #: l �0�3
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❑ [mprovement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Buiiding Addition
$150.00 (if site visit required)
� Well Permit (New/Replacement/Itepair)
$300.00/$200.00/$75.00
`�� ) f ���� YJ� Tax Map: � "��
� � � Parcel#c /S5
.....,. �:..�- �.�����
IE:.+.�.�rnv n.n-aDan_axaa::zn.tian..11 )I lld�.�m.11.�::1a.
tion for Services
Services Re uested
❑ Construction Authorization
(Eee is denendent on the tvpe of
Q�Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: % ���s a�r�r��_
Address: '70 C�S (L�a> >%ria r�/,
��X�n s� �'I C 2 �S 7 �/
2) Name and address of current owner (if different than applicant):
Name: f q t
Address: ,� t (A �.
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Propertyn: j�iUc�
%Kfn %P.iC�� t �uv►fii^ei O�ronl��t �a ✓J
Phone (home):
(work/cell): 3310 SF-v'� "DN2�
Phone:
Lot #:
b.'7
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other�han domestic sewage? ' 3 ��
❑ 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) i�( O L� i1 ��
' ����
4) Proposed Use and Type of Structure: W��y
l
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? 0 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 Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify 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.
/ - l3 �o/�f
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)
Tax Map: �Q
Subdivision:
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��rn�vnsamn�aicxa��ra��n,� �'�a��-��Il�
ParceL• [5.�
WELL PERMI�
(New _ Repair Q/ )
Applicant's Name: C���h R�eAveS
Mailing Address: l� D �
ox ro . �UG
Phone Numbers:
of Property:
Lot:
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire 5 years from the date of issue.
4.) Issuance of a permit does n t guarantee a potablewwater suppl}'
Other Conditions/Comments: �P rrn r�t'� / n�Q %� //n }�
Permit issued bv:�
�1ew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Date: j- �3 -/y
Certificate of Completion
�ner:
EHS/Date
Depth: d '
Grout: 5 - J3- I �
DAbandonment:
We1lDriller: JQ/, Y ���Z.ar�S (,�i��S /Qar ��.
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Heaith
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date:
Method/Materials:
License #:
License #:
Date: - -
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
' 11/26/13
0
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Date:.�..� � '
Owner:
Location/Directions:
.
1'�RSON COt1N"L'Y ;I:NV.I:RONP;`'N1'f:l, [1LALTEI
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lJl?(.L I.00
SR#
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,liv��?V1S101Z N�lI11C: ___ .�.,OC �
Drilling Con�-actor: � ,,�,,,, s �c��,�/ /�, �
WEL,I., CONSTRUCTION
Distance from Ncarest Proper�y Linc — llis��uicu from Source of ' - �'�
�;::: ��;..
Pollution_ ro�v/c�,_.c � • � `��
Total Dep.th: - Ft. Yicld:_�___GPM Static WaterLevel Ft. ..,:,: .`
Water Bearin Lones: Dc th -' I��, � �"�
:g P --�.l�s----- -��-��'t• Ft. �1�t. �
... {� i .:..
Casi.ng: Depth: From U to_�_�_Ft. Diameter: 6=- Inches
TYPE: S teel � • . '``�..� �
Galvanizccl Steel .�- � � -":�:.:.
If Steel, does owncr approvc: Yes No ''�
��
..
� Weigh[: �,� Thickness:��; Height Above Ground: �,�. rnches
Drive Shoe_ Yes ✓ No = .
Were Problems Encolintercci in Settiiib t�ie Casing? Yes � No � �``
zr ��y�s� ���� r�����:
Grout: Typc: Neat Sand/Ccmcnt �-- Concrete � <��'�`����
Arinular.Space Wadth_ � Inches �
Water in Annular Space: Xes No c�-
Method: Fumpcd; Prc:ssurc 1'oureci �-- . . .
Dcpth: From_ �3 to �� Ft. �
Materials Useci: No. Bags Portland Ccmcnt � f. Weight of .1 bag_ s,�; lbs.
IF mixtui-e (sand, gravcl, ctittinbs) -12atio:__� _ t� _
ID Plates: Yes �/ No :. � . �
4 x 4 sIab Ycs ✓ No �
-- T�RTT .T TN�; T rl�:
I HEREBY CERTIFY THAT THE �OVE TNFORMATION IS CORRECT AND THAT �"
T�S WELL WAS CONSTRUCTEll I:N ACCORDANCE WITH REGULATIONS �SET
FORTH $y�THE PERSON COUNZ'Y I-IL;ALTI-i DEPARTMEN`1'.
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Si�na[urc of Concractor Date