A40 166,�rsnlic�tion Date� �—�— � �
�pnonrrt Paid:
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Pers�n �c�ntv �lealth �eAartment �
�rnrironmentai Heaitt� Sec2ion
APQLICA?lOW FaR SEiiVICE�
., .:.: ..�.:.:.,. '...;.. �er,in"cc:,�e,��,�,,.,y�,, . . >.;K�:v :i� .
:.i:: ;�i:�s^%;:::::�,r::^:::+:f's.e�.��.-.?�.,-_.-�---.---r�!�• •.: ^� � ry'"•'.�'ej;::_•..+�=�'� i:
(RCCD[d2d LC� � r515O.00 0 WEl1 Pe![Rd (NE1WReQ�e
- (Unrecotded La� - $750.00 ❑ E�ting Syafem Inspe�ot
(Mablle Home Rep�nentlAdddFon)
�ax �ae� � *'• � 7'" �
Psr�! �: � � �
1) Petmit requeated bY (Own gertt/prospective owne�: � /� • �-�=�-�
Home Pttone: i3• _ dy� Address: o � �,,�.--
Businas Phane: �/.�- � a' -y/L �l Tn�� ��- �,�G /X- /� y �
2) Name and addr�s oi° currertt ormer. d� Q�-�w .
Go / � � ,
�i�v,o�- i GG , 3 4 G/ -/ G, � 2r
3) Praperty Deacription: tat s�ze: ��ownahi� _���'ot K
Diredtons to the property (induclinq road names and nu ers): �Q S��`� ��� /�1�� �a-�-n
' Lo � �.s�o/ � � .
4) Proposed Use and Strudure DescriQtion: answer each of the foilowing questians:
a) �P�� Exi�dln9 t1 .
b) S�dc Built �. Modutar 0. Single Wlde q Dauble Wide ❑ G. 0 G
c) Number af fledrooms: ?— . � Number of occupants or peapie to be served: �.
, , :e�.., B�se�iei� Y�sj�J.. No 0_If.yes, # af.basement fatu.*es � _ �_:y� ' . _ _ . - . .
-: . __....._-__ . _ . . .. __..
� Garbage Dispasai: Yes q Na � �- . . ��
: ,. ._-.
g) Dimensians of Proposed Strtu�ure: Widih: � 0 De}�th: �d �t
� Water Supply Type: Private,�(new�$,'cre�dsfin9 �, Pubf(c q Communityy �. Spring-�
. Are acry wells an adjoining properi�? Yes� No Q If yes. lac�tion
6) Please Indicate Desired Sys�em. +YPe: (systems can be rankeat in order of yau preferencsj
,�ConvenHonal _�Ilodifled Comrentlonal _ Aitemative . lnncvative
Other (specity):
CL.�ARLY STAItE ALL CORNEi�S AND i1NE5 OF THE PROPEiZTY,
STt1KE THE CORNERS aF ALL PROPOSED STRUCTURE�.
Pl.�SE ATTACH SURVEY PLAT OR SRE Pl.AN TO TiiiS APPLICATI�N
1 h�rebY make appiir.a�on ta the Persan Caunty Heatth Departrnent for a site evaluatton fnr the en-siie sew-age disposai �sys�tem fcr
the above-descr�bed property. i agree that the corrterrts ef this applir.ation are true and represetrt the maximum fac�7"ities te be
ptaced on the proQerty. I understand if the site is alteied ar the intended use d�anges, the pertnii shail become invalid, f undesstand
that as ap�licant, I am respansibie for identiiying and marking property lines, camers and malcing the siie ac�ss�ie foc the
persanne! of the Persan Cawriyy Health Departmerrt to cendud their evaluatians. I understand that i am re.sponsi6le for noidying the
He epartmerrt ifi my ProP�Y co�ains any wetlands as designafed 6y the Army Cc�ps af Erigineess.
. �-9'OI
� owner or Legal Representative �- Qate
. PCHD, rev.10!'t2199
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE S TE, LOCATION IMPROVEMENT PERNIIT
rnQn�l �- ani�.-��,Ch�e.l
rn
Not for waste water s tem constru ion. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # A—�i � Parcel #
Zoning Township
Owner/Contractor
Location/Address
divisidn N
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S.R.#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �s�Q-C- Size ofTank a- jQQp (�(�,I �,1'1 �
SFD � Mobile Home Size of Pump Tank
Business # of Bedrooms_� Nitrification Line �{ QD i`� d �
Max Depth Trenches a� 1 n c.�,�
Permits may be voided if sit`e is�ltered or i
Well and Septic Layout by iC.,C��'1 �Q,(
Comments:
Date Installed by
-� P. �e,-r�-u mu5� b.e. marlCed b,�, �.0
�Well Permit Paid ❑
Individual
Site Approved__
Well Head Approved
Grouting Approved_
WELL
Semi-Public.
Replacement
ed use changed.
Approved by.
Y
Required Slab _
Air Vent
Required Well Log
Well Tag
1 a�
�-�1 �.Z.Q� Q�1
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r���� uvcu uy
This report is based in part on information provided the homeowner or his/her
representative in the application 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
o Person County tiealth De}�i
A m o u n�t p a i d '�� ��� �25 S. MO!'�2(1$tf2�:� g J g/�G,
Roxboro, N.C. 2757u �� � �
R:<.c e i p t �� ��.0 �1`j �Q41�i81''i!l2•?3-is D a t e
1
�� � � APPLICA'�ION FOR SERVICES
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.....,'��.a"a�«.,�..:r`vy�3.d'.Sv.a..t'¢.....�..9.:.:i;�cJ i.c.w"r.�ea.., Fa•,.;..,?.2«we.::,,h..-,.ra,-».-»�,.�,> +r....,.. .w,�+ .w�w...,.. � ... , . >. . .... . .
�. Improvements Permit. (EstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing)
_ Im�ovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
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Improvements Permit (Mobile Home Replace) �,_ Permit for New Well
Bacteria
Pecmit (Addition)
_ Chemical
_. Replace Existing Well
_ Petroleum I _ Pesticide � _ Lead
1. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospective ownerlagent: / � ��`� Width: �a � �
e,�.��A��• /n�lf 1 a.��( L�t� . Depth: 1L _;
:ome Phone #: ��- �7 � `t `
usiness Phone #::��9- �L 7� \.1
Name and addre�s of current owner:
`�/' �'ca ,�'f-c.� CJ i �li ��� 5co �1 _
Propertv Description: Lot size: � �
. Tax Map#: �l . �- o .�,
Parcel#: `��
Township:�. � ✓v �
. Directions to property: State Road #& Road
,�tc. �(
; -�.. �,U � e -�� ,� �r N o
Number of occupants or people to be served:
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?
9. Water supply t5•pe:
private �j, . public ❑ community ❑ spring ❑
Are any wells on adjoining propert ?Yes ❑ No �.
If so, identify location: �� �( 7 -
10. Type of structure/facility: Proposed: �Existing: Q
Type of dwelling:
� House: �Mobile Home: C� Business: ❑
Type of business: �
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes f�( No �
- Basement? Yes ❑ No� If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY Ai�ID THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COunty �ealth Depat'tment for a site evaluation for the on-site
sewage disposal system for the above described propercy. 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
issued, 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 property to the Health Dept. wichin 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
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Signcc� Owner or Authorized Agent
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This plat was prepared in accordance � �9�, Larry G. Dov�s � i ; �.'�
vith G.S. 47-30 as aaended. � ,• n DB. I32, p.86 � Alonx� N�Ison � �
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Tax Map tk
_ . .. .. !4pPitran�.
: -: . Locaflorc -
PE�SON C�3UNT�f E�IVIRC�{VME�ITP►L HE�,LT�J
Township
Im�rovement Permit
New �ddition Type of Strudure , �a.tC,� 1.,P,�
# of Occuparrt��L, � of Bedrooms 2 Other
Projected Daily Flow: �CU g.p.d. « Permit�/ali
Proposed WastewaterSystem: � � a�a�
Proposed R�pair.
Permit
►, (
Owner or Legal
Authorized StatE
i�
PIN
ael8action Lotlt�
Water Supply �
System Type��
nir�4Cn.,
�' ]L `S . t � � �r� �� t ,�O�vh�c� i U!'f �i
� �/u r� Uv��y j
v� �� �`�_
�� ° �av�, �-( C�,p,
Date: O'- /.iY� 6 /
Date: l ��� l
The issuance of this permit by the Health Dep�rtmeM in no way guarantees tfie issuartce of other permits. The permit holder is
responsibte for chedcing with appropriate go�em�ng bodies in meeting their requirements. This sibe .is subject to revcca#ion if
the site plan, plat, or the intended use ct�anges. The Improvemetrt Permit shall not be af%cted by a cl�ange in ownership
ot the site. This pertnit Is subject to compliance with the provIsions of the Laws: and Rules for Sewaga �reatme� and
Disposal 5ysiems of the North Carolina Administrative Ccde. - "
• Authorization To Construct Wastewater Svstem (Reauired for Buildinq Permit)
u t� �
Wastewater System Description: i i� L A-P Wastewater Flow: � ,p.d. Type�
Facility Des ' tiort: Fl �� � iVew� Repair ❑ Expansion 4
Basement?�(es ❑ No Basement Fnctures? Yes O No --
Wastewater Svstem Requiremer�ts . .
Tankage: Septic Tank size.��l� gal. Pump Tank size ` gal. Grease Trap size r�%, gal.
t ,c
�� Trenches: Total length �� ft. Trench Width � � Z ft. Total Area �� sq. ft.
S' Max. Trench Depth: � In. Aggregate Depth:� in. Soil Cover. � in. Trench Separation �ft on center
�� � � ` �"`�
��� Permit Expiration Date:
Authorized State Agent � Date: � s� u�� .
*See attached site plan and addendum pages for additional pertnit canditions.
The type of system permitted ❑ does � does not difFer frnm the type specified on the applic:ation. I accept the
specifications of 1fiis. permit ,
Owner/Legal Repneserrtative Signature• J• Date• �,�"�%�
Oaerafion Permit
System Type (in accordance with Tabie Va) �
This system has been instailed in compiiance with appiicable North Carolina General Stahibes, Lawa and Rules for Sewage Tr�eatrneRt
and Disposal, atrd ali conditions of fhe Improvement Permit and Ca�truction Authorization. Issuance of this permit implies no
guara�ee fhatthe system instaited wi(1 iunctia� properlyfo� a�ry given period of time.
Authocized State Agent
Date
PCHD, rev. 03l07101
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. � a System Type (1n Ac�andanc� Wiih Tabie.Va): �� .
TH1S SYSTE�A l�lS �E�1 BNSTAI.I.F� tM C�MPl.lANC� WIT��� APPLDC�IBL� NORT�i�
_ CA�OLIN�►► G�►L S'iATU'i'E8, RULES Ft3R S�NAG� TRE�►�IIE3�1'i' A[VD DISPOSAL,
.J�1D �A11. Ct3MDf�lIONS OF '�E�E 1�IIP�OVE�AE�lT PE3�tT �AidID CaNSlR41C'f1�N
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PE�SOId COUNiY ���IIR�NME�IT.;1L HE�►LT�
PL.�►SE ��� ���+C9�E� PL.�o� F�R 11VE�.L S1TE LA'��1��
Tax Map �I:
v p�# ��C�
ZoNng _ TownshiP
Applfcanx �Uti�/�i � . "�
I.acaUon:
� �� � � '�� ��
' � ,.� lS�
subaivislaa. ' i'u �. sedton:
Tvae of Water Supplv:
Reauirements•
Well Permit
Individuat
Site Approved by �►+ � o�ra -� t
Groufing Approved b ��-�a ��
Welt Log
Well Tag �
Air Vent
Hose Bib
Concrete Slab
Community Public
. ..
Well Dritler: G 5 j ' � N
- � �. .
Well Approved By: D a�. �' Z
,.
**See Attached Site Sketch**
Welt� must be 10 feet from property lines. �
�elis must be 100 feet from septic systems.
ells must be �at least 25 feet from any building foundation.
Other condiiions:
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PCHD, rev. 11/29/99
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10/15/2001 19:47 8043740001
Oct-l2-tll 0�:29P
Date: iv - .� o�
Owner: �
Subdivision Namc� _ _
17rilling Contractor: i
HENSLEY WEL
PERSON COUN"1.'T ENVIROI�A4ENTA� HEALTH
WE1.T. LOG
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T� � n`�rt � � n l:e. iS'�i- S Lr_7 �
PAGE 01
P.02
SFt#
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f (� ,
I..OI #__� -
Discarzce hom Nearesc P�operty Line ,�D' Distarice fram Source af
Pollu�ion /D D ' �-
Total Dep.th: / D Ft. Yield: GPM Static Water Lcvel � O Fc.
Wacer Bessring Zones: De�h �t. I� O Fc. Fc. Fc.
Casing: Dep�h: From,.,,,,jv� _co��Fc. Di3meter: Lnches
TYP�: Sceel � Galvanized Sceel r.--r" 3 3'
If Sceel, docs owner approve: Yes Ir'o
Weigh� ���77ucicntss: t�3,�_,Height Abc�ve Ground: 1 oZ Inches
L�rivc Shoe: es„�._,,, No
Were Problems Encowteeted � Setting the Casing? Xcs No,,,�,^
If ��yCS�� givu rc�.SOR:
Groui: Typc: N�ac Sanc4lCemzr,c Concretc X
Aruiular Space Width ,�,�� Inches
Watcr in Armul3r Spacc: Yes No^�_,
.. Mechod: Pumptd - � Pressute Pour�d_ X. •
Depth: �rom C� co_ �o Ft.
Materiau Uscd: No. Bags Portland Cemcnt,�_ Weighc af 1 bag Q`� ibs.
If mixcurc (s�uid, gravel; cuttings) - RatSo:_�_ to [__
ID Platcs: Yes___�__�_ No � ..
4 x a slab Yes�� No�
Z HER�BY C�RTIFY THAT THE A�OVE TNl ORM�►TION IS CORR�CT AND TWAT
TH�IS WELL WAS CONS7RUCTED ZN ACCORDf�NC� WITH R�GULATZOiVS SET
��R�'H 8Y THE PERSO�' COUi�rT'Y HEALTH DEPAR�'M EN�'.
� _.
� /p �s �
Signatace of actor D�.c
f`orth Carolina Dcpartmcnt of Environmcnt S hrtural Resourccs
Di�•ision of Water Quality - GroundN•ater Scction
Ia3G Mail Sen•icc Centcr
' R�lei; h, NC 27699-163G Plione: (919) 71=-0=9�
��'ELL C(�NSTRUCTinN RECnRD
DRfLL1NG CONTR.�CTOR: NanGl P� wpl l�il l; ng Inc. �
5TA7E 11'ELL
CONSTRUCTION 2459 � �
DRILLER CERTIFICATION NUh4[3ER: PGRAIIT \L`��IIiLR:
1. WELL LOCATIQ�: (Sl�ow s(cet h of the location
Nearost Town: `�> > i County: _
(Road ommuniq�, or Subdl�ision and Lot
2. OWNER 0.tf ' ,n �,,`
ADDRE$5 ('�� I ��lu r R ,
(Street or Ro4le Yo.)
' �.��trL(E ��-.�4�, � � 7--71�i�
Cin•or To��n S�acc Zip Cudc
. 3. DATE DRILLED 10 I USE UF WELL �- �1+�-e-V��
-t. TOTAL DE:PTH ��
=. CCTTIVGS.COLLECTED l'ES ❑ NO �
.. DOES �1'ELL REPL.aCE EXISTIDVC ��'ELL' YES O NO,�,
�. STATIC ��'ATER LEVEL Below Top of Casing: � FT.
(Use "+" if Above Top of l:asino)
8. TOP OF� CAS[,VG IS � FT. Above L�nJ Surfacc•
•Casino Terminsted �dor below land surf:►ce is ille;:►I unless a�.iriance is issucJ
in accoi Jance with 1�A NCAC 2C.O118
9. 1'IELL (;pm): � DIETHOD OF TEST�
I0.11'ATER ZONES (drptl►): % � � w- ( � � � .
l t. CHLORI\ATIO\: Typr � c� ,�-_Amount �s
13. C.�SI`�G:
�1'all Tliickncss
Depth ��meter Or 1'ej;bdFt. h�`'1� latcri�
From � � To � Ft. a ' �
From To Ft.
From To Ft.
U. CROG'T:
Depth hlat�C e�� � hle_ tl�odr
• From �_To �_FL � �t�.Gs.d.B��.e
' From To FG
:
l�t. SCREEY: )�J�
Depth Dinmecer Slot Size Dlaterial
From To FL in. iu.
From To FG in. �n.
From To FG in. �.i.
15. S.�ND/CR�+IVEL P�CI:: ��,E-
Depth Size Ma�erial
From To F�
From To Ft.
FOR OFFICE L'SE ONLY
QI:.�D hU 5ER1,\L NO.
L�� Lony R(j -�'
Mmor Oi.in
0»in Code
Fle�dcrEnt G\V•I C•m.
1��
DfPTII
Fruin Tu
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a2 ES � — � 7G ,
❑
DRILLIVG LnC:
Form:�tion Dcscription
If addi[ion�l sp:�ce is nre�eJ use b�c6 of fu: �
L(1('aTl(�V Si:£TC'H
(Jl�u�v directiun �n� Jist�nce (rom at le�st I�vo $eate
K��Js, or u�hcr m:ip reference poincs)
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16. itE�LaRfS: �
! DO HER.EBY CERTIF�' 7Ha1T THIS �1'ELL WAS CONSTRUCTED 1N .aCCORD�NCE 1VITIi 15.� NCAC 2C, 11'ELL
CUNSTRUCTION STaVDARDS, AND Tii11T A COPY OF TI�1S I�,F,I�ORD H��S,BE .F�N YdtOV1ll�D TO THE 11'ELL OIYYER.
.!a' � ,Gl /
G11'-1 REV. 11/99
SIGNATURE OF COIY`l'It�C��,�CE1T D��I'E
Submit orivinal to llivision o 11'�tcr Qualiry and a cupy to wcll owner.
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