A40 188'- ; � � _
.R + "'�' . .
� ' Amount paid
, 'Receipt ��
o�
. � ��-�-rr-
� �01 G
PFrs:r� C��unty �-a11th Cc�_:
32� S. ��',o.►,2n Stre�t �
�oxcoro, N.C. �: �?y
��c:s^er ��2.�3-15
�., ,, i •ra., ,-v. .----•..
,�� � , ,� _ .�:� �'" t^.Secvices;
_�:.
�Imprcveme�ts Permit. (Established/Recocded L.at)
Imc;ovements Pecmit (Unrecorded Lot)
I_ Improveme�ts Permit (Mobilc Home Replace)
� I_ Improvements Pecmit (Addition)
�
�^ � � . . - . ara �. .1,. � < - f� �."lLr� ..r�
O ` � •�R 4
, �. � , � .•s �ti;.€.. YaEer. �amplE
.
, , .._..,.. . .�-...�..........:. .r . ..�...'-.:..w'3�:..�.':':� �r�.sY1�.� s�...t........�i�•.w�
� � _ Bacteria � _ Chemical �
1. Pe �� i: : equested by: �' iQ-� /�1 Y
owner/p; ospective owne;/ ,ent:
Address: � ,S��F S. ,5 �v /r !� �-!
�
J
:.:�
� Home P�;cne `• 3 ' a-s� �
¢ usiness Phone #: ''
G
/�-'a�-o/
Da te
:equ�fed , .. , ; - K �;-�.L�, ,
,�» -..� • �.�.:�: ;�"�� .�
_ Reinspection oF Existing System (Loan Closing)
Re�air/Replace existing Septic System
vPecmit for New Well
_ Re�lace Existing Well
:1,s'('!.;11e;.E��7. _
_ PetroIeum � _ Pesticide � _ Lead
r.v /�/ri/,s 7. Dimensions or Pr000sed Scructure:
Wi�th: �� �
�. �-S � De�th: `o
.�
�9s`7 3. 8. What type (if any, additions, expansions, vc
re�iacement is anticipated to the structure or =zcility
tha� this sewa�e disposal system is intended :o se��e?
. Name and address o[,current owner. SQ-�i F_ 9. Wacer suoply t}•pe:
� privace �ublic ❑ community ❑ spring Q
Are any wells on adjoining property?YesO�i�io [�
If so, identify location:
. Prope�y Descriation: Lot size: /. �� � �•
. Tax Ma�: . 7`1"/Fa
Parcelz: L
Townshio: .�f3-% . �����P
. Directions to property: State Road n& Road
iames,�tc. �
��.a-�- �'r � c n� Ps��� r�-�; �oti
�S' Y'�k E P�-�7-r-� r� o,� �/,p,
o'%l� o� l�ii-►� Ur4c�c�" i. u7- w iT/�f c�,ps►
I0. Type of structurelfacility: Proposed: �Existing: Ci
Tyge of dwelling:
House: ❑ Mobile Home: �Business: Q
Tyge of business:
Number of Employees:�_
Number oE bedrooms: _ �f .
Garbage Disposal? Yes ❑ No Q'
� asement? Yes ❑ No Q�f so, tt oE basement fixtures:
�6. Number of occupants or people to be served: �- _ �
� CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUCTURES.
I hereby ma(ce application to the PersOn COunty Health Department for a site evaluation for the on-sit
�sewage disposa( system for the above desccibed propeRy. I agrec that the contents of this application ace [rue
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
'ntended use changes, the pecmit shall become invalid. I understand that before an Improvements Pecmi[ ean b
issued, I must present a survey plat of the propercy to the Health Dept. I understand thac in the event I have not
delivered a survey plat of the propccty to the Health Dept. witiiin 60 DAYS afte� the date oP the eva(uation of
'� the site by the Health Dept., this application shall become void and all fecs paid forfcited.
z
Signc� Own�c or Authorized Agenl
�'�� = � ��i�S�N CC3lDR1T`l E�IVIRONME�VSAL HE�4LT1-�
. � P�.�SE S�� ��'�Ct�E� PLAN Ft3R WE�L Sri'E LAi(�19�'
Tax AAaP #I: �� O Parcal S 1�+ �
Zoning
TownsidP �IQ� l� 1 V C�
����� �am m� �i a W K ��s -
�,� $�c erm it .
� 1�, � �p
-tR � u�r Pla����: �
s,�,,�a FIa
Tvae of Water Suapiv:
Reauirements•
Well Permit
�Individual Community Public
Site Approved by
Grouting Approv �y
Well Log ��^`, ,\
Weli Tag ✓ �a �lN ��
Air Vent � Z��
Hose Bib
Concrete Slab
Weil Driller: ` �
Well Approved By: �
Date• �' G'��,
**See Attached Site Sketch**
Welis must be 10 feet from property lines.
Weils must be�00 feet from septic systems.
Welis must be �at least 25 feet from any building foundation.
Other conditions:
ZnS-�-
� � a,5 s(.�c� n on S i-�e-. S K c-��-� .
PCHD, rev.11/29/99
Apr-10-02 09:29A
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a) Pr��r �on: �t a�c .1 �._ Tarn.��: �„ su�o� �t�� .A, v�e� �c�t l �
Dhsa�bra b the p�ql (hx�udin8 rwd.�mes ard nut�ra}:
�} Propo��d l�a d�� � attewar �tt dtha �p qt�otl�oltc : .
�) �Pm� � ��A —, Z'Sl� � �� ' V�Adttr. be�k
-�b) t�N►��r B�droorn� . NumbM' d ooaq�� arp■opM tA be � a � , .
c� B�wn� Ya� � Na�V1�� ba p6.�fik+� In ilw b�srtt�nt'� �
� ��!4� �oi+� Y� � � � '
� Wl�e' m�py►'1j�pK Pri�r� (�r► � ot aods�g _,,,,. P�i�a,, �*�► � ��0 , .
Mr•rny rw�s an p�op��� Y�„ Pb _ ify� �ie�s MdctlM r�Mr�l� locaticm on 4� s!N phn.
� D�t � p�op� �!■t plsnfoufly idrt�d j�tr�oo�l �11�d�'t YM _ No �
PI R��t Y[fRw'Tti� MA1 1 t�if,- , , . ' _
'> A p1.AT Or M PRCP�TY' 011 sf't� }�1.�N 1�1ST sE a1�TTE� YR'!ti Tliaf J1P�LIr.�►T10K:
Y Pl�OP�t7'Y L11iE� AND COltl�fie IWST � CLF�Rl.Y 1MRl�QD. .
D.7'FI! �OPO� L.A�'�J1770M OF ALL 8TRl1C�1� fUQ� 8� �f�l� OR P�AL�D. • .
D T!� 8f7t MJQt' 0L' 1�!►Dd.Y A�.L lrOR J1l1 E11AL11A110M S1f THE l�EALTH �!►R'I1�fT BiAF�.
1- r� mai� ap�on �c tha P.raon ca� t�ie� o.�rtr�nc i�r a�r aw�u�on tb� �s a�►-e�m e�pe �
BY�nt fa�- th� piope�ry. 1�e� itt� tlte cot�br�' af tttih oppBc�lon �e htya and t+�7�+da�tt tt�e mn�xun
�ta m ha pl�ced on ths praperty, t und�M If th� �s b� � a� the t�d use c�uir�gee.ltw p�am�t �etl
�vaBd. 1-}�� � `, � �
Ow�er or Leval Rao �re � " O� �
�Q.�p. �r.10tt7At1
�
AFplication Date: � � � �
Amount Paid:
Receipt #:
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobi[e Home Replacement or Building Addition
$150.00 (if site visit required)
W�II Permit (New/Replacement/Repair�
$300.00/$200.00/$75.00
`--��, ?, l f ���� �� Tax Map: � ��
�,' �^ � � ���� Parcel#: 1 �
]C�,�,�.��� �-��� �»m.�:.�,ll IHI Q:.�.11 a:ll�
ication for Services
Services Re uested
Construction Authorization
(Fee is denendent on the type of
Permit Revision
$75.00
Repair af Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
) Applicant Information:
Name: C�/'✓ ����� S Phone (home): 33�0� S� y—o �2 /
Address: g ,' or. c (work/cell):
2) Name and address of current owner (if different than applicant):
Name: Phone:
Address:
3) Property Description: Lot Size: �ubdivision:
Address and/or directions to Property:
Lot #:
❑ 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 than domestic sewage?
❑ 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) ���-�-
4) Proposed Use and Type of Structure: �O r('�
❑Residential � � �( � !.�
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ 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
❑Non-Residentiat
Type of business:
Maximum number of employees:
Total Square fcotage 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
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to �onstruct', p:ease indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided above is complete and corf�ect. I also understand tiiat if the information p-rovided is
inaccurate, the site is subsequently altered, or the intended use changes, all perrnits arid approvals shall be invalid.
Sj�nature (Owner/ Legal Representative*)
* Supporting documentation required.
G �
ate
Permits are valid for either 60 months or are non-expiring when accom�anied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site eva(uation.
(10i15) Person Count.y Envirorunental Health, 325 S. Mor�an St., Suite C, Roxboro, NC 2i573 �336-597-179�)
1
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•�. ~ � � ����
l���n�-� ��.��.¢�►.Il. IF3C �.�.Il�]I�.
L��
T��x ��rl�'� i' P��rc�el � � i
S�uhc�livisioi�i � �
Pl�r�se Sec�t�ion Lot =
Improvement Permit
Permit Valid for �Five Years _ No Eapiration ,
✓ � !/
Type of Facility: _ j)') Ob� l� /-fom c
# of Occupants ��, # of Bedrooms
Proposed Wastewater System: �7n Vc
Proposed Repair: CD/l VC/1-�iDn� I
Permit Conditions:
Owner or Legal Represe
Authorized State Agent:
Nevv Addition Water Supply r� W+�
Projected Daily Flow' (DD g.p.d.
Typ.e: �
_ Type: .T�
m On Co�-E�c,�r
C il /1 RC{ � 1% n
S�'tC SKt C�,. �
�e:
�5
�( a� �u� by E-�,5�_ Kc
Date•
�Date: 4 �/S- v�
The isauance of this permit by th� Health Deparbnent in does not guarantee the issuance of other permits.'It is the responsibility of the
applicanVproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requizements are met Thie
Improvement Permit Is subf ect to revocatlon if the elte plan, plat or the intended use changes. The Improvement Permit ls not affected
by a change ln ownership of the property. This permit waa Iaeued ln compIIance with the provlsiona of the North Csrollna `Laws and
Rules for Sewage 7lreahnent and Disposal Svstems' (15A NCAC 18A .1900).
`� 'Authorization to Construct Wastewater System (Required for Bullding Per,n�t)
* See site plan and additiartal attachme�ts (�.
Proposey�'Wastewater System: �nVc.l1-�i0�- � Type � WastewaterFlow o� .p.d.
New V Repair Ex ansion Soil LTAR: .�3� .p.d./ ft 2
Type of Facility: %YIObi 1���m C Basement _ Yes �No
Wastewater System Reqwirements �
Tank Size: Septic Tank: � gal Pump Tank: IJ% l� gal Grease Trap: N/�} gal
Drainfield: Total Area: �,a�0 sq ft Total Length �0� ft Maaimum Trench Depth �_ in
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: 1 ft
: Distribution Box
(Specifications: Sr1,5-� �� �pn C
V Serial Distribution Pressure Manifold
Dt,�r GtS flc� ti�c a� an ��f by ���5, /11Ci�1'ftcrn �oC� �c�0�
Authorized State Agent:
Permit Expirati Date: -
The type of system permitted is ✓ Conventi�nal
the pennit.
Owner/Legal Representative: �
Date: � ��s ��
Inn��at;ve Atternst:vc. I s�cept the specifica±ions of
Date:
���.l;�J ���� `LJ'A �7 .
� � 0.J l�! 11 �
I�+ aa�n�r��*+�.�an�in.Il IH[�a�,A.tE]En.
SITE SKETCH
N�me _<��� rn �?'� y I�Q�J K i n5 . .Tax Map # A�o Pazcel # ���
Sub i'on I��iVzc- lantca.-�i'�n Section/Lot# La��� /O
�-la-oa
Authorized State Agent ' Date �
System cor�tpotteHts nepresent a�ipro.ximate contours only. The co�tract�vr must, flag the system prior to
beginning the iristallation to insure that propergrer,de ia maintained ,
If," 1�,
Scale:
�
0
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1 •
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uo . 5�
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� �p l (p�\
� ���d� us
�" � �g' � l5'
� 5 � . -�
�
,
155
lotal oF $cjp ��ncc�.r
� Fce� nF i-�nc wcre,
Fla��td cn 5�tc,
PCHD, iev. 09/12%01
. . . ����ay',_' �� .fii. Ll..���i/��� .. . • .
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-- - -_ . .. _.. IE��a-����ffi��.Il: 7E3L,o.�.Il�
Tax Map #: �T �� . Parcei #: � a g
Zoning: Townshlp: ���� �� � c�
Subdtvision• ��������r P�u�'f���� Section: Lot: ��
Applicant• i-- i,4a (.J I�( I�/�'► S.
Location•
4peration Perm it
;
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPR�VEMENT PERMIT AND CONSTRUCTION
A ORIZATION. �
4-�-0� �
Authorized State Agent Date
_ ._._ _::,_; _.. _ _ . . . I
�
r��� �f ���� �� D�� OD � ��(�
�' > , � c� � jCT�T�� ° ° � �..s��,� ��1� ,��.
IEa=a�aso�a�� �aa��.1Z �-���.71�7�n. � � ' ° '=%- '�� ��
Well Log
Owt�et: �- r %�r.-i.0 `L: vt �- Tax Map /� /�) Parcel # 1,���'.
Location:
Subdivision: �/�:� /-i�.��71� y��z-1�,�:-, Lot # �'� '
`' Well Construction
Distance From nearest Property Lin�(Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: �_ ft Yield: � GPM Static Water Level: �-� ft
Water Bearing Zones: Depth��� ft ft ft ft
Casing:
Depth: From � to �_ ft. Diameter: �i �/- in
Type: Galvanized Steel � c
Weight: 'clrness: ,/�L� Height above Ground: � 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 Annular Space Yes No
Method of Grout: Pumped Pressure Poured �/ Depth to Ft
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
Drilling Log Location Drawing
From To Formation
�
1 C G �j
� �
QS � /'1�C (Y f/'�.
y ~ f t � �•�.�Yt
° ��- �j� y.
� �� � � , ' �
� ��y��� �
ly1%�P5 f` `
� y�no
I hezeby certify that the above information is corr c d that this well was constructed in accordance with regulations
set forth by the Person County Health Dep
% , � `` L _
Signature of Contractor,�' yr(.� � ID# �;��-�/ Date j,� /�i�
PCHD rev O1/16/02
. �� �
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1) ' �� � � '
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<-� � ��..� I I-1 �- ,:� I � I �
Suilding Additions/ Mobile Home Replacements
Tax Map #: �c �� Parcel#: ti g� Address: a-� q i�l � s�o �r � e V � t�a
� I�o � C � 7� ��
Approval Requested for: Mobile Home Replacement
✓ Building Addition / 2 �,C J � � �,��
Applicant Name: �er�- y l,� , l�� q,� S
Address: �q q W��,� or; c V�� a
�ox�»ro N C
Phone #'s • 3 3 6 - .�o �- —b ( � � �
� ;_ Permit Located: '� Yes No
t.
" "Tnstallation Date: �} -a.� -d Z- Design flow: 3 ` � (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) �r `
�oJered
Comments: F ro��- �Porc�,� 1 a x► ik
' rU�.��Jr�'� � >>, .� �y�d;4f� ��"�t�—� c; ✓ �s�ic; c`�r , r.r,��e'.;1�
Addition/Replacemea�t Approved
,
,
Enviromm �tal H th Specialist
Date
Person County Envixonmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790I Fax: 336-597-7808 www.personcountv.net
� ���� 7. ) � 1L ��� �� � . � �'
. --�� �.� ���
lE�-��-��,.,r,_,���.�.�. IE-3L�,�.]t�Ha .
Tax Mep #: �' 4'(7 Parcei #: � U� �
Zon1n9� Townshlp: �I�{ ��.uc�
Suhdtvision: Fl�t �� �' �� Plan��-� �.� Sectlon: lot: ��
Applicant: �.- i� CJ + 1 l r�c n'► S.
l.ocation•
�peration Permit
System Type (f n Accordance Wi#h Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WlTH APP1.lCABLE NORTH
CARDUNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
A OR(ZATION.
�
` 4 -�3-0�
Aut[�orized State Agent �Date
t�y ,aZ
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