A40 204n Count Health �ar�ment . z
Sewa e em ents permi �
g Syst Improverr t
Date: � - '� - � Permit Voi After 5 Years �Permit # F_ If -a � �
Owner: -1- �� f• -. — SR# S S.
Location/Directions: __ � ._ _
,-. - '
Subdivision Name:�/c�.� ��-«-,–�� ��'f'� – #�;� .
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Lot Size: J- �F � L-- _ Type of Dwelling:
Water Supply: Private: �� Public: ��'� Community: �
Bedrooms: 3 Garbage Disposal �
Basement Basement Fixtu3es,_ �
INFORMA D B G-�L�.�
SBIll�C1118i1: owner or iepresaita ' �
REPAIIZ: REEVALUATION:
-------------------------
Size of Septic Tank/ � gallons Size of Pump Tank:
Nitrification Line: �/ o o" x 3'
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved:
BY
BY�l1/ng ys
Well should be 100 f� from any sewer system
Sanitarian _
. Sanitarian �
� � ...... ... ,�.�TE OF COMPLETION ,�
Contractor. ����(,� �
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Sewage System location, installarion, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
ni 'tnFicarion line must be inspected and approved by a member of the Person County
Health Depazunent before any portion of the installation is covered and put into use. If
the site plans or intended use change this permit is subject to revocation.
(G.S. 130 A-335F)
Location of sew dispo al sewage system sketched on back.
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� �f�erson County Heaith •par�ment � �
Well Qermit
Date:_��,� Th' Permit Void Af_� Year�
Owner:��rr.�. �1 t _ \ � v,�e�
Location/Directions: �
Subdivision Name:
Drilling Contractor.
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Distance from Nearest Property Line Distance from Source of �'
Pollurion �
Total Depth: G Yield: � GPM Static Water L,evel F� �
Water Bearing Zones: Depth .�� FG Ft.�l,Ft.
Casing: Depth: From ,�.,__ w �Ft Diameter: �0 � Inches
TYPE: Steel Galvanized Steel
If Steel, does owner approve� No
WeighC Thiclmess: Height Above Ground: Inches
Drive Shce: Yes No
Were Pc�oblems Encouncered in Setting the Casing? Yes No
If "yes" give reason: _ / ►l7
Grour. Type: Neat Sapc�ement Concrete �
Annulaz Space Width l�— Inches
Water in Amiular Space: Yes No �
Method: Pumped Pr �_ Poured
Depth: From � to � Ft
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand. gravel, cuttings) - Ratio: to
ID Plates: Yes � No
4 x 4 slab Yes —T No
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN CCORDANC WITH R GULATIONS SET
FORTH BY THE PERSON COUNTY T EP MENT.
99
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Date
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
�� NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
.
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
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' at later date. Note location of water supplies on adjacent lots.
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��a��s���� �d�fl�ons/ I��o���e :�offie �e�flae��a���
Tax Nlap #: �% � Parcei#: � � �
Approval Requested for: 1i!�1V4obile Home Replacement
� Buiiding Addition
Applicant Name: Da .� � �� � � �'�6�-i �a �`-r (' S ,
Address: �S r 7o v .-�4 �-, -
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Phone #'s• 5�i 7� Ss'� g
Permit Located.: Yes No
Installation Date: o`� 3dl q � Design flow: ���(gpd)
Current Contract with Certified Operator on file (if required):
Water 5upply: -�i�Well Public or Community
Wastewater system .shows no visual evidenc� of failure on: � a-1 a"�' l� l. {ciate)
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nvironmental I3ealth Spe�ialist Date
11/1 �/OS
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B 1467
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PERSON COUNTY HE�LTH DEPAIZTME1vTT
WELL AND SEWAGE SITE, LOCATION IlvIl'ROVEMENT PERMIT
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Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shalt be issued until Authorization for waste water system construction
has been issued.
Tax Map # /-I yv Parcel # ���
Zoning Township �-c..� r� � v�- ti
Owner/Contractor S i,a nl c. � Y D A`f � Date //30 /� �
Location/Address µ,,,�Y ��� 5 -; i� �� �. 5;�•z�c V��-�-ACr� �� ,
T/.� o.�/ G�liE2c� �4vC , i//z o•✓ 4v�.z/ati"rrS.R.# /s7 �
Subdivision Name f�qTR�v�R P�ANTATivti/' Lot# ,2� �
SEWAGE SYSTEM SPECIFICATIOI�IS
Repair Lot Area /, /8 � � Size ofTank �XiS TI�1 �r /U�� �r� �
SFD Mobile Home r! Size of Pump Tank
Business # of Bedrooms � Ntrification Line � x� 5 i i a 4- � �o' x 3�
Max Depth Trenches -
Permits may be voided if
Well and Septic Layout by_
Comments: �c �� �. �
or intended use
Date Installed by ��;—�-=,=�! ! Approved by,
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIQNS ,
Approved
I Head An�
Comments:
Required Slab _
Air Vent
Required Well Log
Well Tag
Date Installed by Approved by
r�. M, l-1
This report is based in part on information provided the homeowner or hislher
representative in the applicatioa 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 D
responsible for concealed condi�ions 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 ��
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specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:lamipro\permit.sam O1/95 rev.l.l
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Application Date: z Z oc�
Amount Paid: � . o0
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Receipt#: �
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Application for Services
(Septic Svstems and Wellsl
❑ Impro ment Permit (Site Evaluation)
$200.00/$300.00 (if> 600 d)
obile Home Replacement or Buiiding Addition
$150.00 (if site visit required)
�� Well Permit (New/Replacement)
$225.00/$125.00
T� Map: -��---
Parcel #: 20�
Services Re uested
Q Construction Authorization
(Fee is de endent on the e of s�
C Permit Revision
$75.00
❑ Repair of Existing Septic System
No Charee
Important: If tlie information in the application for mt Improvement Perntit is incorrect, falsified, or t1:e site is altered, then t/ze
Improvement Permit and tlie Authorization to Construct sf�all becon:e invalid.
1) Services Re uested by: ��s
Name:
Address:
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Phone # (home): �[ 1-5 5 3 �
(work/cell):
2) Name and address of curre t owner (if different than applicant):
Name: �, ra�- L�
Address: �- .
, �% f�Y t�
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3) Property Description: Lot Size: !� � a Subdivision: �lG��,�,v�G ✓ Lot #: ��� Z�
Address and/or directions to Property:
4) Proposed Use a ype of Structure:
Residential Business/Type: Other
Number of bedrooms �/ Number of people served (seats/employees):
Basement: Yes No _(wrth plumbing: Yes _ No � Garbage disposal: Yes _ No �
Approximate size of building foundation: Length 7G Width �
�) Water Supply: �
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 completed application must a[so include:
➢ A plat/site plan of tlze property that s)tows property 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 County Health Deparhnent. The information
provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become
invalid.
aignature (Owner/Legal Representative • / Date: Zr �� ` �
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27�73 (336-597-1790)
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SiTE PLAN
Name L q rP�'S � 4 �.(J Taa Map # � � Parcel # � � � .
bdivision � � uP� Secson/Lot# Z D a
��'P�v c� e- a-� o q�—
Authorized State Ageut � Date
System cnmponents represeat appmadmace conmurs on/y. The contr.xcto�mustflag t6e system pdor tn be�ianing rheinstallarioa m
insure rhat pmpagrade is mainraiaed
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Person County Environmental Heatth
325 S. Morgan Street
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Roo�oia NC 2�b1S
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AUTHORIZATION FOR WASTEWATER SYSTEM COT.TSTRUCTION
(Voi7�'si�ty (60) months from date of issuance)
DATE: o � " �`, �1��, ,�ROVEMENT PERMIT #: � / `/ (� '%
t,� . '
TAX #: _ fF yv �'���_ �RCEL #+�';. �d �f
OWNER/OWNER'S REPRESENTATIVE: S��,v Lc � ,c�,4. Yc
LOCATION/ADDRESS:
l S� S �/�2 d�/ i-� i s Td �z i c v� � �.a. �,�-_ ��
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SUBDIVISION NAME: ��,4r ���v�� /����e�—�-i�c>i�1 LOT #: .��
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION IS
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AUTH(�IZIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit # . The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
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