A27 92The District Heolth Department
Orange, Per,s.3n,� Caswell, Chatham, Lee Couniies
�
Water Supply and Sewage Disposal
iIM ROVEMENTS PERMIT�No. -�`
� Dat r � 7 / :s' ,
Owner: � � ^ `+ ^
/ , �,
Location: �C
� .-� � �a �
Contractor: � � — `�^"^"
Water Supplp: Private �-�'`� Public
Sewage Dis osal Facilities: No. b�
r
washing machin o �grf au�olnat
Size of tan : � �I � �'•-1
_ Dishwasher, Disposal,
� appliances ` � �
Nitrification 1�nP� � ` � -
�/h �1� G �
Other disposal facility: � `'""
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
5eptic 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 INSPECTEI? AND AP-
PROVED BY A MEMBER OF THE DISTRICT H�ALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE NST LATION IS COV-
ERED AND PUT INTO USE. �� ," .l�
% ! �` �� / � � � � �
;��; �
Date approved: Signe
Sartitarian
Well:
Sewage Disposal:
By:
Counter-
signed
,.-4�Owner or his representative)
, ( ,.
Certificate of Completion � � ��, � �
! -- � t f ,� �
Date Approved: � �' By: ��� ��'�"
(OVER)
Location of well and sewage disposal facilities sketched on back.
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
at later date. Note location of water supplies on adjacent lots.
Application Date: a �� 13
Amount Paid: �1 '�
Receipt #: 180 �'a5
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if > 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacemen e air
$300.00/$200.00 5.00
��� ) f �Jl��� �A. � Tax Map: i� Z1
�; � • � Parcel#: �12
N_ � � ����
I�n3vna-oaasaauan4ctfl lE�viaIll:fla
Services
for Services
Construction Authorization
(Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair of Eaisting Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant In�'ormation:
Name: � rGj ►/IS �At48i'��
Address: � O 6 S Vi �Qi i lx1
� 2oxfaoro Nc. Z�s��
2) Name and address of current owner (if different than applicant):
Name: G�f �n Ck, �n/�►� � e�
Address: � 3 y�/ �PohP� f 3P� t
�Po I' bn.�'`'o .12 Zz �"7 �/
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
j �avi5
Phone (home): 3� 6- 5'8 �-' ��/ 2`i
(work/cell): Soh n - 33 �6 - �d - <6 3 6
Phone: .� ��� � y`1 `� PS�
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wedands?
❑ 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:
❑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 exisring 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
1 certify that the information provided above is complete and correct. l 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.
z-17-/3
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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Tax Map: A- 21 Parcel: �
Subdivision:
WELL PERMIT
(New _ Repair �
Lot:
Applicant's Name: gj� ��p,e. v�(��- ►T �
Mailing Address: �2�� t�. �iY����y � •
? �
Phone Numbers:
Location of Property: ,��Q� ,Pp/�2T�D�i Q1� -
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 S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: � _ Date:
�Tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Certificate of Completion
iner:
EHS/Date
Depth: 53 �
Grout: �u��o cTx.s.�irc
W�ell Driller: ��.(�. 1�ii1fl�Z.0� Lu�"�-1 _
Pump Installer:
Approved by: Q�jZR�c�. �} 5�"�
DA6andonment:
Date:
Method/Materials:
License #:
License #:
Date: I i �3
Additional Comments: O�A t„��..• t�a�t�rlb NaA @, �' �Oo �-uf ____
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
ConnectGIS Feature Report
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Page 1 of 1
Person
Printed December 17, 2013
See Below for Disclaimer
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CE: Recent�y, we have had several aser report broH�ser compat:tility issues when :^�ing io acces� oar GIS eveus te iyp,cally, tha prob!em stems from users wY
recently upgraded to the Windows 8 operating system or a new version of Irteme; Explorer. 'Ne were able to resolve tnis issue by directing users ?o the tnterrn
rrer Compatibility View tooL This link is to Microsoft's "How To" for the tool: httpl/windows.microsoft.com/en-US/internet-explorerlproductslie-9/features/compatibilit
If this does n�t solve the problem feel free to contact us at the number listed on our main page. Weicome to the Person County GIS Website. ConnectGlS has bee
3red for the inventory of real property found within Person County: and is compiled from recorded deeds plats, and other public records. Users of GIS system ai
�d that the aforementioned public informa?ion sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectGl
re no !eoai resoonsibilitv for the information in this svstem Grid Is based on the NC state plane coordinate svstem, 1953 NAD
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http://gis.personcounty.net/ConnectGlS_v6/DownloadFile.ashx?i=_ags_map 1 d3eda19d3... 12/ 17/2013