A27 94� -
_ P�rson County Health Department
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Sewa�e System Improvements Permit
Date:�� �r' `r� is Permi Void r 5 Years
Owner: U %ViT ✓ �� 5R# � 3 ��
Location/Directions: �
(�:� / n ' � e; :�.i /-L,�. � ��1
Subdivision Name: � ��L,ot #
Lot Size: �- Type of Dwelling: . �
Water Supply: P�vate: ' Public: � �-, •
Bedrooms: h Garbage Disposal ���'�'�`� "� �
Basement „ Basement Fixture G �
INFORMATIO�, / R�' ;�F�ED Bj�� � .1.+.�.�,�� -�I � � rp.�lantic/
58711[1i1t111: : J � � ( ' � y ;�.,•7'.� -t oaner or repiesentative �.
REPAIR: :.��— ������ REEVALUATION:
Size of Septic Tank: ��j�?'7 allons Size of Pump Tank:
Nitrification Line: ���� � :"� � �
Depth of Stone: 12 inches �
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Appmved:
BY
Date Se a S/���im,
BY � ?� �
Well should be 100 f� from any sewer system
��o
CATE OF COMPLETION
Contractor. `l t / �,,� 6�� �
_ �
Sewage System location, installation, 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'd
nitrif'ication line must be inspected and approved by a member of the Person Counry �
Health Department 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)
I.ocation of sewage disposal sewage system sketched on back.
(OVER)
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
� .
�t�I�tEr date: Note location of water supplies on adjacent lots.
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; � I�er,son County Health Department
- • � Well Permit
Date:�z� 's Permit Void After 3 Years ��/�
Owner � _% +� SR# ��1'--G�
',,/� r
L.003�l0iya�lIeC�l0I1S: �s.-�� i���.� � oag�id��'o�����9 t���i �'7�1��
Subdivision Name:.
Drilling Contractor:
WELL CONSTRUCiTON
L.Ot #
Distance from Nearest Property Line Distance from Source of
Polluuon�� /�
Total Depth:l Ft Yield: �F�GPM Static Water Level FG
Watet Bearing Zones: D�_�t�— F� FG .� /FG
Casing: Depth: From to .,�� FG Di�met� n�� Inches
TYPE: Steel � Galvanized Stee�l/
ff Steel, does owner approv��� No
WeighG Thiclrness: Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountereci in Setting the Casing? Yes No
If "yes" give reason: J
� GrouG Type: Neat Sap�Cement Concrete
Annular Space Width 1 Inches
Water in Annular Space: Yes No
Method: Pumpad� Pr Poured � -
Depth: From to Ft� "
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand, grave,l, cuttings) - Ratio: to
ID Plates: Yes V No
4 x 4 slab Yes �(,rJ No
I HEREBY CER'FIFY T�AT THE ABOVE INFORMATION IS C
THIS WELL WAS CONSTRUCTED IN P�CORD�AN�CET�T
FORTH BY THE PERSON COUNTY HF�1IJIj[�
Date
�
�
AND THAT
,TIONS SET
Sanitarians Signature Date Completed
Sketch well location on reverse side.
,1.�TOTE: 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
00 ?Ersan County Haalth �e�i
o ji n t p a i d � 0 0. 325 S. Mof�an Str��d �_ � g_� c�
-e i p t �� '��.a �, Roxboro, N.C. 275T�i
Gqurier'�02-y3-15 D a t e
'� � � � � APPLICATION FOR SERVICES
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q� :x�y/:.�_aj:.f.w..{�PJ.i:.Wi� i�e1�r L.W��;:'�L�&'�*iYsa`M`" ��erv�ces.litQq�Wl� �: � �Ya��iwi�rhF'3R Kxin 7�uYs+;l:.`. i k`s���'!`��+y��-.
Improvements Pecmit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
Permit requested by: .
ner/prospective ownerlagen
dress: � �l LoE'lA'S STa 2
7. Dimensions or Propo d Structuce:
y� �LRtY� Width: I � � �fo�
- _ Depth: 17.� ?�F��
7
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U Home Phone #: 336 - S�iq -0�47
� usiness Phone #: 33�- �q -5iZ(
2. Name and address of current owner:
Description: Lot size: C a�r�es
Tax Map#:
Parcel#: _
(,t�
Directions to property: State Road #& Road
mPc Ptc_ STltik/ (�•,dD�-i�1343
Num�er 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 c�isp,psai system is intended to serve?
9. Water supply t}•pe:
private,� public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes �' No p.
If so, identify location: (LU/t, �u.��1�e1�1� �
10. Type of structure/facility: Proposed: �xisting: Q
Type of dwelling: Sitnrzoe�'v� � �rQrccge�
House: �_ Mobile Home: C� Business: ❑
Type of business: N/Pr
Number of Employees: O _
Number of bedrooms: � _
Garbage Disposal? Yes ❑ No�
Basemen[? Yes ❑ Noi�;If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'Son County Health Depai'tmellt 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 ttie 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 tha[ in the event I have not
delivered a survey plat of the property to the Health Dept. within 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.
z Signcc� Owner or Authorized Agent
, �''; �
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Person County Health Oepartment
�xisting SeNaqe System Report For: Hobile Home Replacemen
_��Addition— dk�__'� -.
' /� S �g-I�l�,f
Requestee: �D��-r� � �-1Y�ne- �la ►'�] Home Phone# 't %
23 LO ' S re, susinessn 5�q 5'72(
1��1�-�� J i� 0��7J `Pax Hap# 'l��-QL/
Location/Uirections: �� �1�-- L� -S ��pf'�..
�s ✓� L ��� 1
Original Permit Located �
Septic Syste�a Uesigned �or:
Etesidential � E3usiness
Other (specify)
# Bedrooms � # �,mployees Other
Uate '1'nstal? ed ��Q Water supply �� �_�Q-�
1 �
Type ot System �l`�%�Y��l.�--� O�Q•I
Nitrif ication Line �' C�� X��
Tank Size .._�
u /�4
, Certified Operator Required / v�
On site wastewater disposal system showes no visually apparent
malfunction on ��-�' �� � I�
Yermission is granted to: �,� )C�U � IQ-
According to the attached site plan.
Comments:
/� � 5�
Environmental Health ��C.• .� �� �� �/� c �
DATE
rroN Sua�ner
proµ
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