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A28 128
son County Health Department S��r�g�e System Improvements Permit Date: b' ' G This Permit Void Afte 5 Years Permit # Qwner• CI Ak �(�j%%� (�+ni c SR# ��— Location/Directions: Subdivision Name: i'l � T�'� q 1 v Lot # Lot Size: ��%T� � j��� Type f Dwelling: Water Supply: Private: —�,� Public: Community: Bedrooms: Garbage Disposal Basement Basement Fixtures - ' INFORMA']f 3��D B�' F/'� � 2 ; � , �� % � c....:...".... /,� % ���L'� w_. �r✓�`�"� owner a representa ve' REPAIIt: � REEVALUATION: Size of Septic Tank: ��L�gallo f Sizejf Pump Tank: Nitrification Line: � �T=' Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remazks: �:'7 1 � I 1 . � .-� ,_- —_ . , Date Well Approved: Well should be 100 ft from any se er system BY Sanitarian Date wage ste pproved: �� -�U- � n . •— BY Sanitarian '� "�'`� ! l o�� _ CERTIFTCATE OF COMPLETION M uS� � me� Contiactor. Ji �nn, �i �w�� l� �'�� ���j ���„ � —*�, ------------ ----- � b Sewage System location, installauon, and rotection must eet state and local' � ��. regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained by owner in such manner as not to create a public health hazard. Septic tank and nitrification 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 plarts or intertded use change this perrrtit is subject to revocation. (G.S.130 A-335F) Location of sewage disposal sewage system sketched on back. (OVER) ` � 'NOTE: Make sketch of inst�llation showing lot size and shape, location oi house, septic tanks, privies, water upplies, etc. Note: special' problems exis�ing on lot. Write in measurements in order th;�r installations may be locat�'d gt Tates date. Note location pf water �upplies adjacent lots. , �1� �'` p �—�t C�" �t,�,,"�y �? �a-�-' '�v [ 0 �)`� ' , . �,.n !J , � i �` ; -- —_ V" '�' � l:piversion ditch 30 inches deep shall be dug above�rainfield all the way across length of drainfield to divert water off drainfi 2.�eptic system shall be no deeper than 24 inche�. 20 inches is olc. � 3.For a 3 bedroom house 600 feet of drainfield shall be nee�.ed. 4.If septic system cannot'be installed on grade at a depth of 24 inches or less then pump system shall be required. However less drainfield will be needed for pump system. S.Septic system shall not be installed when ground is wet at all. 6,Drainfield area shall be left smooth, and fescue seeded on it. a Person County Health Department � '` � � " Well Permit � Date:�L'I7v eimit Void After 3 Ye�s ���, Owner �Gn%t �.� I/�/,�/� G t� g SR# Lacadon/Directions: Subdivision Name: V � V Lot # Drilling Contracwr. ^ v' � � UI z(1 l`--- Distance from Nearest Praperty Line I�j �n S Distance from Sourcc of Polludon � � ' Total Dept}►'3�� � Yields�.�_GPM tadc Water I.evel _�� FG Water Beating Zones: Depth �,L_s�� Ft. Ft. Ft. Casing: Depth: From �_ � FG Diameter: / Inches TYPE: Steel Galvanized Steel �— If Steel, does owner approve: Yes No Weigh� �,� Thiclrness: �� Height Above Ground: ��nches Drive Shce: Yes �--- No Were Problems Encountered in Setting the Casin,g? Yes No �-- If "yes" give reason: l Grout: Type: Neai Sand/Cemeat�_ Concrete Annular Space Width � Inches Water in Armular Space: Yes No�_� Method: Pumped Pressure Poured_�. Depth: From �,� � �LL F� ' I��Used: No. Bags Portland Cement �_ Weight of 1 bag Ibs. If mixture (sand. gravel, cuttings) - Ratio: � to j,� ID Plates: Yes �� No 4 x 4 slab Yes � No � k b � ''d � I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT � THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET ,� FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. � /� I .�%l.� � . 1 � _{ !�_�� Si nf Cou�actor � Date Date lssued Sanitarian's Signanire Date Complete3 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 installatiorlg•may be located at later date. Note location oi water supplies on adjacent lots. . �1� (2) ■■■.■■■■■.■.■. ■■.■■■■■■�.■■■ ■■■■■■■■■■■�■. .■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ .■■■■■■■■�■■■■ ■■■■■■■■■■■■■■ ■■■■■.■■■■■■■■ ■■■■■■■■■■■�■■.■�■■■■■■■.■■■ .■■�■■■■■■■■■■ ■.■■■■■■■■■■.� ■■■■■■■■■■■■■■ ■■■■■.■■■■.�■� ■■■�■■■�■■■■■■ ■■■■■.■■■■■■.■ ■■�■■■■.■■■■■. ■■■■■■■■■■■�■■ ■■■■■.■■■■■■�■.■■■■■■■■�■■■■ ■■■■■■.�■■■■■. ■■■■■■.■■■■■■. ■■■�■■■�■■■�■■.�■■■■■■■.■■■■ ■������e�������������������■ ■������u������������������■ Application Date: � 3 � . - � Amount Paid:� `'� ' f .�D � fl0 Receipt#:� ..��-,� S� ���.���T .._ - = �-- � � � u��°�� I� :�ca -e..n �r-.,ca .trn.aaa-n..v aa. �:xn. Il. I�ZI .c^�.es.11. R;.iEa. Application for Services (Sentic Svstems and Wellsl Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 if> 600 d) Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement) $225.00/$125.00 Tax Map: �C � � Parcel #: � ❑ Construction Authorization (Fee is dependent on the type of sys ❑ Permit Revision $75.00 0 Repair of Ezisting Septic System No Char�e Important: If the information in the application jor an Improvement Permit is incorrect, falsified, or t/re site is altered, then t/ie Improvement Permit and the Authorization to Construct sliall become invalid. 1) Services Requested by: Name: l�c.�k g Pa r�e� n L.1 ����C rhs' Phone #(home): � 36 -�s"� 9- 9�/� Address: � Q,a u n h i � B/ u e .��, _ (work/cell): �%oX�orn /U.G 2�7s"7y 2)Name and address of current owner (if different than applicant): ��� " r� Name: S �- (h L �}� r �r � � Address: s (� (Y1 � '`�e'S W i r,�s �'ec►c� / �c 3) Property Description: Lot Size: �-��Subdivision: Lot #: 7 v Address and/ordirections to Property: q� Qonv�ye �kc� � Ra. -/S- foWercL ,Len��iwn� e,S�- � a., �n e., O Sap.nd'. cas�l@ a �e� �a ��/ �- a� �Oc ,Do�r f'c�l.. o�'�.T� i� � e ' i1 �N Q, •R` C�.h� l�0 l�� Je.11i�a a� A.i � '..�.s�r •„�� Qd�ni e, 8�ue 1�v . 5 0�D �^ clv'�C�e o� Y� y�. s;d� .( wayoN wl�ae(r a'�" e�d o�F �! ����e we� o j 4) Pr o p osed Use and T y pe of Structure: alo�- o� �Q.Ts- ih y a�rd ,� Residential L/ Business/Type: Other Number of bedrooms �_ / Number of people served (seats/employees): �_ Basement: Yes No �'(with plumbing: Yes ✓No � Garbage disposal: Yes No � Approzimate size of building foundation: Length 76, Width 32 , �--,_ S7 Water Supply: Private Well � (Proposed Existing t/ ) 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 also include: ➢ A plat/site plan of the property that shows property dimensions and the size and tocation 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 Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representative): /'�iL. (,✓ � � r � Date: %'��i`�� 11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) . y� ro.,, , t. _ .,. -.� 60R�1N . . . . . • /69. 98 - , ;,, - 229. OF� ` . . - /� � `/�! { �.. � r/� ,, /S . � , � �� "� ' � � o , . t ,�..ti . � � � � � a = 232. 67 , ,�, � � � � � � . :. . � . � = ,�• � a - . � . W . ..F _ /45. �/ � - +� ' �' � � � Q Q �p S .xe �n �. 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N `i h i �t.�x � . �/ I . . � , 1�� . . • ... � � 7i , ... : � ' . ^'�arY'',�e�K'+. T'�. �1". � .. . � . . . " N-�'• ;B-2/.E �rr{�vMa�,.-."'. +°'a`�,,..+sn�f"`'" `!"�w�yYrs��"' .. 452./2 '',.�` �.�;r.^'{.:.t'."''��O%- a " .- _ . SB-?/.E 489.76' N.p>. sg-= c' � 434. �p' 'V- O' SE � ' � 2'� �3 yc No�lh J. L. Mo�rpK. OroG � � ; , � �� � , 1 � � �ad �; � �`. � / �1 . �� `�.� � .A. V � 1i ]�':��.�-�.���.�:�,.-�:�.�..�..Jl �-��.�.�1�+�. �a������n� ������a��l Iv�o����e ���a� ����������g� Tax Map #:� Approval Requested for: Parcel#: V 1YIobile Home Replacement Building Addition Applicant Name: �Q y� (( �- �,�2�R i ��r a v►� S Address: i {6 Phone #'s: 33(,- 59g- 9Lol(� Pemiit Located: V Yes No Instailation Date: �p -�p - 9 y Design flow: _.�j �0 (Dpd) Current Contract with Certified Operator on file (if required): Water 5upply: Well Public or Community Wastewater system shows no visual evidence of failure on: S— � 1—O� (date) (Applicant's signature if sit� visit is not required) Comments: A������a/��}p����s�a���� ����°��r�� � - S`�� dFl Enviro ntal I�ealth Spe ialist Date 11/15/0� •���,�� ��s'r���� _� � � �7��� �]m"6'rIl7L'��rn ie�rn �3L.'�'i�.JL ���� � SI'I'E S�T'C�-I .� . Name �,an, 4� I'ame�a ' ���tQ►nt Ta$ IYIa.p #.�. ,�_Pa:tcel # /�� Sub ' ' n . � Scction/Lot# � $—l( o� � Autho�ized State Agent . � Date . . .%yst�rra cmm�imnents a�e�,resenP a�i�a,ID�cis�rate�cont��ars ea�a�: �'he cor�tsti¢dtor �nsr�fBas� t�ae sgr��r�oa� t� began�irag t3ee i�astallataon to srss�are tds�`ps�o�ergrr�s� a:s nscsisat�ss:ed _ _,� . s �� K� . �� � . J � �. m � � U.ir� 0.l � a.f( ���� � 2.,s ` -�-a+� w el ( I,�. l�� 7Y'ow�.. � I S G SI�S�m Qvtd �vL(n. �' � s .�: __ _ __ _. _ __._ __. _._ � _ _ ._ _... __. ._.... ., a _ _ _ _ .i, ..: _ ._ __. _ _ _ . _ ._-- - - ._. _.. _ __.���_ JQ 30-�2 _ `_ �,. _ _ __ _..- ___ ___._----- __ _ _.._.____ .__. __ "'�. _ ,' � y�; �� �, : t� �",��,� _ , _._.___. _ .__._...... .... _. __ . . ____ _ _ _ . _ _ _ ._ __ _._._. _. .. _ k _ _ . __ �,� � y `v ,L � 1 ' ,� cY ' _��'� l�' ��,_ � ♦ _ _ _. __.. _. __ ___.__ _. . .. .. _ _ �J�� .... .. . _ _ _ — �0 h -- ,':��,_ _... . .___ _.;�;�C_ �af'� . _._ _. _._. _._ _ __ _ _ a ' -,� . _ � _ `;� -a '? �� � '` i�`�5 ' � .3 � � _ __ �. _ __ __ __ . _ . — ,� �� `� \ — � � __ . � ___ . __ . ,; _ _ _ ��: _ _ __ ._ __. __.. ti ___ ``,y. 1 � _ . �,�./��;3 �;�5 j ��` _ . _ _ _ � .,:_, � _ ..___ __-- _ _.._ _ G� _ __ _.. . _ -- _ , ;� � 5 e�� � ...._�� � .._. _.._ . _ .__. _._ .. _.._. . _. .. .._ .. . ... ..,... .__... C1 � ._ .__.. . , � __ _._ __.. _ � � ti-�- ? ,, �r•�a�� _ _ _.. __ _ _ _ ___ _ �i __ __ _.. ���� ' .,1 _ _ _._. _ _ __ __ _. __ ;, _ __._.__ ,� . / :;. j��;va�A _I�o��i . j �S/? !lS$ —�i , _ _ _ r_ _ - - _ __ _ _ _ � � ���� 1� ,� � �� � � �' ` � �� ���- � Q rJ . � � � ��s �v� F �6 X .32 ,'� s�-� C