A28 175Person County Hreaith Department
Well Pe'rmit �
Date:�S1JL'This Permit Void After 3 Years
Owner: `��' ��l/' �.��, T � SR# ��
Location/Directions:
Subdivision Name: Lot #
Drilling Contracwr. � ,i:�h .s �.- f� ��
W
Distance from Nearest Line � ' Distance from Source of
Pollution.�� d w s
Tatal Dep • Ft Yield: _�_GPM Static Water Level _�FG
Water Bearing Zones: Depch /s�� Ft Ft. Ft Ft.
Casing: Dept}►: From 6 to �_ FG Diameter. Inches
TYPE: Steel Galvaruzed Steel ✓�
If Steel, d owner approve: Yes No
WeighG � Thiclrness: Height Above Groimd: � Inches
Drive Shce: Yes �� No
Were Problems Encountered in Setting the Casing? Yes No —
If'"yes" give reason:
Grout: Type: Neat Sand/Cement `� Concrete
Annular Space Widch � Inches
' Water.in Armular Space: Yes No `—
Method: Pumped�_. Pressure� Poured �
' Depth: From � �—
IviateriaLs Used: No. Bags Portland Cement �_ Weight of 1 bag
�_ Ibs. '
If mixture (sand, gravel, cuttings) - Raao: '� to �
" ID Plates: Yes ✓ No
4 z 4 slab Yes �� No
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I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT ''
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET �•
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. �
Sign se of Contr tor Daze
Gll � �%Z
tarians Signature � Date Issned
Sanitarians Signanize Date Completed
Sketch well location on reverse side. �
Person--County Health Department
��age�-System Improvements Permit
Date:���.This Pern►it Void After 5 Years Petmit #
Owner. "�g Y+'�/-�i I/ SR# G��
Location/Directions: _ _ _ _ �z—, ,_. r � c�
Subdivision Name: ' Lot # �� � �
Lot Size:—�- ���{.�c Type of Dwelling:
Water Supply: Private: � public: Community:
Bedrooms: 'S Garbage Disposal � �(, -y fl
Basement �. Basement FixWres _ � � • w
INF��iMA�y �� BXA ��c'' �
Sanifariian• �!.Yt t�.lp��N 1'�a • ownet or eatative �
REEVALUATiON:
Size of Se,ptic Tank: �_ gallons Size of Pump Tank:
I�itrification Line: i�� '�X � /
Depth of Swne: 12 inches
Max Depth of Trenches:
Aliemative Sysnem: Conv. Aunp Lpp pump
Remarks: _
Date Well Approved:
BY
�'Af8 $CW� $ysfl[m �OLV 1L�:�
BY-- �•,�. �.� e,,.,
Well� should be 100 ft from any sewer system
s����
� Sanitarian
� TE OF COMPLETION �,,,�
Contractor. _� i w� � o.. � t , �
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Sewage System location. installarion, and protection must meet staze and local �
regulaflons. Septic tank should be pumped out every. 3 to 5 years and shall be maintained
by owner in such mannet as not to create a public health hazard. Septic tank and
niuification line. must be inspected and approved by a member of the Person County
Health Depazunent before any porcion of the instailation:is covered and put into use. If
the site plans ot intended use change this pem►it is subject to revocarion
(G.S.130 A-335F)
Location of sewage disposal sewage sy�t�m sketched on back.
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Application Date: 2 C� Tax Map: -a�
Amount Paid: '��� Parcel #:
�— ��
Receipt#:
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— —_ c�����i`�
1Le �a-a� u u �ca ga. �•-,,•-„ <c3 �z�.a d�..cz�. � �1��'� �c�+.�n. Il�:�a
Application for Services (Septic Systems and Wells)
Services Re uested
0 Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if > 600 d) (Fee is de endent on the e of s stem ermitted)
Mobite Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uired) $75.00
� Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Char�e
1) Services uested y:
Name: ,� � � c�
Address: YO h 1 r �
C ,rr, ��, Z]�7G/
Phone # (home): �3� ! 5� 3 � �� 3 �
(work/cell): '� 3 � -3 � Y - 25b 3
2) Name a d address of current owner (if different than applicant):
Name: 1�e
Address: �O l.t
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property: �,.� Q-� �
4) Proposed Use d Type of Structure: /,�',�,�
Residential � Business/Type: ��'�� 3�1 U u►�t5� Other
Number of bedrooms — / Number of people served (seats/employees):
Basement: Yes No �_ (with plumbing: Yes No �
Garbage disposal: Yes No _ �C
5) 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 comnleted anplication must also include:
➢ A p[at/site ptan of the property that shows property dimensions and the size and location of a[l
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid. / � � � _
Signature (Owner/Legal Representative�
Date �'/�' — l�
10/OS Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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,13.=a�.`�"i3C"QDiZ"ti �'�"� �.�1".bl�.S1.� 1!. 11.��..��1'�il7t
�ui�di�ag As��ati�n�/ I�Ydo�ile �offie ���lac��ae�ats
/� l �
Tax Map #: �`� Parcel#: ` � S
Approval Requested for: Mobile Home Replacement
� � Building Addition
Applicant Name: � � ( �Q� Vj� S� � •
Address:
Phone #'s: � 3 — �G� S� — � �
.--�—
Pernut Located: � Yes No
Installation Date: Z� Z Desi� flow: (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: 3 1z fo (date)
� {Applicant's signature if site visit is not required)
Comments:
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En ir ental Health Specialist Date
11/1�/05