A28 218�
Application Date• 3�— � 3 JG .U� ��l ( f���Q L, ��\T
Amount Paid: 3� `f J �_�,� llp. ` \,
Receipt #: �d __�� . � ����7�/��7
�� �� � �0��'Y1�•V:[]II734`.]➢d:tAll i�-i11713��.1]
Anulication for Services
Services
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 �ndl
Mobile Home Replacement or Building Addition
$150.00 (if site visit requued)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
Tax Map: �
Parcel#: ��S
Construction Authorization
(Fee is dependent on the type of system pernutted)
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: �/� /�
Name: J ae � ' P E�radS� r"
Address: !
�d� ,J< 2.���
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: Subdivision:
Addtess and/or directions to Property: t 4 e� ,�
Phone (home): ��j �8.3 �o ! l
(work/cell): � j� 3.Z3 9'�S �
Phone:
ra
Lot #:
�c /-l�f�r� /[d '-r' ll�r'u� vv� le f-f- �c �ar� �i�'or� L`►c✓i.•r
❑ yes C'�"no Does the site contain any jtuisdictional wetlands?
❑ yes CiSo Does the site contain any existing wastewater systems?
❑ yes � Is any wastewater going to be generated on the site other than domestic sewage7
0 yes C�6" Is the site subject to approval by any other public agency?
� yes C o Are there any easements or right of ways on this property?
• (if `yes' is checked, please provide supporting documentation)
o,.
4�) Pf� posed Use and Type of Structure:
�esidential
O�w Single Family Residence Malcimum number of bedrooms: �_
❑ Expansion of Existing System If expansion: Current number o bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? es ❑ no With plumbing fixtures? es ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Ma�cimum number of seats:
5) Water Supply: ��w well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property7 ❑ yes Ci-rt6
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� tha e information provided above is complete and correct. I also understand that if the information provided is
inaccura or �the sit�i subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�wner/ Legal Representative*)
documentation required.
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 S�, Suite C, Roxboro, NC 27573 (336-597-1790)
���.ss ���.���
� �--�' � � � � � �
]C�s��a���� ��.��.Il 1L���.Il�I�
Applicant: �cE�. +� K►�.��,�,y
Address/Location: �58 w�sY' 7
C.NAf.�� C.A�.{t- RO
Tax Map: A� Parcel: a�� '
Subdivision
Phase/Section/Lot #
tlt� � t�.+vE or� l�Ft' Acl�nss
Improvement Permit
Permit Valid for: Five Years Non-expiring
Type of Facility: S+�1tot�. �•.��,•� Rfs�p¢�c�E New x, Addition
Number of: Bedrooms 5/ Occupantslo'"`"i' Em loyees / Seats:
Proposed Wastewater System: AGc,EP�, � a57�, R$a�►cxtv
Proposed Repair: Acc�pc�.p aS 7 ��1c'�1,c
Permit Conditions:
S
Authorized State Agent:
(X) Owner or Legal Representative: �
Water Supply: (�,�vat� �J��,�.
Projected Daily Flow: bcp gallons/day
Type: ��_
Type: �_
_ Date: 1, 0�
Date: ti%1
- �'1
The issuance of this permit by the Health D�ct(ent does not guarantee the issuance of other required permits. It is the responsibility of
the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina °Laws
and Rules for SewaQe Treatment and Disaosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply wiil
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: Acc�p�p � aSZ.� �o�,�� (*)Type �� Design Flow IoOQ gal./day
New � Repair _ Expansion _ Soil LTAR: O. 3� gal./day/ft2
Type of Facility: S„i`� ���v I�€s�Dfr.t�ck Basement: x Yes No
(*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank �a50 gal.
Drainfield: Total Area l� 5p�p sy. ft.
Trench Width � ft.
Pump Tank �' gal
Total Length 504 ft.
Min.Soil Cover �( _ in.
Grease Trap ^' gal.
Max. Trench Depth �$ in.
Min.Trench Separation 9, ft.
Distribution: Distribution Box %� / Serial Distribution i'� / Pressure Manifold
Specifications: `��5' , L►t,�S ��00,
CALL. S31e- 5q't— t'1 q 4 1�. �
Authorized State Agent:
Issue Date:
Permit Exp
Tlie system permitted is: Conventional /Accep X/ Alternative / Innovative . I accept the conditions
and specifications of this permit. �j2 f f` ?
(X) Owner or Legal Representative: Date: ! V
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
_�� S� ���� ��
`�' �-�= � � ����
IL�aa.v nsosaaaa.B�ra��.Il IE-7L�a,m�1�7�a
SITE PLAN
Nasne ���—d' K1�'►�X Qt�Q6�.�. Tax Map # A� Patcel #���
SuJzdivi'syon Section/�qt#���
dL1�a..Jl. ► '
Authorized State Agent Date
; System camponents tepresent appmximate contours on/y. The contractormust flag t6e sysrem prior ro beganning the installation ro
lnsure thatpropergrade is maintained.
.__._�_..__..�.._....._..__..._�.._..___...._.._._._�.��:�.. .
�L:,p�'�. �g �
�
(��i'v',�,: �,L .
�
.� oa
��, � �
� i,.., , ��
r,� j t�ri
�
�...�
��`�r 3�.C� 1��
,(��'s� �`�-. �.
�,.,�..
,•�,-.
.. ....•--
.. . �.
.� � —�
�
z
� ��.' ;_,".....--' i ` `•�
._
� � �,� `�`� M �' t�..��
�
�
l
w
0
�
�
���. sf ���.� ��
�� � � ����
I���na-������.�.Il IHL ��,II�I�
Applicant: ,IarZ �- /C�� a�� . .�
Location:
(�U��°�.tlOil ���"Yill$
Tag Map �`� Parcel # 1:tL�
Subdivision
Phase/Section/Lot #
# of Bedrooms �
System Type (From Table Va): Product (IIIg): f'Z� .�
Type V&�I Expiration Date: Type V& VI Renewal Date:
This system has been instaIled in compIiance with applicable North Carolina General Statutes, Rules for
Sewage Treatmenf and Disposal, and all conditions af the Im�nrovement Permit and Constructian
Authorization.
(Author�zed gent)
� � �� �
L' � f
(Licensed Contractor)
µ
1�/
�,� ' � u
�y
�� .
�� ��
�o
---, ��-� ,�'�
� � � � � �,.__,�.- n
�
�
Scale �(/��
PCFiD, rev. 12/14/12
�z�
�o�
w/v.�.5�r.��.�a
«o �
��.
� ��� �
� Z-�alr�'
(Date)
���1��,�'
(Da+e)
Tax Map: ,��Parcel #: �! �
Septic Tank System Checklist (Type II-I� System Type:
Pump �ysiem Checklist
� Pum Tank ; InitiaVDate
State ID 8c Date:
Ca�acity:
R.iser (6" min.)
NEMA �X Bos �
Model: �
Piggy back lug
Hard wired
Alarm functiuning
Mounted on ost
� Ab�ve grade (12")
Conduit sealed
�ressure hZanifold
Number of taps:
Size and sch: � � �
Contracted Certified Operator (Type IV Systems):
Notes•
T`ank Com onents InitiaUDate
Purn mo�el:
Black (4")
Nylon retrieval rope
Float tr�e and attachments
On/Off float swing: in. ��
Aiarm float (6" se arat�on
Anti-si hon hols
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet se�led
A prov�d and secured riser
S� lv Line
Siz� a.nci material: in. sch.
Length: ft.
��� s f ���.� ��
---� � � � ����
I�;��a����.��.�.�.Il THI��.]1�1�
WELL PERMIT (New�Repair�
Tax Map: /q$� Parcel: �1K .
Subdivision: Lot:
Applicant's Name: �a�� �' K�Mb�s�..�c Q�►osN�.tZ
Mailing Address: 15l Ror+A�is P.�
9�Qett.o � �C, a�5��i
Phone Numbers: 33b-�o3- ta�1 q��t �3�3� 4`��a-
Location of Property: i58 w Es�r -'� Q o+�► -�ri�� N�s� 4� -� DR►�N-►A�
oa � A ttt,�s� �� U�v.� � CaaS�. '�
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.
Other Conditions/Comments: I�i�' w�-�.�. rx,' �►s� SO' Y�*� A��-
S�.Pn e. Cor� Pc��%'c 5
Permit issued by: �Q,�, Q_ � Date: (� � 8�0� l3
CERTIFICATE OF COMPLETION
New Well Inspection:
EHS/Date
Location: ''' !�
Grouting: c� ,r�'�.,
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Liner Inspection:
EHS/Date
Installer:
Depth:
' Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: ��/,�&�j�,/'o,,%y.��,�iy,1/,��c/6,/�//ifLtNse.c� License #: Z. �o,�,�-
Pump Installer: License#:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C'
Roxboro, NC 27573
Date:
Date Results Mailed:
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
WELL CONSTRUCTION RECORD �
�'orth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
��'ELL CO�TRACTOR qVDIV10UAL) NAME (prlat)_WIL.BERT �pNFG
��'ELt,CO�'lRACI'ORCO�iPANYNnME__RANKTj�j {qjTT.T.TAMen*� T� CERTIFICATI0NN�9_A
��h� - PHONE N � 1
STATe ��'E1,L CO\STRI:CTlO\ PERMITN
_ (ifapplicable) ASSOCUTEDWQpERMITN
(if appliCable)
�•«'ELL USE (Check Applicable Box): Residential � MunicipaUPublic O Industrial O Agricultural p
��toniioring O Recovery O Heat Pump Water Injection O Other ❑!f Other, List Use
?• WE[.L LOCATI
Nearest Tou•n:��� County �-l'�c�,ls Topographic/I,and setting
ORidge OSlope OValley �Flat
1 S�rcci :.ame. \umbers. Community, Subdivisioo� Lot iJu„ Zip,Cod�� , (check appropriate box)
O e� . Latitude/longitude of well location
3.OWNER: C D��E�
Address �, . (de8rces/minutes/saonds)
��� R � o � Latitude/lonbitude source:�GPSOTopographic map
C ��5?� (check box)
CiryorToNn Swte ZipCode � � DRILLIN nr,
( �. From Q ation Description
Arca code• Phone number ' � , � — • ' 0 � � 8� /� /L(�
4. DATE DRILLED �" �S ^l4 -�" 7
5. TOTAL DEPTH: ' Q `'
6. DOES WELL REPLACE EXISTING WELL? YE O NO I3'
7. STATIC WATER LEVEL Below Top of Casing: _,,� �__�,
8. TOP OF CASING IS 1 FT. `U=�«;��fAboveTopofCuin� -----
FT. Above Land Surface'
•Top of casfne termtnated aVor below land sur(ace requlra a �
�•arl�nce In aceordance ISA NCAC 2C.0118. !
9. YIELD (gpm): �� METHOD O'fEST�IR BL.nw
10.1NATER ZONES (dcpth): _ (�o $" ��j. ��4—�,p- Z�a
1 l. DISINFECTION: T e_ t.'S�3 �.00ATION SKET H
12. CASING: Yp ` Amount �T_ H _ Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. lnclude the road
Depc� ` Diameter or WeighdFt. Material numbers and common road names.
From -�0 _ To p�, 61 4 SDR 21 �py�
_ . From To pi
From To —'—
Ft.
13. GROUT: De Material
From_ Q To� Method �
Ft. CONCRETE _POUR f58� �
From To F� ----
� 4. SCREEN: Depth Diameter Slot Si;e Material
From To Ft. in. in. • ���
From To__, Ft. in.
IS. SAND/GRAVEC PACK: —� ��� �
� �a.7Cs(�.
Toth Size Material . � � �
From F�
From To__ F� . '
16. REMARKS: •
I DO NEREBY CERTIFY TNAT THIS WELL WAS CONSTRUCfED IN ACCORDANCE W1TH 15A NCAC 2C, W�LL
CO��STRUCTION STA��DARDS, AND T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PE ON CONSTRUCTING THE WELL • y�`
DATE
Submit the oriLinal to the Division of Water Quality, CroundwAter Section� 1636 Mail Service Center. Ralei�h, NC
27699-16J6 Phc�nc no. (9�9) 733-3221� within 30 days.
• GW-( REV.07/2001
,j
,:
' 3(�It�
�
' �✓o,r�•� c� o,� p�.«r �� s.��u,rt-���, s�w �J c Ca� a�c�c o� �
F�r• Pa� -rnc�-�r C.^ �- acx�s> . dOA.a
I �}�a�j'�3 �� �,,f � C�+-�� Co�,:.�� �co o�s�s j sr� t-�a�st �-
�
`' t�c..o«lb �P��r►E�'. �.,I �s�n�c P�-nR�r�� ��rt�.o v,.\
;
i QR�v�Qys l.�A'{oLLZ' t��t 4�. Zv Oc1 S�zt�. Q�5'rR.�4st,Tti�.�
r �
� "; .��aA.� I3 ��-t�o v-� �,L (�asr�t°t_ flr�v� r �1�a�,� �,-��2 . , . s�c�L.�.
� ' s�,� � P�
;; wa-�ab �� s�a.v��.ari t�-ok, p�-' i
�
� � � iJ4n�' �^'�-£�� � -rw o .
:;
(�FAc'E�.z"i AacS`}�!1T 'T�o 3h3 ,1�EE t��-tL KLO
lo� �a� � � %�t�+.n,s� w C 'Tfl� t�rHP �" %r�c,�,�, # a� Aa•�- �18.
� �' � � � � �`
� � ��
l
�,
�� �i`�% '