A28 27Application Date: � �3 � � �
Amount Paid: 300 .0 �
Receipt #: ► ot, 10 f y
C/ °� #�z q �'-�
� Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit reQuiredl
ir)
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�..nno-nn'aDvav.�r�n.ae.+.3ndan.Il )HI�.�..Il.ti.:ir.
ilication for Services
Services Re uested
� Construction Authorization
1) Applicant Information:
Name: i�n y�q �Co�-� (Ylb�rp�
Address: �� q 4 i1vE� yeS�f �•
Tax Map: Z�
Parcel#: Z�
C.�l ( � � Q ��
(Fee is dependent on the type of system permitted)
0 Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home)• - - S
(work/cell)• 33 (o - ,Sq'ot' OSS�}
Phone:
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Pr�perty:J�Od O� �O UQ�L�S �f'�1'� 18'� 3�1otlZrk �i�U �•
l�O�r / NC Z'7 5 r]'�I
❑ yes g no Does the site contain any jurisdictional wetlands?
❑ yes 8 no Does the site contain any existing wastewater systems?
❑ yes B 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? ❑ yes O no With plumbing fixtures? ❑ yes ❑ no
�Non-Residential �, N �
Type of business: ( D�j�C[.D �Qf 1'"1 Total Square footage of Building:
Maximum number of employees: �Gtsor�e�� Maximum number of seats:
5) Water Supply�Ll,New well ❑ Existing Well ❑ Community Well � Public Water ❑ Spring
�Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I 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.
�
SigKature (Owner/ Legal Representative*)
* Supporting documentation required.
0��31��Z-
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A comp►eted `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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1�.���-��.a���.�.�.11 .IE-�L� �.11�.1�..
. W�+ I�I, IDERNIIT (New�Repair�
Taz Map: � .Z� Parcel• � 7
Subdivision:
Applicant's Name:
Mailing Address: �
ro C�
Phone Numbers:
Lot:
Lacationof�r�operty: P,�,� „��r�Y,nS �� (g�.3 ��a�oc�
r. ,
I'ermit C'onditions:
1) Seg attached site plan for proposed well location.
2) All applicable State and County regulations governing consiruction and setbacks apply. �
3) Permits expire S years from the date of issue.
Other Conditions/Comments: 1 l� � ' ' ' . I � � � , ,, ' _
i
P�r�it issued
I�ate: / -�'/ Z
C]ER'I'IFICATE OF COldIPLE'ITOI�T
New Well Inspection:
EHS/Da�
Location: ✓�5 ��Z
Grouting: �/ '�
Well Log:
Liner Inspection:
EHS/Date
Instailer:
Depth:
Grout:
Well Tag:
Pump Tag: Well A.bandonment:
Air Vent: EHSlDate
Hose Bib: Completed:
Casing Height: Method/Material(s): _
Concrete Slab:
Well Driller: ��Sp�_ License #:
Ptunp Installer: License#: .
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
I)ate:
Date Results Mailed: ' I
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
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Name �co{--�- 1�'� o�ra �,,J Ta.g Map # Z`�a Pa�cel # 27
Subdivis' n _�.�._____. Section/T:nt#
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Authorized State Agent Date
System c�mponemts rTepresent approxirrsat'e�contours only. The contractor ssaust, flcxg the syste»a�iraor to
begir�ning the instadla�iora so ansure that pvmpergrade a's maintained
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RESIDENTIAL wELL coNsrRucriorv �coRn
North Carolina Department oF Envsvnment �nd Natuial Raourca- Division of Wata Qwlity
WELL CONTRACTOR CERTIFICATION !1
1. WELL C RAC7 -
.
W eN u� am� .
Co. Z C., '
. W aN CaNra�Yor Comparry Nams t
' STREET ADDRESS � �� !' d�
��`2[�C�-� n� S 7� � � j �-
�rty
�r�. �?7- 3�a�`
Arsa cods-�hone nurr�bar
2 WELL IN�OR111ATION:
SRE w �:u lo �r(u s�ptc.w.�
STATE WELL PERMIT*(uappUeabN)
DWQ or OTHER PERMIT �(if eppUcabla)
WELL USE (Check Applicable Boxj: Rasidential Watat Supply �
DATE ORILLED I' 3G -' �1> I a—
TIME COMPLETEO AM ❑ PM Q
s. WELL LOCATION:
CITY: I,n X�'ii� (�f� COUNTY pP �5[�/1
�L:z �� f o.lor.l�� �r..� i�r
(Sf»�t Nam�, Numbws, Canmunity, Subdlvisbn, No„ Pa eN, Zlp Cod�)
TOPOGRAPHIC / LAND SElTINO:
OsbPs ❑Vaqey ❑Flat ❑Ridys OOther
c�,.�.����
M,y � � ae�,
u►TRuoe .� _ �,c�, � a
LONGfTUDE �" � �'"�� ��
Latitude/longitude source: ❑GPS OTopographic map
(bcatlon of welmusf bs slawn on a USGS topo map and
atteched to lfuis /am7not usiq GPS) �
1. WEI.L OWNER
OWNER'S NAME
STREET ADDRESS I P
b �
City cr Tawrt State Zip Code ,.
�.-.��
Area code - Phons number
S. WEIL OETAIIS: /
a. TOTAL DEPTF� � .�-7
b. DOES YYELL REPLACE EXISTINfi VYELL� YES O A10 (�
a WATER LEVEL Babw Top d Casing � FT,
(Use'�• it /1bo�s Tap d Casinp)
d. TOP OF CASiNd IS f+ � FT. llbove Lard SuAacs•
'Tap d casinD termnated atlar belaw land surfaca may require
a vari�nca in aocard�ce wilh 15A NCAC 2C .011 �.
�. YIELD (9Pm1� � METHOO OF TE$T Q�vL
� OISIf�ECTIOIk
p. WATER 20NES (depth�
From�_ To�� From To
Fram To From To
Fram�— To ��P PiFrom To
Y
�. c.�►su�,o:1�5 n,�a,es�
From � � �� p� /_ �er N( '� Mat
iay
From To Ft �� �� STG'
From To FL '
Z GROtlT: �eW► : Material �—
From a To �'� Ft ��'-S
From To Ft
Fram To F't.
: �,�
a. SCREEN: Depth Olametac._ Sbt Sias + Mrtarfal
From To Ft in.• h: `
� From To Fl in. ` in.
From To FL in, in.
9. SANO/GRAVEt. PACK: � '� • �
�epth Sizs Wiatertal
From To FL
From To Ft
From To FR
10. ORIWNG LOG
From To
� / c7
/_ 31s
Formatbn Descriptbn
11. REMARKS:
100 NEREBY CERiFY THAT iFMS W ELL WA9 �D N ACCOROANCE 1MiH
1SA NCAC 2C. WELI CONSIAUCTION$TANOAROS. AND THAT A COPY Of TFIIS
RECORD W,5'BEEN PROVDED�D TME YVELL OW NEt�
OF
OF
Submit ths origl�ai to the Divtsion ot Water Quality withi� 30 days. Attn: informatlon Mgt,
161T Ma(1 Se�vic� Cenbr— Ralaigh, NC Z7699-1617 Phon� No. (919) T33-7015 ext 56a.
l �3�'-�/.�
OATE
Farm GW1a
Rev. 7/OS