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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) ���,�f� I��I�.���T ������ �..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) `��, ; � �� ���� �� `..►,.� �{ (� � ���� �`.� 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 .����,� / �1����� . j ,_, ,� _� �, � ��.7��C�C l�,m-�-� u• �,r„ ,r,.,, ,�.�¢,m.]1 7HI�� ll �11a �I'I'E ��'I'C�-I Name �co{--�- 1�'� o�ra �,,J Ta.g Map # Z`�a Pa�cel # 27 Subdivis' n _�.�._____. Section/T:nt# _ l� � _�Z 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 � I��,:�,;��-���,�� � 1 � ���'��'�-�:�� , � � � �. �� r i - �t � � . . �,, Tn ., I-` �- . _ z, � a � _ , ��_' r s. ,''� � � , � � r �'� ��. ':i�, � �" G _ � � s � � k � '� Y ,. # r L,� �i,i T 03 ,i. 1�' .:�� .... yi ''�t � , . ' Y' � Y' ,,F. � y - K > ". �s ,h, 3Y � ; � � t � � � Ts � �4� � �- �k i'. �:& „�t �£ �-;;A"+ � x. :,� --�' y�, '� �u 4� 1;u�. I a I �� '� � , e� u = 2s �� -� s�t . � '�c' "� '��.� . 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' _ � ,. _ , . — ._.- .� �,� _ __ � ,. _ . - — ,., l i , _ — - _ �c"'-- —�� � � • � � ' _..,---" , i� ,... � i -. _"-�-�—' —_-�_ ___ _ _ _ — �� _ — � . . �� .. . � ��' . . _r- = —. - ' _ — .. .. �. � . . _ . �. , . . . . . . . �: -� � _� �� .� � -- � ,� . ... __— � _ - . �� _ - -_ _ � � � �� :� �5(},°r7 .�.� �-- Y - Y� �a�', "�:65 - ��,� ��' � . �� � � '' ' � �t�a` � ��� � „ '�<`��' � : i 00 Fe�t � 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