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The District Health Department
CASWELL - CHATHAM - L� - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPAOVEMENTS PERMI�' No.
� Date ' 1 _ � � '7 � t
� I (> �
Owner: ��-� � _� �' ` � n' �.� s1a,J �
Location: G
._� !�� �i / � < 7 ��
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Contractor: '��
Water Supplp: Private • Public
v
Sewage_Disposal F.acilities: No. bedrooms `' Dishwasher, Disposal,
�w�shirlg machin � other automatic appliances �
Size of tank: ��f �<^%�.,�_} �� r Nitrification line: -� L, G _?
.- ` � � _.� f / -� / i i .....� --
� sal �facility: yi� ,' ��� / _- � r •.
Other dis o
:.� � `
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Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations. .
Septic tank should be pumped out every 3 to 5 years an3 shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTAL'LATION IS COV-
ERED AND PUT INTO USE. % ,�
/. �1�� � � �
, ' t j�ti-, � /' `;' � t,i. � 1 � •
Date approved: — Signed - `�
, �f Sanitarian
Well:
Sewage Disposal: Counter-
By: signed
(Owner or his representative)
Ceriificate of Comple2ion
C, �.___..
Date Approved: _� By.
anit��n
(OVER)
Location of well and sewage disposal facilities sketched on back.
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 installations may be located
at later date. Note location of water supplies on adjacent lots.
.
�
Application Date: 2-I o-lj
Amount Paid: 7506 G�� 5Zo�7
Receipt#: (��3��(7
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�a.-av nu .cnga.���<c�,�rndm7l �E-3rx�,an.11Q.71a
Tax Map: �
Parcel #: �_
Application for Services (Septic Systems and Wells)
Services Re uested
0 Improvement Permit (Site Evaluatiou) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d (Fee is de endent on the e of s stem ermitted
❑ Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 if site visit re uired $75.00
Well Permit (l�Tew/Rep t/Repair) ❑ Repair of Existing Septic System
$300.00/$20D.0 $75.00 � Application: No Charge/ CA $150.00 or $300.00
iervices Requested by:
Name: L,c!I�s/�.�/ /�'?,�:,�?�l4 u s •>
Address: �f-% , jL/A1.�.�i� ,6"'. d; � �q-
�tY �tt.1� /UC - '� 71� 7�C.
Phone # (home): �� � — Z. f� ��
(work/cell):
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
4) Proposed Use and Type of Structure:
Residential Business/Type: Other
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No �
Garbage disposal: Yes No
5) Water Supply:
Private Well (Proposed Existing �
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
Lot #:
(please show location on site plan)
Note: A comnleied annlication must also inc[ude:
➢ A pladsite plan of the properry that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is su6sequently altered, or if the intended use changes, all
permits and approvals shall become invalid.
� � �
Signature (Owner/Legal Representative): ��+;c'�ct�.i, u�� � � .�>�� G- � Date :� Z —%U--//
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
�.��y 7,�� � ll ��� ��
�~ � � � ����
I�.�� � � �. a-�. �.� � �.11 IL--3I � �.11 � I.II�
W�I�i, PERMIT (New Repair�
Taz Map: 7$ Parcel•
Subdivision:
Applicant's Name: c�o�1 '
Mailing Address: z ' �
C
Phone Numbers:
Location of Property:
Lot:
:�
Permit Conditions:
1) Seg attached site plan for proposed well location.
Z) All applicable State and County �egulations governing construction and setbacks apply.
3) Permits expire S years from the date of issue.
Other Conditions/Comments: -�- nsi-Q�) l.iheY -
P�rmit issued by:
1
I�ate: Z - ! b ' ( f
CER�'IF�CA'TE OF C�IdIPLET'IO1�T
New Well Inspection:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Liner Inspection:
EHS/Date
Installer: '�+�n� � e
Depth: l� I �k
Grout: �. I a i I � i��-
Well A.bandonmeat:
EHS1Date
Completed:
Method/Material(s): _
License #:
License#:
Date:
Date Results Mailed: ' �
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
RESIDENTIAL wELL coNSTRucTTorr uEcoRn
North Carolina Departrnent of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # J� cS 7"'/7
1. WELL CONTRACTOR:
. �.z. 67 --f
Well Contractor (Individual) Name
Bamette Well Drillina Inc.
Well Contractor Company Name
611 Barnette Tinaen Rd
Street Address
Roxboro NC 27574
Ciry or Town State Zip Code
3c 36 � 599-0015
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicabie)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 2 � /�,�1
TIME COMPLETED /� nSs AM ❑ PM p�
4. WELL LOCATION:
CITY: � ��Qp COUNTY S
`tr� �/�� � �/� lZ;�I� � - z7.s��
(Street Name, Numbers, Community, Subdivision, lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope pValley L�Ft�� ❑Ridge ❑Other
IATITUDE 36 "_' " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 " ' " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: �PS Qfopographic map
(location of.we/f must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER n -
W�S�Q t/ �l�l��
Owner Nam
�-Ss B/� L. ���Z ,�T'�Q�� �� . .
reet Ad�c ress
DY����C. Z 1 y 7 S�
City or Town State Zip Code
c336����- 7-4'-3�
Area code Phone number
6. WELL DETAIIS:
a. TOTAL DEPTH:��O
b. DOES YVELL REPLACE EXISTING WELL? YES ❑ NO ��
c. WATER LEVEL Below Top of Casing: �� FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS �_ FT. Above Land Surface'
`Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 'L METHOD OF TEST BIOWII ZOtll
f. DISINFECTION: Type HTH anount 1/2 CUq
g. WATER ZONES (depth):
Top Z Z� Bottom�tf�0 Top Bottom
Top � � Bottom�� Top Bottom
Top Bottom Top Bottom
Thicknessl
7. CASING: Depth Diameter Welght Material
Top d Bottom G� Ft. T,���R �U�r ��/G
Top Bottom Ft.
: Top Bottom Ft.
8. GROUT: Depth Material Method
Top aottom Ft. Sand/Cement Poured
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
: Top Bottom Ft.
Top Bottom Ft.
, Top Bottom Ft.
11. DRILLING LOG
Top Bottom
esa i�
/
/
/
/
/
/
/
I
/
i
12. REMARKS:
in.
in.
in.
Material
Formation escripti n
6Gt/s c
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
`1� �M� 2^Z I-11
SIGNATURE OF CE TIFIED WELL CONTRACTOR DATE
� .7 �--
P INTED NAME O PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300
Form GW-1a
Rev. 2J09