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Person County Health Department
Sewage System .Improvements Permit
Date: -�' ` ThisPermit Void After 5 Years ��"�r
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Subdivision Name:.: �''N�3 %-�. r;. �' � �! ''�` = � Lot #�,,,_� �
Lot Size: ,2. � l;% L r� Type of bwelling. - . �
Water Supgly: Private: ��-'� Public•. � �Community: .
Bedrooms: ie� Garbage Disposal� "
Basement � � +� Basement Fixtures
INFORMAT19N('�'7}'RT� BY :
Sanitarian: t)� pY7'� � (n�w-e.�. � � owne or repmsentative.
REPAIlt: v � REEVAtiUATION:
�------- _ �
Size of Septic Tank: � gallons S;e of Pum� Tank:
Nitrification Line: �. ��,�{ �
Depth of Stone: 12 inches •
Max Depth of Trenches: �
Altemative Systcm: Conv. Pump LPP Pamp '
Remarks: �
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Date Well Approved: Well should be 1(?0 ft� from any sewer system '
BY Sanitarian
Date S e S m pp ved: � �
BY Sanitarian �
OF COMPLETION
�
Contractor. �_i / � . . ) rc� _- "
_ �
Sewage System location, installadon, and protection must meet state and local �
regulations. Sepdc tank should.be pumped out every 3 to 5 years and shalt be maintained �
by owner in such manner as not to create a public health hazard. Sepdc tank and'z3
nitrification line must be inspected and approved by a member of the Person County �
Health Departinent before any portion of the installation is covered and put into use. If
the site plans or intended use change this pe�mit is subject to revocadon.
(G.S. 130 A-335�
L,ocation of sewage disposal sewage system sketched on back.
(OVER) " ,,
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Person County Health Department �
Well Permit �
Date: l 2-9a ' Pe 't Void After Years 6�
Owner: ' SR# /S�'��
Location/Directi .
Subdivision Name: � t #
Drilling Contractor:
WELL CONSTRUCiTON b
Distance from Nearest Property Line Distance from Sonrce of �
Pollurion
Total Depth: F� Yeld: � � GPM Static Water I.evei FG ~
Water Bearing Zones: D� F� F� t.
Casing: Depth From to Ft Diameter: Inches
T'YPE: Steel ' � Galvanized Steei
If Steel, does owner approve: , No �
WeighG Thiclrness: Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered.in Setting the Casing? Yes No
If "yes" give reason: ''d
GrouC Type: Neat ement Concrete �
Annular Space Width � Inches
Water in Armular Space: Yes No
Method: Pumped Pres Poiaed �
��: F�� � �
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand gravel." ttinN )- Ratio: to
ID Plates: Yes .d
4 x 4 slab Yes � No �
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CO CT AND THAT
THIS WELL WAS CONSTRUCTED CC RDAN Wl�'H R TIONS SET
FORTH BY THE PERSON CO �I �•
Date
Issued
Sanitarian's Signature Date Completed
Sketch well locadon on reverse side.
�r�iR��tioa �ate: 1 � �,2� � 7
Amount Paid: , D
Receipt #: 1 30�
0 Improvement
$200.00/$300.00 (if> 600 gpd)
0 Mobile Home Replacement or Building Addition
$150.00 if site visit re uired
Well Permit (New/Re ce� epair)
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]E��s��.�����.Il 1E33[�mIl�
Services
for Services
❑ Construction Authorization
(Fee is dependent on the type of
0 Permit Revision
:ax l��vQ: �a�
Parcel#: �
FQx -�Q
0 Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Info mation: �
,
Name• _,,. 3�,r-��; �c�_I �
Add1'ess: 5S 5 r cn�vrP � b-
�,clao v� � z�s � `I �
2) Name and address of current owner (if different than applicant):
Name• 5�,,.P
Address:
Phone (home): Q I S-�f S I- I�5 3
(work/cell): �5q,�,�
Phone:
3) PropeMy Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: �
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
0 yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be geaerated on the site other than domestic sewage7
❑ 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: r
�Residential � •
O New Single Family Residence Maximum number of bedrooms: / Occupaiits:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
� Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
ONon-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well O Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any tcnown ground water restrictions or sources of contamination:
�,6) If applying for `Authorization to Construct', please indicate preferred system type(s):
O Conventional ❑ Accepted � Innovative 0 Alternative ❑ Other ❑ Any
1 certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the �te is sub,s,equer�tly altered, or the intended use changes, all permits and approvals shall be invalid.
S�ignature (Owner/ Legal Representative*)
* Supporting documentation required.
I/'aa'1 �
Date
Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evatuation.
..
(] 0/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N� 27573 (336-�97-1790)
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7E�rn�nu-�annaamuv.d�o.11 IHCC��.Il�ILa.
Tax Map: ��� " Parcel: _��
Subdivision:
WELL PERMIT
(IVew_ Repair�)
Lot:
Applicant's Name: � ' � fC�
Mailing Address: , . �
Phone Numbers:
Location of Property: ��+
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.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: Date: /
QNew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Addi[ional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Certificate of Completion
iner:
• EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
i.'
Phone:336-597-1790 Fax:336-597-7808
11/26/13 '"
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �
Address �J" �7 �t/ Q}n��g County
Collected By� �
Date Collected ,�� Z� -J( Time Collected ���
Source: �Well ❑ Spring ❑ Other
Location: �'House Tap ❑ Well Tap ❑ Other
� �� ��t�l�
0'No Charge � Charge
........................................................................�
*******************************�****************************************
Total Coliform
FecaUE. Coli
Present
❑
n
Results
r �
,
Reported By '
Date Reported � � � � �
Ab ent