A28 84�, .
•T Application Date: a �� ,7
Amount Paid: � � 0
Receipt #: I�
Clred�r
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (Ne�Rep ac, t/Repair)
$300.00/$�00.00/$75.00
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tion for Services
Services
Construction Authorization
(Fee is denendent on the tvpe of
Tax Map: �
Parcel#:
F� ��
o,,.�n�:,J
—'c . , :1 l i�
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
��licant In ormation:
� Name: �VYj�I � �-Y1C.�.u1 -�-�'0 i�
Address: p
'(�o�L,tJ[' �'7 S'7
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): �J3(P ✓5�3 `�/�����
(work/cell): _�,� (D--� —(p�/05 ��
Phone:
3) Property Description: Lot Size: �� Subdivision: � f� Lot #:
Address and/or directions to Property:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ 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:
OResidential
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: Cunent number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building: :
Maximum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any knowri ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional �❑ Accepted ❑ Innovative ❑ Alternative ❑ Other � Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subs,equently altered, or the intended use changes, all permits and approvals shall be invalid.
�wner/ Legal Representative*)
documentation required.
�a����
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.
(10/15) Person Count.y Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map: , 1f Parcel: �
Subdivision:
WELL PERNIIT
(New_ Repair�
Lot:
Applicant's Name: �- � �
Mailing Address: / _
�
Phone Numbers: -J�'�l� .-92!! .����GQoS
Location of Property:
Permit Conditions:
1.) See attached site plan for proposed well locatiorr.
2.) All applicable S�atE a•rrd Couriry regulatiosas governing constructian and sEtbac�cs upply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potabde water supply
Other Conditious/Comments:
Permit issued by: ��C.���
Date:
�er+tificate of ��mpletion
Ql�1ew Well: � iner: f({�� � I�,.�.�� �
EHS/Date E S/Date� �� ��
Location: Depth: sr� �g _ � �]' W �` �l �,M �',,1
Grouting: Grout: ( ,
W I1L •
e og.
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Ad�i!iona[ Com.ments:
�ate Sample Coliected:
EHS:
Person Caunty Environmental Heaith
325 5. IVlorgan St.,Suite C
Roxboro, NC 27573
(�AAnandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results ivlailed:
Phone:336-597-1790 Fax:336-597-7808
31/26/13