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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # ;� � 1 Parcel # ���
Zoning _ __ Township i
Owner/Contractor
C:�
Subdivision Name /�7�'.11 ;
Date . �—
�_ S.R.# I J.��
Lot# l c�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area %. Q�3.�-G Size of Tank `
SFD ✓ Mobile Home Size of Pump Tank
Business # of Bedrooms � Nitrification Line �f� 'X3'
Max Depth Trenches �? �{`�
� �� ����
Permits may be voided i�
Well and Sep,X't�Layout by
���
ell Permit Paid
altered or a
� . p - .
by ; Lc c.� i Approved by
� a a . 8 -�.4 -6 f
iELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab ✓�f( `�"`f "��-
Public Replacement Air Vent 1/ ��" ��9 ��
Site Approved �� 2 Required Well Log ��
Well Head Ap oved ✓3 F4 -`1'� .� Well Tag ✓ J� `�` �"o�
Grouting Ap roved ! � oZ o5c Bib v��� ��'`� �'
�omments:
�L
ate�_q_� Installed by E �5 �'t I! Approved by
This report is based in part on information provided the ho�eowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
AYpEi��tioa �ate: � 3 � 7
Amount Paid: Q �00
Receipt #:
C..�'� � '�
� �.
��� �J 1L 11a������i I :ax lYdap: �� �
`..,,: ► • � Parcel#: l ��
������
IE��s������.Il �33[��.Il�
for Services
Services Re uested
0 Improvement Permit (Site Evaluation) ❑ Constructioa Authorization
$200.00/$300.00 (if> 600 (Fee is de endent on the e of system ermitted
obile Home Replacement o uilding Addition� ❑ Permit Revision
$150.00 if site visit re uire $75.00
0 Well Permit (New/Replacement/Repair) ❑ Repair of Existiug Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
,,-1) Applicant Info ation: � � / /� �
Name: v c o� ! �—a Phone (home):
Address: (work/cell): .3:1 G� R 2— 3 2 2—�
2) Name and address of curren�owner �f different than applicant):
Name: � l2t�r S' l�a ��� s' Phone:
Address:
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Properiy: � � 7 �c ���� �
❑ yes �`no Does the site contain any jurisdictional wetlands?
�-}�es ❑ no Does the site contain any existing wastewater systems?
❑ yes � Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes Is the site subject to approval by any other public agency?
❑ yes o 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 �
�� ���
P G�G
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
0 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
❑Non-Resideutial
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 well , spn s, or existing waterlines on this property? ❑ yes 0 no
Please note any known ground water restrictions or sowces of contamination:
.�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 comp[ete and correct. I also understand that if the information provided is
inaccurate, t it is subsequently al , or the intended use changes, all permits and approvals shall e i alid.
Signature (Owner/ Legal Representative*) D e
* Supporting documentation required.
Permits are valid for either 60 months or are non-ezpiring when accompanied by aa approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site e�aluation.
(]0/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC27573 (336-597-1790)
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Tax Map #: � a � . Parcei #: �a �
Zoning: Townshlp: � � I V L �� � �
SUbdtvision: ����StU1 ��G I2 i c�y�;���.: ..• . sect�on: Lot� ��
Applicant: 7�nY �45��-i/
c�
Location: 3rd �La-r ��OL c�rl f����� ��
C�peration Perm it
�
System Type (In Accordance With Tabie Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL C�NDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
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August 3, 2017 1:1,128
0 0.0075 0.015 0.03 mi
TaxParcelPublishing Person Co���t�� Environmen!al Heafth ����/' �� ,��T����
;;�::� '�� i��organ Street ����,,� 0 0.015 o.os 0.06 km
��l'� � Esri., Inc., Person County GIS
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RU;.u�!lll� 1'ro.i L1��3
For Refe�ence Ony -Nways �eferto the original source.
Person Coun[y Is not responsble for the use, misuse, or m'sinterpretatlon of this informacbn.
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Building Additions/ Mobile Home Replacements
Ta�c Map #:_ F�_ Parcel#:1'� Address: �/ ��� f�� ,�.
Approval Requested for: Mobile Home Replacement
►�Building Addition ,(,Q.� g
Applicant Name: _`-✓�Z�f�z�,Q�� ,��i✓�ly' � �
Address: �
Phone #'s• �Z - ,�2?�
Permit Located: ✓ Yes No
. Installation Date: 2oa Z Design flow: f� (gpd)
Current Contract with Certified Operator on file (if required): �_
Water Supply: � Well Public or Corrununity
Wastewater system shows no visual evidence of failure on: � 7(date)
(Applicant's signature if site visit is not required)
Additioa�/Replacement Approved
Environmenta Hea th S cialist
Dat-- e '
Person Caunty Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcounty.net
��
P�RSON COUNTY �NVIRONM�NTAL H�ALTH
WELL LOG
Date:_ 1 _ �� o �- .
Owner: .� � � SR# � � �
Location/Dire tions: �- � �
I�o �t �� l/ ���1�-�
Subdivision N�une: _ _ __ _._ _ Lot # �
Drilling Contractor:
WELL CONSTRU ON
Distance from Nearest Property Line ,/s�l�.s Distance from Source of
Pollution c a � /�,� �
Total Dep.th: ,�-v�- Ft. Yield: /�_ GPM Static Water Level Ft.
Water Bearing Zones: Depth �/D Ft. /� zFt� Ft. Ft.
Casing: Depth: From_____�_to�_Ft. Diameter: G% Inches
TYPE: Steel Galvanized Steel ,�
If Steel, does owner approve: Yes No
Weigh[:�_ T}llckness:�_ Height Above Ground: ,% Y Inches
Drive Shoe: Yes �' No �
Wer,e Problems Encountered in Setting the Casing? Yes No �� �
If "yes" givc rcason:
Grout: Type: Neat Sand/Cemen[ J Concrete •
Annular Space Width 3 Inches
Water in Annular Space: Yes No �--
. ._ Method: Pumped . Pressure � Foured �' . ..
Depth: Fr�m �� :o - n Ft. -
Materials Used: No. Bags Portland Cement Weight of 1 bag 9 y lbs.
If mixture (sand, gravel; cuttings) - Ratio: to1 �
ID Plates: Yes � No �
4 x 4 slab Yes `� No
I HEREBY CER'I`IFY THAT THE ABOVE 1NFORMATION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDA.NCE WITH REGULATIONS SET
FORTH �3Y�THE PERSON COui�'TY HEALTH DEPARTMENT.
�� ��1� �, - � - � �' � �-
Signaturc of Contractor Date