A29 148�
The Disfrict 1-leatth Deparfinent
Orange, Person; CaswelL Chatham, Lee Counties
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S PTIC TANK PERM1�' � �'�
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Name of owner: -
Name of contractor: � � ' r
No. of persons to be served Bedrooms 1, 2,�4.
Additional appliances to be used: Disposal, dishwasher, washing
machine I`� r ��j P
Recommended• 5eptic ta ��
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Nitrification line:
Above recommendation based on information received and observed
soil condition. Sentic tank and nitrification line must be inspected and
approved by a member of the District Health Departmeni staff before
any portion of the installation is covered.
Date Approved: � � �0� �
Countersigned
Signe�
Sanitarian
O. David Garvin, M.D., M.P.H.
District Iiealth Officer
(Over)
• NOTE: Make sketch� of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date. , -
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BUGGESTED INSTALLATION (Date ) FINAL INSTALLATION (Date )
(Road or Street (Road or Street)
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DATE IS�
OWNER: /�
ADDRESS:
DRILLINC
WELL PERMIT
Caswell-Chatham-Lee-Person Counties
��/ DATE DRILLED:��-�i (J COUNTY:
� �•- ROACZ/�TI��ET:
{y /g BEf2MIt� Yd D.AFTER O YEAR
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ADDRESS
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Total Depth: t. Yie1d:�GPM Static Water Level• Ft.
Water Bearing Zones: D�pth: Ft. Ft. F f/ Ft.
Casing: Depth: From �.� to Ft. Diam�ter: 9 Inches
TYPE: Steel Galvanized Steel ��
If Steel, does owner appr Yes No
Weight: Thickness: Height Above Ground: Inches
Drive Shoe: Yes: No:
Were Problems Encountered in Setting tt�e Casing? Yes_ No_
If "yes" give reason: /
Grout: Type: Neat S Cement: Concrete
Annular Space Width Inches
Water in Annular Space: Yes No
Method: Pum ed P ure Poured /�
Depth: FromP to _�� Ft.
Materials Used: No. Bags Portland Cement ' Weight of
1 bag lbs.
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes No Chlorination: Yes No
4 x 4 slab Yes No
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANC I H` EGUL ONSCSE FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. PT.
Signature of Contra r Date
FOR HEALTH DEPARTMENT USE ONLY
REASON FOR NO INSPECTION:
. �-J� s�
Sanitarian's S' ature Date
Sketch well location on reverse side. Use es lished ference
points.
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Application Date•
Amount Paid: 7 . Gl'S
Receipt #: � �}4 I 4 (
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Services
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 (New/Replacemen air
$300.00/$200.0 �5 0 �L� N�`--
for Services
Tag Map: �'% 2�
Parcel#: /�
eMa� I �-o �
. �_
uested � 9�rna� � � + oM
ConstrucNon Authorization
(Fee is dependent on the type of system pernutted)
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: j.i .F
Address: ;r %/;n
� 7 �7
2) Name and addre�s of�rrent g�w�,er (if different than applicant):
Name: ��� n /� �/f i1
Address: ✓; � C
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3) Property Description: Lot Size: Su�vision:
Address and/or directions to Property: J rorr�
Phone (home): �'33�) _3 �2 - W 'EL�
(work/cell): �3�sL� s�3 - G 6 3 6
Phone: �� � �'� 3D(� - 025-�
Lot #:
T//� vPastd;ll� lt�o/� �i�s� ol�; �c O•-, �tff .
❑ yes ❑ no Does the si e contain any jurisdictional wetlands?
❑ yes C7 no Does the site contain any existing wastewater systems?
❑ yes 0 no Is any wastewater going to be generated on the site other than domestio sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
0 yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
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4) Proposed Use and Type of Structure:
�Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System if expansion: C�crent 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:
Ma�cimum number of seats:
� 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
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conven6onal ❑ Accepted ❑ Innovative � Alternative ❑ Other ❑ Any
1 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 suhse� ently altered, or the intended use changes, all permits and approvals shall be invalid.
Sig�ature (Ow�r/ Legal Representative*)
* Supporting documentation required.
`7 � � �/ ���
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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
Tax Map: �
Subdivision:
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�° �rn���ram�n�a��ra�as�.� ���aa.�.��a
Parcel: �ti$
WELL PERMIT
(New _ Repair� )
Applicant's Name: Jo� �E�� � �A*�OY A�.�
Mailing Address:
Lot:
Phone Numbers: 33�-583- b\o�b 9�g - 30�, ���5�
Location of Property: $� 01��.. �o�S� �� I,e�c,P �D
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 frorn the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments: � L� tJE'�. �
Permit issued by: �.�-�CJ�. � • 51�'t1��
ONew Well:
EHS/Date
Location:
Grouting:
Well Log:
VVell Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date: � �`� r�
Certificate of Completion
�L,iner:
EHS/Date
Depth: � �
Grout: ��en.,�1�t
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
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y1�1��r
� 1
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13