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PERSON COUNTY HEAL'TH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Tax Map # Parcel #
Zonin� Township o 1 t V�1-� ; �(
Owner/Contractor
�.ocation/Address
S.R.#
Subdivision Name Lot#
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A 1772
SEWAF
Repair Lot Area
SFD bile Home
Business i # of rr
SYSTEM SPECIFICATIONS
Size of Tank
Siz Pump Tank�
Max Depth Trenc
Permit Void after 60 mo . Permit Void if n' compliance with zoning
Permits may be voided if site i ered or intended us nged.
Well and Septic Layout by
Comments:
Date Installed by Approved by
WELL SYSTEM SPECIFICATIONS
dividual L/ Semi-Public Required Slab
�blic Replacement �� Air Vent
te Approved Required Well Lo� ]—/d�, —q�
ell Head Approved Well Tag
�outing Approved� � � --9q� � � a _
Comments:
�
Date Installed by " v Approved by "
This teport is based in part on infortnation provided the homeowner or his/her representative in the application submitted for Uus permit. The
enduonmental health specialist is not responsible for false or misleading infoanation contained in the application. The environmentat 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 Pecson County nor the environmental health specialist wazrants that the septic tanlc system will
continue to function satisfactorily in the future or that the water supply will remain potable. c�amipro�pemtitsam O1/95 rev.1.0
ORIGINAL
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I�ate: `�- �.� �.. '
Owner: � d- � 6 --
Location/Du-ections: _� �d n �/g�� r'� rm- .. .__._.._...� • SR#�• •..
(,� r��.:�..... ��_._ .. ............._.__ ---._�
�uv,'�vision .Ni .--...._. . ... _ _._ �
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Distanc ' 1�!1:1.,( :..C:(.7Nti_f _R llC. I [nN , • ..
e txom Ne�u-est 1'c-o ,c, c I..,ii�c: "�
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Pollution .. p d.. �S . O,�`-`�-- 1�is�;�ncc ;lrom Source of �
Tota1.�I�ep.th:. o � �• .
Ft. a icicl:__.��__...._y G�'M Stalic Water Leve] --J .
Water $e rLones: ��1, �
�De � Dep _//-.�_ �'► ' � � �G
Casing: pt1i: � From D to -.. .•I.aSSf�.__�'c..,�,(,�_Ft.___.�[..
TXPE: Steel . - ---... �d_..__I•�. Dia►nctcr:d � Inches
Z�f Steel, docs ow ��.�'���v:lni�`�c:! Stecl v ,
ncr a�7pa•ov�:: � c.:: No ,r'.
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Drive Xes__.._f Nc� � round:�'Zr1che:s', .
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Z� ycs �;zve rc��o,i: I l.fi. Xes___ No �--' •-.
Grout: .Type: Neat � .S:,,i<1/Cc,iicnt —� . �"J"'��`'s
Ar�nular:Spacc Wz��� — _ _____Coricrete • . •..:�=���
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Water in .�A.nniil:�r Sp;ic�: �'�:.• � �o ✓ . . • �°,:
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Z�EREBX CE�TIFX T�I,�AT'1'I-IE ,l�.I3UVL 1NFURM�1'1' 1
T�S WELL WAS CONS �'I�UC"1'L�) �� �,CCORllA,�1C�ON ZS CORRECT
�ORTH �3��TH�� PERSON C:n[1NTY I�I1;n1..TI-I D: � W�TI-� REGULA
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Application Date: 7''-2'�� . Tax Maa #:
Amount Paid• " . D
Receipt#• 2f"fj34 ParcQl#•
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APPLlCATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFI_ED
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. -
1) Permit requested by: (Owner/agent/prospective owner): n�� ��
Home Phone: '� 2 B�' S I%- o� %/ % Address: o �-J �,�� �
Business Phone: cS"� �-o�Y�'^j � �%�7-�0 .z�, �a �Jtf�/�
2) Name and address of current owner: �.t�� �-� (� �-� �
3) Properiy Description: Lot size: f�[r� Township: Subdivi,
Directions to the property (including road names an numbers): s� g s
� �FT d .✓ GJc/��i �).un� �
Lot #
4) P�roposed Use and Structure Description: answer each of the following questions:
a) Proposed _, Existing _, Type of Structure: Width: Depth:
b) Number of Bedrooms: Number of occupants or people to be served:
c) Basement: Yes , No � Will there be plumbing in the basement? �
d) 6arbage Disposal: Yes , No �O - l
5) Water Supply Type: Private _(new _ or existing�, Public_, Cammunity , Spring _
Are any wells on adjoining property? Yes,�No _ If yes, please indicate approximate location on the
� site plan.
6) Does your property cantain previously identified jurisdictional wetlands? Yes_ No �-��
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLlCAT10N.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities t9� be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become ifi�ialid. ,r /
or Legal Representative
�-a_��
Date
PCND, rev. 06127/02
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WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map Aa9 Parcel # I�J Township: �
Applicant: '�r�,.e I 1 'Ca,�.-�nn � �"�- � �� + `Ab,� '�rn-
Subdivision• Lot #
Location: �19 5�('� Gn Nes+�. �� �� 0� c,� ��. t.ar�, �
+�� � ��- �� ---
Type of Water Supply: �Individual _ Community
Requirements:
Site Approved By: CS �7 -8'�y
Grouting Approved By: (� �- a(o�cXf
Well Log: (�g �-�7- oy
Pump Tag: . .
Well Tag:
Air Vent: �
Hose Bib:
Public
Liner:
�Installed by: �
Depth set: -
Grouted•
Date:
Water Sample:
Casing Height:
Concrete Slab:
�Vell Driller: �_ �,T-t�� � ZL L��-3.,��..-�rrcfl
Well Approved by:
****See Attached Site Sketch****
Wells must be 10 feet from property lines. � .j
C�Wells must be 100 feet from septic systems. �
Wells must be at least 25 feet from any building foundation.
Date•
Other conditions: Y����� s, �e s�� —
PCHD rev Ol/27/04
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Tag Map #�a9 Parcel #. � 8.
Section/Lot#
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: Date . ; . .
sy� �� �,��r ������� �y. The co�atto.r must, flag the systes�s
begirrning the i��staAa�on to imsure that pro�tiergmde rs mui�:tained �
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Scale: t�oL .�.� Sc�
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Barnette Well Drilling Inc �36 598 9275
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07126104 05:46P P.001
Dri'ile.r I D +
Com���ny N��mE L , s_
D�t,e DrilJ�ci l
Grout Log '
Owner: I�c, - �• �lLl��/',�,� � `�"'d P� 1-� r -, � P� ��..-� Tax M�p ..�� Parcel # � 1 �l
Locatian: � �. T/.� ,�J� ��< <-- -(� � n,-. rz•�,n
Subdivision• Lot #
Wcll Construction
Distance From nearest �'roperty T.ine (Mixvimum 10 feet)
Distance from Septie System (Minimum 60 feet)
Tot�l Dcpth: �/�p_ ft Yield: �,� GPM Static Water Level: �, ft
Water Bcaring Zones: Z7ep� �ft � ft ft ft
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Casing:
Dcpth: Frann to .�,� ft. Diameter: �� in
Typc: Galvatazze teel �s.
WcighC: 'ckness: . I��' Height above Grourtd: /�i in
Drive Shoe: �Yes Na Any proble�ns cncountered while setting casing7 Yes c�l�To
Tf "yes" give reason:
Groat:
Neat: Sand/Cement r/ Concirete GraveUCement
Annular Space Width inches Water in Annular Space Xes No
Method of C'xrout: Pumped Pressure Poured �/, Depth �_ to �� k't.
Matcrials �scd:
No. Bags � rtland ccmcnt �.��Wer� t� 1 Sag � Pormd.
If mixture sand, gravel, cu n s- Rat�o
ID pl�tes: ,,/5les _ No 4 x 4 slab ✓'Yes ____ No
Lincr: ,
T7cpth; Datc Installed: Grout:
DriIiiag T,og
Installed by:
Locatfon Drawing
I hereby certify that thc above in�ormation is conect and tt�at this well was constnzcted in accord�ncc v�rith rcgula6ans set forth
by the Ferson Couniy �Tealth Deparhnent. 1 '
.
S�gnature a�' Contractor
ID#� D$te ?��l,.�d41
Pump Instal�utemt
Pump Tsastallation Contiactor: �._ �r�,� � �� 1% __ State Registration Niunber: �„�
p,�P ��,, ft Static Watcr I.cvcL• ��, ft
Pump Make & Model• ,��A -� � Ll � _ Pump Sia.e and �tatu�g: i.L_`hP �� SPm
I hereby certz�}► that this pump was installed at�,d the weli head pleted according to the Person County Well Rules in effect
on this rlaic and that a copy of this record has bccn p� 'd t wcll owncr. .
PU�D �nstallcr SignBtur% /_� - � � Aate: _��%� G�Y�'C�A rcv Ol/27/04
JUN-29-2015 11:09A�I FRO�I- �#" �� �'z�'
��+ �,�,.��: � s o ! � � �'a c� �.�-� �1� S� ����ll�l
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Re�pt�: `i 3N.27_3 �3N�yr� � �����'
` _.�,_, En • e,l i�emHEl�
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A lication for Services
' �y���/��,,,A��� Services ne�ted
� �ii��iRR7al.7••"Si�3W7lil0II� rnwefw�.Ainw�nlRn�t�/inn
S2DU.00I$300.00 �> 600 tn
�Iob�e Home Replaamwt or $uildlAg Addition
S150.00 ('ff sine visa nire
WeU Permit (New/Reulacement/Renairl
.QO
T-935 P.001/003 F-945
Taz Map /4 02 �
Parcei#: � �
is deoendmt on me [ype of
pair of E�g 5epdc Syst+em
Applicatiaa No Cha�e/ CA 5150.Ob or 5300,00
1) Applic�utt Informatioa:
I:TilBie.: �� � r � � ifi � � Y L �
Acldre�ss: a �/ ,
, - � ��.C'-��i
2) Nauie and addtrss of current owner (if dif%rent than applicant):
Name: // 1�1�� T�Z�a%�—
Address:
Phone (home): � �3d^S'S'S—o �?�/ F� �""" �
(work/cell): , P�,�- , C�o% s�i ��^�i
Phone: <S `�'f—D��/
��
3) Property Description: I,ot Size: �� Subdivision: Lot#:
Address aad/ar d'uecdons tn Propetiy '
❑ y�
� y�
❑ y�
❑ yes
❑ ys5
�—0'6/o Does the site contsin any j�isdictionaj wetlands?
oes the site coate.in any existing wastewater systems?
o any wactewater gomg to be generated on the site other d�an domestic sewage?
o Is tho site subject bo approval6y any other public agencyT
C�'� Are chere any easements or right of ways on this property?
(if `yes' is checked, ptease provide supporting documentation)
�) Prop�os�d Use and Type of Str�tdure:
❑ittstde�tial
� Ncw ��ulgle FamiIy Residence Maximum number of bedrooms:
❑ Expaasion of Existing System 1f expansion: Current number of bedrooms:
❑ Repair m:�lalfuncaoning System Will there be a ba P� n+P^.t? O yes Cs7-e�With plumbing Sxnues? ❑ yes Q no
E]Noa-R�ccideAtiai � � d X S✓O
Type of busincss: ��� ��y /,� �, yhs r�/ Total Square faotage of Building: S I�
Maximum nacnbet of empioyees: � Maximum number of sears: �� �—
� Water Suppfy: Q New well ls�Lxisting Well � Communiry Well ❑ Public Waier ❑ Spriag
Are diere any ezisdng wells, springs, or eaciscing waterlines on this praperty? es D no
6y If ap ying for `Ant6orizadon to Coastruct', plesse indicate preferred system type(s):
nvcn4onal d Accepted ❑ Innovative ❑ Altemative O Odter p pny
1 cert� thot [he informarion provided above is complete and correct. I a(so unde�stcrnd lhat if the infor»ralion ptovided is
inaccurate, nr if the sile rs sub.sequently altered, or [he in�ended use changes, allpermits ctnd,approvuls shall be imalld.
6-��d i�
S' na ure (Owner/ Legal Rep�esencacive'") Y Date
I � Supp�rting documenration r�quired.
• l'erma�s nre valid Cor eitber 60 months or are aon-expi��ng w��a ac�o�p�o�ed by an approved plat.
• a co���piccc� `Lot Pr�puru[ion' farm must accompany any application requicing a site evaluadon.
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Applicant: �,
Address/Location:
Improvement Permit
Permit Valid for• Five Years ✓ Non-expiring
Type of Facility: �jf�f ,�1���.,�,> New i/ Addition
Number of: Bedrooms / OccupantT % Emp(oyees / Seats:
Proposed Wastewater System: � �' �
Proposed Repair: �'
Tax Map: � Parcel: /��
Subdivision
Phase/Section/Lot #
Water Supply: " -�
Projected Daily Flow: gallo s day
Type: .�d
Type: •�
Authorized State Agent: . Date: �/,�//c.'—L_
(X) Owner or Legal Representat ve: }� �z,vc_ Date: ��lr
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
tl�e applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws
a�rd Rules for Sewage Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: �j,a,�j/� ��� (*)Type �� Design Flow �� gal./day
New :✓ Repair _ Expansion _ Soil LTAR: .� gal./day/ftz
Type of Facility: �l,f ������i�,��,�'�,Od.�L1 Basement: _ Yes �/ No
(*) System Types Illb, IIIbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank 1Q�� gal. Pump Tank gal. Grease Trap gal.
Drainfield: Total Area _��� sq. ft��� Total Length J ft. Max. Trench Depth � in.
Trench Width ^ ft. Min.Soil Cover � in. Min.Trench Separation ft.
Distribution: Distribution Box / Serial Distribution� / Pressure Manifold
Specifications:
Authorized State Agent: Issue Date: T�I $ --
Permit Expiration Date: 7 d
The system permitted is: Conventional �/Accepted / Alternative / Innovative . I accept the conditions
and specifications of this permit. ^�^ 5-----�
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 3�5 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
('��nnectGIS Feature Report Page 1 0l' 1
Persan CouMy Ernironmental Hea�h
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See Below for Disdaimer
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dOTICE Recently, we have had seveiol users report browser compa[ioility issues wnor ty�ny :o access our GIS website. Typically, the problem stems from users who hav
c�cently upgraded to the Windows 8 operating system or a new version of Internet Explorer. We were able to resolve this issue by directing users to the Intemet Explorf
ompatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US/intemet-explorer/products/ie-9/teatures/compatibility-vie
I this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGlS has bee
,repared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system ai
�otified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectGl
;;ume no leqal responsibility for the information in this system. Grid is based on the NC state plane coordinate system, 1983 NAD.
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http://gis.personcounty.net/ConnectGIS_v6/DownloadFile.ashx?i=_ags_map 1 d61604488a5... 7/8/2015
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Tax Map �`1� 2� Parcel # � �l
Subdivision
PhaselSection/Lot #
# of Bedrooms
Oueration Pern�it
System Type (From Table Va): Product (IIIg): ��� �
Type V& VI Expiration Date: Type V& VI Renewal Date: vL
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
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Tax Map: Parcel #:
Septic Tank System Checklist (Type II-I� System Type: � r-�
Notes:
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Ca acity:
Riser (6" min.)
NEMA 4X Bog
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on post
Above grade {12")
Conduii sealed
Pressure Mani%ld
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes: