A29 196J'
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Apcilication Date: 3`l��d�
AmountPaid• 0�0
Receipt #: _ j���' ,F —
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� Tax Map #: �" � `
Parcel #: � � b
Person CountY Heaith Department
Environmental Heaith Section
. APPLICATION FOR SERVICES � .
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED. OR TNE SITE IS
ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME 1NVALID.
1) Permit requested by: (OwnerlagenUprospective owner): f%��'►+'� ��� `�-
Home Phone: ��l`l-5t� �'- Lf/7'�" Add�ess: 3 0� t.�/. �^ � .
Business Phone: 9/9, 3c�-2�i�y irn e c�.., �. �►�r �.� Q y�cz
2) Name and address of current owner. �i/w►-er� p�r/,' �-
.30� Lt;• tY��i�a�... �,
w, � � Gt..,.e �.,l,l .c_ > a7 �r� z
3) Property Description: �otsize: Township: ��� d%11
Oirections to the property (Including road names and numbe�s): ��
4) Proposed Use and Structure Description: answer each ofthe foilowing questians:
• �...
��y� �
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a) Proposed t9!Existing �
b) Stick Buiit �, Modular �ingte Wde �, Double Wide � �
c) Number of Bedrooms: � c� Number of occupants or people to be served: _„_l`� "
e) Basement: Yes 0, No �ifyes, # of basement fixtures:
fl Garbage Disposai: Yes 0, No 19-�' �
g) Dimensions of Proposed Structure: Width: �, Depth: _`
57 Water Supply Type: Private�'(new � or existing �). Public �. Commun"ity �, Spring ❑
Are any wells on adjoining property? Yes � No r�ifyes, location
6) Please indicate Desired System Type: (systems can be ranked in oMer of your prefe�ence)
�Conventional Modified Conventional _ Aitemative Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY.
STAKE THE CORNERS OE ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
I hereby make application to the Person County Health Department for a site evaluaGon for the on-site sewage disposal system for
the above-described property. I agree that the contents of this application are true and represent the maximum faaGties to be
placed on the property. I understand if the site is altered or the irttended use changes, the permit shall become invalid. l understand
that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible foc the
personnel of the Person County Health Department to condud their evaluatio�s. I understand that I am responsible for nofifying the
Heatth Oepartment if my property contains any wetlands as designated by the Army Corps of Engineers.
�� �
.�,s-� % ��-�� ,3 /'�f�- O�
Owner or Legal Representative Date
PCNo, rev. 10/12/99
. ► � �
PLEASE SEE ATTACHED PLAN FOR
Tax Map #: !� °'� 1 Parcel #
Zoning _
Appiicant:
Location:
Subdivision:
Newi,/ Repair _
1���11�1�
i � � / '�
Improvement Permit
Type of Structure
D SYSTEM LAYOUT
� Lcop ��
Lot: ,�_
,�
Water SupplyRj`I
,
# of Occupants # of Bedrooms � Other •
Basement? �Q_ Basement Fixtures? �j(L
Projected Daily Flow: � g.p.d. Permit Valid For. Five Years ❑ No Expiration
Proposed Wastewater System Ty�e:� ����! G �Y� �� � t`� �
Pump Required? Yes ✓ No
Permit
Owner or Legal Representafive ;
Authorized State Agent:
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The peRnit
holder is responsible for checking with appropriate goveming bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Type of Wastewater System���i!�,U�:�►1G I �Vastewater Flow: �.p.d.
Y�,U ► �, �
Facility Type: �Repair DExpansion 0
R�ccmcntO fl YFas o Basement Fixtures? O Yes �lo
Wastewater Svstem Reauirements
Septic Tank Size: �,_ gallons Pump Tank Size: �/ I gallons
Total Trench Length: � feet Maximum Trench Depth: � inches
��l' " Soil Cover. � inches Trench Separation: � Feet on Centei
Other:
Permit F�cpiration Date:�� ����
AuthorizedStateAgent:,���, n�� t`/,(�G�
The type of system permitted O does Q does not
the specifications of this permit. G
Owner/Legal Representative Signature:
i
Aggregate Depth:L in.
from the p pecified on the pplication. I accept
, Date: � V ��
?CHD, rev! 10/12/99
Applicatfon #:
Tax Map #: /-�-�.`l
Parcel #: � l a �
Person County Health Department
Environmental Health Section
SITE SKETCH
*�( nn �' ��� �� � � I l r° Cl��% l�f �8
Applicant's Name Subdivision/Section/Lot#
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uthorized State Ag nt Date
System components represent approximate contours only. The contractor mustJlag the system
to beginning the installation to insure that proper graae rs ma�nrainer�
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Scale: I'� =(D��
PCHD, rev. 90/12I99
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax MaP #. � � ! Parcei # � L -
Zonfng Township
ApPiicanC �-f �n n� i �' S
Locatlorc - - ,
b } rjprf'/� I.y
Subdivislon: ,
R11, I�iL �! � l lt l 1 I ril 1, Section• LoC
Well Permit
Tvae of Water Suaalv: �Individual Community Public
Reauirements•
Site Approved by � �
Grouting Approved by r '�
Well Log CSs � �- �s -�.
Well Tag
Air Vent
Hose Bib �
Concrete Slab ✓ �a������ � N
Well Driller• �'n'�'�
Well Approved By:
Date• �� � O -Oa
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD, rev. 11/29/99
�i/2�/1995 �4:09 8�44547843 BENNETT WELLDRILLIP�G PAGE �2
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waa co�o�
� Pro,m � Pro�oety I.iae (M�maum lo &a�) .
D�nce fln�n Sq�tic 3yaoe:a {M'imi�m 60 8ed)
Ta�t ne�; sr � x�eaa: �.'�, a�M sc.� w��a: �„�o ._�
w� �� z�: Depth � ft�0 ft 8� s
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wai� / �/�o ,'Ibidm�sa: �_ xesg�t .bawo c�roa�d: ��..- �a
D�iva Sbuoo: _� Yes No Aay probl�e a�oo�n0o�d �vMte satti�g c�siag? Yes .� No
If `�nes" �v�o roeaon,
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N� _J� Saud/Caa�,aat Ca�c,ro�o C#�vd/C�t
� s�ew�_�_� w����s� Y� ,� r�
MetLod oi C�c+o� Psm�pod ✓ Pre�+e Paaied Dopth ___Q__ to 2a Pt
Dlaeeelsl� II�ed:
No. Bega Partl�d aeRa�t � W�ight of 1 Hag �, Po�da
if �mi�c+a (e�md. s�avd. �) — R�tio to
� IDpL�+e: ✓Yea,�No 4a4eiab�Yea_No
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Lo�xlion Aran�lo�
i Dereby ccrtify tbat thc abavo in�camoerion is coinct e�d th� this wdl area can�ed in accord�ace arith regulatia�s
sot �rth by t�c P� Cowaty Haiskh Do}�er�.
Qh...ti..�..d �`m.er.atn� ��•/�°L�`ix�v.�.�' ID� o2G 9f1 Dah / 0- � y- a 2.
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IE�.���omm.� ���.11 IL 33L��,71�.
Applicant: ���� ��
e
T��x fvl��{� ►� ► F�:rc�el r �
S�uhei!ivi�s�iam '►�u�"'
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Pha�se Sec�t+io���'Lot r �
Oper�tion Perr�a�t � _
System Type (In Accordance Wiih Table Va): � ,,
THIS SYSTEM HAS BEEA1 INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROL1Ni4 GENERAL STATUTES, RU.L`ES FaR SEWAGE TREATMENT AiVD DISPOSAL,
�►IdD � ALL CONDITIONS OF : Ti;{E; ::IMPROVEMEAIT PEi2MIT Ai+11D CONSTRUCTION _ �
AUTHO TIO ' . , . � �
. . . . � � �. ' . . . : �, �j �� .3�� �. �. . � . . . �. .
_ _.. .
� orized State Agent. .. . . ,. . . ; , . _ . . . . Date � . . .
. . �� installed By: � � F--�Wt� , . Date: � . � ��`� 2 . . . . �- , , .
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�� ,�,rQ,, PCHD, rev. 07/29/02
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s��-�c �c iNs�E�c-no� �����s�- �z��e �a - n.�
Tax Ma� #� Parc2! # � Sysiem Type able V)
Owner/Appiicant S�bdivision �
Address/Location SeclPhase Lot #
Se�t�c �'ank n� a ate �tn catior� nes n�t�a ate
State iD/date
Tee and Flter
Baffle
Sealarrt �
Riser if applicable)
Tank Outiet:Seai
� Permanent Marker
, Pump Tank
tate
. Capa
. � ` Wate�
Riser
/Sealant
�dth �, ft-
Depth in.
Len4th � � �.� ft.
Grade � �
Spacing
�pth and Quali
�tepdowns etc.
+e.Laterals
Sleeve � -
�ups/Protectars `
equired Setback�
Water Tight � From Wells� �.
� Pump _- From Property lines
' ; �. _: . .Gheck Valve/Gate Valve: �_ . ... . . . .� _ . � . _ _ . � Structur�s/E3asem�r�ts
.-�-_ : Ant�-s� on o e . � r�c . es rama�e a�
�: � - - � � Floats/Switct�es '. � .. _ . . ... _ . _ .. . .. ` _.: .. __� .. . Surtace Waters -
Alarm visable and audible Pubiic Water Sup lies
Electrical Components Vertical Cuts �2 ft.
Rate gpm Water Lines
Approved Pump Mode! Vehicle Traffic
Blocic Under Pump
Pump Remavai Rope/Chain
Distri6ution System
Serial Distribufion '
Low Pressure Pipe • �
Aoar. Pioe Material and Grade •
Easements/Right of W�
Other
; Easements Recorded .
Tri-Partate
Cominents
pci�d rev. 3113/01
PERSON COUNTY HEALTH DEPARTMENT
325 SOUTH MORGAN STREET
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant C �� n''� p� atc. ��(J ��j � r� ►'1 c-�� i.5� � �
Address�,�ScU t � �C �� �, County �L�'S��1
Collected By
Date Collected �`'�-3 � v� Time Collected ����
Source: 1� Well ❑ Spring ❑ Other
Location: ❑ House Tap [�,Well Tap
- �10 Charge ❑ Charge
❑ Other ��n��,-�����'�
�l ��� ��
**�*****���*��****��**********�************�**************�*�********�**�*�***
*�****��*x**��*********************�**�****�***�****�***�**************�***�*�
Results
Present Absent
Total Coliform ❑ �
Fecal/E. Coli ❑ [�
Reported By _ ����-t�, ✓�'1�--
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