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�"" " ' The District Health Department
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CASWE�'L - CHATHAM - LEE - PERSON COUNTIES
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s Water Supply and Sewage Disposai
IMPROVEMENTS PE MIT�_
Date
����� Owner: V
0
� . pq Location: —
p, Contractor: �� t—��+�1i �
� Water Supplp: Privat� ��blic
Sewage Disposal Faciliiies: No. bedrooms Dishwasher, Disposal,
washing machin er sutomatic appliances
i
Size o! tank: NitriBcation line: �
... � _ �
Other disposal facility: `""'" "- - - �' �'�
On � `
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations. �
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:
Well:
Sewage Disposal:
By:
Certificate of Completion �
Date Approved: " �-:� B .
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
� OTE: a e
� supplies, etc.
at later date.
: cu ��,�AL
r�
w
N
f insta a ion showing lot size and shape, location of house, septic tanks, privies, water
al problems existing on lot. Write in measurements in order that installations may be located
tion of water supplies on adjacent lots.
c2�
=r�:��.:�ti�a ��.#e: � I I 7 7
Amount Paid: _� 0 . o
Receipt #: 3Q�
0 Improvemeut Permit (Site
❑ Well
Home Replacement d�r Bnilding Addition
$300.00/$200.00/$�75.00
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~•►•��J Parcel#: �
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]E�.�s�������.Il IE3[�.m.Il�
Services
for Services
0 Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
❑ Repair of Eaisting Septic System
Application, No Charge/ CA $150.00 or $300.00
. 1 Applicant Information: �
Name: �ru n k; � u n e�� ti� _„
Address: ��� I ����tis �rn
2) Name and address of curren�ow�r (if dit%re�t thaa applicant):
•;
Name: a ��Q r�. -r< s!� � c� e,,ti,.,,d`
Address: SZ z I L� ur � f�m
� o X c� , /��G .�2 7��
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
Phone (home): 33b � ° `� `�� G �'
(worWcell): � � r �
Phone: 3 3� S o f �%D /
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
� yes ❑ no Does the site contain any existing wastewater systems7
❑ yes ❑ ao Is any wastewater going to be generated on the site other than domestic sewage7
❑ yes ❑ no Is the site subject to approval by any other public agency? I_ ���k
❑ yes ❑ no Are there any easements or right of ways on this properiy? S�j � �� � CJv � �
(if `yes' is checked, please provide supporting documentation) �/
S � Z� r� �D ��f-
4) Proposed Use and Type of Structure: r �� SD�+�'f"
OResidential �
0 New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ 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
ONon-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: � New well D Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing welts, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any knovm ground water restrictions or sowces of contamination:
' � If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventiona( 0 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,�site is subse uently altere , or ' ended use changes, all permits and approvals shall be invalid.
� ��z� p �u� /l-�?-l7
Signature (Owner/ Legal Representative*)
'� Supporting documentation required.
Date
Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
A completed °Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N��27573 (336-�97-1790)
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Building Additions/ Mobile Home Replacements
Tax Map #:�2 _ Parcel#: Z Address: 5Z2 ) Bur(�;�a4�,,, �d•
. �XYfl�YG NG � 1 �J�'7
Approval Requested for: Mobile Home Replacement
�uilding Addition
Applicant Name: �ir�nK�� D une�,�r�
Address: 2 u d,
� o�xre ►.1 C, Z� Sl �{
Phone #'s: �,3�- Sb�i - N102
Permit Located: ✓ Yes No
Installation Date: 3- 22-8' Design flow: 3CpU (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: v Well Public or Community
Wastewater system shows no visual evidence of failure on: �l - 22-I� (date)
(Applicant's signature if site visit is not required)
Comments:
Addition/Replacement Approved
�
Enviro ental Health Specialist
/! - ZZ-/,
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net
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Building Additions/ Mobile Home Replacements
Tax Map #:� 2.� Parcel#: �
Approval Requested for: Mobile Home Replacement
��Building Addition �
Applicant Name: '�
Address: " 221 t ' id�
c� 2757�I
Phone #'s:
Pernut Located: V Yes No
Installation Date: 3- ZZ -$+� Design flow: �IT (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: v Well Public or Community
Wastewater system shows no visual evidence of failure on: o—�Z- �� _ (date)
(Applicant's signature if site visit is not required) .�' _
('.nmments�
Addition/�2eplacem�nt Approved
� .� �� —lz-��' .
Enviro ental Health Specialist Date
11/15/OS
Jun-20—01 07:44A
�mour�t Paid• ��— �
Rscsl !: �—
Psrson Countv H�a1tA De�ertrnent
. . : Erviron�asntai H�skh Sectloa
�
�p�owrtfel7b PlfA1tl - 5100.00
(MoblM tlams R�wrUlddltlon)
�) i�ORllft by •
Hane �`39-
Bus! Pt�ons: �
z) Name ari�addnas �
3) Froi�h► Dac:tpqona
Dirsdlor� to th� P�aPE
d)
�� u•. a� s�
a) Propc�ed �, F�stln9 �( _ .
b) StlClt suilt �f�AOduler Q, �i�gl� Wlde 0. Doubte Wldp �
c) Number of Bedrooma: ` • � Numbsr oi occup�trts or people to be s4fved:
e) 6asert�ar� Yea O, No �.If # cf bassmant Podur�as. ,
fj � G�u�sps. oispoca�: Yns , `;� a _ . . . . . . . . .
B) �imec�ians of Proposed 3ttu�urie: wWth ,,,_,_, Depth; . .
d. . �� y� � ' _
Insp�cllon -
0
P.02
T3x Man �h. �� �
Aarea! i�: �
5} Wat� Supply Typ�: Prlvate �sw q or e7dsling p� Pubtic D, Cotnmu�ity 0, SpNng 0 i� m'� ��"� �'Y`�"'`'m
Ar� any wdls un adjoining property7 Yea Q-Na p if yes, iodion $�r�S �� D ti �a :�
Q) Pleaso l�dkats C�lrsd Sy�tarn Type: (sysbms can b� rankad in ordar ot yout prsferenco)
✓Caawntionsf ,ModM�d ConveMtonal _ Albomative _(n�rativa
Oth�r (apKl[y):
C�ARLY �TAK6 AL� CORNFRS AND UNEB OF THE PROPEHtTf.
3TAK� THE CORN�RS O� ALL PROF+OSED STRi1CTLIRES.
P{.EA9E A7TACN SURVEY PI.AT OR StTE p1�W Tp THIS APPUCAYION
t hereby rt�aice �ppiicetiqn to tt18 Person Caurity Healihh Dq7a�rtrnant ior a sita evaluatlCn tnr the an-site sewage dlsppsai system %r
fh� abave-dascxib�d P�'oPoli►• � a9ree thst the ca�tenis ot thts a�plication are Mue and repressn!'the maximum facilitles to be
placed an the Properhr• I tptderstand if ttle aite is Altsr� or the i►ttanded �e c���nqey, the pertnit shsi! became invaltd. I unde�sta�d
�$t � aPPM�attt. t arn rosponslbb for iderrtifying and meriting property liaes, cornara and makltig tha site accsasiWs fw the
� n°� °� �� p�� ��Y � �ps+'tmsnt to candud their ev8luadons. I understand thet ! am resporisfbte far na�fying the
�e ��� ' �rty ins any wettands as deaigrta�ted by the Arcny Corps of F�gi
� �zop
Ovmer or Representative fl�
PcHo, �. �a�tiss
PERS�R9 COUNi`� �s�VIR�NNIE�IT�►L HE:4L�'H
PL�S� S�� �i�;�C�3Ei3 Pl�a� FflR WE�L S1TE LA�OU�'
Tax Map �:
��� a
ZoNng T���P
APPlicant
LocaUon:
i
Subdlvisia� Sectton: �
Well Permit �
Tvae of Water Suaalv: Individual Community Public
Reauirements•
Site Approved
Grouting Ap ov by ��' l
Weil Log
Well Tag
Air Vent
Hose Bib
Concrete Siab
WeU Driller•
Well Approved By: � Date:
.
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
Vjlells must be 100 feet from septic systems. .
Weiis must be �at least 25 feet from any building foundation.
Other conditions: �-�� � �'�5� �� � � �- Si .�
�� I S �,�` (�e � �� s� [1
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� � PCHD, rev. 11/29/99
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: '
Owner.
Location/Directions:
SR#
Subdivision Name: Lot #
Drilling Contractor:^ we.�� � ��-�� � ��
� WELL CONSTRUCTION
Distance from Nearest Property Line 1 v Distance from Source of
Pollution ( G o
Total.Dep.th: Ft. Yield: 1� GPM Static Water Level a.S" Ft.
Water Bearing Zones: Depth 1Sd Ft. Ft� Ft� Ft.
Casing: Depth: From CS to�.��_Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
� Weigh� Thickness:�. '� Height�Above Ground: 1�i Inches
Drive Shoe: Yes ✓ No �
i
Were Froblems Encountered in Setting the Casing? Yes No � �
If "yes" give reason:
Grout: Type: Neat Sand/Cement / Coricrete
Annular Space Width � Inches
Water in Annular Space: Yes No
_ .. Method: Pumped - Pressure � Poured � - � � �
Depth: Fr�m O :.o a C� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixture (sand, gravel; cuttinas) - Ratio: to
ID Plates: Yes � No � � �
4 x 4 slab Yes i No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�'vi�ITX HEALTH DEPARTMENT.
. �
� al__-
S� ature oF Contractor Da c
NnT FnR i rr.e i iicr .,_ __ __ ,. . .....
����,� r«C �,��
� �,���-���d
�e��n ��un��y �nvir���r��ii �i�i��
325 S. Morgan Street
su�e c
Roxboro, NC 27573
� c='— - / �
��,
11 2Z-(�
11/22/2017 i1fU i r Uk ���wL U5E
Feet
0 90 180
0 0.015 0.03
Miles
N
A
270 360
0.045 0.06