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Apoiication Date: '¢ ���� I . + TaY Maa #: �� �
Amount Paid• D �'` � � �a�
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,� APPLICAT70N FOR SEi�VIC�S �
IF THE INFORMATION 1N THE APPLICATION FOR AN IMPROVEMENT P�}2MIT IS 1NCORRECT FALSIFiED
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME fNVALID. -
1) Permii requested by:(Ownerlagerrt/prospective owner):.��D�/� �e�o "� `T�
Home Phone: .597 � 3 6 7 o Address: o/ 7 f�:��G� 7`0 � o�
Business Phane: ��c /�y>2 a , C �7S7S�
2) Nlame and address of carre�rt owner. � P
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3) Property Description: Lot size: ��C Township: �,� Subdivision: Lot#
Directions to the property (Induding road names and numbers): r9�� 5�9. Soc��-s� Adn�T /
�iLe r»i �e�'r yY G.�r�vGd �e 3,Rd o.+� /�,F'r
,-9fT�R ,lJ�ts s �rv�. _ ,.f�s.�e � G.L c7AXLe j/
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4) proposed Use and Structure Description: answer eact� of the foilowing questions: %� �
a) Pro'osed ✓, Existing Tyre o� stn,�n,re: ane Width: � Depth:
b) Number �f Bedrooms: � Number of occupants or people to be served: �
c) . Basement Yes , No � Will there be plumbing in the basement?
d) �arbage Disposal: Yes . No �
5) Water Suppiy Type; Private �✓ (new _ or existing�, Pubiic_, Cammunity , Spring _
Are any welis on adjoining property? Yes�No _ ff yes, please indicate approximate locatiori on the
�site pian. �
6) Does your property carrtain previousfy iden 't�f'ied jurisdictional wetfar�ds? Yes_ No �
PLEASE NOTE THE FOLLOYVING:
➢ A PLAT OF THE PROPEi�TY OR SiTE PLAN MUST BE SUBMITI'ED WITH THIS APPLICATI�N.
➢ PROPERTY L1NES AND CORNERS MUST BE CLFARLY MARl�D� •,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE ST�D OR Fi.AGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEiVT
STAFF. �
I hereby make appiication to the Person County Health Department for a siie evaluation for ttie on-site sewage disposai
system for the above-described property. I agree that the cantents of this applicatio� are true and represent the maximum
facilities to be piaced on the property. I understand if the siie is altered or the intended use ct�anges, the permit shall
become invalid.
or Legal
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Date
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Applicant: • A) u�2
Location: yq S �
Ta�x M��� ' Parcel # - -
S��i k� cl'ivi�5�i o ia
Fh•���se Sectiom Lot u
Improvement Permit
Permit Valid for E/ Five Years No Ezpiration
Type of Facility: �i' �.,.�t. ��4-4: New ✓ Addition Water Supply „t„o
# of Occupants �.o.X # of edrooms 3 Projected Daily Flow 3C�o g.p.d. �
Proposed Wastewater System: C,�x.,,t„�-� � . Type: .�:Q
Proposed Repair: 3���.$•�� C'�s % c��.w� -- ,�-ma.,, ha� ,w ��,,.� Type� � .
Pernut Conditions: ��n.�a.h ��ra�s, ���c� �a.�.�- s�is�er� n,-,`�- ��`E,s�Gla�w
� . � . . .... , . „ . ,
Owner or Legal Representa�i,ve Signa �' �- Date: 5-/ /� v�/
AuthorizedStateAgent: ( Q � Date: +s-�v-cx/
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Bu�ding Inspections requirements are met This
Improvement Permit is subject to revocation i# the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownerslup of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewa�e Treatment and Disposal SYstems' (15A NCAC 18A .1900). 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 w�11 remain
potable.
Autho.rization to Construct Wastewater System tRequired for Building Permit)
* See siie plan and additional attachments (� ).
Proposed Wastewater System: (�...,,��,.-,,,� Type �_ Wastewater F1ow3C� g.p.d.
New � R�air Expansion _ Soil LTAR: '� , a�5 g.p.d./ ft 2
Type of Facility:2si� �...1�, �b�Qt;,,,�, __ Basement _ Yes � No -
Wastewater System Requirements
Size: Septic Tank: /ovo g� Pnmp Tank: r gal Grease Trap: -- gal
field: Total Area: �'3�� sq $ Total Length �rUc� ft Ma�mum Trench Depth � in
Trench Width � ft Minimum Soil Cover: �_ in
Distribution: Distribution Box � Serial Distribution
Specifications• l\AQ,rn�. ��z�t`� Q� � A�- �l (�
Authorized State Agent:
Permit Expiration Date: �-I -
Minimum Trench Sepazation: � ft
Pressure Manifold
Date: S-I�-w
The type of system permitted is �_ Conventional Innovative Alternative. I accept the specifications of
the permit.
Owner/Legal Representative: Date: 'S- ! /-U �%
PCHD7/30/2002
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Subdivisi� • � Se�tion/Lot#
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WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map � aq Parcel # a� 3 - Township: t�. v�c1,u ��
Applicant: Att��� roel�,�., '�
Subdivision: Lot #
Location: uq s� 3`= �•v� �• � n�S�- ��� 9�;5 T�
Type of Water Supply: ✓ Individual _ Community
Requirements:
Site Approved By: �/�-� t �_ �8 -��1
�'Pa" � � Grouting Approved By:✓e�3 �-fF�-�zl
Well Log: C�� f�-1F�c�.�
Pump Tag: ✓ CS
Well Tag:
Air Vent: Q-a9-t�(
Hose Bib:
Casing Height: �
Concrete Slab: ✓
Public � I / D
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Liner: .
Installed by:
� Depth set: _
Grouted: _
Date:
Water Sample:
Well Driller: i���1c;4, �,11 ��r.s.y.
Well Approved by Date:�! -Z-�'��
****See Attached Site Sketch****
Wells must be 10 feet from property lines.
��Wells must be 100 feet from septic systems. �
Vells must be at least 25 feet from any building foundation.
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Other conditions: J�n I(�.� s, h s l.� �c,�. �k�goQ ,
PCHD rev O1/27/04
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Grout Log � .� Q
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Owner: Tax Map � Parcel # ,�
Locarion• SR u 9
Subdivision: Lot #
� Well Construction
Distance From nearest Property Line (Minimum 10 feet) �
Distance from tic System (Minimum 60 feet) •
Total Depth: � ft Yield: 2.0 GPM Static Water Level: c3�0 ft
Water Bearing Zones: Depth � ft 115 ft ft ft
Casing:
Depth: From � to � 1 ft. ' Diameter: � in
Type: Galvanized Steei t%--
Weight: Thiclrness: $� Height above Ground: �2. in
Drive Shoe: Yes No Any problems eilcountered while setting casing? _Yes .�No
If "yes" give reason:
Grout:
Neat: Sand/Cement � Concrete GraveUCement
Annular Space Width �_ inches Water in Annu�ar Space Yes � No
Method of Grout: Pumped Pressure Poured ✓ Depth �_ toZQ_ Ft.
Materials Used:
No. Bags Portland cement ��eight of 1 Bag � Pounds
If mixture (sa , gravel, cuttings) —Raho 2 to �
ID plates: ` Yes _ No 4 x 4 slab _ Yes _ No
Liner:
Depth: Date Installed: Grout: Installed by: _
Drilling Log Location Drawing
From To � Formation
I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth
by the Person County Heal Department.
Signature of Contractor
� ID # Z310 Datc� � — (, 'Qy
Pump Installment •
. ,, -
pump Installation Contractor: State Registration Number:
Pump Depth: ft Static Water Level: �
Pump Make & Model: Pump Size and Rating: hp gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of this record has been provided to th�.well owner. .
Pump Installer Signature D�te: PCHI� rev O1/27/04
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Applicant:
I
Ta�x M�p �' F�rcel #
Su�bclivision
Fhas�e Sect�ion Lot #
# of Bedrooms
Operation Perm it
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND A L CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHO TIO
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Authorized State Agent Date
installed By: j��-cv� S Date: ���o`i
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MAR-21-2012 11:57AM FROM-
Applica6on Date: 3 �23- I�
Aroount Paid: 7 .00
Receipt #: � � � 1 %�
C�'�.-� � �'� 3,
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ilication for Services
SenFices Requested _ _
0 Improvement Permit (Site Evaluation)
$200.Uo/$300.00 (if> 600 gpd)
❑ iNobile Home Repla=er_ient cr B�ilding Addltion
$150.00 (if site visit re uire�
Well Permit (New nt/Repair) ,
$300.00�$zoo oor$�s.00 �� N e 1�
� Construction E►.ucnor�
(Fee is dependent on the
❑ :°crmi: iteviuon
$75.00
T-854 P•001/�O1 F-89T
i ax iv�ap: A�. 9
Parcel#: _��
�ux �
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of svstem permitted)
❑ Repair of Esisting Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Infor 'on:
Name:
Address: � /
N
2) Name and address of current owner (if di erent t6an applicaut):
Name:
Address:
3) Properry Description: Lot Size:
Address andlor dicections to
erty:
ision:
Phone (home)• �� ��J7����
(work/cell):3�1. �9 _7.��`�
Phone:
Lut #:
yes no Does the site contain any jurisdictional wetlands?
.�yes boes the site contain any existing wastewater systems?
❑ yes no Is any wastewater going to be generated on the site other than domestic sewage?
O yes �C1 no Is the siee subject to appr�vai oy any other public agency?
0 yes .e( no Are there any easements or right of ways on this properry?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Rcsidential
� New Single Family Residence Maximum number of bedrooms:
❑ ExpacLsion of Existing System If expansioa: Current number of bedroams:
�P_epai• t� r.�alfi�nctiocir:g S�stem Will there be z bzsem4nt? rJ' yes � r.o With pismring fixtures? ❑ yes ❑ na
�Non-Rcsidential
Type of business: Total Square footage of Building:
Maximum number of employees: Maximum number of seau:
5) Water Supply: ❑ New well �Existing Well � Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on [his properryl ❑ yes ❑ no
6) If appl�ing for `Authorization to Coastrucl'', please indicatc preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative � Alternative ❑ Other ❑�Y
I cert� �hat the information provided above is
inaccurate,� if the sice is subse,quentiv alrerec
Signature (Owner/ Legal Representative*)
* Suppnning dacumentation required.
plete and correcl. I also understand that if the information provitied is
the irttended use changes. Qll permits and approval,e hall b invalid.
, te
�ermits are valid for either 60 months or are non-expirit►g when accompanierl by au approved plat.
A completed `Lot Prepara�ian' focm must accompaay any application requiring a site evaluation.
110�111 Persqn �Quntv Lnvironmental Health. 325 S. Morean St.. Suite C. Rnxhnr�. N(: 7.7573 (33h-597-174f1�
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WELL PERMIT (New Repair� � � u� �
Tax Map: � ( Parcel: �" �
Subdivision: Lot:
Applicant's Name: /� l� �►Z R �� �S ��
Mailing Address: �
Phone Numbers:
Location of Property:
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 from the date 9f iss� Sc��w�
Ot� er Co�nditions/Comments: � Q � 1 0 cf � � G2 �
/r vt ��'' °�v� o �-� �' ►� �c��-►'�t -
Permit issued by:
�°.
�'''�'�- Date: 3�2 3�/ 2
CERTIFICATE OF COMPLETION
New Well Inspection:
� EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Liner Inspections
S/L�ate
Installer: ' q' ih (�ff �� ����� ��
Depth: '7
Grout: ' za z
Well Abandonment:
EHS/Date
Completed:
MethodlMaterial(s): _
License #• '
License#:
Date:
Date Results Mailed:
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
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