A29 228Application Date: %��i �
Amount Paid: —� 0-�0 ,00
Receipt #: � �f
v,��"a.�IJ�Z A
0 [mprovement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Buitding Addition
$150.00 (if site visit required)
0 Welt Per)uit (New/Replacement/Repair)
��� ) f Jl �Jl\l��l �y Tax Map: ./4��
.__.,.�•� Parcel#c �
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IE:�ca�*n.a-�m�axa�.2a.Qi�.11 I�-3la�s.ald;!En
tion for Services
Services
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $ t 50.00 or $300.00
"1) Applicant Information:
Name: G�.C� �, �n� � � S
Address: -P_/ Q
S � %� � 5� o
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): - o� g�P- �aa�7
(work/celi): ���� — 31— G7 7 �
Phone:
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: �Plf p( S �-e r.�-�
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
0 yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
� yes � no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
�esidential �
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? 0 yes � no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential � e T �^ � ��
Type of business: Total Square footage of Building: q�rc�
Maximum number of employees: Maximum number of seats: edrpoM�
� � �� �
5) W er Supply: LrYNew well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional 0 Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I 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 subsequently altered, or the intended use changes, all per^mits and approvals shall be invalid.
Q d�o�G � �a`^ ��v Z y, Z� ��
Signature (Owner/ Legal Representative*) Date
* Supporting documentation required.
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)
: 1
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Applican�
P�r�vit �alid %r
Type of Facility: .
# of Oc�upants �
Proposed Wastew
Proposed Re�air:
Permit Conditions:
�S
T�x fV1a�� ' � � �rcel tt •
SUIbC��iVISIOtI . �. � ' � ��
Pha:s�e:Sect+ion.'Lo�t � '
/ Yffipraven�ent �ermit
�'i�j e � IYo �zpiration /
J�tp �Si�or�� �New V Addition
,� # of Be�}rooms Projected Daily Flow �(
SySt�: ��-��c�e , [`z. :�{� .�,r. c%a�,b�Y�
Owner or Legal Represe
Authorized State Agen�:
�ater S�pp�Y �
g.p.d.
Tyge: �r
TYPe• ,q
:J
The issuance of t}ris pe�mit liy the Health Departmesrt in does not g+iaran�ee the �G��A*+�r of other p�. Tt is the responsib�ity of the
aPPli�P�Y owner to in sure that all Persan Coimty Pianning and Zoning and Bu�ding Inspections requnements are met This
Ymprovement Permit is subject to revocat3on if the site plan; �pl�t''or� the intended use changes. ahe Improvement Permit is not
a�ectesl by a chan.ge in owner"ship of the propefty. This permit was issued in complianca with the prnvisions of the North Carolina, .:
'Laws and Rules for Sewac�e Trermnent and Disnosal Svstems' (X5A NCAC 18A .1900). Neither Person �ouuty; uor�:tli�` "� �
Environmental Health Specialist warrants tttat the septic tank system w�t cantiuue to fnnction satisf�ctorily in the futnre'or:tbtaf .
th�water supplp w71 remain potable. . .
� Autlaorization to Constrnct VYastewater Spstem (�equired for Bw'iding Permit) �
* See site plan med additional attachments (_). . . -.
/ � .
Proposed/�astewater Syst.�m:� n��v..,�� (� Z. �aw �,,- ��a,«"�''�''i�,.pe �� Wastewater Flow 3(�D g.p.d. .
'on I � • Soil LTA�: , �� . .d.! ft 2
New V R.epatr Expa� _ . g P
Type of Fact7ity: r; �, QSi � e nC� � � Basement _ es _ No
'qVastewater �ystem Reqiairements
'iank Size: Septic'�ank:� DOd gai Pnmp Tank: '—gai Grease Trap�--�'gai � 1�`*}
I�rainfield: Total Area: I� 8 sq ft Total Length i¢ f� ft
Treac� Width 3 NYin�nm Soil Cover: �_ in
IDist�ibntion: � l3istribution �oz � Serial �istribntion
��Q 'Aa i� _
' N.�a�mnm TrencL Dept� j 2. �n �
M'inimnm Trea►cin Sepazation• 9 � �#� � �
Pressnre lA�anifold
Spe�i�ications:
The type of system permitted is Conventionai �/ Acc�te3 Alternative. I ac�ept the specifications of the
p� ��a/.�Ir.rw l i�t�i�'�
�e�l���l �Epa'�sea�tave: �� � D�-' Date:
' pCHI� rey. l l/10/45.-
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Name �c�� (•hn'sfo Q Taz Ma #�q . Paxcel # 22
a d a vi S � i�
Sub . • Secti.on/Lot#__1.�____
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utho�ized State .A.gent . � Date .
System cumponen�r neps�erent apptnacimr�ta�contours only: The coniritclor must, fl'ag the system prior to .
beginning the rnrtaA�'ion to i�sure that propergnrde is maintained
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Tax Map �_ pazcel # 1� Tbvvnship;
Applicanf: �Saac �r-it�nn�ipr� %Qvi
n--,- �--� -
Type of Water Supply: _�dividual _ Community Public
Ytequirements:
Sita Approved By: _ �'jL' l�/�b���
Grouting Approved By: �,� ; /���
Well Log. —,�iG //fio f i� 7� .
`�P�P Tag� .
Well Tag- _ E�AS ��� ��—�
Air Vent:• —`— �
� Hose Bib: �
Caeing Height: v '
Concrete Slab: ,� S �I 43 1 ����,��r,,�,�
Linar:
7nsta1led by: _
Depth set: _
Grouted:
Date:
Water Sarnple;
Well Driller: `V�����s,_.}- �Ir..�ti.,-.�.�� g,�►�.� ►�1 C-� � 01 ��„��a N�
Well Approved by;
****9ee.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 %et from any building foundation.
Other conditions:
Date:,
PCHD rev 01/27/04
WELL CONSTRUCTION RECORD
horth Carolina - Dcpartment of Environment and Natural Resources - Division of Water Quality - Groundwater Section
��'ELL CO�TR,�CTOR (I\DIVIDUAL) NAME (prinq _ WILBERT TONF.S
CERTIFICATION q�9—j�
��'ELL CO�'I'R:�C"1'Olt CO�iPANY NAME RANKIN WTT,T.TAMC�IN ��[`n _ pHONE M( )
S'fATE ��'ELL CO\STftI;CTl01 PERMITq ASSOCIATED WQ PERMITk
_ (ifapalicablel , . .. .. .
��'ELL USE (Check Applicable Box): Residential O MunicipaUPublic O Industrial O Agricultural ❑
�fonitoring ❑ Recovery 0 Heat Pump Water Injection � Other O If Other, List Use
2. �VELL LOCAT ,p
Ne r st To�vn: �n� � County c�%1t�
'� E o
ISucct Name. Numbers, Community, Subdivision, Lot No., 2ip �ode) •
3. 01VNER. rl�� �
Address " V -
— �r� �_ISir,�e,eTt or R`ou't; N,o.)1 _ ► /` . � �D
W� 1 V 1 W� ►�► 45
Cny or Toµ•n Scate Zip Code
� � i
Arw coda Phone number• ' � � �
-�. DATE DRILLED � �" 6" l�I
�. TOTAL DEPTH:_ %D'
6. DOES WELL REPLACE EX[STING WELL? YES O NO 8'
7. STATIC WATER LEVEL Below Top of Casing: �_�,
8. TOP OF CASING 1S 1 FT� �Use"+"ifAboveTopofCasing)+
F7'. Above Land Surface
•Top of casinQ terminated ador below land surfaee requfres a
��arlance In accordanc Ith 15A NCAC 2C .0118.
9. YIELD (gpm): � M THOD OF TEST AIR BLOW
10. 1ti�ATER ZONES (depth): __ �5--1� --'2�5p
1 l. DISINFECTION: Type Amount HTH
l2. CASING: Wall Thickness
From " 0 DeP� ' Diameter or WeishdFt. Material
_ To� Fc. 61 4 SDR 21 PVC
- _ From � To Ft.
From To Ft.
13. GROUT: Depth Material Method
From� To� Ft. CONCRETE POUR
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. ��.
From To Ft. in, ��,
I5. SAND/GRAVEI. PACK:
Depth Size Material
From To Ft. .
From To Ft.
I6. REMARKS:
Topographic/Land setting
❑Ridge OSlope ❑Valley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrces/m inutes/seconds)
Latitude/longitude source:OGPS�Topographic map
(check box)
EPT • DRILLING LO�C,
From T Formation � ��
- - • "R�D � �3 ��y
' �� r'
�.�z� . � x�:
�� . �.--_ �
I.00ATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. lnclude the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WF�LL
CO�'STRUCTIOh' STA�DARDS, AND TJ-!�T A COPY OF TH1S RECORD HAS BEEN PROVIDED TO 7'HE WELL OWNER
/ N 1 _ N r'f
SIGNATURE OF P
CONSTRUC'tING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
?7699-1636 Plinnc No. (919) 733-3221, within 30 days.
. GW-1 REV. 07/2001
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IE�-�a-�������.Il IHI ��.Il�l�n.
Apglicant: i sHac, G�R�s�v4r�t. DA�►s
Lacation: y9 5. � PArr Hw�c 4�,ot,. .
---7 Qo„�zo� .��\
a�
��1��°�.t1011 �G'�'illi.t
_._____._.�.�
Tag Map fla`1 Parcel # ��
Subdivision ��wsTv�. Fs�v�^6
Phase/Sectian/Lot # 1 f!
# of Bedrooms 3
i��c�S 5
System Type (From Table Va): �� Product (IIIg): �Z- �w
Type V& VI Expiration Date: — Type V& VI Renewal Date: —
This system has been installed in compliance with applicable Narth �arolina General Statutes, Rules for
Sewage Treatment and 1Disp�sal, and all conditians of the Impravament Pea�mflt and Gonstruction
Authorization.
�.�ctw�, A_ sM,�
(.4uthorized Agent)
M�c�At,Z.. ���v�S
(Licensed Contractor
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Scale ir'S
PCHD, rev. I2/14/12
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(Date)
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(Date)
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Tax Map: A�q Parcel #: a a$
Septic Tank System Checklist (Type II-I� Systein Type: �IS. E,
Se iic Tank IniiiaUl?ate
State ID & Date: S'�'�-3�. p� �� �
ia--11-1
Capacity: �j�5-tioap
Tee ana filter
Ba.ffle
Vent v
�Riser r1
Outlet boot p,t� 1i �. t�-
Perm. Marker
DistributiQn
D-box levels set) --
Senal �s �� ►a- 1
Pressure Manifold ----
LPP �--
Notes:
Pump System Checkl�si
Pum Tank InitiaUDats
State ID & Date:
Ca acity:
Riser (6" min.)
NEIVIA 4X Box
Model:
Piggy back 1� ug
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressur� Manifold ^�
I�'umber of taps�� __ _
Size and sch:
Contracted Certified Operator (Type IV Sysiems):
Notes•
Tank Co� onents InitiaUDate
Putup model:
Block {4")
Nylon retrie�al rope
Float tree and attachments
On/Off float swing: in. j
Alarm float (6" se arat�o�)
Anti-siphon hole
Check val�re
Threaded ur,ion
G�te valve ^ ~
Conduit seaied
Outlet sealed -
A prov�d and secured riser
S� 1 � Line ;
Size anci material: _ in. sch. j
Length: ft.