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A29 25Application Date: �, 7 AmountPaid: oQ. 0 U Receipt #: 1_ � �-�-�--� . -: Improvement Permit (Site Mobile Home Replacement or Building Addition $150.00 if site visit re uired) � Well Permi lacement/Repair) ��� i� ������ ..:..,... . r � � t�;-���t7 �� l� .TE'.�ra�a+$�',��aaaa.��n ]Hla�.si.11:�.11�. Services for Services Coastruction Authorization �Fee is dependent on the type of Permit Revision Tax Map: �°2 � Parcel#s �� pair of E�sting Septic System Applicatioa: No Chazge/ CA $ I 50.00 or $300.00 �� � • � • Applicant Information: Name: S � � . Address: 6 � 1 l�x 6 �� ,�, ��� s �� � 2) Name and address of current owner (if different than applicant): Name: � Address: � Phone (home): 3 3�- s y�-.S-L s y (work/cell): 33 � -Ss�3 -.�'� ��S Phone: 3) Property Description: Lot Size: � A�,�,ubdivision: . Lot #: Address and/or directions to Property: � 7� �j es �� r� r S�o �e 12�- ❑ yes �,no Does the site contain any jurisdictional wetlands? j0 ye� ❑ no Does the site contain any existing wastewater systems? 0 yes � no Is any wastewater goiag to be generated on the site other than domesric sewage? ❑ yes t� no Is the site subject to approval by any other public agency? Q yes Ga no Are there any easements or right of ways on .this property? (if `yes' is checked, please provide supporting documentat�on) 4) Proposed Use and Type of Structure: , . m�tesidential ' ❑ New Single Family Residence Maximum number of bedrooms: Z 1 Occupants: O Expansion of Existing System If expansion: Current number of bedrooms: � Repair to Malfuncrioning System Will there be a basement? 0 yes ❑ no With plumbing fixtures? ❑ yes �. no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: S� Water Supply: ❑ New well 0 Existing Well � Community Well ❑ Public Water � Spring . Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes � no Please note any known ground water restrictions or sources of contamination: 6) If applying for `Authorization to Construct', please indicate preferred system type(s): C� Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understaizd that if the information provided is inaccurate, the site is subsequently pltered, or the intended use changes, all permits and approvals shall be invalid. Y�? (Owner/ Representative*) * Supporting documentation required. �'� �-/7 Date o Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. ! 9�����ie±ed `Lo! Prear�r�tinr�' form must accampany a�y zpgl3ca.iom re�uirtng z site evaluatian. _ . . r� tn nnr n•.� n� ci__t.._ �.. , .+...+...��.. .�_' �_ '_'_' �� ti '. �w.. . S s 4 r�..�, y�. , i � �`: �, i � ' °'� d � �r'� � � '� t�t �, � a . j ..q`s�. ; �.,p�-�Cj �,� .� � ,� „.�+�'",.'� . . .. �2 „� � � ;� � °�� ,.-. . � �T �� �' ���� t� `� � {"� ...�...�*�^r""� `�•� fi � ` xt ; �' � �� � �� � � , � ���� �� ;`, � �� . � �,�g,��a . s v 1 � � '.. � . ' - � _� � R �e� �,.. �� . ` �y � . . t � �. ' ��� �'T.� . 1 �%' � � k 7t . .� ,�� �� � � � �T � d��� :. �. .����•j . e�'� � i �. Q ' � �ta . ���� �� Yk��_ �'' �'_ ��y � , �t �• � *� '� ,'��� � : � ..~� .. � i, '�t: � June 12, 2017 TaxParcelPublishing Person County ��� ,��� �� ��� .._. � ' �$ ���` /� •j � �i �� • � �� �� ' � I� . .. '� < ���+�1 �� '� �� �� � �e�'� � �� � � � i A � ., _. 9 ,� �. �b : � . - ��I x�� i � � ��`�� i�+�� �;' ' ��, :��.: �*� � �� a +! � ` ��.�`� + . . d .�.:� 'r � s � .. . . � � �� � .�� �.. �n� �� , , �f���r�� . , ��,� ��',4 ' S s �,A } # � � � �i i� � at f w'� �,�.:� �, ,. t.. " �u�' ^ S �, �,: . . 'a� '��a� g, �: � �4° I � g� � � ' � � � . � � -� - � '"� � '� � � . . �� �� � rn r �� �� .'� � f ' j' � k� � % � ' �, � . `. �` ' ' � 4 .�i "��;�c��- �� . '*a�� � Y�+ �� � � _ ��� -w Y, • s.�a��y.�x . . �,0 `� . � . . . .. � . . � � ��; . `,+�/� d� , , x> J � t. . �� ,� ""' 'x� ` ��Y� '���� .w� �� � � � �,; ,j�- �:t ��� �1 � � ..r�-,. �°` � � � , .: 44f � �k"� a i & `{�: , 7 Hy3'� � p�� : +1 _ A � .� �����7-i�� • _ � v ` 1:564 0 0.00475 0.0095 0 0.0075 0.015 Esri, Inc., Person County GIS 0.019 mi 0.03 km For Reference Ony -Always refertothe original source. Person CourKy is nol respmsble fa the use, misuse, or misinterpretalion of this iMormacpn. Tax Map: � Subdivision: ���.sf �I��.��� . � � ���� IE�rawa�ra�aa�a��ra�am.Il 1F3C�a.m.11 �l�a Parcel: � WELL PERNIIT (New� Repair_ ) Lot: Applicant's Name: � Mailing Address• � ,� , � Phone Numbers: .�'-�3- �'�/ � Location of Property: �7� f�Tt�2 5 ��� �GA _ _ . _ Permit Conditions: 1.) See attached site plan for proposed well location. 2.) All applicable State and County regulatiorts governing construction and setbacks apply. 3.) Permits expire S years from the date vf issue. 4.) Issuance of a permit does notg� rantee a potable water supply Other Conditions/Comments: ___ _ (�' r✓�_'� �L ' ..�.r l���l� ,�trJ'.�rO /l��'✓.� Gi�i���'l�ivZ��1/��' GrJlf�+.s1� fT! /5 $%� �lt.�Q/i�' Permit issued by: � Date: ONew Well: EHS/Date Location: �`�� Grouting: Well Log: — 4j.�,v Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: � Certificate of Completion � D[[,iner: EHS/Date Depth: g�.1�v�J ►Z-� Grout: ► ''�►<� �a 1 � .�.t,K ti�-1� ��gs ���� DAbandonment: Ct�l �j�- ?'�`� Date: � � .}.. �, � Method/Materials: Well Driller: � �.,,��� Pump Installer: �� Approved by: Additional Comments: Date Sample Collected: EHS: Person County Environmental Health 325 S. Morgan St.,Suite C Roxboro, NC 27573 License #: �����' License #: Date: Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 11/26/13 �'�� �,=,a�s s,v� �a . ?�l� �•�.• ,��g - zs- � �r=�'1'�' Person County � �-d8 9�. � I�, $� g7 `D .lune 13, 2017 TaxParcelPublishing �djtd�l� � - r �� . *� V��ZG �2��� Person County Env�ronmen#al Health 325 S. Ma�g�n Street Suite C Roxboro, NC 27573 �u��� ��E 32 37 � � zs-r.zti. /'��-b�l �:ssa 0 0.00475 0.0095 0.019 mi �-r � d---T—r i' i� 0 0.0075 0.015 0.03 km Esri, Ina, Persan Courly GIS For Refe�ence Ony -Always iefertothe aigirel scurce. Persm Caurty is not respmsble (a the use, misuse, a m'sinterpretation of this irdormacion WELL CONSTRIICTION RECORD llus fuin can bc �ed 6oc sn�te armWtiple wdls 1. Wdl Coatrador Informatioa: � � a ev�u � e � - �� �. , w�i co�K� �� �6-/� xc w�u ca�c�s�n H�� Barnette Well Drilling, tno. �,'N� .i3z9 2. �Vdl Constrnetion Permit�: � �Q� � Ltst all applicoble meR comtrucwn �nfa (Lc C�t+Y• 3. �Ydl Use (cheek wetl oseJ: �'Vater Snpply �1 e1�. DAgricutaual OM�un paUPubtic- ❑Geothecmal (Heatmg/Cooling SuPP�Y) �+c9dtahel WaiesSupplq {single) orRa�ui�m�+ QRcsida►rial WatcSnPP�Y ��) OAmufer fted��rga nGco�dwata'itan�a� QAquifec Sm�age aod Rxnvcrt� OSaliniiy Barria ❑Aquifa�l'est ��0���� QE�mm�l'Cec�nology O�� �Geotha�nal (Cto� ImP) �� - - - - a nace�aq:� com�aerea: g-9�/ 7 wdi'in� /4 Z 9 sawat � r�au;ro�c�'�'�� Faiotaml ike OHI.Y- 242s 295� � 2.S �'A' n � 6 i c5 fi �es feR s�Ac K.�- r��t na� �. �d z� p�e.�2.so/� �. cow�q� I PaoaTde�i6�onNa�PIM Sb.I.atitadcand La�dein d��sKoadsaar deei��t d�ee� (ifwelt Sdd, ooe ladloog +s m�aaoc) 36 ►• �s��C�S� N ?9 •n�'2S�i �► � , 6 is (an) t�e�Cs� �ernaaent °r OTempera� 9.Isthis�a;epaie'toanc�stingwdL• QYes or � themtmeofilx �thfs7sa`�epatr.l�a�tlaro+sermllavrmrmcidw+L�a�► � repctrrmder&II rar�lattaton orme r6e6act�ddsfam. 8tihamf�ecof�Tswastrnct�d: � - For.mdttpfe tr�ac�000r��Y�rOJYLYwBkibesmata�3'�+� srrbadrmeelam. /� 9 Total4�dldcpW bdow[aadmtfarc ! -U� �tt) 13r�o u+�slrvoltdepda fl� f�e`�°' °���10� 10. Sta�c waterlevd 6elow Wp of as� 2- � ��7 Ifxatcrkoe[isa6oreo� � -}' I L BortGGolydiametec: _ V- C�-i IZ Weil conshvcfion me8iod: /' / � t� � �r, �, a�eea�, �-1 r� R a Q 6'i� �- Sc�R z. ��P ��- {4 ft iO- � � 3n. �- Z(� � � � � � R � � � �� - � r�tT'.�l�1�1�l.] Z�� s� � so� oQ 7 O'� � � � n ! iz � � nc� ` 8� �� j 7 ��� � ,�„�� � ������ �� � �,«� ,.�' ��"�.'�- �Er t �rbcreII(s) (�+t) xldrlSiNUC01CAl�orTSAHG[COIC.QI00 iPell Ca��m�thara eopyof�s{eom+tfior6em�rav�adm drewdl mmer. ?3�. Site �iag�a� °rsddd°°atwdt d� Yon may u� thc �adc of $ds pa�e to �O°'de a2ditiara7 vxll ste daaz'Is or well �m� ddetls Ywtmay slso � additional ���}= SUB113TlTAI+�R'UC�'��� T,4a, For !W WeUs �Snbffi this fccm wt�lim 30 days af aa�P1� �v�xil �fbex�iicwib� DivSsiOaofNatcrQuardf,Warmati � � � I617D�ait Sm_ice Ceatex', Rsl�gb+ ?�4L. For Iuiee6a� Wdt� Tn � to � d�e foao �o tbe addtess ia?Aa abpey atsu 3u6mtT g caP9 of dus fam vvithin 30 �ys of �°��vueli e�ad�mmthe� lk�iou e� Wat�x Qua4�Ya IIu�«'g�d �j�� Ceabd Pt�m, � ic�ea�as«:�c�,�.rtcrr��s FOR'�irATBR SUPPLY�i'ETdS OTiI-Y: . ,Z� ?AcRar1t'aterSsm�+aclnieclian�ifdl� Taaddit►�m�S�f�tto � Metlwdoftat B1oW�120 t�tiil the addce�(es) abo4a. aL90 snbmrt � oc�q of dsis fas� wiifim 3Q days oi 73a. Yidd (gpm) - �� � wdl w�� �o du eo►miY beatU' d�� of the w¢�+tY � �� 112 Cup �� 13� D;sinraaon t�c HT Nat6 Cmo1'm � � aodi7atm[ Ruom�s— Di,�owo�w�uuQmGcy Rar:ttdha.ml3 ` . — _ _ _ ------- - - _ .