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)
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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
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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.
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June 12, 2017
TaxParcelPublishing
Person County
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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:
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Parcel: �
WELL PERNIIT
(New� Repair_ )
Lot:
Applicant's Name: �
Mailing Address• � ,� ,
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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:
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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
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Person County Env�ronmen#al Health
325 S. Ma�g�n Street
Suite C
Roxboro, NC 27573
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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: � �
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Barnette Well Drilling, tno.
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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-
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QAquifec Sm�age aod Rxnvcrt� OSaliniiy Barria
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