A29 286�pplicatiaa Dat�: �-I �g � 7'�'Ij
Amount Paid: 00 , Ov ��'O.bo
Receipi #: � 39 i 3'� q� 3 4 Z�( l
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iax P�Iap: �
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C.a� Appli�a�ior� for �ervi�e5
Services Re uested
Improvement Permit (Sit� Evaluation) 0 Construction Authorizatian
5200.00/�300.00 (if> 600 d) (Fee is de endent on the ty e of system ermitted)
❑ 1�Iobile Home Replacement or Building Addition ❑ Permit Revision
�1�0.00 (ifsite visit re uired) 575.00
❑ Well Permit (1'e�v/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/S7�.00 Application: No Charge/ CA $150.00 or �300.00
1) Applicant Informatio : �,
Name:
Address:
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2) Name and addre�s of current o�vner (if dif%rent than applicant):
Name: ,r�_ (v�r�-�r ipV��Zf�
Address: Z
�1�; �, i�C. Z�5-7u
Phone (home): �j3(.P-���_ �j �j�
(�vorlJcell):
Phone: ��,-�SS� _(�15'`�
3) Progzrty Description: Lot Size: �3�Subdivision: ---- Lot �:
Address and/or directions to Property: ��� _-��n�—(3 (�[��.���v�
❑ yes
❑ yes
❑ yes
❑ yes
❑ yes
no Uoes the site contain any jurisdictional wetlands?
no Does the site contain any existing wastewater systems?
no Is any �vaste��ater goin� to be generated on the site other than domestic sewa�e?
no Is the site subject to approval by any other public agency?
no Are there any easements or right of �vays on this property?
(if `yes' is checked, please provide supporting documentation)
�3)1 ro�osed �J�� ancl T'yp� of St�uctur2:
esideniial �
e�v Single Family Residence l�taximum number oi bedroems:
Expansion of Existin� System If expansion: Current number of bedrooms:
❑ Repair to 1�lalfunctionin; System �Vill there bz a basement? ❑ yes ❑ no 1�Vith plumbing fixtures? ❑ yes ❑ rio
❑Non-Residential
Type of business:
Nlaximum number of employees:
Total Square foota;e of Building:
Maximum number of seats:
�) Water Su�ply: �New well ❑ Existing Well ❑ Community �'Vell ❑ Public lUater ❑ Spring
Are there any existing �vells, springs, or existing waterlines on this properiy? ❑ yes ❑ no
6) If applyinb for `Authorization to Construct', plzas� indicate preferred system type(s):
�Conventional 0 Accepted ❑ Innovative � Altzrnative 0 Other ❑ Any
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I C2Y1 � 1j1Qt fl1E li�0Y371Q1[Q31 �JYOVICI�CI CIbOti2 IS COi71�1I212 Cli1CI COYY2Ct. I QISO tl12RT2Y'SlQ11C� fIZLlI f 1I12 111f0Y�ZRlI0Y1 �73"OVILl�2C� IS
inacczrrate, or if tlze �te is szibseqarently altered, or the iftterra'ed trse changes, all pert�iits and appr•ovals shall be ifzvalicl.
Signature (O�ner/ Le�l R�prese
h Supporting documentation required
ntative�)
�-Zo�Zoi�',
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an app►•oved plat.
A completed `Lot P-repaYation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 32� S. i�lorgan St., Suite C, Roxboro, NC 27�73 (336-597-1790)
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Applicant:
Address/Location:
Taz Map: 1I Parcel:�
Subdivision
Phase/Section/Lot #
-- '? 1-�—�---�-�_
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Improvement Per�if
Permit Valid for: Five � ears _� Non-expiring
Type of Facility: t• New�/ Addition _ Water Supply: �- cJ
Number of Bedrooms / Occupants / Employees / Seats: Projected Daily Flow: gallons/day
Proposed Wastewater System: �L�-P� , � Type: __ ��
Proposed Repair: �r Type: __�
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Permit Conditions: .�LLDid �i,l� 5�_.,�Cl,�. i�YJI/lL �l�/Sr,C�t�/'� �!� _�,stl+D��'/Y�(/�" T-n�
Authorized State Agent: �
(X) Owncr or Legal Representative:
Date:
Date:
The issuance of this permit by the Health Department does not guazantee the issuance of other required permits. It is the responsibility of
the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if t6e site plan, plat or the iatended use changes. The Improvemeni is not affected
by a change in ownership of the property. This permit was issued in compliaace with the provisions of the North Carolina �Luws
mrd Rrcles for Se►�ag� Treatment and Drsnnsal Svstems'(15A NCAC l8A .19Ut)). N�ither Person County nor the Environmental
Health Specialist svarrants that :he septic system will c�ntinue to f�nciion satisfartorily in the future, or ihat t�e water supply wit!
remain �otabfe.
Authorization to Construct Wastewater �ystem
See site plan and additional attachments (_).
�
Proposed Wastewater System: ,��' '�;Q�� "� S� Y' (*1Type �� Design Flow _�`� _ gal./day
New t� Repair _ E pansion Soil LTf�R. ' 3 galJday/ft2
Type of Facilir,�: _� �!� �' �IP� (L Bssement: _ Yes _ I�o
(*) System Types Illb, Illbg, IY, und V, require periorlic system inspections by the Ferson County Hea/th Department.
Wastewater System Requirements
Tank 5ize: S�ptic Tar�k /pD0 gal. Pump Tank `� gal. Grease Trap '�' gal.
Drainfield: Total Area /�Do sq. ft. "fotal Length �D__ ft. Max. Trench Dzpth � in.
Trench Width _� ft. iVIin.Soil Cuver �p in. Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution_� / Pressure Manifold ____
Specifications:
Authoriz.,d State t�►gent: issue Date: 7�!/%S
Permit Expiration Date: Z�
7'he system permitted is: Conventional /Acezpted ?Q� / Alternative / Innovative . i accept the conditions
and specifications of this permit.
{X) OK�ner or Legal Representative: � _'��� � Date:
Person Counry Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC �7573/ph: 336-597-1790 (rev 5/12)
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SITE PLAN
Name �,�{ ��,�[' ',_.(,�� Tax Map # Parcel #/ Z��
Subdivision , Secrion/Lo�
Aut�ioriied tate Agent Date
Sysrem compoaents reptesent approximate contouts oa1y. The contractormusr flag t6e system pdor to beg•iariing the insraliation to
insure rhatprvpe�gradeismairtrairted.
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WELL PERMIT
(New� Repair_)
Tax Map: ��lf Parcel: �`��-i'
Subdivision:
Applicant's Name: �T.� �������/
Mailing Address:
Phone Numbers:
Location of Property:
Lot:
a�
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 of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments: �1.1,�-.�/�✓L��/ ���i1C�� . ���'1?� r�<,�
y�L�'�'.���il��i G�i!l.=��:7J��w c - S/t.=�?L�.7n� .��/'��'�•Z��IJ `i
'' '' � —:/ ��. 1. i
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�ew Well:
« E S/Date
Location: _���j
Grouting: ►i
Well Log: —Li�
Well Tag: ��
Pump Tag: l/
Air Vent: �
Hose Bib:
Casing Height: �
Concrete Slab:
Certificate of Completion
Ol,iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date: _
Method/Materials:
Well Driller: ���.4-p License #:
Pump Installer: � License #: _
Approved by: Date: — ` �
Additionat Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
WELL CONSTRUCTI�N RECORD
Thu fnrm cnn bc used for aing,lc or multiplz wells
1. �Vdi Contractor Iaformation:
Joshua Robertson
Wctl Coiatractor Nnme
2461-A
NC Wcll Comractor CertiFicatioa 1Yumber
Triad Drillers, Inc.
Compsny Namc
2. �Vell ConstrucHon Permit #: �9 286
Lttt a!! applicaAle we/!pe'mits (I.e. C.c�unry, Srote, Gariuncr, lojrctian, e1c.)
3. ��'eil Use (check well use):
�Vater Snpply Well:
❑Agricuitural ❑A4unicipaUPubiic
�Geothermal (Heating(CoaIing Supply) S7Residential Water Supply (single)
❑InclustriaUCommercial ❑Residential WaterSuppty(sharc�ci)
Far Intomal Use ONLY:
74. \VATF,K ZANN.0 � � . � . . - . . . .
tr. I rc I _ $ 9Pm @ 80,
Ft ft.
0 h( 63 f� � 61!$ '°- � SDR21 PVC
Non-Watcr Supply tiVeil: �
❑Monitorine nuP�,..,P.., 3
[�Aquifer Recharge ❑Groundwater Remediation t<
❑A uiFer Stor e and Recove e1
9 ab ry �Salinity Barrier
� C7AyuiferTest ❑StonnwaterDrainage
OExpzrimental Technolog}r ❑Subsidence Controt
�'JGeotherma! (Closed Loop) OTracer 2U
�
OGt;othemial(Heating/CoolingKetum) CJOti�er(ex lainunder;i21 F'.c-marks) 0
4. Date R'c1I(s) Completed: � 0-23-'� S Well ID�F 3
30
Sa. Wel1 Locatiun:
Carolina Customs 5�
FacilitylOwner!Qame Fac�ity IDrF (ifapp[icable)
1310 John Allen Rd.
Pliysical Address, City. and Zip Zi,
Person
C'ounty• Parcd IdcntiE:.auun �o. (PIN)
�b. I.Htitude and Longitude in degreeslminuteslsecouds or decimal degrccx: zZ
(if «�e(1 tictd, ono laVlqng is suEiicirnt)
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tt, I ft I ;n.
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AGGl� �� � � � _
TO DIAMETER FLO'f S(ZB TI{1CKNEfiS MATERL4(,
R. fG in.
f1, ft in.
AErp >
TO D7A7'ERIAL EbiPI.ACEMEhTM%iNOD&AMQCi.N7
se. 3 r�. Bentonite Pour
r`' 2� f� gentanite Fump
fL fL
ft
ft
rc g
ft 30
a- 50
s`' 125
ft
ft.
n
tion;
Pt
FL
Sand
Sandrock
Granite
36 2012.62 ti 79 04'26.64" ti`, �,\. �� � l� /f�I �,y 1/_��
gn� e o CcrtiFed 1Ne11 C itr�cto� llat�
G. is (are) tlie ivel{(s): pPermaneqt or �Ttmporary
By , rgning tlris feirnr, I lfereby cerrify q7ar tlee we1/(rj w�rs (were) cunsrructed in uccwd�uce �
wit lS:1 NCdC" OIC .UIO(1 or /SA NCAC 02C .0204 H'e!t Cunsrrvction Sr.im6�rdr anJ thol a
7. IS thlS a Te�INir to 8p CxiSting WCll: OYCS OC PJYo � cop � oflhis recorJhnx beeir provided In tfte weU nx�ner.
/f �ht.r is a repair, fil! oul known H�ell caxttruciron ii f�rmntion qnJ erplarn ihe noture oJthc l �
�epnirxrtder al! remarksscrtiun o�onthe hackoj�hisjonn. 23. Site diagr&m oT Addi60na1 Well details:
You rnay use the back of U�is pane to provide additional we[I site defails or �a�ell
3. Number of welis constructed: � construccion details. You may also attach additional pages if necessary.
/%or ma�Itipfe injeclian or na�-water.qgrply well.s D.NL}' wiJh rbe srune corestruc&nn, yr�u can �
submit nne jorm. S[1BAiITTAL INSTliCTIONS
4. Tata[ we[I dept6 below land surface: � 2� ({�� 24a. For A►1 �Vells: Submit this frrnn within 3U days of compfetion of well
Fur muhiple wells list alldepths rfdi. jferen� (ernmple- 3�OG' and 2Q100'} construction to the following:
10. Stafic water level belotiv tup of casing: 30 ���,� Uivision of Water Resourcex, Informatiun Processing L1uit,
ljwute� leve! r.c ahvve cosiag, use "+ ^ 1619 hiail Service Center, Raleigh, NC 27699-1617
I I. $orehote diameter. 6 ��8 (���.j 241r. For iniection �Velts ONLY: In addition to sending the form to the address in
Rotary 24aabove, also submit a copy of ttiis fonn within 30 days of completion of well
12.1Ve11 coastructiun method: conswction to the following:
(i.e. uuger, rotary, cable, direct push, etc.)
llivision of Water Resources, IJndcr�rouad lnjecfion Conirnl Propram,
FOR R'ATER SUPPI.Y WELTS ONLY: Ifi3b htail Service Center, Raleigh, NC 27b99-1636
13a. Yield (gpm) $ _;4lethod uf teck Alf 24c. Fnr �Yater Suppl & Injection Wells:
Also submit one copy of this form rvithin i0 daysofcompletionof
13b. Disinfection typr: HTH qmaunt� � 60Z. well constiuction to the county health departmcnt of the county where
constructed.
Form G W-1 Nort}� Cazolina Depamncr�t of Environmcnt nnd Nanual Rcsources - Division of Water Rcsourus Revised �ugust 20l?
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Tax Map � Parcel # Z$�
Subdivision
PhaselSection/Lot #
# of Bedrooms
. � . --_
Applicant: %C�r�vr
Location: , � �,� ��
Oueratio� Permit
System Type (Frorn Table Va): % ^�
Type V& VI Expiration Date: �_
Product (IIIg): C �M � +/
Type V& VI Renewal Date: �_
This system has been instalIed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of ihe Improvement Permit and Construction
Authorizallon.
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( oriaed Agent) �
��c�e C� �
(Lic nsed Contractor)
Q�� °��' s
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Scale �D �t•� J� �`"''
PCFiD, rev. 12/14/12
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(Date)
pr-r���5
(Date)
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Tax Map: Parcel #:
Se tic Tank �� C��"' �'�
p System Checklist (Z'ype II-I� System Type:
Notes�
Pump System Checklist
Contracted Certi�ed Operator (Type IV Systems):
Notes:
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