A29 34�
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WELL PERMIT
Caswell-Chatham-Lee-Person Counties
DATE ISSUED: -' IYQ DATE DRILLED: �� �,��J COUNTY: i y-
OWNER: '`'�Q s�� Q Z� �y�r_�i � ROAD/STREET: �
ADDRESS: • PERM T OID AFTER NE YEAR
DRILL CONTRACTOR:
NAME ADDRESS
WELL CONSTRUCTION '
Distance from Nearest Property Line - Distance from Sour/ce of
Pollution�s
Total Dept Ft. Yield:f�_GPM Static Water Level: �Ft.
Water Bearin ones: De th. S{_� Ft.�Ft. � Ft. Ft.
Casing: Depth: From�_to�Ft. Diameter: �Inches
TYPE: Steel Galvanized Steel ��
If Steel, does owner approve: Yes No '
Weight: % � Thickness: ��Height Above Ground:��Inches
Drive Shoe: Yes: No:
Were Problems Encounter d in S tting the Casing? Yes No t�
If "yes" give reason: — —
Grout: Type: Neat 1� Sand/Cement: Concrete
Annular Space Width � Inches
Water in Annular Space: Yes No t�
Method: Pumped Pre ure Poured �
Depth: From to S Ft.
Materials Used: No. Bags Portland Cement�Weight of
1 bag �_lbs.
If mixture (sand, gravel, cuttings) - Ratio: � to �
ID Plates: Yes ✓ No Chlorination: Yes No :�
4 x 4 slab Yes� No
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. HEALTH DEPT.
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REASON FOR NO INSP
�,aniLariar� s ,sugnature Date
Sketch well locatinn on reverse side. Use established reference
points.
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Application Date: � '�'� �
Amount Paia: 7 �o o
Receipt #: �I�3 9 � `�
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❑ Improvement Permit (Site Evaluation�
�200.00/$300.00 (if> 600 gpc�
G Mobile Home Replacement or Buildin�
�^ 1 i0.00 if site visit re uired
e11 Permit (l�iew/Replacemen epan
$300.00/$200.0 5.00
�-.�� ), f ll ����� Tag Map: �} 2�'
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lE�-,-�.�M���a�fl 1H[m�,.9�. "
tion for Services
G� Construction Anthorization
lFee is deuendent on the type of
�75.00
G� Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Infor-m�{�ation: t ;1 \
TT2Iii6: LJG�tn Yti f.c%�.�cf �.t� � ZL-rGY !
AddreSs: .Q�� j;r :li,��. ,•�:
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2) Name and address of current owner (if different than appIicant):
Name: � S Z3.-n/�►t�i�nan
Address: t S Q ; f/.� hn •�
o'�c�ro L ?�y S7�/
Phone (home): ���i.� ��2' ��LL
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(work/cell): ��,i S"��.. �(�3�
Phone: L 331�� 3�p ��''J%�
3) Properfy Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: Fro�r• �� -� � %
�r'/�a �P„���. ,� l. /��� ,�/. /.�.��� .� � �
❑ yes ❑ no Does the sitercontain acty jun�dichonal'weuanasr
❑ yes 0 no Does the site cantain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than dome�tic 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)
�) Proposed Use and Type of Structure:
I�Residential
❑ New Single Family Residence Maximum numbar of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
L7 Repair to Malfunctioning System Witl there be a 6asement? ❑ yes ❑ no With plumbing fixtures?
❑Non-Residentiai
Type of business: Totat Square foorage of Building:
Maximum number of employees: Maximum number of seats:
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❑ yes ❑ no
5� Water Supply: 0 New well ❑ Existing Well � Cammunity Well O Public Water � Spring
Are there any existing �vells, sprinas, or existing waterlines on this property? O yes ❑ no
6) If applying for `Authorization to Consiruct', please indicate preferred system type(s):
❑ Conventional 0 Accepted ❑ Innovarive � Altemarive � Other 0�Y
I certify that the information provided above is compiete and cot�ec� 1 also t.�ndepstand Ihut if t�2e Infopmatlon provided is
inaccttpate, or if the site is subs�quently altered, or the intended z�se char�ges, all pernsits and approvals shall be invalid.
Signatnre r/ Legal Representative*)
* Supporting documentation required.
�% -10- �U/S
Date
a Permits are vaIid for either 60 months or axe non-e�piring when accompanied by an apgroved pIat
o A compteted �Lot Preparation' form must accompany any appliea6on requiring a site evalnation.
�t n�t tl PPt-cnn ('.rntntv Environmeut�l Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573 (336-597-1794)
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Applicant: (,A�E.� �3•
Address/Locatian: � �S�S
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Taz Map: A ag Parcel: 3`}
Subdivision
Phase/Section/Lot #
Improvement Permit
Permit Valid for: Five Years � Non-expiring
Type of Facility: 4�u5�, New _ Addition _ Water Supp;y: Pi��� W��.
Number of: Bedrooms 3/ Occupants / Employees / Seats: Projected Daily Flow: 3�0'o gal(ons/day
Proposed Wastewater System: Type:
Proposed Repair: �cc.�p�p Type: � 6
Permit Conditions: �'f` �EPA\R.�'t'
Autf�orized State Agenc: �.RWc��. , Sr►i� Date:
(X) Owner or Legal Representative: k' Q,%?�� �imm�,z�r,a�� Date:
The issuance of this permit b� the Health Department does not guarant�e the issuance af other r:,quired permits. It is th;, responsibility of
the applicandproperty owner ±o insure that all Person County Planning and Zoning and Buildina Inspections requirements are met. This
improvement Permit is subject tu revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issned in compliance with the provisions of the North Carolinx `Laws
ani! Ru[es for Sewa�e Treatment and D�cnosa! Svstems'(15A NCAC 18A .1900). Neither Persoo County nor the Environmental
Health S�cecialist warranks tnat t�e septic system �vi3l contiuu� to function satisfacto::iy in thc future, or that the water sugpfy r�ifl
remain potable. _ _ __ __ ___ __ _ ___ _
Authori�ation to Construct Wastewater Systerr�
See site pla�n and additional attachments (�.
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Proposed VVastewater System: �cc�FtEO "' 2 S l, � (*)Type �G Design Flow �' _ gal./day
New Repairx EYpansicn _ Soil LTAK: O.`�O gal./day/ft�
Type of Facility: 3-'3R. }1eil5E Basement: _ Yes � No
(") System Types lilh, llibg, t'i ; c�nd V, require periodic system inspections by the Person County Health Department.
o���o�v�ea� �r�e
Wastewater System Requirements
Tank Size: Septic Tank �as�b gal. Pump Tank � gal. Grease i rap � gal.
Drainfield: 'Total Area $h� sq. ft. Tota.l Lengtl� oZ9 4_ ft. Max. "french Depth 'l10 in.
Trench �Nidth 3 i�. Min.Soil Cover �o in. Niin.TYench Separation h ft.
Distribution: Distrihution Box / Serial Distribution x/ Pressure Ivianifold �_
Specifications: �►as�u. A ta�w -cEE ar_F���tl. �,�s,pE kx�sr,��-��`t,; --Ca�cC Pc,HO w� ��.sc�aaS
(,33b1i 59`� - \�19Q
Authorized State Agent: `�rc,4.�(i�c� A- Sr�c<i\ issue Date: ��'� �
Permit Expiration Date:
The system permitted is: ram�entional /Accepted �(_/ Alternati�e / Innovative . I accept the conditions
and specifications of this permit. ,
(k) Owner or Legal Representative: � �� � Date: h/ o
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/plz: 336-597-1790 (rev 5/12)
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; SITE PLAN
; Name ��'E0.. �• Z.�rv+�c.'Rt+t�+.� Tax Map #�� Pazcel # 3`�
Subdivision Secrion/ t#
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Authorized State Agent Date
System compoaents rcpresent appmximate cantaurs on/y. The conmctormust tlag t6e sysremprlot ro begianirJg the Insra/lation ro
lnsure thatpmpergrade is mainttined.
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Tax Map � Parcel # �_
Subdivision
Phase/Section/Lot #
# of Bedrooms 3
Applicant:
Location:
���erati�n Perm.it � R�-���.�
System Type (From Table Va): �
Type V& VI Expiration Date:
Product (IIIg): ` �Z--
Type V& VI Renewal Date: �1
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This system h�s been insialled in compLance with applicable North Carolina General St�tutes, ItuIes for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
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C7�1�.,...l�. l:c • �
(Authorized Agentj
-Qiv�/3�
censed ntractor)
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n� 100� 2r�'�\ %
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Scale � /1�'
PCHD, rev112%14/12
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Line Length
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Total Zbo'
Tax Map: � Parcel #: �_
Septic Tank System Checklist (Type II-I� System Type: �
Notes: �✓ �� � Intioxn b v SS ah � K_
Pnmp System Checklist
Contracted Certified Operator (Type IV �ystems): �
Notes•
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Tax Map: �� Parcel: �5F'
Subdiv�sion:
WELL PERMIT
(New _ Repair � )
Lot:
Applicant's Name: �7,,,�, �_„�,�,t�
Mailing Address: t S� �o��� �, L � t.,�� '� . ��,L , �� �
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Phone Numbers: 3 p-�.3�7 9 ?iZZ.�- R?i .��
Location ofProperty: 1��5 `j�i,e;,�.�/i ��£� j �
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:
Permit issued by: �T��
Ql�tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
_�
Date: ��- �
Certificate of Completion
iner:
EHS/Date
Depth: 6�0 �
Grout: ��a�o
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DAbandonment:
Date:
Method/Materials:
Additional Comments: L1JP�- V»�AS �sa� ��1�c'R-
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