A29 36Tax Map: ��
Subdivision:
���, sf �II��.� ��
' � � �T�T��Y
�uawn�c-�aa�ra�a¢3�rad�.Il ��a�a.�.��a
Parcel: � _
WELL PERMIT
(New,� Repair_)
Applicant's Name: 2i ��i �- � td � c r�
Mailing Address:
Phone Numbers:
Location of Property:
Lot:
S�� �t�o/� -� �a'i- � n
1��� � 5'�-� vnQ�� `'��
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Q►Jti�e.r ��+05� l�-2�l S'�`� •
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:
Permit issued by:
�New Well:
EH-�Location: �
Grouting: �
Well Log:
Well Tag: �
Pump Tag:
Air Vent:
Hose Bib: _�_
Casing Height:
Concrete Slab: �
Date: 2 "'� � I �p
Certificate of Completion
OLiner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
Well Driller: �qYnk,�-� License #:
Pump Installer: « License #:
Approved by: Date:
/
Additional Comments:
Date Sample Collected:
EHS:
Person Caunty Environmenta� Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
:
`
Date Results Mailed:
Phone:336-597-1790 fax:336-597-7808
11/26/13
D�_t..-c____,
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)C�dira�a�r-o�ra.mm-r a�irn��.Il ����.Il.��n.
Tax Map: 2q Parcel:�_
Subdivision
Phase/Section/Lot #
Applicant: �W���� S���Mo:�
A�dres`s,/�Location:
'l I"�� i'cr � S V—Q i"�l 0 a v1 �. I Ju S�' lai�1/� �-Q Ue� �
Permit Valid for: Five Year�
Type of Facility: 3�31� �:f
Number of: Bedrooms � / �
Proposed Wastewa er System:
Proposed Repair: �
Improvement Permit
� Non-expiring
:� New � Addition
�cGunants (n / Emnlovees / Seats:
Water Supply: W'�l �
W'
Projected Daily Flow: 3�o gallons/day
Type:
Type:
Permit Conditions: �P� �I� t�'� ��Q ✓t
Authorized State Agent: �� vv�✓ Date: 2 f�'I
(X) Owner or Legal Rep sentaHve: wj Date: �' j'l;
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicant/properry owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to 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 issued in compliance with the provisions of the North Carolina `Laws
a�rd Ru[es for Sewa�e Treatment and Disnosa[ Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will contiaue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: C�✓j'j p %%,9 • (*)Type�nQ_ Design Flow 3�0 gal./day
New Repair _ Ex a sion Soil LTAR: �'3 O gal./day/ft2
Type of Facility: � i`�i�? /�,o S• Basement: _ Yes � No
(*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank ( �ii�
Drainfield: Total Area 3 0 O
Trench Width �
Distribution: Distribution Box
Authorized State Agent:
gal. Pump Tank �O� � gal. Grease Trap "� gal.
_ sq. ft. Total Length n O ft. Max. Trench Depth 2o in.
ft. Min.Soil Cover �p in. Min.Trench Separation � ft.
_ / Serial Distribution,� / Pressure Manifold
-�x►
�e�
� a�a�4� l�a � �a
Issue Date: 2— (�—1 (p
Permit Expiration Date: 2�(4'r�Z 1
Tl�e system permitted is: Conventional / ccepted �/ Alterna ' e / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: � � Date: 3- 3/7
Person Countv Environmental Health, 325 S. Morl;an St, Suite C, Roxboro, NC 27573/ ph: 336-597-1790 (rev 5/121
Tax Map: Parcei #:
Septic Tank System Checklist (Type II-I�
Se tic Tank nitiaUDate
State ID& Date: O��G—� 3 Z
51�3 l�lz-
Ca acity: lpd �
Tee and filter
Baffle ✓'
�Vent ✓'
�Riser �/'
Outlet boot ,�
Perm. Marker t�
Distribution
D-box levels set)
Serial
Pressure Manifold �
LPP
Notes:
S stem T e: �' ,��A���C�N' �
y � �
Pump System Checklist
Contracted Certif ed Operator (Type IV Systems):
Notes• �
�1,i . i , J f ���� �.b. �7
` � � ����
I���.a-��.�m���.Il IEE� ��.Il�
Applicant: Lvi �� >B lo✓�ro,.t
Location: , � „ _ . � n
�
i�aR i�aY � �'�i'Coi r�r �_
Subdivision
Phase/Section/Lot #
# of Bedrooms _ `3
Oueration Permit
System Type (From Table Va): �� Product (IIIg): ` C� Q'Z' �
Type V& VI Expiration Date: Type V& VI Renewal Date:
This system has been installed in compliance with applica6le North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
�„uthorization.
(Authorized Agent)
�. r/�a,-���.�Z
(Licensed Contractor)
D
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Scale Oh�
PCFiD, rev. 12/14/12_
(Date)
`���4�� $'
(Date)
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CORNER �� R E C N 20332 i T" p�pE
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ENT JOyJOH ..� z S��S �' c��,' �.�
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^ �oL �6 ' �, �pC it 3-199 oso C I I � E T� i� 9. 7 j�T �` � v C � N TRp�
� 350 � . _ � �, E Or �, �, - ORNER
� Q.� RECN 1253 �. A _ R�M��E pC; ��
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� . �-'� 20' SEPTlC '' �3' EMN
`�.��'� k ' ��NE EASEMENT _ � 32'S7„ W ��»
' � - S �-- 4v,
�,9 �� S 7�' 39=14=' ��- �- •- - �— N ' 39' 14 432 -
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'i.%C }q+�� � i `_�_.�._ � . Q �' � rc �
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11 62 (HES T E R' S S T� R� R} ' `�� S� I������ T
— SR � --= � c� � �Tl��'�''
LINE TABLE � r (� � ���s�'m�.�m'��.n.� �a�.�a�m`
LINE LENGTH BEARING (�u�� �jr4Q. '�711f�'�� I��C. SITEPLAN ' n
L1 30.09 ' N 9'58'18" W � ), Q
L2 20.06 N 9'S8'78" W � �j ' JI ; 1 V` �dlhd✓i TaxMap# 1 Parcel#�
L3 41.45 N 52'14'9" W ✓"Yf ��` ���� �� � d�e� '"'� � S bdi i io Section/L.o L_
L4 19.33 S 54'4'30" W ,'r /+ •
LS 152.32 N 49'S4'56" W C1(�) SS �� W Q� i.,=�sg ��`� �r� � uthorized State Agent Date �
L6 61.67 N 81' 1'2" W `,I � �Y'-Rr� �
L7 78.60 S 14'46�37" W W Q A� �f System componertts represent approzimale contours an/y. The con�ractor mus� Jlag the system prior to beginning the
installalion to insure that propergrade is maintained.
L8 163.51 N 65'S7'26" W Note: An Accented svslem mav be used in p/ace oja conven�iona! system without permit authorization or modification.
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CONTROt
CORNER�
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DRAiry�j�ACREg ,.
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SQ. AMB�S �
� DB 173-199
^ro���� ' pC
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�l C �Q�r 1253 e :
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f— -- SR 1 62 (N�STER'S STORE RD}
LINE TABLE
LINE LENGTH BEARING
L1 30.09 ' N 9'58
l2 20.06 N 9'S8
L3 41.45 N 52' 1
L4 19.33 S 54'4
LS 152.32 N 49054
i a at �� .� ,
�o� io^a�l N_65'5726_ W' .
... ���vtR 111 �
� pC 600-826 �
/ 2->>s .
3 RECN 17041 �
ol� �
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I i RECN 146Z� ;
N_7g_6'16" E� l
� 122.30' I�� De py q�LE.N i
2Z4-
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� I� RECIY 20332� � �� PlPE
Irn [�
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Q �1 %7� 1 F'22 E xrn .
149.98' C
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S g, "S 8• � o�o, � P1P
U 94 � i64 �� .
N£TQe����oTq` ` mJ CR�L
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1.75 ACRES M�VEp 1` ���� r�,
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Wt�L �\```Ss
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187.26' -�— 1
r �—�— � i
60 PUBLIC R/w S��� 1 = 1��
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Name � �" `d d✓l Tex Map# � l Pa�celN�_
� Su6divi io ^ Section/Lo _ _
uthorized Stata Agen Daro
Syrtem companents repnsent approxlmate cantaurs on/y. The conlraclor mur/ flag the .ryslem prior to 6egUning the
• lnstaliallon lo trtrure that propergmde (s maintatned.
� Note: An Aecsnted tvstem may be used fn place oja eonven�fow( ayslem wi�h6ut permit authorisatton or mod�cation.
���:s.�- ���.� ��
v � � ����
�aav�-a�anaa�rna.a�aa�.m�. g—�B,a]�YG-1{a
, NEMA 4R Simplex Contml Panel
� I1
�4" X 4" Px�essare Tseated Post �
' Sloped To Shed Watex
' 12" Sepdratiox
� Electx9cal Co�it —
6" Covax •. ' � � Access Cover• � •• ' ' e ~ � .y � i
,. .
. '•� • � r • . '-� J
• � �� l i;� . y+ .
� r _ _ . •. �• • ,
i,. Opan+� F'illed�ilith �`• Axiti Siplwn Ho1e• •
I�nlet Fmm Septic Tank Portland Cement Givut �� � �
4" SCH AO PVC Pipe � • .
' � Check
T�x M��a � F�rcel # '
Suhcllivisioi�
Fh:�•s�e Sect,ioii Lot #
Duct SealBotk
Es�d� Of The Cond�t ��te Riser •
-'- 24" Mininmm '
T..�_
�. , -• • ' • • - ' b° Separaticn
Tl�t�eaded Gate Valvp • .
IIrion . .
• • .' =�:.�c+' -
�._..--PortLmdConcrete Gxout -
, MaS41C � • ' •
Zip Coxd �,. � OpeningFilled With
Tizs Supply ''� port� Cement Crraut
Line • ; '
� Oatlet To Distnbutiox
v�� •EN�plon . 2" SCH40PVC Pipe
High Water ALu ; Levpl p F7oat Wires ��: � I���
:. �
(6" Separatiun � � �
_ iiiglt Level- Runp Ox • • � �� ✓In�l�
�.� � i� '�VaposLock Flaats +;�� , t
� � o n� $o� � ' � �� 1�0 �� �0�-2
� � (tTP H� ' {_R,emovable • �' • `A /�� ,�—
F7oat Tree ; � U 1"C �
•' •Law Lavel -Pump Off � � /� � � n �,
,. • • • V. L.J
:.. '. ' Runp . /� �
P:ecast Concrete Taa]c � Q� � �..Q
' � ;•; (MatexialStrnagtk}3500PSIj $�ck�te r ' '':• �� _ �
� ,��'•. �• ' r � . " �- - f�' , � . � '� � . • \ -° t �' • �.
� � l a o� ���.a�v� T�
� ':.
� �_ � �
Pnmp Must Se Rated To DeLiver
�'Zr7 Gallons Per Hinute ,
Agaiast 2� Feet OE Tota.l
Dynataic Head (IDH) .
��`�. � IPI��.���
-�- ������ �'j��
IE:�-�.��,*,,,,�„ ���.v. 1Hi�,�.11,� Owner: J�INI �t-�— Sc1�°Y''�w1
Tax Map: Z Parcel #: 3� D e: ?-- I B'—( (�
�ft of line x 65 gal. per 100 ft= � : 100 = gal
75% x ga1= —gal per dose 2� gal per minute (gpm) = I'low Rate
Friction �ead l
L,oss: � 75� ft per 100 ft of supply line x� ft of supply.line =100 = �3' � ft
�',�-L. ft x 1.2 =�� • 5 ft of friction head �.
Manifold Size: � " Force Main 3ize: �' " PVC
�otal I3ynamic �ead =,�_ft of Elevation head +� ft of Pressure head +�G ��ft of
Friction Head = �; TDH
Pump Requi�ement: ZS GPM @ Z�r. ft of Head
Drawdown: 2�o ggal per dose : 21 gal per inch =_L �� inch dra.wdown per dose
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�» �lII �
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� 4ma�
' ' . _ , ' �'iow sr T�P
�ue ;Llrii¢rial FTowG?LI
�,'• Sclied 30 �.�
�. Sctied 10 "-_'
S, •s �Cl:ert HO I � I
=: " Sched 40 L.�
Dec 151704:04p Barnette Well Drillinglnc
VYELL CONSTRUCTION RECORD (GW-1)
i. Wdl Contractor Information:
y �p L/-r
�� lif �lIJ L~e.�L !S. J... L( 7_-_
Wc:l Conrractor Name
3_3 � 6��9
NC VTell Contraaor CertiHcation Numbtr
Barr�ette Wel1 Drilling, Inc.
Comparry Name
2. tiVel! Constroction Permit €t: _ � � �
List af; app(ic�ble ne!? consrructin� prrmits (i.e. UIC, Counry, Sta7e, ['onmxe, e!c.j
3. Vb'ell llse [cLeck well use):
Water Supply welL•
Agricultural Q Municipa]IPublic
Geethermal {Heatinv_JCooling Supply) �x Rcsidential Water Supply (single)
Industrial/Commercial �Rcsidential Water Supply (shared)
!tti ation
Yon-Water Supply V1'ell:
��(onitoriag Rccovery
lnjcctioR 1'Vell:
Aqaifer Ftec6arge QGroundwater Remediati�n
Aquifer 3torage and Rec:over�• QSaI'mity Bartier
rlquifer'I'est �Stormwater Drainage
Experimenta[ Technetogy �Subsidence Control
('seothermal (Cbsed I.,00p) �Tracer
Georhermal (Eleatin�.+Coolin Retum) Qther (explain undcr #2I Remarks)
4. Dafe Well(s) Completed: i 2- ISI � wa� m� '�!
Sa Well Location:
f ,.� �`� h7` Sa /d ��
faci?ityiOwn2'r Name Facility IDtl (if agplicahle)
�eS��/'J IL � � � . +�. L� ! L`�/t^— LY
Ph}sirsl Addness, City, and Zip
fe�e5�� 3 �
Couaty Prrcet Ld�;ntification No. (PII�
%O ft
.26 a �- z �n �-
1 S. OUTER CASING fo�
FR03�I i0
/�. CL �i�fG
!s
16. [n NER CASIIYG OR'
F120M TO
ft. R.
ft. tt
0 n- �
ft. CL
18. GROlJ"i'
xRoni �ro
� ca � re.
j ft CL
ft ft
tt, fL
k. tt
E1,ING LOG att�
Z'o
K. � � ti.
rt. -� _ t�.
«
it
fG
[t.
ft.
ft.
�G
k.
R.
336-598-9275 p.1
5b. Latitude and longitude in dcgreeslminutcslsemnds or decimal degrees:
(if well ficld, �e 3ad[ong is sofficient) 22. Certifica0on•
36 •353��' � ,� �. 4�"SK� w � .
�
6.Is(arejthewdl(sj�ermanent or �Tcm�orary SignatureufCacicedwcllCootra m
7. Is this a repaic to an cxistlog wc�i: QYe� or �ftr
If this is a�epair. )'�I! ow known well conslructiorr irtformalian �rd erplain tfu; na�ttre oftbe
r�prrir under :1! remarta� srchon or on the 6ac1c vj�hisform.
8. For CxoprobeJDPT or Qoscd-Loop Geothermal ��'d!s havingthe same
�nstruciion, only 1 GVY-1 is neede�. IndicateTOTAL NLJVI}3ERofwells
�rillcd=
9. Total wel[ depth below laad surface: ��� {t'L)
Formuitiple weils (u� a!! deprha ifdijferent /example- 3�a�20U' m�d 1 ��I00')
10. Static water levd below top ofcuing: 25 ((�)
!j water!evrl is abuve casing, ecre "-'.
fJ
� �0 1
�1
�elb OR f1YER ifs tica6te
R CIQ'lFSS MAT'EAIAL
� R z r Pv'c�
Hhernosi -Lao
R CKIiFSS MATERIAL
IA
lh
9y sigrring [hisJorm. : hereby cr '� r '!he M•rflf.iy
wuh rs.a ;vc��c o.c.utou of �s.9 v�.� o�c.ozva
copy oj[hq record hw� ber� p.roviu d 10 well owne
23. Site diagrarn or:ddition wel details:
You may use thc bacl: of this age o provide
construction details. You mav so uddii
24a. For All �Vells: Submitl this
construciion to the followin�
Di�•ision of li'ater
1617 M�i1 Ser
l]. Sorehole diamcter: (in.} 24b. For [oi�tion Wells: v
. Air rota above, also submit one copy
12. Well coostruction method. ry canstruction to the foltowing:
(�e. auper, mtarv, cabie, direct pasb, ctc.}
Division of Watcr Rcsoui
FOR WATER SUPPLY WELLS OriLY: 1636 Mai1 Sm
13a. Ydd (gpm) Met6od of lest: gIOW@CI 2O Mln. 2q�, For Water Sunnlv & 3
C.hiorine �f4 Cu �e address(es) above, aiso
13b Disinfection type: Aroonnt: P completion of wcll wnsVuct
where constructed.
u red
i� rU �
2a
1 r -`��'f7
Da[e
/werrJ coreslrLcrea v� oecunlanca
CnnstrucYion Stcndards and that o
ditional a•ell site details ar well
a! pages if nccessary.
xm with� 30 days of completion of well
es, [nfo tion Processi s UniL
ter, Ralei 6, NC 27699-1617
m to sendi g lhe fo�rn k� the address in 24a
fo�m with 30 days uf completion of well
dergroun Iaj�ion Coutrol Program,
ter, Ralei NC 27699�1636
nit�ine copy
to e counry
addition to sending thc form to
F this form within 30 days of
ealth department of t'ie county
�omt C W-1 hteith Carolin� Depat[rneni of Fr�vironmental Qualih' -�ivision of Wa[er Reso�rces I I Rer'_ed 2-22-2016
Pers�n County Health Department
Sew�ge System Improvements Permit
Date: '�� - t[ This ermit Void After 5 Years
Owner: �• �em��'t�s SR# % l�pZ.
Location/Directions: .
- �..�Y"1 t � �t'' �• ••7v� o t7Me on .S , �
Subdivision N e: Lot #
Lot Size:` � �� Type of Dwelling. ""f ',�
Water Supply: Private: .- Com unity:
Bedrooms: G age D�spos
Basement Basement F'v e � � .
INFORMA D BY � ' � ,
S�j(�j�: owner or reptesentat�ve
REPAIR: REEVALUATION:
Size of Septic Tank: l+�0 gall�ns �Size of Pump Tank:
Nitri�cation Line: _� DD K 3
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump Lpp pamp
Remazks: _
----------_.______________
Date Well Approved:
BY�
BY S_l_1LQ._,l/r� � pro .�Y17
Contractor.
Well should be 100 R from any sewer system
'�E OF COMPLETION
— — — — — — — — — — — — — — — — — — — — — — — — — '-3
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tanlc should be pumped out every 3 to 5 years and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and'd
nitrificadon line must be inspected and approved by. a member of the Person County �
Health Department be�e any portion of the installation is covered and put into use. If
the site plans or intended use change this permit is subject to revocation.
(G.S. 130 A-335F)
I.ocation of sewage disposal sewage system sketched on back.
(OVER)
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Person County Heaith Department �
'/� � Well Permit �
Date:�.`1� This P rmit Void After 3 Years '�
Owner �d ( ;h � ��j(S' SR# �
I.00atIOflID1IeCIlOi1S: 1� �
/i✓) e �_� �l D f�W V m Dki [�
Subdivision Name: •
Ihilling Contractor.�
#
WELL CONSTRUCTION . ►d
Distance from Nearest Property Line Distance &om Source of
Pollurion �
Total Depth Ft Yield: . � GPM Static Water Levei Ft �
Water Bearing Zones: Dep Ft. Ft.
Casing: Depth: From � to .� Diameter Inches
TYPE: Steel � Galyanized Steel �
If Steel, does owner approve:� No
Weight: Thiclrness: Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes"'give reason: 'C
Grout: Type: . Neat S�etnent Concrete �
Annular Space Width � Inches
Water .in Aimular Space: Yes No ��
Method: Pumped Pres e Poured
Depfh: From � to Ft �
Materials Use3: No. Bags Portland Cement Weight of 1 bag
� lbs.
If mixture (sand, Sraye,l, cuttings) - Ratio: to �
ID Plates: Yes � No .p
4 x 4 slab Yes �— No ti
I HEREBY CER'I�Y THAT THE ABOVE INFORMATION IS
THIS WELL WAS CONSTRUCTED IN ACCORDANC$ W1T
FORTH BY THE PERSON CQUNTY
�,�%� $1�1 Of
LJ " �
`- V �
��.�� _ anitarian s Sign
Y G��.
, Sanitarian's Signature
Sketch well locat►on on reverse side.
v
OR ANDTHAT
REG TiONS SEf
4 �
Date
Date Issued ,
Date Completed
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Application Date: � a� I �
Amount Paid: a00 .
Receipt #: g aa �{ �f
V` �
nit (Site Evaluation)
.00 (if > 600 �pd)
I1
or Buitding Addition
$150.00 (if site visit required)
Wetl Permit (1�1ew/Replacement/Repair)
$3 00.00/$200.00/$ 75.00
9�
�
� l 3 f. 11 ���'L.Yl � Taz Map: 9
� ► • �, Pa rcel#:
� � �,���
3Ey+un� n u-� an mra �: sn d,ac Il 7HI r. en 1l dl�a
Services
for Services
Construction Authorization
(Fee is dependent on the type of
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: .
Address: ti s-% r's �o
.0
2) Name and address of current owner (if different than applicant):
Name: w h 1 1, � K�
Address: l.l�►-►+n o
c •L
Phone (home): —
(work/cell): �— -
Phone:
����r
3) Property Description: Lot Size: Subdivision: Lot #: �� �2� O
Address and/or directions to Property: �}�e.s-�-�r's S�n re 1Q
❑ yes C� no Does the site contain'any jurisdictional wetlands?
❑ yes � n Does the site contain any existing wastewater systems?
❑ yes 0 o Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes C3To Is the site subject to approval by any other public agency?
❑ yes Ca 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;
C�esidential
C�f'1Qew Single Family Residence Maximum number of bedrooms: �_
❑ Expansion of Existing System If expansion: Cunent number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes � no With plumbing fixtures? ❑ yes � no
❑Non-Residential
Type of business:
Maximum number of emptoyees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: � New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing watertines on this properiy? ❑ yes ❑ no
6) If applying for �Authorization to Construct', please indicate preferred system type(s):
Gt�Conventional ❑ 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, r if the site is subsequently altered, or the intended use changes, all permits and approvals shal! be invalid.
� _����� ����v � � �+ �
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
Date
Permits are valid for either 60 months or are non-ezpiring 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)
Application Date: 1 I-q-t 5
Amount Paid: � . �"
Receipt #: __��`�S'��/
��,:,�� �J1d���L.1��
� � ������
�� Jl:.sn.� �i�rc»�rnnva�e;irntL�en.� 1���a-ta.�tL��
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 Qad)
Mobile Home Replacement or Building
$150.00 (if site visit required)
Well Permit (New%Replacement/Repair
$304.00/$200.00/$75.00
Auplication for Services
Services Re uested
Construction Authoriz�
(Fee is de endent on the
Permit Revision
$75.00
of
i�
Tax Map: ��—�3
Parcel#: �
Repair qf Existing Septic System
Application: No Charge/ CA $ I50.00 or $300.00
1) Applicant Information:
Name:
Address: �e,s � s S
. L.
2) Name and address of current owner (if different than applicant):
Name: 1.,,� h, ' G �
Address: U h,
�
3) Property Description: Lot Size:
Address and/or directions to Property:
Phone (home): _� 31 '3 � �--3103
(work/cell): , 3 3 L'��3 — 5�i ��
Phone: � 3 �- �5 � a �a y
ti
0 yes Cfi o Does the site contain any jurisdictional wetlands?
C�yes D no I�oes the site contain any existing wastewater systems?
p yes I�-no Is any wastewater going to be generated on the site other than domestic sewage?
(� yes C3T Is the site subject to approval by any other public agency?
�es ❑ 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:
OResidential
ew Single Family Residence Maximum number of bedrooms: �J / Occu ants: �_
�Expansion of Existing System If expansion: Current number of bedrooms: �
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes �no With plumbing fixtures? ❑ yes ❑ no
ONon-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: lJNew well 0 Existing Well ❑ Community Well O 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 contazni�ation: ''
6) If applying for ` uthorization to Construct', please indicate preferred system type(s):
�Conventional �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, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
i��l� ��-� �S
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
Date
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.
(10/1 I) Person Count.y Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
'� ,� �� � � �
J � � 1
�
C `/� � � r�, � •
�- ,, �.:� � �---� �-.,:� � � �,
Building Additions/ Mobile Home Replacements
Tax Map #:-� Z� Parcel#:� Address: �� ��S�S � r"1,
0 7 S7
Approval Requested for: Mobile Home Replacement
� Building Addition
Applicant Name: �4�. � (v✓�-r��,�,
Address:
Q✓k-c a S 4 w-2
Phone #'s:
Permit Located: Ye,s ,�� No
Installation Date: (i1 i� s �I�(' Y-e f Design flow, 3� �(gpd)
��r� i' 2- ( �-1 �p
Current Contract vrnth Certified Operator on file (if required): ✓ C�
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: �j (date)
(Applicant's signa if site ' it is not required)
4s`X �►s�
Comments: �C�'�,�k� ��r S�+o.p �i��p• ✓�,-e� czl� E�v,
Addition/Iteplaceme�t Approved
� ►-�e�
E irorunental Health Specialist
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790! Fax: 336-597-7808 www.personcount .y net