A29 4The District Health Department
Ora e r n, Caswell, Chatham, Lee Counties
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Wa e u ly,hn� Sewage Disposal
r Date �'1� � �;�
Owner: X I t-' ���U� f�
,
Lo ation:
i
�
!
C"nntrartnr• � r �
Waier Suppl • Private !� Public
i�v P�i
Sewage Disposal Facilities: No. bedrooms dZ' ' Dishwasher, Disposal,
washing machi ther automatic appliances
J
Size of tank: Nitrificatio� line:
.. _ � _ . ..
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Above recommendations based on information received and observed
soil condition. Septic tank and nitrification line MUST BE INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PARTMENT STAFF before any portion of the installation is covered
and put into use.
�.� �
Date approved: �—
Well:
Sewage 's �
By:
��1 ����
Sr
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date.
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A�aaitcatlon Date: �.•� -Q 3 7ax Man #: A 2 i'�'
�lmount �aid: l .
Rec�i� . Parcai��:
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•IF THE INFORMAl70N IN THE �►,PPL•1CATION F+DR AN IMPR�VEAAENT PEi�Mrt' 1S� INCORREi;T P,4LS1h�Ep=
. CHANGED. CfR THE SITE IS ALTERED. THE�I THE 1f1�PROVEiNE�IT PERMiT AND AIITHORI�A►'i1�Pl 70 .
GON9TRUCT SHALL BECONIE IWVALIQ. -•
1) Permit requested by: (Own�elapent/prospective owner�: o•n M y C�1 � v- ,� 2. /��- y
Home Phone: '• Addreas• � q o !�b G K �' �+ �� ' � �
. Busineas Phone: ,�'9 9' - � / � 1 � L� I � - �
o L� T �.cJ �i ��/.� �
2) Name and �ddress af caarrent av�mee; f// Y 1��
' � 9a / kn� �,vc,T� .✓ i''i �v _ -
• � � 26.��U.n�, N� . .}-0 IU
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3) Property Des�cription: lAt size: Tawmshlp: Subdivision: Lot #
Dir�ections to the property nduding rnac# names•and numb�ers): _�� M�� I�� o O� 4 q-S ,
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4) Propos�ct Use and Stnacture Descri�stlon: answer eacti af the follavutng questians: �
� a) Propoaed _, Existlng . Typ� af Struc�ure: � Width: � t7epth:
b) Numher af �edrooms: Number of acaupan� or people to be� sen+ed: •
c) 8asement Yes . No _ WW there be plumbing in the•basameni7
d) Sarhage �ispasal: Ye� � .�
� W� �P�� �IP�: Private,_ (new _ ar exlsting�, Puhlic_, CammuNty� , SP�9
Are any wells on adjotning properiy? Yes �a _ if yes, Pl�ase indtcate apptnxirnate location on th�
�site pi�t. •
' 8j Daes your prcperty c�ntaita_prevlousty identt�d jwisd[cti�nal w�tlands? Yes No
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➢ A PLAT OF TWE PROPE�tTY AR SITE PLAN II�U�'T HE SUBMIiTED WITti TH1S AP�9.IC,AYION.
➢ PROP�RTY UNES AND CORNERS MUSI' BE C1.FARLY 611AARl�fl. •,
➢ THE PROPOSED LOCA�TION OF ALL 8TRUCTURES f11UST BE STAk� OR FLAGG�.
9 THE �iTE MUST BE REA►DIL.Y ACCESSIBLJE F�R AN EVALLIA►TION BY THE HEALTH DEPARTTAIflF.i�1T'
sTa�. . � � � �
I hereby make applic�tlon to the Person County Healtl� Department for a site evaluatIon fior the on-site sewaga ��posai.
system far the ahave-described property. 1 agree that the cor�tents of this appiicatlon are hve and represent the maximum.
f�ciii�es to be plac�d on the property. ! undetstand ifi the site is aitered nr the intended use changes, the perm� st�alY
hecame irnalid. �
� � 1�-� -O 3
wner or Legat Represe�tatrve Date
PC'ri�]� rev. 06127102
Application Date: � 1 � I �
Amount Paid: �
Receipt #: $ ( �
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�
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit reauired)
Well Permit (New/
$300.00/$200
�..�1,) f ������ Taz Map: �
��- � � ���� Parcel#: �_
T � aawan-cDiana3a-ua�ull �E�Icralll,la
tion for Services
5ervices
�� �
Construction Authorization
(Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: �v I•�n �,�' �-tn
Address: `7o$a1 U� /'S! li ,�o.. 2��•
!1 o,�h� r� /l G 27S 7W
2) Name and address of current owner (if different than applicant):
Name: Gf%t ���; C � �,�I :
Address: l.�901 �jcl��in�%+ � •
iQox�o�o I'�G 7 yS7y1
Phone (home): (33 (o� � 2� ' 1� � �
(work/cell):1'��i�,s'.R�(�
Phone:�3�b) 33l' ' �T 93b
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: �iom �o�.ln �+e�Kc Ng Sou�G, /. S�%��S l�5�
�iti � t.,/�.� DG �� � SI'LJ"1�o r� �n %� ��'
❑ yes L7no I�oes the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
CJ yes O no Is any wastewater going to be generated on the site other than domestic sewage?
C) yes ❑ no Is the site subject to approval by any other public agency?
C) yes � no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
(.i�r»�I G•N� %
Q�� l�/�c'i`�
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing Systcm If expansion: Cucrent 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 employees:
Total Square footage of Building:
Maximum number of seats:
5) Water 5upply: ❑ New well �E�sting Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for �Authorizallon to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovadve Cl Altemative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is syb,�equently altered, or the intended use changes, all permits and approvals shall be invalid.
Legal Representative*)
* Supporting documentation required.
y-IS-�D/�1
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.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Ma.p # o� Parcel #�
Section/Lot#
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Date
System com�ionents represent apprnximate�contours only. The contractor must, flag the syste9n j�rior to
begznning the installation to insure that jiropergrade as muintained
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WELL PERMIT�
(New_ Repair �/)
Tax Map: ,� Parcel: �
Subdivision:
Applicant's Name: i
Mailing Address:
a
Phone Numbers: ___;'3i�- �30-qq30 _
Location of Property: ��D
Lot:
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:
QNew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Certificate of Completion
Date: �
tbLiner:
EHS/Date
Depth:
Grout: � y-?,�-��
�Abandonment:
Date:
Method/Materials:
Well Driller: IjJQ�1� C�l 7/Q(� �Johh U1"�C License #: 30 Le�et R�
Pump Installer: License #:
Approved by: Date: - Z/'
Additional Comments:
Date Sample Coltected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
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�9_.T LaJA� J��'i 12.1 3231�13�i� ��Ltl 1'�� 'W S' p.9 . Jl S� �.M�� V i �
'I'ax Map #: ,� Pazce�! # _� 'I'ownshi�a
ApPlicant
Subdivisiori: Se�tion: I.o�
'I'�e of Water Su��l�: „� Individual Community Public
Rec�uireffient�• .
Site Approved by �
Grout�ng Apgt�ved bp � ���
Well Log ��
Well Tag
Air Vent �
Hose Bi`b
Concrete Slab
Well Driller. � /I I�(VI �•J �
We�l Approved Bp: %)a#e•
'�See AttacHiesi Site Sketc��
Wells must be 10 feet from propertp lines.
WeDs must be 100 feet from septic systezns.
Wells must be at least 25 feet from anp building founda.tion.
Oti�er conditions•
PCf�, rev. 09/07/Ol
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'- �— ��� � � �'II� � ' ° P�u� �� �dIJ Kfl��•��Al� I-L-U �lY1�S�tS �C-
)�n-n-vii 1r••�caii-a�rn-n.Rrirntb.�n.�1 �L��v.an.�.ct�a �� �Q °�4� "3 "Q3'
Owner: �,V 1
Location: L�
Subdivision:
N
Grout Log n -
Tax Map 1V Zq__Parcel_# ��-
Well Construction
Distance From nearest Property Line (Minimum 10 feet) �
Distance from e t�c Sv�tem (Minim i 60 feet)
Total De�th: � ft Yield: �� GPM Static Water Level: �� ft
Water Bearin� Zones: Uepth �� ft �y� ft ft ft
Casing: !� . _ _.
Depth: From � to �� ft. Diameter: `7� in
Type: Galvanized Steel 1�
Weighr. Thickness: �� Height above Ground: in
Dri��e Si�oe: Yes No Any problems encountered while setting casing? ._Yes _ No
If "y�es" give reason:
Grout:
i1'e�t: SandfCement ✓ Concrete Gravel/Cement
annular Space Width inches Water in Annular Space Yes No
,:�lethod �f Grout: Pumped Pressure Poured ✓ Depth � to �.� Ft.
i�Iaterials Used: __ _. _ __
No. Ba��s Portland cement Weight of 1 Bag Pounds
If mixture (sar�d, gravel, cuttings) — Ratio to
ID pl�i�es: �� Yes _ No 4 x 4 slab I� Yes _ No
Drillicig Log Location Drawing
From 'i o Formation o `-�
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I hereby certify thac cl�e above inf�rmation is correct and that this well was constructed in accordance with regulations
set forth by the Per�c,n Counry �Iealth Department. .
Si nattire of' Contractor � ID #�� (U Date ' � �3
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� PCHD rev 09/30/�2
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(/� �� . -- - � � A 0 + 5 5
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION Il�ROVEMENT PERNIIT
Tax Map # ��j Parcel # 1,}
Zoning Township
Owner/Contractor � � � P �1� Pr��J Date �,-, -- f ,� — .C'.��—
Location/Address
/�' _
S.�i"� v
Subdivision Name _ _ Lot#,
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SEWAGE SYSTEM SPECIFICATIONS --''
�'�L�aiT iJi «;:;u _ CI -i?? ;,!"Tank- �_ _.__.__..
SFD _ Mobile Home Size of Pump Tank
Business # of Bedrooms Nitrification Line
Ma�c Depth Trenches
Permit Void after 60 months. Permit Void if'not in conipliance with zoning regulations.
Permits may be voided if site is alt ,r ct or � te ed changed.
Well and �-�t�.���Y���a,l�.'�� ,���'e—�1,ddL��_
Comments:
Date
Installed by
Site Approved_�
Well Head Approved.
Grouting Approved_
Comments:
Date
_�:ipprovPd by
� , WELI. SY�iE1bI SPE.CIFICAIIONS
Semi-Public _ Required Slab ;/ � / �
teglacement A.ir Vent i
� Required Well o� d� a.� 4�
� �C (o �4 S .-- i Weli '3'ag
Installed by
Approved by
This report is based in pazt on information provided the homeowner or his/her representative in the application submitted for this pemut� Th�
environtnental health specialist is not responsible for false or misleading infoRnation contained in the application 'The environmental health specialist
is also not responsible for concealed conditions on the properiy or for statements in this report that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tan}c system will
continue to function satisfactorily in the future or that the water supply will remain potable.
ORIGINAL
c:�amipro�pemvtsam O1/95 rev.1.0
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1`I;It�;I1N ('�111N'I'Y I:N�4"�ONMI:N'fAl. I11:A1�1'll � � '
WELL LOG
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Own��- _ � � W RC � � � S�# .
Locati�n/Directions: . _ . ,
Subdivision �Name: • 1'°L �
Drilling Contractor: �� � ���
WELL CONSTRUCI'ION .
.- Distance from Nearest Properry Line Distance from�Source of
Pollution � � � �
Total Depth: � Fc. Yicld: �J GPM Static Water Level Ft.
Water Bearing Zones: D:e Pth Ft. —F�- - �� F� �t.
Casing: Depth: � From C� to �" Ft. Diameter: Inches
TYPE: Steel � ��?:►a.Ziz�3 S�epl �ES
If Steel, does owner approve: Yes NO - Inches
� Weight: � _ Thickness: .• Height'Above Ground:_
Drive Shoe: Yes_ No . —._---
. Were Problems Encountered in Setting the Casing? Yes -� No_______
If "yes" give reason: . .
Grout: Type: Neat SandJ�ement _ Coricrete .
Annular.�Space Width � Inches � � �L..
Water in Annular Space: Yes No P� �=
�Method: Pumped � Pressure —
Depth: From �–� � � �� �
Materials Used: No. Bags Portland Cement_.. Weiglit of .l�bag_lbs.
If mixture (sand, gravel; cuttings) - Ratio: _ to .
ID Plates: Yes � � No � � � � �
� 4 x 4 slab Ycs_ ✓ No
�
�
I HEREBY CERTIFY THAT THE ABOVE TNFORMATION IS CORRECT AND THAT ,,. �
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT. .
� � — 2b 5 .
Signature of Contr tor Date