A29 5111/20/2001 14:57 9105990678
Nov-20-OI O1:fi2P
TONY WESLEY
PAGE 01
Aoclica�en Date• � '020 '� � T Ma �: -s� �'� 1
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Ap�ucAnoN FOR s �,�s
P.Ol
1) Psrmli �eguest�d h:(own�r�►g entiprospactive ownery: �
Hpme Phane: — �f Addresa: � h
Busk+ess Phorte: � Yt -c=„ L ,3
2) t+fame a�d �ddre�s of currunt owner; �dY► �.(��5��
3) PropartyD�a�,rtpNon:� Lotsize:p�� Townahtp: DIr� �� Subawisian: %U � L.at�:
Directtons to ttte propar�y (includi���ped net�s �nd numbers):
a) Proposed use and_Structure Dosoripdon: a�awer eachp� the fnllowinQ questbns;
a) Propose� �Existing _, Type of 3tnrcture: �-�CJ'� �1.► i t� 1�•1-0,�;� W�dth; Depth: �„_
b) Number. af.Bodraoms; ,,�_ Number of oxupants or peopte to be served: �,
cj Basement: Yes . No � Wf1! there be ptumb�g In the basem�nt� �
d) Garbage Dlspcsat Yea � No �
S) watet Su��y Type: Prlvnta �new or exiatfng �, Pubtic . Community � Spring _
Ar+s arry weAs on adjoining propc�? Yes � No _ If yes, pEea�e indicate epproxirnate lop�rion on tne aite pian.
Q) boes the prvporty conaia p�viou+�ty idarttUloet Juriadictlonal wetlsnds? Yes _ No ✓
P�..EAS� NQT6 THL� P4LLOWINdi
D A pLAi OF 1'ttl� pROPERTY OR 31T� PLAN Mtl9T BE SU9METTED WfTM TM(S APPLlCAT10N.
> PROPERTY tINES 11N� CORNER3 MU$T 8E CLEAiiLY MARICtp.
> TN! PROPO�CO tOCAT10N OF ALL 8TRUCTUREB MUST 8E STAKED OR �LAOGED.
➢ THE SRE MU$T BE REIIWLY AGCE5�IBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF.
I nereby make mpptication Eo the Person Counry Hesith OepaRment for a site evak,a�on fo� fhe ao-site a�wa�o di�posal
system fw the abwe-deacribed property. I agree that the contents ci tt�is appilcatlon are true and rep�es�nt the maximum
facilitles to be p12c on the property, i understand (f the site is alierad or Ute intonded u8� Ghaltge�, Ute permit stf�ll
bxome (nv�alid. .
%�-s2D —E�)
or Legal Represanta6v ' Date
Pc�+n. ►�w,,anrro,
P�RSON COUNTV E�VVORO(VfNE�lTe4L HEAL�'H
Tax Map!!: �� Parcel#_�� Township 1 11 ��i �- 1"���� -- -_- PIN
ApPitcanC � ( ubdiyision Phasel5e�ion LotS��,�i• �/ //}(,,
L.ocatlon: � i- 4- ' \
Improvemen Permit
New �iAddition Type of Structure 3 1� 1\ St-� Water Supply
# of OxupaMs�� # of Bedrooms �_ Other System Type�
Projected Daily Fiow: � g. .d. Permit Valid For. �-Five Years 4 No Expiration
Proposed Wastewater System: ` ' �
Proposed Repair.
Permit Conditions: ���15�-01.`1 d(1 � f1�n c,� .["�. ,
Ovmer or Legal
Authorized State
Date: � 2 0 � �
Date: / ��� �U �
The issuance of this permit by the Health DepartmeM in n�l way guaraMees the issuance of ofher permits. The permit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if
the site plan, plat, or the iirtended use changes. The Improvemerrt Permit shall not be affected by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and
Disposal Systems of the North Carolina Administrative Code.
Wastewater System Description:
Wastewater Flow: .p.d. Type: �
Facility Description: ��Y� 5�JJ New � Repair ❑ Expansion ❑
Basement? 0 Yes o Basement Fixtures? ❑ Yes [�ld6
Wastewaber Svstem Requireme�s
Tankage: Septic Tank size I�V gal. Pump Tank size ���'i gal. Grease Trap size �_ gal.
Trenches: Total length �_ ft. Trench Width �.�ft. Total Area � sq. ft.
Max. Trench Depth: � in. Aggregate Depth:�_ in. Soil Cover. �_ in. Trench Separation �ft. on center
Perrnit Expiration Date: �— — �
Authorized State Agent Date: � '�-0�
*See attached site plan and dendum pages for additional permit conditions.
The type of system permitted a does ❑ does no# differ from 4he type specified on the application. I accept the
specificatio�s of this permit
Owner/Legal Represerttative Signature: ` Date: � I-�� ���
O�eration Perm
System Type (in accordance with Table Va)�
This system has been installed in compliance applicable North Carolirta General StatuOes, Laws and Rules for Sewage TrealmeM
and Disposal, and all conditions of the Improvemerrt Pertnit and Construction AuthorQation. Issuance of this permit implies no
guarar�6ee that the s tern installed will function properiy for mry given period of time.
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utho " e te A nt Date
PCND, rev. 03/07/01
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Person Counfij Health Departmeqt
4 Environmental Health Section
Tax Map #: 7 1 � Parcel #• � I
�I�V '
Zoning: Township: i � � 1�� I
Subdivision: Section: Lot: �_C o1��%!*C�
Appiicant• � ` C . Gt3 �4-�- `��l - _
Location: L � ���' � T )
Operation Permit
System Type (In Accordance With Table Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITiONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION. _
�. �-��a
uthorized State Agen ` Date
Tax Map #: �r�%I Parcel #: �� _
PCHD, rev. 10/12/99
�_ �e:s�tioa ��*e� � .,29
Amount Paid: ( 0 . 0
Receipt #: 1 °1— 31 b
C� � � � � Am
0 Improvement Permit (Site Evaluatton)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (ifsite visit required)
❑ Well Permit (1�Tew/Replacement/Repair)
$300.00/$200.00/$�75.00
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L:.,�� �J "�' ��,�, � ���: � I �: a� ����:
`.,' ►, � 1L 1LG" �� �l � Parcel#: �—
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1E��aa-o�**+�+�* �an��.Il IE3[o.m.Il�lla
Services
for Services
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
❑ Repair of Eaisting Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Infor 'oa: •
Name: 3� ? ca ����' .
Address: u iK �;.:. .
�' _. �,c► � 2 � �
2) Name and address of current owner (if different than applicant):
Name: �Arti 'Z.
Address:
Phone (home): �/ ���/'s "s�j-�
(work/cell): /c'i- �/ �'�05'
Phone:
3) Property Description: Lot Size: 2 v,� Subdivision: Lot #:
Address and/or directions to Property: ,��� �,� !� .�� /�c �
❑ yes 0 no Does the site contain any jurisdictional wetlands?
C7 yes �s Does the site contain any existing wastewater systems?
❑ yes Q�"n- Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes 0�yn Is the site subject to approval by any other public agency?
❑ yes C G" n o 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: : �� �/ 2, c� ��" ��t,r�� ��� ,� � f�.
OResidential
❑ New Single Family Residence Maximum number of bedrooms: ! Occupants:
0 Expansion of Existing System If expansion: Current number of bedrooms:
� Repair to Malfuncdoning System Will there be a basement? 0 yes ❑ no With plumbing fixtures? ❑ yes ❑ no
ONon-Residential
Type of business:
Maximum number of employees:
Total Squaze footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well C�3"�xisting Well � Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or exis6ng waterlines on this property? ❑ 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):
❑ Conventional ❑ Accepted 0 Innovative � Alternative ❑ Other ❑ Any
�
I certify 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.
Signatyfe (Owner/ Legal
* Supporting documentatio �
/-���— ��',��`
Date
Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
A com�leted `Lot Preparation' form must accompany any application requiring a site evaluation.
..
( t 0/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N� 27573 (336-�97-1790)
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Building Additions/ Mobile Home Replacements
Tax Map #:�� Pazcel#:�� Address: �`j � f'gu►- l�k �,� �
� L'� �nrsl _b�,^ ��
Approvat Requested for: Mobile Home Replacement
� Building Addition .
Applicant Name: -.. SCo �-4- M �s Z�
Address:
�4'►�-P 4 S �i` ov—�2
Phone #'s• � Q- So3 �
Permit Located: �'� Yes No
Installation Date: �� z- o z Design flow: �� (gpd)
Current Contract with Certified Operator on file (if required): ��
Water Supply: � Well Public or Commwuiy
Wastewater system shows no visual evidence of failure on: _ 2— t—( s/ (date)
(Applicant's signature if site visit is not required)
Comments: ��w„ss;,,._ � �1�; ial�� zf�',��v � l��f.�� �a,.�,._
Addition/Repiaceraiea�t Appraved
� � .
Enviranmental Health Specialist
2-c- t�
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv net
Tax Parcel Viewer
Page 1 of 1
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Person County Environmental Healti� �-�q^5 I
325 S. Morgan Stree�
Suite C
Roocbora NC 27573 y�, � �'��
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2,�_ �g, �
https://gis.personcounty.net/TaxParcelViev��er/ 2/1/2018
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I���a-��,.-n-T ���.�.0 IL���.Il�]�
Owner: / A
Location: L
Subdivision: 7
D��aoP �� � �o � i
c�oc�p� a� _�,� ��.- � r D�-. �l l.` �. F
Do�' DD [r��[]al __ J_ ��,. o �
Well Log
Lot #
Tax Map,�� parcel # ��/
Well Construction
Distance From nearest Property Line (Minimum 10 feet) �
Distance from Septic System (Minimum 60 feet) ,�
Tota1 Depth: _�� $ Yield: �_ GPM Static Water Level: -��$
Water Bearing Zones: Depth J/� $�SS ft ft ft
Casing:
Depth: From �_ to ft. Diameter: b � in
Type: Galvanized Steel �— —�
Weight: �_ Thickness: 8' � Height above Ground: � in
Drive Shoe: -�es No Any problems encountered while setting casmg? Yes �io
If "yes" give reason:
Grout:
Neat: SandlCement ✓ Concrete GraveUCement
A.nnular Space Width �_ �ches Water in Annular Space _
Method of Grout: Pumped Pressure ✓�oured Depth
Materials Used:
No. Bags Portland cement Weight of 1 Bag 9� Pounds
If mixture (sand, gravel, cuttings) - Ratio _� to��.�.�
ID plates: �es _ No 4 x 4 slab �Yes No
Yes �io
to Ft.
Drilling Log Location Drawin¢
a
From �o For ation
� v �
� Q L
r
I hereby certify that the above information is correct and that tlus well was constructed in accordance with regulations
set forth by the Person County Health Department.
Signature of Contractor r"`�-�-i ID# I)ate �. Q 7.�
��/ � /
PCHD rev O1/16/02
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IE�n��waa-�sa��-n-+� �aa��n.I� ���.m.71.�11�a.
_ - __ _ _ _
WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
q y� � if
Tax Map #: � 1 Parcel # �� Township l_J I��'� f'l � I(
Applicant:
Subdivision:
Lo
Section• Lot:
rl �L � t���"
��%`�0� ' .... -
T�e of Water Su��l�
Requirements•
✓ dividual Communitp Public
S�te Approved by � �� �-o-�
Grouting A r ved by ,� �� �-��
Well Log_ _/-oZ -
Well Tag�c �2 ,�-fl z
Air Vent �X Z Zz-�z
Hose Bib Q� ZrzZ��z
Concrete Slab �zz�z
Well Driller. 2�
Well Approved B �_ Date: �-��-UZ
'�*See Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic spstems.
Wells must be at least 25 feet from anp building founda.tion.
Other conditions:
PC�ID, rev. 09/07/01