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A30 126. V `-� , Amount paid o��d�'� .'`'iteceipt ll ' 176 C � �J�� �/ 9� '� I I 76 7 f d'� D a t e � O � � � w U � a Improvements Permit.(EstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing) mpxovements Pern�it (Un�ecorded Lot) _ Repair/Replace existing Septic System �mprovements Permit (Mobile Home Replace) ,_ Permit for New Well Improvements Permit (Addition) _ Replace Existing Well ����-tia��"�������� ���,�y�.a�e�'r�S�am�e ���Co [ecfe�d:,�����1�� vyr..w�.m . �n.t+ ..iF� 't�W A�MMM�.� - ..TMY�'.:ltinw. . )r ii .�.. _Bacteria _Chemical Petroleum Pesticide 1. Permit requested by: owner/prospect ve ow � Address: •�' a • F Home Phone #: S�%%—�%',7� ,_S'�99 �.Sy' Business Phone #:�p� ,,�� 2. �me �d a��L. of cu�t owner. rri _ . . i /'l�.i/l�G �� 3. Propercy Description: L.ot size: , Tax Map#: � � C��' Parcel#: , ` Township:_ � _ � `7 . Directions to property: State Road #& Road iames,�tc. , � � _ . . Number of occupan[s or 7. Dimensions or Proposed Structure: Width: _, Lead 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? 9. Water suppl y pe: -- private ublic ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ I�Io �. �,If so, identify location: I0. Type of structurelfacility: Proposed: DExisting: Q Type of dwelling: House: O Mobile Hame: usiness: ❑ �j►pe of business- Number of Employees: �dumber of bedrooms: _�_ Garbage Disposal? Yes ❑ No IBasement? Yes ❑ No so, # of basement fixtures: le to be secved: � CLEARLY STAKE ALL CORNERS OF THE PROPERTY A1�ID THE CORI�IERS OF ALL PROPOSED STRUC�'URES. �I hereby make application to the PerSOn COunty T:�ealth Uepartmen� for a site evaluation foc the on-site sewage disposal system for the above described property. I agree that the contents of this application are tcue and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can E issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of tha site by the Health Dept., this application shall become void and all fees paid forfeited. Sienc� Owner or Authorized Agent .. : , B PERSON COUNTY HEAL�H DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT 2396 Not for waste water system construction. No permit(s) for Construction Location or ,\ Relocation Activity shall be issued until Authorization for waste water system construction U,� has been issued. 0 � � W � a l� �Tax Map #� �Zoning � Owner/Contractor Location/Address Subdivision Name ti Lot#�� SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area � Size of Tank �� SFD �/ Mobile Home Size of Pump Tank N� Business � # of Bedrooms_� Nitrification Line�1. � Max Depth Trenches Permits may be voided if site ' altered or i Well and Septic Layout by Comments: (�lV1 GI� Date �S ��i� Well Permit Individual Installed by rubtic Site Approved_!� Well Head Approved Grouting Approved_ Comments: � D F Date use �Approved SYSTEM SPECIFICATIONS -Public Required Slab _ cement Air Vent Required Well Log Well Tag _ � � �� Ds�- 6� � Installed by ' Approved by l�� 3 This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person Couoty nor the environmental health specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l P/� � AUTHORiZATION FOR WASTEWATER SYSTEM CONSTRUCTIOI�I (Void sixty (60) months from date of issuance) DATE: � Jo� � / �1 IIvIPROVEMENT PERMIT #: TAX MAP #: : PARCEL #: OWNER/OWNER'S REPRESENTATIVE: � � LOCATION/ADDRESS: SUBDIVISION I�IAME: � � � �'�1,� � �Q. �- E' r LOT # � ��I�� a� � SECTIOl�I OR BLOCK: AUTHORIZATIODi-F�4R CONSTRUCTIOI�I ISSL�D BY: AUTHORIZATION CONDITIOI�IS 1. The Wastewater system construction and installation must meet all of the conditions of the attached site plan and specifrcations as set forth in Improvements Pernut #/�7 �3q� The constnaction and installation must also meet all applicable rules and laws. 2. No portion of the Wastewater system shall be covered or placed into use until inspected and approved by the Person County Health Department. 3. Any a[terations in site or soil conditions (including structure locations) or modification in use, design wastewater flow, or wastewater characteristics as specifred in the associated improvement permit and application, may void this authorization and associated pernlits. 4. Conditions: ����.��}� �� � ,6�'6G� �2� �� — o� � . _ ,/-� . _ _ __ _ _ ____ ____ _ 6� � L r �� f l , o�= � � �� I ��" �°� �, . _ �� � � M // `� � 0 �_ ' . . , ...._._.. ( �� � 2 �, $ /Z � � _... _ _�w � - � ; , _ _- - --- ---. � 3o,'z y �9 . 3�9.�9 �� - ` �-/ � � � J ��_"". � l�N LJ �-� � L �/��i� �Q.cJ /��ii- �t �' Date: . r r � J Owner: ,c� Location/Directions: Subdivision Name: Drilling Contractor: _ ... . .. ..... ..... . ....:.. _....... -. _..� _ . ... .... . . . . .... � . PERSON COUNTY ENVIRONMEPiTAL HEALTH WELL LOG �� SR# WELL CONSTRUCTION � Distance from Nearest Properry L��e �6 Distance from Source of Pollution_y,�p '� Total Depth: �14p Ft. Yiel:�:_ <<'___ GPM Static Water Level�_�:� Water $earing Zones: Dcpt}�5 ��'L�2,a�t� Ft._ �F� Casing: Dept}i: From d to��_Ft. Diameter: �,Q�_jn�h�; TYPE: Steel � Galvanizeti Steel � If Steel; does owner ap�r:-ove: Yes No � Weight: � Thickness: • l88 Height�Above Ground:�_ Inches Drive Shoe: Yes � No Were Problems Encountered in Setting the Casing? Yes No � If "yes" give reason: Grout: Type: Neat Sand/Cement Coricrete Annular. Space Width Inches Water in Annular Space: Yes No _ .. Method: Pumped . . � Pressure � Poured ��'. � �. : . Depth: From o �o ZS'J Ft. . MateriaLs Used: No. Bags Portland Cement Weight of .1 bag__lbs. If mixture (sand, gra�ttings) - Ratio: to �ID Plates: Yes No � � � � �� 4 x 4 slab Yes ��No � I HEREBY CERTIFY THAT THE ABOVE TNFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH $y�THE PERSON C�ui�`I'Y HEALTH DEPARTMENT. ignaturc of Contractor Dat�. ►_ . b� � Amount paid ' Receipt .l� '� `7c� O —� .. . � H O � � � w U � a % z Person CouMy Haalth Dept 325 S. Morgan Streei Roxboro, N.C. 2757v Gqurier �2•33-15 �-�� �� Date .__...._.. Improvements Perntit-(Established/Recorded Lot) ._Reinspection of Existing System (Loan Closing) ImpFovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System Improvements Permit (Mobile Home Replace) _ Pecmit for New Well rovements Pecmit (Addition) _ Bacteria 1. Permit requested by: . �wner/oros�ective ownec _ Replace Existing Well Chemical � Petroleum I _ Pesticide ( _. Lead 7. Dimensio s or Pro osed Structure: �agenr`��� �j,Q,� �Qt�►� Width: �(' A�� ome Phone #: �O� - O�SUi usiness Phone #: = _ �L- =(p (93� , Name and addre&s of,current owner: ._ . Lot size: Tax Map#: � ' Parcel#: , a� . � F �, . Directions to propercy: State Road #& Road Number of occupants or people to be served: 8. Wha[ type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? 9. Water supply type: private �. public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No �. If so, identify location: 10. Type of structure/facility: Proposed;�Existing: Q! Type of dwelling: House: ❑ Mobile Home: C7 Business: ❑ Type of business: Number of Employees: Number of bedrooms: Garbage Disposal? Yes ❑ No � iBasement? Yes ❑ No�.7 If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PerSon COunty T3ealth Depal'tment for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand [hat in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfei[ed. .� . Yerson County Health Department Existing Sewage System Report For: �obile Home Replacement Addition Requestee: �� Home Phone# 5 03--D85`� �� 15 �.un�,i-r��on � a us ine s s� ��QI� � riC ai5-�3 'Pax Hap� "�� �d10 Location��irections: I•� �� ��tQQ,QIt� �C�-�P� �.���b(�' Original Permit Located Septic 5ystem Uesigned �'or. _ Kesidential v f3usiness Other (specify} # eedrooms ,�_ # �mployees Other _ Uate '1'ttstalled � q Water supply (�'Q.Q� . - . - I � 11��I����I11.«'l �7���1�11� �!_i I • �' ► - Tank Size Certified Operator Required � o On site wasL-ewater disposal system showes no visually apparent malfunction on �„� ! Yermission is granted to: Q,�e.,- arn �`�" 1 � �I�,h(� �1,Q1� QY ��.F� - I �` m u�-e�-l. A�cording to the attached site plan: , � Environmental Health $'�G.. [in�� 1�L� -Y��IT_ . DATE � �,�,Cra�tl-on t�UCL4 /l�-C�-u��, ` � :.� C�r��+-�.�`� �'�- �� .