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A30 17A
Applic�tion Date: % ;;13 -0 � Amount Paid: ,t/�� Receipt#: `--_��. S ..� I�I�I�..� �� - � � � ����- 7.E-�'1.3rn-as�i.n:.r.aarn..lrss�n_.eR:�rn�.m..l� 7E: IIa.^.zn.11.ti:;l�. Application %r Sea-vices � lSentic Svstems and Wellsl Services G dmprovement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) C Mobile �Iome Replacement or Building Addition $150.00 (if site visit required) � C Well Permit (New/Replacement) $225.00/$125.00 Tax Map: .� 3 � Parcel #: j 7 �, ❑ Construction Authorization . (Fee is dependent on the type of sy; ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System No Charge Important: If t/:e information in the application for an Improvement Permit is incorrect, falsified, or the site is altered, tlien t1:e Improvement Permit and t/ie Authnrization tn Construcl shal[ become invalid 1) Services q ested by: Name: � , �- �Q i Address: �` v t� Phone # (home): �a �`�l ��f� (work/cell): 5 0 3- Z� o S 2) Name and address of current owner (ii different than applicant): Name: Address: �-, ��� 3) Property Description: Lot Size: (��e Subdivision: Address and/or directions. to Property: � t�. 7 Vc u�: � S 4) Proposed Use d Type of Structure: Residential � Business/Type: Other Number of bedrooms �/ Number of people served (seats/employees): Basement: Yes No �/' (with plumbing: Yes No � Garbage disposal: Yes No l 5) Water Supply: Private Well Proposed Existing _) Community Well: Public Water System: Are there on the adjoining properties? No Yes Lot #: (please show location on site plan) Note: A comnteted a�plication must also include: ➢�4 plat/site plan of the property that shows property dimensions and t/ae size a�d location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the properly is ready to be evaluated I am s�abmitting �his application to request seraices from the Person County I�ealth I)epartment. The information providesi is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representative):� aJ�, ��.L Lz..� I)�te : ���% 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ,. ��� ��i ���b..�' �� �:. '. ��� A, � , � � � ���� � ��.�.a-�mm � ���.�.11 1L 33L�.a,.11� . �ppIicant: _�Oc' l� C► � 1'$x3nat �alid for V\ �'ive � Type of Facility: � # of Occupan#s � # Praposed Wastewater System: Proposed Repair: _�� Permit Conditions: �nrove�en� �ermit T��x IVIa� � • � ��rcel = • Suqd'ivi�s•iora F�h a s�e;'S e�cti�o�n.� Lo��t � Water SnPP�Y ��'� g-P.d. Type: Type: � ►% Owner or Legal Representativ Si �•�-: �_��� Date: o—/ u—v I Authorized State Age� M► . ' Date: �,"�—�-� .... The isauance of this permit by the Healti� Departmevt m does nat guarantee ttte issuanca of other permoits. If is tl�e respons�b�ity of the . aPPli��P�Y owner to in sure that all Person County Planning and Zomng and Bn�7ding Inspections requi�mcuts are met This Improvement Permit 3s snb,ject to revocatlon if tlie site plan; `pl'ati.''�� ti�e intended use chsnges. The Improvemeat Permit is aot a$eete�i by a ci�ange in owner'ship of the property. Tl�ia permit was issued in compLta�uce with the proaisiona of the North Carolina, .: `Laws and Rules fur Sewa�e Treatment and Disnosal Svstems' (�5A NCAC 18A .1900). Neither Person Conniy�. mor°"#tie.`. '� Environmental $ealth Specialist warrants that the septic tank �ystem wi71 cantinne to fnnction s:dtisfactorily iu the futare�or:#liat- the-water supply will remain potable. � • � � Anthoriz�tioa to Constract �9i�astewater System (�,tequaed for Bnilding Permit) � * See site plan and additional attachments (_�. • � .�-. ('_ . Proposed Wastewa#er System�: 1.���i.� �'L1.�, R��. � � T��pe ��i Wastewater Flow �.p.d. New � Repair ExPa�sion _ � ,- 30�7 LTAR: .�? S— _ g.p.d1 ft 2 � Type of Facility: ' ��� S•� � Basement _ Yes � No . `PVastewater System �nirements T�nk Size: Septic'�aak:' �� �� gal Pnmp Tank: gai Grease Trap: gal � . ])rai�fe�d• �otal Area: % 0 sq ft Total Lengt4 S�� ft ' lYtaai�num Trenclt Depth 2 2 in .-� �. Trencii �i�idth 3 fi 1VTinimnm Soil Cover: `P iu M'inimwri'IYench Separatiton: �#t �. C, . Distmtbution: I3isiribution �oa %„ Serial Distribntion Presanre Manifold . . SpediHcations: � . � -- � _ = .. A�ntiao�ized State Agent: �� Permit Eapiration Date: Date: The type of system pennitted is � Con tional Accegted Alternative. I acc�t the spe�ifications of the �ee�/�ag�l �E�r�s��tatiae: CL'"'� Date: O —� 6 �� % ' pCffi� rey. 11/10/05_: � .. .. . � _. �= � � C.Q.p�,r- i ���-f�. , . . . . � t���e� C . '� : . 'G :�,� S�� . . �. � Y ��,��' : _ . . .:� �� �'` : . _ ; � 5 �s �Y�' �� ��s . _ � �-,�-� ��- � .�o _ �� �O� . , � s5� ��� �'s � S. S�.P�-, p-„� �o '� � U� �� � . . � j � _ ��,.� � �,,,g'�,��;-h-� � . � � � 4 � � ' . � v � � � .. ' ` � � �`�-�.<.,- /1 ...., � A � ," . n1 �� _-�� '' � , . � . - ; . .: V� v� ' �e% � Q�� � � � ...�, - .� . • . � T o � , . � � (� ' p 2��� o •,'� I � � �o . � � ` ��'� ,t� o. . a . a. . �' " `� � o L, � '��•e' . � 3� �' • • �j° � . . �`^ ~ \ �. ; � ' ,� �'j� � ' � s � ad T � �r � . . . �d �8 � � t.'� � \ � 'L � �' � '' \ � � � �� � � /O � � � (y�� 1s 1 '�• RQ ` ` ` " . :�! ' �' b o 0 � �: � v : A a � • :, , � • � �y � \ Q .t � . � . ` �- 63 0 . v WQ11 � � - . � 2�,� � E r i�,{ , �� s� . �1/ � ui� ( � - I . �i,�� .'r, .'�— �� . Q��''`� e � � � %�'' ���.;� . � ............ . . . - �,� 1�� f r . . \ �� ' ' . ' ` , � � � ... ,, ' . . - �C �s• � PRoP� � 7-�- > G,E"o��,� s. S o,� o�cyy .. �. � Sv/✓e 7 • q � '9 J ' t c, g .. � � . c�Vl-�� G` �1 I - ` �- �a � � : "9 . . ' cs� /� ..so • . . : -- . . . . • �. ,- � . : � . . ��o l �-�4 � �� � - . . - : : �� � � . ' �. :; � . �G ?G ` ( ���' i ��� ���� �� \� � � �� Jl 1!. . �E���-�mm � ����.I! ZE�L��.7L�1� � WELL PE�tMYT� PI.EASE SEE ATTA('�n pLAN FOR WELL SITE LAi�OiJ'I' Tax Map #: /� 3� Parcel #�/' � Tomnship S11�t�1V1810II: �.��1 j1 � ■r■a��•i:.i�i�1w : � 0 Tvne of Water Su�ul � Individual R�4uirernents: $CC�'IOII: — Site Approved bp � � /� 7 Grouting A� roved bp Dpe11 Log �T !D !/ o � . �Iel1 T o � o _ . Air Vent � Hose B� Concxete Slab Well Driller. �ar-�t e.�►-�' � . „�� e J Well Approved. By: '—�7 �.. •� � � ' e la 'k'�°5es Attached Site Sketch'� Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be ax least 25 feet from any bu�ding foundation. Odier conditions: � B PG�ID, sev. 09/07/01 �+>.(7. ��.:.. ...y'.v...� :�.�f'_:.� w.��s • �.� �� / �,'af/'Y'� '... A£ �•f. Y--_`. ':y.` . ��[]��{p�������yp� O� 1 , •fC.�.��..•r(,",J�, . "•.�'^ .Z.t� ; ' ;.,Yy{ �•':• • aJ�1WYl�7Y � :.�;:_,-..i. :�"" ��:�:�:�::�.� �.�:��:: '. ":::-�':..�:. �-�;�: ;�:T-.�:�;..�~�;�`����'. �'�`� v�e.-�. �iJe-L� ������.�a;;�;:-,. � •�:i�:; : ��.31;�- . L� o a � CY C � _ c� . . . �' Location. �,�� r � Grout iog _ Tax — - - - �.�.�v..�si �ca; � � v � � • WeII COustradioII Distanae firo�n S�'�c �Y ��nimuna IQ feet) � O} ;n e� SysOem (1V�nimmmi 6o fect) 2 0 0 Total Dept�: � ft YeId f O CxPM - Siatic Water I,evel: $ Wat�ac Beariug Zones: Dept� �� ft ft �} � ft t �' ��I ���� , � \� � � ' D��: � . � m t z � �. ���: b�;m, - �: �� st�t � - Wei8% Tiuc�ess: � fs $' � geigiit above Cn�unc� j.2 fn � : Drive Sha� Ycs l�To Any problems enaotm�red whle settinb � S3 Ycs�%No �`��T ��: � Gron� • � � ' ' ' • N� Sand/Cement � Conanete Gcav�e�/C�nt • - Annular Spacae Width • mch�es Wates- m Ann Sgac� Yes -✓• No Method of Garouk P�nnped Pc�essure Poimeti,� 17eP��._ �.�_Ft l��atetials Dsed: No_ $ags Portland cemeat ' Weig}�t of 1$ag � p� 7£m�me (saRd, gravecl, c�)—Ratio � � ID�1� � Yes _ No 4 x 4 s�ab �Yes No �:mer: � - -- -- • . �� Date Installcd: �r �� bY. - �g � To Lacatiion Drawiag / � . . . (� � � �t � . I b,ec�by cer6fy that the above� mfamatian is corrtct and t8at this vv+cll was consEtucted in a�ocordarbce with �+egulatio� set fort� bp th� Pe:son Co�mdy HeaIih Depa�ta�t _ ., • . s�a� ofco�r ��� � ��— _ m # �6 Da� .- -� � . . ��p i�s�ltmeat . . - - �P �tion Comtrac�or. �'i'�.(i V[. �� j �/' / ��.�1�__t� g State Rc�on Nutnbu: f l0 /� . � Make & 1Vloc�e1: c,r�. �! � S ft �� / 2 bp iu and ,�._ 8P� I hereby certifY �at this pump was utstalled and thc weil h�ad completed a�ord'mg to the Pesson Camrtty Well Ru�s in effect an tt�is date and tfia2 a capy of t�ris record bcen gmvided to-the well awner. _ - en�u� insEaQer S;�.e . 1 �� � ' i'Ci3D rev OU27144 6'd �LZ6-86�-9££ e�auae8 •� y;ia�{ d66�Z1 LO Ll ��0 //-� � . T Sf�3 ° �� l�° �Wl� %� r ' < � �� � � ° � O(n� �-�. � ���..b� � ��� ` b 1 ��'� � � ���� � P(�ol�c�`�6a��o� � 1LO���L�.'�IDT7T �Y7Y'] �.�L�� ���.�� �`-"' o� D O 0 /+ ♦ Applicant: � �� `Q''� � Location: . r� � � . � a �:� .�-: :- :� •:�.� ��:7 •,, �-.; - ;. L � System Type (In Accordance Wi�h Table Va): �J THIS SYSTE�lI H.4S �E��9 1NST,�LLE� IN COMPLIANC� WITH APPUC�.BLE . NORTH G'AROLI➢!�A GEiVIER�►L STATUTES, R[J�ES FdR SEVilAGE TREA1'MEAlT AND DISPOSAL, AIdD • ALL CONDITiONS OF � Tt-8E IIVdFP�OVEiVtENT PER1VIlT APlD COi\lSTRUCTION AllTHOR ON. � . . � �� �� ?,-�� - Au orized State Agerrt Date lnstalled. By: ,� � � � Date: . �[� '' 2—J% ' ��' G►,�� a Sr � � rt �p Z � . �d " :3 � �a' � � Y �o�,�`�.'' �o << �v �� r `� � �� � . �y,.����r ►� ��� ,,.,., �s� _ � + �z�IZ 7,3�i '�� . �� P9�s in s�s�r�-, 6 -�?-07 -p�S�Dd� S� �`�� ��5� ,�3 �� � 8'3'lsr�' S �3 lY �r . . � �3 YYr� 8�31� ?14��� p � �� 0 9'0'� 1,� r � , �� 6S PCHD, rev. 0 i /2Q/0�? ��' � P�� /� ����� ��� �������a�� �u'����.�� 9 '���� �� � �� Tar, IVlap � VT .� }�arc�! # ' Sys�tem Type (Tabie Va) Ov+merlAQplicant Subdivision �ddress/L�cation SeclPhas� Lot # � Se��cc.'�'a�k 1�0�"sa9/Da� �at�a a��ora �n� Int�h� at� � State-(D/date � ✓ Trenct� Widih� 3� ft � Ca aci �t� al. � Trench De tii 2 Z in: ✓' Tee and Fii�er - • Trencii Len � ft. ,/ Baffie � Trencfl Gtade � � Sealant Trencl� S acin t/' Riser ifi a licable � � Rocic De tii and Qual" � �'ank Outiet Seai Dams/Ste do�nms etc. Permanent IUla�ker Pressure Laterals � � Pump Tank � Q Hole Spac9ng � ._— Cf.,+a /.�l.�+a - Q Pi �Z�: ISealant Riser Water Tigh# � � P�pra� Ct�e�lc Valve/Gate.Vaive and au�ible m � Rate m .. A roved Pum il�ode! Blocic Under Pum � Pum Removal Ro e!C . � Dis�ribu�ion: Sy�. � Serial Distribution Pressure an oi �.aw Pressure Pi e _ A r. Pi e l�iateriai and , ,-,- -_- .. Pi e. Sleeve Tum- slProtectors Ftequireci' �eiba�fl� From� Welts � From Property lines :.�--�--- �-------.._ .. Surface Waters Public Vl/ater Suppi Ve�ticai Cuts (>Z ft Water Lines �� .. - ;�. �/Righf of V� Ot�e� � Rer.orded � � � � pc;�d rev. 3113/01 � �-�J-f �� PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIDLOGICAL WATER SAMPLEANALYSIS � �/� � Name �f �wYer �r TeYant ct � /' � (.. � G l `" � � � � � Address I�� � � v��y � C� Q�p I County ���S �1 �. �, � n �. h � ,-� , � � -�-� 5 7 � .�- �-� a � j� , Collected By v'� `' �� w�� p� Date Collected �`7 l��l �� Time Collected_ Source: �Well ❑ Spring ❑ Other Location: ❑ House Tap �Vo Charge ❑Charge � � ; �oa,,,, ❑Well Tap �Other � c9 �`r S � ��' S� 2 � a %— ����**�*��**��**�*���**����*��*���������*����������*�*�����*�������*��**��*��* ���**��*�***���*������*�������*���*�������*����*����*�*�����������**�������:��� Total Coliform FecaVE. Coli Results Present Abse�t 0 �� ❑ � Reported By • � t `� � , �1�� �L bactreport