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A30 19The District Heaitli De�artment Orange, Person, Casweli, Cha3ham, Lee Counties Water Supply and Sewage Disposal IMPROVEMENTS PE IT o , (� ie r,--/� �to- Owner: �� Location: � � -� � � j� ��..g.�'r..�'�-3�-- ' � �`L,I � t -- � Contractor: � Water Supply: Private �� Public Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposai, washing machin o her �tdm��appliances Size of tank: i� � itrification line: ' Other disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT STAFF BEFORE ANY POftTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. . :l1 Date approved: t� � 1 �' � �' Signe � � ��ti Well: anitari j � � / Sewage By:_ Counter- signed (Owner or his representative) Ceriificale of Compleiion � , � ,�-�" Date Approved: " � t � By� S�i itarian (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. Wrzte in measurements in order that installations may be located at later date. Note location of water supplies on adjacent lots. (1� (2) �� Person County Health Department � Well Permit � Date: ' - 's Permit Void ter 3 Years '� Owner:_�'.�- r jJ ,� 1 � oo r�; SR# � ��9 Locatioci/Directions: r o — Subdivision Name: ' t # ' Drilling Contractor: � WELL CONSTRUCI'ION ►� Distance firom Nearest Property Line Distance, Erom Source of �' Pollution c�, Total Depth: Ft. Yeld: �GPM Static Water Level F� � Water Bearing Zones: Dept�_ %� FG FG t. Casing: Depth: From _�,� co � Ft Diameter: Inches TYPE: Steel Galvanized Steel If Steel, does owner approve: -. - rJo Weigh� Thiclrness: � Height Above Crround: Inches Drivc Shce: Yes No Were Problems Encoimtered in Setting the Casing? Yes No ff "yes" give reason:" / � GrouG Type: Neat Sandl��t Concrete Annular Space Width � Inches Water in Aruiular Space: Yes No Method: Pumped Pr Poured � Depth: Fmm �� to FG � Materials Used: No. Bags Portland Cement Weight of 1 bag ibs. If mixture (sand,.grav�cuttings) - Ratio: to _ ID Plates: Yes No ►ti 4 x 4 slab Yes ," / No � I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRE�1' AND THAT THIS WELL WAS CONSTRUCTED IN A L O�R�ET ��,�tEGjejLATIONS SET FORTH BY THE PERSON COUNTY H � I Conorac � \j Date � �/Z� ��d � enature Date Issued Sanitarians Signature Date Completed Sketch well location on reverse side. � 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. Note location of water supplies on adjacent lots. (1) (2) . i. ■■■■�%1'�■■■■■■. �.■■■.�■�■.■■ �■■�� .■■■■t..■■.■■■■.■■. ■■■1.��`.� ■�■..f■■■■■■■■■.■■. ��i��r��s�� .��N��■ ��:::J��■ ■��■ ■�■��o ��■��■ ■��■��■ ��■�■■ ��,��i ��■;;,��■�■�■ ��r�� ■��■ ■■��■ ��■ ��■��►�� n�■ ■��IL��1�■�� ■ ■■ � � � �� x�Y �. '-- 77 . Ap�lication Date: 3 0� 7.� Amount Paid: J !� ,00 Receipt #: 3 Q � _ �2-� �z �� y ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) [ILPVTbile Home Replacement or Building Addition � i SG.00 �if site visit required j ❑ 'Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ��„��,� ��1 V Tax Map: q 3 0 , �,,�- � �.��,�� Parcel#: 1 � I�"'.�rn-s-an-rcnar,.,�,� �zn.4:an.Jl IHI�.a.1Ld,l�n. Services for Services 0 Construction Authorization (Fee is dependent on the type of system permitted) 0 Permit Revision $75.00 0 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Inform tion: I� Name: /�lG��% l ,L/j,��L Address: � G/ .Z � //s _ i�c ��5�/ 2) Name and address of current owner (if different than applicant): Name: � C�'/ ,<}/�e�, Address: � � �T ,fJ�/,:,��,., ;�.J _ f��ikb �s-a ivC �757 �/ Phone (home): (work/cell): �Zl y- y76� Phor.e: sy'r �iS-..2 3) Froperty Description: Lot Size: �� Subdivision: Lot #: Address and/or directions to Property: �/�' � � L S/�,,,,<< c,�,r_,r.i e�,: �Zd T. r2_ �J , i _ , , i � - ❑ yes B no �s O no ❑ yes 0 0 _ ❑ yes Q o� � yes ❑ no Does the site contain� jurisdictional wetlands? Does the site contain any existing wastewater systems? Is any wastewater going to be generated on the site other than domestic sewage? Is the site subject to approval by any other public agency? Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4�) �Pr°posed Use and Type of Structure: OResidential ❑ New Single Family Residence Maximum number of bedrooms: ,3 � Expznsion of Exi�ting System If expansion: Currzr,t runber of bedro�ms: ❑ Repair to :�:zlfun�:ioning System Will there be a basement? 0 yes � With piumbing fixtures? ❑ yes � ❑Non-Residential Type of business: Mzx:mu:n number �f employees: Total Square footage of Building: �zximum numb�; o: seats: �) Water Supply: ❑ New well �-�x�sting Well ❑ Community Well ❑ Public Water � Spring Are there any existing wells, springs, or existing waterlines on this property7 L9 ye's ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional 0 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, or if the site is subs�uently altered, or the intended use changes, all permits and approvals shall be invali� Signature (Owner/ Legal Representative*) * Supporting documentation required. .��7/3� 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) ') � !) ' . ' ��l J \ � � �.�,��.�,I.�. �_ � � �..� I 1--I <- .:� I � I � 5-2�-rs Nt��,ae.( wl��-{- l�r,d �-t,� +��K u��o�ere�. CveY�fl�,n� ��Ks �ood• Building Additions/ Mobile Home Replacements Tax Map #: J� Parcel#: ��t Address: y6 ' e.> , rr0 ��D`�s� �D Po;„a�.�r � � Approval Requested for: � Mobile Home Replacement Building Addition . Applicant Name: Ct-Li �/� ��Q v; Address: l, i �s _ _(�u�l� dr Phone #'s: 5�9 - 8152 Permit Located: Yes �, No Installation Date: ? Design flow: 3(c0 (gpd) Current Contract with Certified Operator on file (if required): Water Supply: � Well Public or Cammunity Wastewater system shows no visual evidence of failure on: �- Z-(� (date) (Applicant's signature if site visit is not required) , - � -- - - I� w house 4r-� /�will �a�e. ta 6� !►��J bacK -}a M��'� a�r� e� eK�Sil'n o�ra�'n'�1�� Addition/Replacemen� Approv�d . � � o-l.s Enu ronmental Health Specialist Date � Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 r�L__.,. ��G en� �711l11 L`.,... Z2� G07.'7Sil1Q �anana� r►Prennrrnintv nat -� l�r l�s o�Anra�S K ��_ �i ��.sf ��.�� —= � � �� I��a-��.11 I� 33C��.Il�]� SITE PLAN Name l�.(:) �I� Tax Map #� P•cel #� Subdiv' ' n N 11' Section/Lot# J�I � A orized State Agent � i5at� System components represent approximate contours only. The contractor must Jlag the system prior to beginning the installation to insure that prope�grade is maintained - - . _ _ . --- - _.- _ e f-�c��e -�v r/�o �%�'r� e r l�c�rv� �� r� i � � �"(�ew �►o�iSe. SI'�. W �(i ht�vQ, -(a �O� � a�recl �a K a �aa-�- �.rn� cxis-4;.Kz Irv,�,so -�a Me�- Si��AcKS -�cm S��c. sys � � MI�S{` hav� �jt��uhc�� D �Qi��, Sure r% is darna q� vr leaKi'��: E�i o�{'ce +o bz cul no� � 1�� O '�y�S��G-{-.1 �'G -i-anK. � }�l�ave ''�-" � �il�er i'Ks�f�ll�c ` �,, �I-«� K i� h��e�e�, S�a� `� -�. � � � � �� f � ,!� �u'�+'L R ��i � S �S �km M� 11�iyt '� �;; �j �, � � a �� u� .� . � ��'� � c� Pu�^P p � � � ,� .� � �. o � ��„Y� � ` :� z�� ` �' ./' � � ,�� -�`�� : ��''�� v- -- /�ti , ':- �?��i . - � '�� ..-`'� pf� .�"�' � �,,,� /% �/" -.�"` ��'� ✓ �� ,� > �� i� �*�` ��,,,,.^ �� . / ' ' �'�,,� ..✓� C:v �� :,§ -r., � `''� �' w�K�S ,