A30 86Application Date: g �8 �
Amount Paid: 7 , OG
Receipt #: �! 3 �{ 36 7
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Services
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Rep nt/Repair) �
$300.00/$200.00 75.0o i--� N e'—
for Services
Tax Map: �- 30
Parcel#:
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n aM /��
F. �. ( � � 0.M � 9-a�
�uested
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: C G /� � �
Address: b O o�
� u a��
2) Name and address of current ow er (if different than applicant):
Name:
Address: _
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property: _� l �
❑ yes ❑ no
❑ yes 0 no
❑ yes ❑ no
❑ yes ❑ no
❑ yes ❑ no
Phone (home): �9 9 — � 1 5 �
(work/cell):
Phone:
Lot #:
�ro� a�.�� �oG.ru� v
Does the site contain any 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)
o��.Ya�- S
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
O Expansion of Existing System If expansion: Current 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 Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes 0 no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurat�or if the site is subseqzyet�ttly alter� or the intended use changes, all permits and approvals shall be invalid.
� �� � �
Date
* Supporting documentation required.
• Permits are valid for either 60 months or are non-ezpiring 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)
3d
Tax Map: � Parcel:
Subdivision:
�,��, sf ���.� ��
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IE��,�,��,�m,���.Il IE�� 8Il �]F�
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WELL PERM�
(New _ Repair )
Applicant's Name: %er.i � ���.e�
Mailing Address: �Q��� P�l,r1,r, � �J,
��,,Y� . u 27s7y
Phone Numbers; 59q —% � 5 2 _
Lot:
Location of Property: �� (� � 0 I �u r � i� n-�r. n ��
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 ot guarantee a potable water suppfy
OtherConditions/Comments: ��erw,ii'�ec� � ihS-l-i�l� ��nrr
Permit issued by:
QI�TTew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Purap Installer:
Approved by:
AdditioHal Comments:
Date Sample Co(lected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Rnrhnrn Nf.7757�
Certificate of Completion
Depth
Grout
Date: �— Ig — f�
� ���h UI �
C1Liner:
EHS/Da ie
. 2
. (�- q�l 5
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
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