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� Person County Health Department "
S�e System Improvements Permit
Date: P rmit Void After 3 Year
Owner. ��T� j ���-- 'SR# _�
Location/Direcaons: , .
ir�� � " _" � � �.�.a�
Subdivision Name: �--� Lot #
Lot Size: -� �Type of Dwelling:
Water Supply: Private: Public: �
Semi Private: If not Private Tax Map#
Parcel # of Water Supply or Name of '
Supplier#
Bedrooms: Gazbage Disposal�_
Basement Basement Fixtures � `
INFORMA C1E D BY i ��/' �_.,..• �
$�j�j�: � owner or resentative
REPAIR: REEVALUATION: �
------- -- -------------- �
Size of Septic Tank: `� gallons �
Nitrification Line: � ' � ' �
Depth of Stone: 12 inches �/
Max Depth of Trenches: h LI '' �
OPERATIONAL PERMTT: yes`"� ' no
Remarks:
Date Well App �/ � Wel', should be 100 ft, Gom any sewer system
BY Sanitarian
Date g m pproved: —
BY Sanitarian � '
'FIFI OF�COMPLETION �
Contractor. � -;!� �
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Sewage System location, installation, and .protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 years and shall be`
maintained by owner in such manner as not to create a public health hazard.
Septic tank and nitrification line must be inspected and approved by a member of
the Person County Health DeparUnent before any portion of the installation is W
covered and put into use.
1
Location of sewage disposal sewage system sketched on back. :
(OVER)
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' Person County ealth Depar ent
Well Permit
DATE ISSUE : (p �
OWNER:
ADDRESS:
DRILLING CONTRACTOR:
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Total Depth: Ft. Yield: GPM Static Water Leval Ft.
Water Bearing 2ones: Deg���Ft. F��Ft.
Casing: Depth: From y L to Ft. Diajne�er: Inches
TYPE: Steel Galvanized Steel v
If Steel, does owner ap�i Yes No
Weight: Thickness. L eight Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes_No
If 'yes' give reason: , /
Grout: Type: Neat Sa�,3�(Cement Concrete
Annular Space Width 1�� Inches
Water in Annular Space: Yes No �
Method: Pumped P s ure Poured
Depth: From �to�Ft.
Materials Used: No. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand,�+ravel, cuttings) - Ratio: to
ID Plates: Yes , i No
4 x 4 slab Yes—� No
DRILLING LOG
De th
From To Formation Descri tion
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND HAT THSS
WELL WAS CONSTROCTED IN ACCORDANCE H REGULATIONS SET FO BY THE
PERSON COUNTY BOARD UF HEALTH. P VdIp AFT�t/�HREE
1 B � .1111_ `.
of Co�tractor ( ) Date
�
Date
Sanitarian's Signature Date Completed
Sketch well location on raverse side.
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.Receipt ll ' ���?��
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�. Improvements Permit. (EstablishedlRecorded Lot)
Improvements Permit (Unrecorded Lot)
, improvements PeRnit (Mobile Home Replace)
Improvements Permit (Addition)
�o i !9$
Date
Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
Permit for New Well
ace Exis[ing Well
1, permit requested by: .
�wn`er prospectiveowner/agent:Me,ri� W� �eae�e+�
Address: 31�� Ui�i�� �rtNt� C(�• Q��•
��.._ai� ��:u� �c. 215�1
Home Phone�,�
Business Phone #:
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7. Dimensions or Proposed Structure:
Width: 3 =� �� '
T1Pnth� �� �'
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage di �p �� system is intended to serve?
Name and addre�s of cuRent owner: 9. Water supply ty pe:
���� w ,� ��,� � � L'�� private f� . public ❑ community ❑ spring ❑
Are any wells on adjoining p operty?Yes ❑ No p.
If so, identify location:
Pro
. Lot size: ( • � Z %� •
Tax Map#:
Parcel#: _ �,
5. Directions to propercy: State Road #& Road
,�tc. .. _ .
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6. Number of occupants or peopte to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES•
I hereby make application to the Pet'SOn COunty Health Department for a site evaluation for the or
sewage disposal system for the above described propercy. I agree that the contents of this application are tn
and represent the maximum facilities to be placed on the property. I understand if the si[e is altered or the
intended use changes, the permit shall become invalid. I understand thatu derstand hat in the even[ hav�
issued, I must present a survey plat of the property to the Health Dep[. I
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluatton
the site by the Health Dept., this application shall become void and all fees paid forfeited.
10. Type of structure/facility: Proposed: �Existing:
Type of dwelling: C���a J�
House: ❑ Mobile Home: C7 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: _
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ No�[ If so, # of basement fixtc
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Si�ncc� Owner
Authorized Agent
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Person �ounty Health Department
Existing Sewage System Report For: �-iobile Home Keplacement
�1/ Addition � ��
I/ � � '� �i' Phone�' # � — J��
Requestee: �nla'�1�- l,� V r� Home � �
c�' �D� �rli vn �t�,. C.�•., � gus�ness# �l -�I�'p—��35
�1 �Q,, V � Z 'Pax Map# 3` � ��I
Location/Uirections: ��lJ / L�(�ii1�I'Z � Vl� �t •
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Original Permit Located
Septic System Uesi ed �or:
Kesidential f3usiness Other (specify)
# E3edrooms � # Employees Other _
Uate '1'nstalled Water supply �
`Pype of System �Jn Y �j��i��iU�1
Nitrification Line
Tank Size
V
Certified Operator Required (�(�
On site wasL-ewater disposal system showes.no visually apparent
malfunction on ����1 �
Yermission is granted to: Y�la.�l� ���v��-
According to the attached site plan.
Comments:
Environmental Health $�OC..
/
DATE
tLI PAVLOVICH
60' R/W
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TO SR 1102 S84'02'�1'� NF �
----- 175.00' ---
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5'21'�5'41
174.� �g�
D. L. WHITFIELD, JR.
50' EASEMENT
COY HANKIN:
CONTROL CORNER
AXLE FOUND
—_ �_ __
�r�::sat�aa �a:e: 1 l �� � 1
Amount Paid: �
Receipt #:
O Improvement
$200.00/$300.00 (if> 600 gpd)
0 Mobile Home Replacement or Building
$150.00 (ifsite visit required)
0 Wel! Permit (New/Replacement/Repair)
$300.00/$200.00/�75.00
�� )� Jl- 1�Le' 11�1� �1� : aa 1k1�p; /�' 3 �
�.� � � J Parcei#: �-
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]E��asomm �+�* o�.��.Il lH[�mIl�a
Services
for Services
❑ Construction Authorization
(Fee is dependent on the rype of
❑ Permit Revision
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: •
Name: �'I.�i r!G �- �� �t.�• �.2�! G,��-�'
Address: 3b � U n;�m Gv��-c. Uti . Cl,�;� •
-F�✓� l G Yl�u � I 5 t�1 L 2'I S-1 I �
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): 33 �O " 3�O `�' 3� Y 3
(work/cell): 3 3 � - 5U �( — 59 �
Phone:
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: �
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
Cl yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
��i C�-C�'
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�x 3 I x�1
4) Proposed Use and Type of Structure: r
�Residential �
❑ New Single Family Residence Maximui� number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? 0 yes ❑ no With plumbing fixtures? ❑ yes ❑ no
ONon-Residential
Type of business: Total Square footage of Building:
Maximum number of employees: 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 ❑ no
Please note any known ground water restrictions or sources of contamination:
�,6) If apptying 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
inaccurate, the site�bsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owne�/ Legal Representative*)
* Supporting documentation required.
l /- a �- -�-a � -7
Date
Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any apptication requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N�27573 (336-�97-1790)
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Building Additions/ Mobile Iio�ne Replacements
Tax Map #: � 3 � Parcel#: l 0 � Address: 3 6 7 U�,; o,� Gro v� C�, ��
l4-u�.\e N� � \I s , NC �r.�'4 (
Approval Requested for: Mobile Home Replacement
./�uilding Addition
Applicant Name: l�'lc�.�1r-% 1... r�we..�
Address: So.�n.e o.� c,�bov� �
Phone #'s: �0 4 —�� �G
Permit Located: �es No
Installation Date: ! � k 9 Design flow, (gpd)
Current Contract with Certified Operator on fiIe (if required):
Water Supply: �Well Public or Community
Wastewater system shows no visual evidence of failure on: «/� ��� 7 (date)
(Applicant's signature if site visit is not required) �
Addition/Replaceme�t Approved
Environmental Hzalt pecialist
�l Zz 7
Date
Persan County Environmzntal Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www,personcount ��net
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SR I10?
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ELI PAYLOYICH
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COY HAMKINS
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