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A31 111Person County Heaith Department Sewage System Improvements Permit Date:��This Permit Void After 5 Years � �r � Owr►er: ��x-L�-,C4 d /��. r� :. �a.;'�.; <<:.,1 SR# Location/Directions: � . , �,. �, _ „ , . . Subdivision Name: Lot Size: . y 2 t��r !- Type of Dwelling: Water Supply: Private: Public: Bedrooms:, ,,,� Gazbage Disposal Basement Basement Fixtures� INFORMATj4N C.�R'j'I�IED BY. . � . �..F.? owner or REPAIR: " � ` REEVALUATION: Lot # Community: •�,.� ;� Size of Septic Tank: gal,�ons Size of Pump Tank: Nitrification Line: /) 1�3 Depth of Stone: 12 inches Ma�c Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remarks: , - z � � Date Well �ed: �1��o Well should be 100 ft� from any sewer system BY s� '� Date S e ys App ved: � 0 By Sanitarian CATE OF COMPLETION Contractor. v. �)1 < ------------------------- � Sewage System location, installation, and protection must meet state and local '� regulations. Septic tanlc 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'd nitrification line must be inspected and approved by a member of the Person Counry � Health Deparunent before any portion of the installation is covered and put into use. If the site plans or intended use change this permit is subject to revocation. (G.S. 130 A-335F) � L.ocation of sewage disposal sewage system sketched on back. (OVER) "' � NOTE: Make sketch o! 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 '�. f ■��a��■�� ■�e��■��■ ■�r��.�� ■��■ ■��■ 1;�,�:�� ■��■��■ ��■��:�� ■��■��■ ��I��l��I,��I��i ■��■�� e��y �� d:'�:�i�� ,��'� �� l��i�,�� ■�� Q�� ■�� ■��c�� ■a��n�■ ■��l��i�i��[� ■��■�■ �� `' � F � , ? , M ,�.t� � y � . ,�„ � ,.�..... �� - -�erson County Heaith Department � Well Permit � Date: This P rmit Void After 3 Years '� Owner: � .� ; l/�!� Vv�!� C-� s'��c�lG��.$�R# /l l Z Location/Directions: - r%r% P � n+ �t ,� . Subdivision Name: Lot� Drilling Contractor: � — WELL 0 RUCITON � ►b; Distance from Nearest Property-Line '_ Distance from Source of �' Pollution c�, Tatal Depth: � 3p FG Yield: �_GPM Static Water Level 30 Ft .. Water Bearing Zones: Depth �� Ft FG FG �G Casing: Depth: From � to��.� FG Diameter: �� Inches TYPE: Steel ' G'dlvanized Steel ✓ If Steel, does owner approve• Yes � No -- Weight: J 3'x Thiclmess: I Q�L_ Height Above Groimd: � Inches Drive Stice: Yes ''" No �� u�2�_-I nl Were Problems Encountered in Setting thb Casing? Yes --' No ✓� If "yes" give reason: — — — � — — _ — ''d GrouG Type: Neat .- -- SanSi/Cement Concrete � Annular Space Width /%L- Inches Water in Armular Space: Yes -- No `� Method: Pumped Pressu:e Poured ✓ Depth: From (? to Z�_ Ft M als Used: No. Bags Portland Cement �-- Weight of 1 bag a � . lbs. If mixture (sand gravel, cuttings) - Ratio: "-` to 'i �. �_ ID Plates: Yes No ��J n��t "'d � ,,-�-�#-s1�U Yes p� Na Y12.Pi t�`- yy • {� Y J I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT I THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEAL ��%�� ..�,� �9(� , Sanitarians Signature Date Completed ��-tch well location on reverse side. 6 u � `\ 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 � c • � Yerson County Health Department Existing Sewage System Report For: Mobile Home Replacement ;��" �Addition Requestee: / v�Qi� ; f1 �-��CkIA�Yl Home Phone#��q�,3� ,a Z2� �G�� ; � �.-p �1C�,✓1 Business# K ' �(� ,`-�� L, � l �,11 ► l � (,�S /1/ G �'Z��{ � 'P a x h1 a p # � - Location/Directions: � �� / �- `�� 2� �� Original Permit Located �- 5eptic 5ystem Uesigned For: ltesidential � Business # 13edrooms � # Employees _ Other (speciFy) Other Uate rnstalled �� o-� (� Water supply ��i 'Pype ot System � nv �fl�-; i_��, Nitrification Line `I��X� � Tank Size Certified Operator Required � 0 On site wasL-ewater disposal system sliowes no visually apparent malfunction on �I�l �� Yermission is granted to: I v u-t-t �;,�'ti C��,T1 ��lClCc,✓V10 _ According �o the attached site plan.- Comments: `�e Environmen�al Health Sy�v. \_��,�n�l��_�,�� I� 1' 7�7 -"-- � DATE v �v��: � � � �.�.y� - �... .+�u�� • � , .� / � � J. E��N Registe� 011ie Long Blalock S_ � 0 50'ss-e � � � nr,79_32 ^rs_w --rr---^-^.,"....»... �l � 1 O� Amount Paid: 6 , Gip Receipt#: _ ��¢ .�:�.� ��`� � � ��.1�'�.� �� _.r.. ;.�- �� ?�y.=C�7'IC'`��'` ID iJ� • JE ��-:CZN'� ii ]t aY:D l�T.::i�T.�[:.".�'�i'I1.'Q'::.LIf..�. ..A.�.L ai_'.).GR..II.�I'L..JL'7. ��p�ieation for Ser-vic�s - __ (Se�tic Systems and Wellsl ❑ Improvement Permit (Site Evaluation) � $200.OQ/��00.00 (if> 600 ;pd) obile Home Replacement or Building Addition _ $150.00 (if site visii required) G Well Permit (Ne�v/Replacement) $225.00/S 125.00 1 a.� Map: , 1d�3 ` Parcel �: �� ervaces Re uested ❑ Construction Authorization (Fee is dependent on the type of sy; �� Permit Revision $75.00 ❑ Repair of Existing Septic System ' � No Char�e Important: If tlze inforsnation in tlie applicatiagr for ar: Irrtproveme�tt Permit is ittcorrect, fnlsified, or� tlte site is a[tered, tl:en i{pe Improvement Permit and the Autltorizafion to Co�tstruct sl:all becvme invalid �1) Services equested b • Name: ��' Address: � � � Phone # (home): S�� , C�Z3? (wark/cell): �C�(� _ Z (,(Q ( 2)1Va�e and address of currerat o�v�er (if d'af%rent than applicant): Name; Address: � 3) Property Descri�iion: Lot Size: l ae , Subdivision: Address and/o directions to Pro riy: �C:t �, �� ,� ► ZI.._ ,.,. -�.., _ _ � �� Lot #: 4) Proposed U and T'ype of S�re�cture: Residential �_ Business/Type: Other Number of bedrooms �/ Number of people served (seats/employees): � Basement: Yes No (with plumbing: Yes � No � Garbage disposal: Yes No Approxianate si�e o�' bualding foundatAoa�: �,ength � Z i Width Z�, S) Water Supply Private Well � (Proposed Existing � � Community Well: Public Water System: Are there wells on the adjoining properties? No Yes {please show location on site plan) Note: A comnleied app�lication �t�ast ralso dracdeade• � A plat/site plan �f td:e pf ope�ty thut sliows prop�rty di�raettsiooas ancd �he saze aa�d loca�'iot2 of all pYoposed structures. � A signed copy of t�ie `Lot �'a��parratiosa' fownz verifj�irtg that tlie pro��•Py z� �er�dy to b� eva�ttated. � am submitting this appIication to r�ques# service� from tbe �er�o�a Co�nry �3[ea�tla �e�artan,eai. 'I'he in%rmation provided is accurate. I unde�rstat�d that if aaay site is altered or tHte intended use c�sanges, all pe�rtaaits shail become invalid. . �igs�a�are (OwnerlLegal Representative): ) �a��. � _ Z�i �c�� 11/07 Person Cour.ry Enviromnental Heatth. 32� S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� _ �.. ti ; � � �' � .�"",�� y✓ � �l./ � � � �' arn,�vn��rn.�.a�nat�.�.� ��.�.�.t��. �taiflding �dditions/ ld�obile �ome Replaceanents Tax Map #: �3 ) Approval Requested for: Pazcel#: 1 I I Mobile Home Replacement D Building Addition � Applicant Na.me: M�rv� n S-� i c�k�ni� � Address: " J�,q Cl�zrl� L..�r� Rrl Nurd I-c 1J�� I l5 , NC �-J'�5� I Phone #'s: ��1—i - Gl7��a ��`� - a �� Permit Located: _� Yes No Installation Date: � �- 2a-�3g . Design flow: 3�v (gpd) Current Contract with Certified Operator on file (if required): _�I � Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on: �3��5�0� (date) (Applicant's signature if site visit is not required) •� '� �. ' �.r � '� ■t �. � I_L . �' � _ vi� I r/ � Acflc�iiioa�ep➢acem�nt Approved �.1'�u.e � Environmental Health Specialist 11/15/OS �3�,�10� Date �� ) � �� `v�' �— � � �� IG��a-�,.,.,r,.,,.a��.]L IE-?C��Il�� SITE PLAN Name MQ'N\'(1 <�Y 1 Ck�Q�(� Tax Map #/-l�l Pascel # 1 l Subdivision Section/Lot �Scuc� `t �-� Authorized State Ageat Date System compaaents rcpresent appmximate caatours only. T3e cnntracmtmust tlag rhe system prior to beginning tfie Install�tion ro insure that pmpergrade rs maintaiued �: �.a�:.�-�a;�u� QQ.� �-�b�C�-S � �� -Q� �-nv ��\ v �� a PNP'� �o� \2'Z "1 L:r'C� � v� �'� `�'.... Scale: �� 547-/�� PCHD, rev. 09/12/Ol