A31 131����—c�
Application Date: la �3 � J�,O � d `�� S� ��q°���� Tax Map: ���
Amount Paid: ��' � r,, .••- Parcel#� � 3 I
Receipt #: 713� `19 9 34a.3s � � ���� �
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A lication for Services
Services Reauested
'F�Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
0 Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
0 Well Perroit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
1) Applicant L
Name: _
Address:
0 Constructioa Authorization
(Fea is dependent on the rype of
❑ Permit Revision
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
�r �-���J1/� Phone (home): �� �` ' �� �t' `tDZ �"�
d? • (work/cell): � (6 • �� • � c� j �
1-h,w� t�Jl,l , 1V` L �-�5�-
2) Name and address of current owner (if ifferent than applicant
Name: " �'
Address: I lt0 ► I�.c..� -l��,r'-� �- d�
S Phone:
3) Property Description: Lot Size: Li-, r�ubdivision.� 1 L�t #: ��
Address and/o directions to Property: ` o
2 — d SS l G��e "
❑ yes no Does the site contain any juris, 'ctional wetlands7
� yes o Does the site contain aay existing wastewater systems?
❑ yes �no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes �t�to Is the site subject to approval by any other public agency?
❑ yes �o Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4 Proposed Use aud Type of Structure:
Residential �
New Single Family Residence Maximum number of bedrooms: �
❑ xpansion of Existing System If expansion: Current number of �oms:
❑ Repair to Malfunctioning System Will there be a basement7 O yes o With plumbing fixtures? ❑ yes� no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square faotage of Building:
Maximum number of seats:
5) Water Supply: �1 New well ❑ Existing Well ❑ Community Well ❑ Public Water � Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes � no
�
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
�Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
1 certify that the information provided above is complete and correct. l also understand that if the information provided is
inaccurate or if s' e is subseguently altered, or the intended use changes, all permits and approvals shall be invalid.
!Z— 23—j
Siguature (Owner/ Legal Representative*)
* Supporting documentation required.
Daie
Permits are valid for either 60 mont6s or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
!in/1 11 PPrcnn ('rnintv FnvirnnmPntal NPalth ��5 C. Mnraan St._ Suite C: Rnxhnrn N(` �757'2 !Z't�_507_17om
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Applicant: �.)YQn
Address/Location:
Permit Valid for: Five Years
Type of Facility: �L�d1r.--L1
Number of: Bedrooms 3 /'
Proposed Wastewater System•
Proposed Repair: ��1��
Permit Conditions:
/ Improvement Permit
✓ Non-expiring
i�e,nC�, New �—Addition _
;cunants I� / Emnlovees / Seats:
Tax Map: �_ Parcel• I 3 I
Subdivision (,�; (d S a.� �P�r,� �i��c�5
Phase/Section/Lot # I b
Water Supply: In1Q, ( �
Projected Daily Flow: 3(�D gallons/day
Type:
Type: q
J
Authorized State Agent: Date: �8�'lS
(X) Owner or Legal Repres tative: Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws
a�rd Rules for Sewa�e Treatment and Disnosa[ Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable.
Authorization to Construct Wastewater,System
See site plan and additional attachments (�.
�
Proposed/ Wastewater System: � ZS`�o e G (*)Type ��l _ Design Flow ,3� gal./day
New �/ Repair Expansio Soil LTAR: J, 2S gal./day/ft2
Type of Facility: p��.icr%a p��� hC� �� Basement: _ Yes _ No
(*) Systern Types Illb, Illbg, IV, and V, requireperiodic syste�n inspeclions by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Ta��k QOU gal. Pump Tank `— gal. ^vrease Trap gal.
Drainfield: Total Area %n�i0 sq. ft. Total Length �� ft. Max. Trench Depth � in.
� .C.
Trench Width � ft. Min.Soil Cover� in. Min.Trench Separation 9 ft.
Distribution: Distribution Box ✓/ Serial Distribution / Pressure Manifold
Specifications: I� ��C( � �p - �
Authorized State Agent:� - � Issue Date: , j-� -/.S
Permit Expiration Date: /-$=20
The system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions
and specifications of this permit. ��� �� ��
(X) Owner or Legal Representative: � r Date:
Person County Environmental Health, 325 S Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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SITE PLAN
Name � C en Tax Map #� Pazcel #(3 I
Subdi ' 'on 5 �i'e(�S Section/Lot# �D
e�'" —/3 ;1,�
A thorized State Agent ' Date
System components represent apprazimate contours only. The contractor must Jlag the system prior to beginning the
installation to insure that proper grade is maintained
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_ _ _ _.1� �+,�a 1 sys�m
— 3�� �Pd / 3 3�
- 5�eo' /�cc�ofe�
- �- box
� - � 2" �Qnc � ��1
� Pla�� c��� - �'` ad�;-�a��
�O�I C6�lef bJff sl/S{�`M
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� s�ew► laid au{- � h ��;
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a , f{-ouse, � �
a�� l z� ' ptu� �'°P�� taP k y �
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�ga�n���n�*-„-„ �na��,Il. ����.���a
Tax Map � Parcel # �
Subdivision ]�; � W�,��r� Fi�.I�S
Phase/Section/Lot # 1 D
# of Bedrooms 3
V�JCI Q1.1V11 i Gl !llll,
System Type (From Table Va): 1 Product (IIIg): �Z.
Type V& VI Expiration Date: Type V& VI Renewal Date: ��
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization. 1
uthorized Agent)
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(Licensed Contractor)
Scale �
PCHD, rev. 12/14/12
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(Date)
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Y a�a S�.
fluse S��-2
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(Date)
Line Len h
LI ?0
L2
L3
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L,S
Total 3(� �
Tax Map: 3� Parcel #: l 31
Septic Tank System Checklist (Type II-I� System Type: �
Notes:
Nitrification Lines
Trench Width: 3 ft.
Trench Depth: � 2 in.
Total Length: 7t, o ft.
Minimum spacing: �j ft.
Rock depth/qualitv
Grade (< .25" in 10'
Cover (6" minimum
Setbacks
From wells
Property lines
Foundations/basements
SurfaceWater
Other:
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes:
InitiaUDate
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WELI� PERNIIT
(New�/ . Repair_)
Tax Map: � Parcel: / 3 j
Subdivision: �,);� „u,_{�n� ��i�,l � Lot:�_
Applicant's Name: ,n
Mailing Address: �(,
rrl lo �s l�N 1-�S� I
PhoneNumbers: 334-SD�l-�f2N9 33(0-�01/- 7o5Z
Location of
� � �L�r-�/ G
Permit Conditions:
1.) See attached site plan for proposed weld 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 not guarantee a potable water supply
Other Conditions/Comments:
� r� i�i-, a�� St' acKS
Permit issued by Date: /-/ 3-/ �
�Tew Well:
� EHS/Date
ti� p�Q� Location: SS
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Certificate of Completion
OL,iner:
EHS/Date
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 fax:336-597-7808
11/26/13
WELL CONSTRUCTION RECORD
This form can bc �sscd for siogle or multiple w�lis
1. Wdl Contractor Informa6on:
�� /�%�/ � �• 0 � l+L � J 1
Wdl Con�-ictor Namc
3 � �6 A
NC Wcll Coatractor Ccrtifiwtion t�tumbcr
Barnette Well Drilling, Inc.
co�y N�
2. WeU Construction Permi[!!:. // � �
Lrs1 a/! applicnble wz!! constrvctian permiu (i.e. Cnunry. Smte, Pariance. e1c.f
3. R'dl Uu (cdeck wcll use):
Water Sapply Well:
❑Agriculhual ❑MunicipaUPublic-
❑Geothamal (Heating/Cooling Supply) �{iCsidrndal WaterSupply (single)
❑IndustriaUCommercial ❑Residentiai Water Supply (shared)
SuPP�Y
OAquifer Reeharge �Groundwattr Remediation
❑Aquifer Storage and Recovay ❑Salinity Bar[iu
❑Aquifa Test ❑Stomlwatcr Drainage
❑�erimentalTechnotogy ❑SubsidenceControl
�Geothermal (Closed I.00p) OTracer
�Geothertnal (Heatine/Cooline Retum) ❑Othes (e�ro[ain under tF2I Rema
4. Date Wcl1(s) Complcted: ` Z/.rWe11 ID# �� 1
sa w�n ��c�ad:
�Aal�[� oN CA�-+�Ae�
FaciGrylpwncr Name Facility ID# (if appliqblc)
�HR 2�i •[ /aic-�2, �� • � D'f' /b
�^
P}rysical Addcess, Ciry. anQ ZiP
P•e�s�� /3/
c��y � ta�s�i;oo rto. (r►r��
Sb. t,atitudc and Lond tnde in degrees/mioutestsaonds or dedmal degreeS:
(fwell Sd� ane lalloug is saE�cient) ��
3�� �7 -2'S� N 7�' ^O3 ��i'C3 w
6.Is(arejthcwdl(sj: L�Permanent. or �Temporary
7. is this arepair to an uisting:well: OXts or �
If (liis is u repatr, frU out biown we(1 conslneCion i�orniatiav� qml erplain dre nafurc oflhe
repairr�rsder k21 rc�++Qrih section or on fhe &rck af th(s form.
8: Namber of wells constructed: �
For mvkiple injecrion or noa-warer ny�ly we!!s ONLY with tGe same co�csdatlios, you am
For ldemal Uu ONLY:
?Z. Certificafiou:
n L
K�� �I � �d `u� --z �/.�
s �eo£CetL�Wel! Conhzator Due
By a�gntng.this forni, / hereby certrfy tfuu d+e mell(sj u�vs (wereJ cnnstructed in aaordance
wirh 15.4 NGiC 02G .0100 or !SA NCAC 02G .0200 F7e!! Corudvcdon Standariir tuid dw/ a
mpyo,%thts rcc»rdhas been pmrt+ied to rhe +rell owner.
23. 5ite diagr�Ym or sddi600al wctl details:
You tnay ase die back of. this paac W pravidc additional well. site details or well
conshucfion dGaiLs. You tnay also.attach addition8l pages if neoessacy.
.r�rbm�ronejorm. SUSMtITALINSTUCfIONS
9.Totalwell depti belowlandsudacc: ��d (ik) 24a- For All Wdis: Submit this.form within 30 days of completion of vuell
Formulriplewe//sG'sta//depthsrfd�ereru(ercun�e-3QZ00'andl(t�(W� con5huttionfodtCf011owing:
I0. Static water levd 6elow top of casing: Z J (t�� Divisioa of Watcr Qnality, Infarmatioa Processiug Unit,
If water leve! is abm�e arsiag, use "+' 1617 Maii Service Centtr, Raltigh� NC 27699-1617
I l. Borehole divaeter• � �n.) Z46. For Iniection Wells: Tn addition to sending the fonn to the address in 24a
�/ above, atso submit a copy of this form within:30 days of compietion of well
iZ Well construdion methad: % f ��C�_�� lL � camstrudion to the fallowing:
�i.e. au�s. mtary. cabiq dicect pus6, dc.)
Division ot Water Quality, Uudcrgroand injcction Coutrd Prngramy
FOR WATER SUPPLY R'ELLS ONLY• 163614fai1 Service Center, Raleigh, NC 27699-1636
13� Yidd (gpm)._ / Z Mcfhod oftesk B�own20 minute 24c ForiVater SnpWV & Inieefion �i'dis: In addition to settding the form to
HTH die add�ess(es) above, a[so submit one copy of this form within 30 days of
136. Disinfectiou type: Amoant 7�2 C+Up �mptetion of wdl wnstrudion to the county hcalth dcparimcnt of the county
whae constructad.
Fam GW-I North Carotina Departmeut of Eavironment and Natiaal Resoucas — Divisi� of Wa�u QuaGry Revised Jan. 2013