A31 146Site Evaluation Application
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APPLICATTON FOR IHPROVIIiEDTTS PIItHIT
1. Permit requested by: ownerl�rospective owner: �),�,(
n agent:
Address: �.�• U25X �l(� �-�(Z12Jl��L /���<.�-s /�•C• c
Home Phone �� : A/O- 36 (�__� Bus ines s Phone �r :
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2. Name and address of current owrier
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3. Property Description: L�t size: .5�4C-
3 � Townshi
4. Tax map ��: �3 l P�
Subdivision Name:
5. Di�r,ections to property: State Road �� & Road N
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Lot ��:
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6. Permit requested for: New Installation: (/ Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
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8. Dimensions of Proposed Structure: Width: � d Depth: 02�
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10. Water supply private? ✓ public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? ' If so, identify location:
11,
Type of structure or facility: �roposed: !� Existing:
Type of dwelling: House: ✓ Mobile Home: Business:
Type of business: Num r of Employees: .
Number of bedrooms: � �Garbage Disposal? Yes No
Basement? Yes Iv'o i/ lf so, number of basement fixtures:
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12. Clearly stake al]. corners of the property and the corners of all proposed structures.i,
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I hereby make application to the Person County Health Department for a site
evaluation or existing system evaluation for the on-site sewage disposal system for
the above described property. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if
the site is altered or the intended use changes, the permit shall become invalid.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 30A-335(F)
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Signed Owner or Au horized Agent
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Permit Issued �j �-4�nc�.vnQ
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Permit Denied
Plat Observed
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i�ACTORS - SITE EVALUATION AREA. 1 AREA 2 ARF,A 3 ARF_A 4
1. SLOPE (�)
2 . SGIi. TEXTURE (12-36 in. )
(Sandy, loamy, clayey,
Note 2:1 clay)
? SOIL STRUCTIJRE (12-36 in. )
(Clayey soils)
4 • SOIL DEPTH (i.n. )
5. RESTRICTIVE HORIZONS (in.)
(Im�ervious Strata. rock)
6. SOIL DRAI2IAGE/GROUNDWATER
(�cternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
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9. SITE CLASSIFICATION DS p
(See below) � 1.5 PS
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R F_COt�NDATIONS /COMMF�iTS :
S?:TE CLASSIFICATION �LAGRAH (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas, �rells, Water bodies, sZope patterns, etc.)
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPRO %� ENT PERMIT
.Tax Map # �3 ! Parcel #
Zoning Township h � !' �
Owner/Contractor � r'+�L� Moo �e _ Date J S
r �..,..:,... � A .1,-1..,...., �Ci �., .. � `-f- � 1 n. .n /' � n �r � � P / /�1��/ %<� � hi- f� %�
Subdivision N
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Iayout \ p� � y�
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�L:�nes �co' x 3 `
5 . S.R.#
Lot#
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ��CrNS. Size of Tank lDab
SFD ✓ Mobile Home Size of Pump Tank � Db��
Business # of Bedrooms� Nitri�cation Line `iDD � K 3
Max Depth Trenches o`t Lo
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is alte ed or i ended use
Well and Septic Layout by�. ,�
Comments: �
Installed by 5`���,,.� 1.�eu�� S Approved by.
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual ✓ Semi-Public Required Slab
Public Replacement Air Vent
Site Approved Required Well Log _
Well Head Approved ���'"� Well Tag
Grouting Approved
Comments:
Date 9 21- g-� Installed by 1,r� � � Ct//�PApproved by �v `� ��-�-+�
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This repoR is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resuited from false or
misleading statements provided ro him in the application. Neither Person County nor the environmental health specialist warrants that the septic
tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant /�bb ��
Address Z! � C�����.� 1� w3 .�.�iZ� - County PERSON
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Collected By .� +' �,: ��EA?'..-y �.' •.`.�
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Date Collected Z�Z � Time Collected ib'. Zb
!�- • �.:.�t � ��t �+�1 "� �.�
Source: B'Well ❑ Spring ❑ Other
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Location: ❑Kiouse Tap ,� �,�p Well Tap ❑ Other
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❑ No Charge C9�Charge , ,
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**********************************************************************�*
Total Coliform
FecaVE. Coli
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Re�� � �,� ,��• ,,�,� �;;� f �:.. ..�� �
Present Atisent
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Reported By , � �Z�
Date Reported � � �
Report Called ❑ YES �NO
Called To:
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant f �� �oD�Q,
Address p `^ �0.r � LD County PERSON
Collected By ��
Date Collected Z- J`7 - �� Time Collected 2`� D a
Source: �Vell ❑ Spring 0 Other
Location: �'House Tap ❑ Well Tap ❑ Other
❑ No Charge s"Charge ��,sQ� �
.....................................�.................................�
*******************�*****************�**********************************
Results
Pr sent Absent
Total Coliform � 0
FecaUE. Coli � �
Reported By , \h
Date Reported �« 1 �`i"
Report Called [�YES ❑ NO
Called To:
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PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant ru � ODr�
Address t� 1n o
Collected By ���
County PERSON
Date Collected 2-(e '�'-� Time Collected � D; D�
Source: �ell ❑ Spring ❑ Other
Location: �ouse Tap
❑ No Charge l�'(:harge
❑ Well Tap ❑ Other
........................................................................�
**�*********************************************************************
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Results � ;� �
P�esent Absent
Total Coliform � � "�"'� ��D
FecaVE. Coli
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Reported By ��„�►��, � C?,c�.�1 �� �
Date Reported � - � — 1 ��
Report Called �'YES ❑ NO
Called To: �Pnrie.-�-}� f�'�6o r�
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Application Date: � ��� S!'- ���� �� Tag Map:
Amount Paid: 7� 0 ._... ��•;�.li- Parcel#:
Receipt#: 1 g3�77 � ������
:Laav a�-o�nsa�r.�ad.r�.D �Hla�eaIlt�a
❑ Improvement Permit (Site E�alµation)
�lication for Services
Services Requested
❑ Mobile Home Replacemen�or Building Addition
$150.04 (if site visit required) • . �
� Well Permit (N
y� _ I;� . qr Construc�t�on Authorization
' (Fee is dependent on the type of
0
� ❑ permit Revision
' � Repair of Egisting Septic System
Annlication: No Char�e/ CA $ I50.00 or
1) Applicant Information: ' , �
Name• �' �..
Address: '
2) Name and address of current owner (if different than applicant):
Name: �
Address:
2
3) Property Description: Lot Size: �.gz Subdivisioh:
Address and/or directions to Property: 213b i��
00
Phone (home): t��,
(work/cell): L��i�o�
. 3
Phone:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
0 yes ❑ no Does the site contain any existing wasi�water systems?.
❑ 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?
0 yes O no Are there any easements or right of ways on this property?
(if `yes' is checked, please pmvide supporting documentation)
4) Proposed Use and Type of Structure: . �
❑Residential . ,
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ 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:
Magimum 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 lmown ground water restrictions or sources of contamination:
� If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Othtr - -. ., ❑ Any
� . . .
I certify that the information provided above is complete and correct. l also understand thai if the informatian provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permi'ts and approvals shall be invalid.
Signature &bwner/ Legal Representative*)
* Supporting documentation required.
. 31ao1l�
I Date
• Permits are valid for either 60 months or are non-ezpiring when accomp�nied �by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluallon.
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Tax Map: _��% Parcel: _�
Subdivision:
WELL PERNIIT
(New _ Repadr ✓)
Lot:
Applicant's Name: _� .%`
Mailing Address: � �Gp, i
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Phone Numbers: r'
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Location of Property:
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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 not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by:
�ew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Date:
Certi�icate of Completion
� iner:
���t�+�1 Z��Wi'�'/�✓�' EHS/Date
P �
L� /µ r�f t,�o' 4t ts «�:. De th:
� Grout: 3�1 /�i7
1bD i i� �C� t-�N f 3�yd� �
� � � �,�.�� � � 3�Z / DAbandonment:
1 Do ilc� ('�iVb� v� Date:
� Method/Materials:
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Well Driller: License #:
Pump Installer: License #:
Approved by: . / Date: Z/
Additional Comments: _
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
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WELL LOG
TJate: �'�q �' � ' .
Owner: �1,� .1V6�,T1� S riO�TC ��6�l.GS � SR#
Location/Directions: � �
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C'���ri��ric��nn 1�Tmm�- � • . � '•
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Drilling Contractor: 1 _ ; . __
WELL CONSTRUC'T'ION
Distance from Nearest Property Line Distance from Source of
Pollution
Total Dep.th: Ft. Yield: � GPM Static Water Level Ft.
Water Bearing Zones: Depth Ft. Ft� Ft. Ft.
Casing: Depth: From�to Ft. Diameter: / ?nches
TYPE: Steel � Galvanized Steel ✓
If Stcel, does owner approve: Yes No
� Weight: Thickness: . _ Height Above Ground: Inches
Drive Shoe: Yes No .
Were Problems Encountered in Setting the Casing? Yes No
If "yes" bive : c:..�on:
Grout: Type: Neat Sand/Cement ✓ Concrete
Annular Space Widch ��, Inches
Water in Annular Space: Yes No
.. Melthod: Pumped Pressure Poure� V _.� .
Depth: From � to 20 Ft. �
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes ✓ No � �
4 x 4 slab Yes 1� - No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
. � . ..
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Signature of Contra D�te
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