A31 160A nilcation �ate: � — �—o � �
AmountPaid: �Sa�oa .
Rec�ipt #• � �
�4� � ? c�
2" �Erson Cauntv Health Department
; r _: ;� =:: Env�ronmental Health Section
-':',�APPLICATION FOR SERVICES
Tax Map #• %-3 (
Parc2! #: � �a
IF THE iNFORMATION IN THE_ APPLICATION FOR AN IMPROVEINEiVT PERMIT IS FALSIFIED. CFiANGED. OR THE SITE IS
ALTERED. THEA1 THE_IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME 1NVALID
1) Permit requested by: (Ownedagentlprospective owner): �% � �- Td � C, f�/; (�.� � S — CoaJT/�-��- :
Home Phone: � r7 ►-9 CC� 8 Address: �� m � S �� L C-
Business Phone: �t �7 ( — R � 6 �
(' , O � �[3 cr� "�21(� l �{
2) Name and address of current owner. U l CTa �2 �_ j-� A c�1 k S ����i �� I��-� ZZ
3) Property Description: �ot s�: 4-.'Ig i-ownship:131�s �+`t FoR.k Tw�
Directions to the property (Including road name and nu bers):�--��U �
C �%�-VJ t� tJ % R G V� C N_ f2_��� 4 o c� b o i,'
S`�i}-'(Zrt v.P i# � �--�- �►P 2ntA El2r� c�rJ N'►`' � 4..1
? D L E YyL c LI�S O �J S,'� , � l c'1
' � C2oss �3RiD6L.��y�
A 2� i= � l tLT fP ! Lly r r.� �Qc NT,�
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed (i�Existing ❑
b) Sticic Built �!(Ulodular �, Single wde �, Doubie Wide ❑ �
c) Number of Bedrooms: � d) Number of occupants or people to be served: �-�,
e) 8asement: Yes 0, No dLtf yes, # af basement fixtures: � � � ��
_..
_ .
,_f, Garb.aae. Disp�=,al: Yes 0. R� '� . ,_ .. � -.. . ::.. _ �. _ _ . . . . „�:. ..
g) Dimensions of Proposed Structure. Wdth: �aG Depth: 3G A
5) Water Supply Type: Private �new �Gr existing 0), Public �, Community D, Spring ❑
Are any welis on adjoining property? Yes ❑ No 0 If yes, laption
6) Piease Indicate Desired System Type: (systems can be ranked in order of your preference)
�Conventional _Modified Conventional _ Alternative. _innovative
Other (sperafy):
CLE�4RLY STAKE ALL CORNERS AND UNES OF TiiE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPUCATiON
I hereby make application to the Person Counry Heaith Department for a site eyaluation for the on-site sewage disposal system for
the above-described property. I agree that the contents of this appiicatian are true and represent�the ma�dmum facilities to be
piaced on the property. I unders2and if the site is aitered or the irrtended use changes, the permit shall become invalid. I understand
that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
pe nei of the Person Courrty Health Departrnent to condud ttieir evaluations. I understand that I am responsible for notifying the
H ai Department ifi y rope contains any wetlands as designated by the Army Corps of Engineers.
. � ��d i
Owner or Lega Representative Date
PCHD, rev. 10/12l99
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: • ,3/ Parcei # �� Township �(�/�1� �/J/%L� �N1�D. PIN
ApPucant _
LocaUon•
Subdivlsion Phase/SecSon Lot#
Improvement Permit
New � Addition Type of Structure �bDUL.4/1 Water Supply l'��GG
# af Occuparrts
Projected Daily Flow: _
Proposed Wastewater
Pro osed Re air.
r
of Bedrooms Other System Type i�
D s�.p.d__ Permit Valid For. Five Years ❑ No Expiration
- . . . �i . .i . ' � . �� _,, � �. ' �i /
Owner or Legal Representative
Authorized State
Date: � `" °20 —G L--
Date: '`� �i',�''�•c'7�/
The issuance of this permit by the Health De�rtment in no way guarantees the issuance of other permits. The permit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if
the site ptan, plat, or the irrtended use changes. The Improvemerrt Permit shall not be affected by a change in ownership
of the site. This permit is subject to comptiance with the provisions of the Laws and Rules for Sewage Treatmerrt and
Disposal Systems of the North Carolina Administrative Code.
Wastewater System Description: ,�i�Ny • Wastewater Flow: _
Faality Description: .f�% �L1£ / New ❑
Basement? 0 Yes o Baseme t Fixtures? 4 Yes o
Wastewater Svstem Requirements
.p.d. Type: �
Repair ❑ Expansion ❑
Tankage: Septic Tank size �DD D gal. Pump Tank size � gal. Grease Trap size gal.
Trenches: Total length � ft. Tr�ench Wdth �_ft. . Total Area /,60 D sq. ft.
Max. Trench Depth: � in.���lggregate Depth:�2 in. Soit Cover. � in. Trench Separation �ft. on center
Permit Expiration Date: `�� � '� � �v
Authorized State Agent: Date: `� " Z7' Z-�O /
•See attached site plan and addendum page or additional permit conditions.
The type of system permitted � does oes not differ from the type s}secified on the application. 1 accept the
spec�cations of this permit
,
Owner/Legal Represerrtative Signature: 'u-PiJ
� Date: 5`� � �`O Z
Operation Pennit
System Type (in accordance with Tabls Va) �-�
This system has been installed in compliance with applicable No�ttt Carolina General Statubes, Laws and Rules for Sewage Treatrneirt
and Disposal, and all condifsons of the Improvemetrt Permit artd Construction Authorization. Issuance of fhis permit implies no
guara�rtee that e system installed will function properly for any given period of time.
� ��i��oo �-
uthorize tat A Date
PCHD, rev. 03/07/01
A�pplication #:
Tex Map #: _�__.
Parcel #: %�'��'�
Pereon County Hewlth Departm�nt
Environmental H�alth 8ectio��
� ° � •� �'�,��.1��
.A piicant's Name
,
-�':�►��.,� � �`
t. --- .
Autha ed � tate�gent
E :;
S17E 3KETCH ..
S�ubdivislon/SectlonlLofi#
��y � � � — �,.�ac>
Date .
SyB�em cnmponen�s represant approxtmale conlour� only. The c�ntrac�or must fl'ag lbe system
pr�or to be�lnnlnA tbe Iris�aClatlon to ldsure lhat proper grade �S �ranlntalned.
r
Cnvironmental Healtl� Deparhnent
20-B Court Street
Roxboro. NC 27573
Pl�one (336) 597-1790
Fax (336) 597-1799
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APP�Icac�C
�� � �Ji�o�/ GP��f G'r,�; �2�,� ��. -
�: s.a�°'� � -
Well Permit � �
Tvpe of lNater Su�t�lv: ✓ Individual Community Public
Reauirements• .
Site Approved by � ,� � -u Z ,
Grouting Appcov by �
Well Log
Well Tag
Air Vent
Hose eib
Cancrete Slab
1Neil Drilier• �
Well Approved By:
Date: ��a � �a
**See Attached Site Sketch**
Welis must be 10. feet from property lines.
V.yells must be 100 feet from septic systems.
Wells must be �at least 25 feei from any buiiding foundation.
Other conditions: rc�oc.� ��� 4�� � -
PC1�iD, rev.11/29/99
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����5� �� � �� �� a� � � , � I
`_ ' c� � �CT�7'IP � �� a�o � � .� 1,ti� L-- L�
����-��� ����.� ���.a�� � �o� �
Owner: �
Location:
Subdivision:
Well Log
Tax Map 3 ( Pazc�l # �
Lot # ---
Well Construction
Distance From neazest Property Line (Minimum 10 feet) �. (�
Distance from Septic System (Minimum 60 feet) � pb
Total Depth: �� ft Yield: 3 Static Water Level:
Water Bearing Zones: Depth p" ft �c� ft ft
Casing:
Depth: From �_ to �� fr.�3Diameter: _ ��� in
Type: Galvanized Steel �
�i�
� Weight: Thiclrness: � � Height above Ground: �_ in
Drive Shoe: Yes t�R10 Any problems encountered while setting casing? _Yes �10
If t`yes" give reason:
Grout: , /
Neat: SandlCement V Concrete GraveUCement
Annular Space Width �_ inches Water in Annular Space Yes t� No
Method of Grout: Pumped Pressure Poured � Depth O to :�o—
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (san gravel, cuttings) — Ratio to
ID plates: _ Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log Location Drawing
Ft.
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.
Signature of Contractor � ID # zy�QJ ?l Dats / 7' G
CHD rev O1/16i02