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A31 71� �a� ��( o��c a Sewage �.� ��� The D�strict�-lealth Department CASWELL - CHATHAM - LEE - PERSON COUNTIES . Woter Supply and Sewage Disposal IMPROVE NTS PE T �_ ' � ,e. J�� ,`Ci1p ate rbwner: � Location: p, Contractor: .(�t���— � � Wate3 Suppip: Private blic ro W . Facilities: No. bedrooms � Dishwasher, Disposal, �o� r4� tom tic appliances �� �� 3 < Nitrification line• • n r � 2.r _ /�i i . Other disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Septic tank should'be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. Date approved: — Well: Sewage Disposal: By: � < Sanitar an � .ter-�� ur`°.u'ii �0 f3Qo.l�+t �,9. ied �Ow�_er o/�resentat' e) � �� - Certificate of Completion � Date Approved: ��¢�—$�By: a 'tari (O Location of well and sewage disposal facilities sketched on back. � � NOT.�: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Wrste in measurements in order that installations may be located at 1�ater date. Note location of water supplies on adjacent lots. (1) . (2) — , =� —�---�--- . T - Tax Map 7nninv � � � k � H Date t c_ � dividual_j� _ • ����W� PERSON COUNTY HEAi�,TH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT # Parcel # � � . TownshiP � � �. - , � Owner/Contractor Location/Address 5ubaivision lvame Date Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is alt e or i end use nged. Well � Layout by � Comments: Installed rte Approved�� �ell Head Approved �routing Approved_ Approved by A 001197 WELL SYSTEM SPECIFICATIONS Semi-Public Required Slab �� ? �� i'?� �-s� Z�lacement Air Vent ,,,/ _�I � { I � `� `:1u Required Well Lo� � 1�I .� r: I q?: �.1'��' ✓ �-J. �:'�1a;, �'_i� Well Tag s� �I �2.1� �, �,I �� : �_������1`�, 1'��i� . . s� .. � _ �� Comments: ` N� W'C.�l l.�`�� 1 ` � p✓ ' A w. u `� � �"` [ Date Installed by Approved by o 1 � r This report is based in part on infonnation provided the homeowner or his/her representative in the application submitted for Uus per[nit The envirocunental health specialist is not responsible for false or misleading information contained in the application The environmerital health specialist is also not responsible for concealed conditions on the property or for statements in Uvs repoR that may have resulted from false or misleading statements provided to him in the applicadon. 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:4vr.ipro�pecmitsam O 1/95 rev.1.0 .w,• -. • - ' Date• ^ ,� V Owner � � K L,ocation/Direct� . .. �, ,. , . . .,. .. : .: . . _ .. _,_ : . . � _, . ...� ��^�sx! ' .r.. PERSON COUNTY ENYIROIIIfEtITAL HEALTH ` '• `,` �f'� . . , • : i�t e: WELL LOG . ` r � '. . i', . � . ' \ � Subdivision N�une: Drilling Contractor: _ SR# Lot # ---- WELL CONSTRUCTION U � ---- Distance from Nearest Properry Line �� Distance from Source of Pollution_(,�O f Total Dep.th: /d''6 Ft. Yield:_� ____ GPM Static Water Level s1 Water Bearin Zones: De th oU Ft._ --�----Ft. .g P _L_— �FL�F�._ �t. Casi.ng: Depth: From___�__to �'/02 Ft. Diameter:_ �_�ches TYPE: Steel - Galvanized Sceel �' If Steel, does owner app:ove: Yes No � Weigh[: Thic�:ness: /�� Height�Above Ground: /� Inches Drive Shoe: Yes ,� No Were Problems Encountered in Setting the Casing? Yes No -- If "yes" give r�ason: Grout: Type: Neat Sand/Cement ✓ Concrete Annular. Space Width Inches Water in Annular Space: Yes No _ .. Method: Pumped . . - Pr�ssure � . � Poured � .._ . . . ,, - - Depth: From ('S to � C5 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 �' No 9 ►.. - - I HEREBX CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONS3'RUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH $y�THE PERSO�t COui�'I'Y HEALTH DEPARTMENT. S- � , ignature of Concractor Datc � Applicatioa Date: 1��-13 ���+SS ������T Tax Map: // � J/ _ Amount Paid: __7 0 7 � '_' �. � ���� Parcel#i �� Receipt#: IE:�rac-au,�a�,•,Y*�,anci�n.fl IHI�e,s.Il2,lln. 0 Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Reptacement or Building Addition � i�G.00 (if site visit required j ❑ Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 �lication for Services Services Reauested ❑ Construction Authorization (Fee is dependent on the type of system permitted) ❑ Permit Revision $75.00 Repair of Ex� stem Anplicati�No Char�e A $150.00 or $300.00 1) Applicant Infor ation: Name: Address: � " . L 2) Name and address of current owner (if different than applicant): Name: Address 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Phone (home):.�3� �6 � �0/ � �C/cell): 336 ��f ? - 73�f / Pr.nr.e: �.,�t #: ❑ yes ❑ no Does the site contain any jurisdictional wetlands? ❑ yes ❑ no Does the site contain any existing wastewater 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? ❑ yes ❑ no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: �Residential 3 ❑ New Single Fami(y Residence Ma�cimum number of bedrooms: ❑ Exgaxision of Existing System If expansion: Cu�rar.t r.irnber of bedrooms: � Repair to :��alfun:,t:oning System Will there be a basement? 0 yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Mzximum aumber of employees: Total Square footage of Building: I�a�cimum numb�; o: seats: 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes � no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative � Alternative ❑ Other ❑ Any I cert� that the information provided above is compleie and correct. l also understand that tf the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid ���� �"/. _ `/� / -aZ fl -�0 /3 Signature (Owner/ Legal Representative*) * Supporting documentation required. Date Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Loi Preparation' form must accompany any application requiring a site evaluation. !t(1/111 PPrcnn ('.rnintv F.nvirnnmPntal NPalth '�75 C Mnraan Ct C��itP C Rr►vhnrn T�T!"' �7G7Z /22�_c0� 1�nm ��,o.; �. ���.ss ���.��� � � ���� ][�e��a���,.-,.-,. ����.Il IL���.Il�I� Applicant: � Address/Location: Improvement Permit Permit Valid for: Five Years Non-expiring Type of Facility: New Addition _ Number of Bedrooms / Occupants / Employees / Seats: Proposed Wastewater System: Proposed Repair: Tax Map: _ 3/ Parcel: 07/ Subdivision Phase/Section/Lot # Water Supply: Projected Daily Flow: gallons/day Type: Type: Permit Conditions: �=� 't3�tdc.c7 -- �✓ C�t���e.f� GD�/�/l�-� �G'� Gd' �7 t��b. Authorized State Agent: (X) Owner or Legal Representative: Date: Date: 'I'he �ssuance 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 anrl Rules for Sewage Treatment and Disposal 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: L'onld 1.I�nor.tt�-�., (*)Type�_ Design Flow �,o gal./day New Repair �C Expansion _ Soil LTAR: �.P� gal./day/ft2 � Type of Facility: ��gE Basement: _ Yes �/'No (*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department. Wastewater System Requirements � $� E��s � �ac� Tank Size: Septic ank I oo U gal. Drainfield: Total Area 720 sq. ft. Trench Width � ft. Pump Tank gal. Total Length ��o ft. Min.Soil Cover _� in � �o�,-� �� Grease Tran gal. i„��-��o� Max. Trench Depth � in � �`� Min.Trench Separation �[� ft. Distribution: Distribution Box / Serial Distribution� / Pressure Manifold Specifications: � �PC+I-� .F--�.�-�, ►,� � � a + �' a Authorized State Agent: Issue Date: �/a�i3 Permit Expiration Date: The system permitted is: Conventional �/Accepted / Alternative / Innovative . I accept the conditions and specifcations of this permit. (X) Owner or Legal RepresentaNve: 7���%���,�'� Date: ?j —�� -/� Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) ConnectGIS Feature Report Page 1 of 1 � I Welcome to the Person County GIS Website. ConnectGlS has been prepared for the inventory of real prope , County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system are noti public information sources should be consulted for verification of the information in this system. Person Cou assume no legal responsibility for the information in this system. Grid is based on the NC state plane coordinate s �� s7 ��ss �� � fa558 � 679fi "RC'P°�� t� Q �vµp �r t ►JS'� . �f � �-r' i rtc -t'AN �. Q l �l�sT��-+- � Lt nl ES (,5 �z � o��..� @ !oo � = 7s�o �►1, �r QQ -re�,� �} -�rro� -�}s -,-o � �.Ev oa r�.,��E �►� (.,.3c ��� ��� �.dE� t,t�l�-� ��" �� �" NI �vr�- � .t�.�v Q��-ria►is GM,� ��ko �'S91-1�90 200 6551 1 : 5D Fee# �,�x:���.��.�,. Ao3� — 07 l _ Person CouMy Ernrironmental Health �`��� �t4�`E �"'`S �� , 3�i S. Morgan Str�eet Suite C Roxboro, NC 27573 http://gis.personcounty.net/connectgis_v6/DownloadFile.ashx?i=_ags_map35be9345dba84c... 3/5/2013 ����� ) f ���� �� �_' `—ti— � � � � � � IE��a- �����.��.Il IE-Ii � �.Il�7� Applicant Location: Taz Map � Parcel # v7i Subdivision Phase/Section/Lot # # of Bedrooms Operation Permit System Type (From Table Va}: _� � Product (IIIg): This system has been installed in compliance with apglicable North Carolina Ceneral 5tatutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction A nthnrization. (Authorized g -�l �,vis . •r•_ .��h%= (Licensed Coniractor) �� : ��� �— .�-. � c.�► �•+p '—' 77v �. �r, 1, v�o .�r 3 � t�s�r��� G � �Rr z' � �� ��� ��� ����� y�� �''�'V �z.ip SC�e: �� ''i3�i0�� ��, ,� �. .�— � —�,. � �� �o��.., .� y� � � �I � ��,�� `1il��u �"7p� _� '1b 1 r..� �� �' � �i'�+� }-9 V � l �•a '� �! L r. � I �D'� � �� �%�. 'T'�3 'S� i'� I (Date) � �� (Bat.,) �_ —�PJP��-� ��b��i '�'►�. � � ' ���� L��J� g �1.�J'✓�l' !vZ-o ��v -���q- 9 �{�}-.c��-�- F�-�- -t� ► tJsrat t� � ���� � ���,� C�-��'� ��► � �� o.� �-,��- �l M,x� �;�,�, ,�,��N� �N �l• Tax Map: Parcel #: Septic Tank System Checklist (Type II-I� System Type: Se tic Tank InitiaUDate State ID & Date: Ca acity: Tee and filter Baffle Vent Riser Outlet boot Perm. Marker Distribution D-box (levels set) �N Serial ' Pressure Manifold LPP Notes: Pump System Checklist Contracted Certified Operator (Type IV +Systems): Notes: NOTIFIED BUILDING INSPECTIONS: (Revised 12/09 BH) Copy of OP e-mail Date: