A31 927
j Person County Health Department
� Well Permit
I .� -7"' COUNTY:
I DATE ISSUED• �I DATE DRILLED:12 � �
OWNER: �•�'-sn. Iyl�'t+ %fi=C� OAD/STREET: �eL%. 1 I i��
ADDRESS : ' � �W W I�� � R�%'� W 1.�C-
DRILLING CONTRACTORt -
i N� ADDRESS
. WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Total Depth: Ft. Yield:�� GPM Static Water Level Ft.
� Water Bearin 2ones: De h tr Ft. Ft.
Casing: Depth: From�_to l Ft. Dia[qe�r:�nches
i Galvanized Steel �
TYPE: Steel
� if Steel, does owner app Yes No
� Weight: Thickness:�Height Above Ground: Inches
t Drive Shoe: Yes No
i Were Problems Encountered in Setting tha Casing? Yes No
if 'yes' give reason:
Grout: Type: Neat Sand/Cement Concrete
� Annular Space Width Inches
' Water i.a Annular Space: s No
I Method: Pumped--f�t-- Pr sure Poured �
Depth: From V to�Ft.
Haterials Used: No. Hags Portland Cement Weight of
1 ba9 lbs.
If mixtura (sand, gr�jvel, cuttings) - Ratio: to
ID Plates: Yes �� No
4 x 4 slab Yes� Na
I HERESY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT D THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE 7TH REGULATIONS SET ORTN BY THE
PERSON COUNTY BOARD UF HEALTH. P OID ER T YEARS•
ti
Sigaature of Contract r Date
4lJ� .�.L�.,ew• ''�-1�—��'
Sanitarian's Signature Date Issued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
`� ;- ,� PERSON COUNTY HEALTH DEPARTMENT
, �� SEWAGE DISPOSAL
IMPROVEMENTS ERHIT NO.
� Zssue Date: � � �3 - �$
� a !
Owner:
��� Location: �
.�_"'
t
eptic Tank Contractor:
Building Contractor:
� Water Supply: Private � Public
�.
All wells should be 100 ft. from sewer system.
Lot Size: I t r5 C�LC/l..Q.rY
Sewags Disposal Facilities: No. bedrooms � 36a � X 3`
�
Size of tank: ��p�y Nitrification line:��
s �@.��. � : .i�.i7lsPr�.ri� . .�.eDq. �-ty.l.7�..l� e.
Otner disposal facility:
Water supply and sewage disposal facilities location, installation and
protectiion must meet state and local regulations.
Septir. tank should be pumped out every 3 to S years and shall be ,
maintiined by owner in such a manner as not to create a public health
hazazd. Septic tank and nitrification line.MUST BE INSPECTED AND
APPRO'lED BY A MEMBER OF THE PERSON CO. NEALTH DEPARTMENT STAFF BEFORE
ANY ]?�)RTZON OF THE INSTALLATION IS COVERED AND PUT TO USE. THIS
PERMIT VOID AFTER 3 YEARS.
��q ��p��
Data well Approved: Signed_ (�tJ_QrC.X+ �.�.Gi/�n, �
BY=� �Sanitarian
Date Sewage Disgosal Approved:
� L � � O Counter-�� � �% �s
eY� �0`,0�7 _ __ti sigae� �� =�e:.��
Gt/� /i. (Owner or his representative)
�
Certiiicate of Completion
Date Approved: � 1i ��-- O� gy, �jt%�� ��^„r
Sanitarian
(Over)
Location of well and sewage disposal facilities sketched on back.
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' The. Distr�cf Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply ond Sewage Disposal
IMPROVEMENTS PERMIT No.
�J � D8t
Owner: ��/
Location:
i
Contractnr• ' � 1S ,,.
Water .Supplp: Private � Publir
d�
Se��ra�qe_DS: 1 Facilities: No. bedrooms Dishwasher, Disposal,
rerashing machin er sutom tic appliances ��
5I2t� of tsnk: � Nitriflcation lAine: * � .,
y.. ....,�,--�--- - - � _. _ � .rU _ ,
Other disposal. facilityc — � �`'' —
• 1 , .
'�►ater supply and. sewage disposal fac► ,' ation and �i `
prof.ection must meet state and local regulations. ;
�epkic tank should be pumped out every 3 to 5 years and shall be maiti- �
t:ained by owner in such a manner as not to create a public health hazard.
Septic tank and nitri8cation line MUST BE INSPECTEIJ AND AP-
PRJVEI} BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT j
aTA�F BEFORE ANY PORTION OF THE INSTALLATION IS COV-
FR7E;D AND PUT INTO USE.
Date approved:
well:
Sev�rage Disposal:
�Y:
�CertiScate od Comp eti n .
Date Approved: ���
�j aY;- I
Signe mN'� ' �"'�e� �
58111t8T ��
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` . � �r�..�/✓ ;
Counte � � �����%
sign M�"'�c�, i
(Owner or his representative)
1Location of well and sewage disposal facilities sketched on beek.
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Application Date: SJ �a�� 3 ��� �� ������ Tax Map: q3 �
Amount Paid: �C� ..� ." ��- ����,� � Parcel#: 4 Z
Receipt #: 3 ����1 C�-
JEr, �� n n-� nns� � �. �.,�,.Il lHi � �..➢. �,1lr.
Analication for Services
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 epd)
0 Mobile Home Replacement or Euilding Addition
$I50.00 if site visit re uired�_`_
ell Permit (New/Re ace epair,�
$300.00i$200.0 /$75.00 �,� 1J �
equested _
❑ Construction Authorization
(Fee is dependent on the type af
❑ Permit Revision
$75.00
0 Repair of Existing Septic 5ystem
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: ���( W�� ��iA�'�B�hC
Address: ? 06_.,,jfy � j� �.
Ko.�o �u" � � � 5� L1
2) Name and address of current owner (if �lifferent than applicant):
Name: IYlr�rk L�vere.t-i-
Address: -� q� U n� n'►��,- rv�� G�^ I�Z
� N�G rc� I c�l, ) �� '�7 ��1�
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
Phone (home): 33 �— ��'3 -A�/z9
(work/cell):
Phone: 33{ - 3 ! �/ -31�! 3
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
!7 yes ❑ t�o Is ar:y wastewater going to b� generated an the site other than domest:c sew•agz?
❑ yes ❑ no Is t}:e site subject io approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on diis property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Nlaximum number of bedrooms:
� Expansion of Existing System If expansion: Current number of bedrooms:
Cl Repair to Malfunctioning System VVill there be a basemer.t? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square fo�tage of Building:
b4aximum number �f seats:
5) Water Supply: ❑ I`Tew well ❑ Existing We13 ❑ Community Well ❑ Public VVater ❑ Spring
Are tl�ere 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 0 Accepted ❑ Iimovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is complete and corf•ect. I also understarid that r.'f the infor�nation provided is
inacczrrate, or if the site is sarbsequently altered, or the intended use changes, all per�friits and approvals shall be invalicl.
� � _�
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
� Zca-r3
Date
Permits are valid for either 60 months or are non-espiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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1� ''.n'n.�Il7�ammm rmm �n.'a.¢.�.Ji, JL J1A�.ffi.JL'�1CIl.
. V�+ �L PERMIT (New �2epair �
Taz Map: �� Parcel• � _
Subdivision: Lot:
Applicant's Name: ��� �� L2 v� r-%I
Mailing Address: � ro.r
u
Phone Numbers: 3(e'� — 31 �13
Location of Pro�erty:�i(r��P A�� r ��S l�c%. � lK) on ifn �ev► �rro�e
I'ermit C'onditions:
1) Seg attached site pdan fo� proposed well location.
Z) All applicable Staie and County regulations governing construction and setbacks apply.�
3) Permits expire S years from the date of issue.
Other Conditions/Comments: -
P��arait issued bv:
�ate• � ZD �/3
CERT�'ICAT'� O� �O'�'LE'I�I�1�T �
New Well� Inspe�tion:
EHS/Date
Location:
Grouti.ng:
Well Log:
Well 7'ag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller• .
Pump Installer:
tiVell Approved by:
Date Sample Collected:
Lgner �spection:
EHS/Date
installer: �
Depth: (,�_
Grout: -ZI' 3
Well Abandonment:
EHSiDate
Completed:
Method/Material(s): _
License #:
License#:
Date:
Date Results Mailed: ' �
Person County Environmental Health
325 S. Morgan St., Suite C Phone: 336-597-1790 Fax: 336-597-7808
Roxboro, NC 27573
8/1/08