A32 127. ` t�
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Person County Heaith Department �
Sewage System Improvements Permit
Date:.t�-' ' is Permit Void After 5 Years a�%,
Owner: ° �G+w�in tf .11'i���� �%� SR# � 1
_L��n,� l�iin � r�`{- i J` atcl ,�I�� o�-t�� `�vP e'2.p lt�c,�1 �.
f� f ~
'��9iblk�'�e; r r ' r�c Q<<< �e �en � r i v
Lot Size: ��i C►`P a x��
Water Supply: Private: � Public: °S ' t'�'`' f_r �
Bedrooms: 3 Garbage Disposal
Basement Basement Fixtures �
INFORMA BY
Sc1111C�'1�11: owner or rep tative
REPAIR: REEVALUATION:
Size of Septic Tank: � gallons Size of Pump Tank:
Nitrification Line: 3 �� �� 3 �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
Date Well Approved: Well should be 100 f� from any sewer system
BY Sanitarian
Da Sewapze Syste A ov • � —
BY Sanitarian
� ERTIFICATE OF COMPLETION
----- — ----------------- �
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained �
by owner in such manner as not to create a public health hazazd. Septic tank and'd
nitrif'ication line must be inspected and approved by a memtier of the Person Counry �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pernrit is sub,ject to revocadon.
(G.S. 130 A-335F)
�J
L.ocation of sewage disposal sewage system sketched on back. i`l
t
(OVER) � �
� .,
�� Person
Date: - �1 �This
Owner `
L.ocation/Directions: _
Drilling Contractor:
County Health Department �
Well Permit �� �
'�crnit Void After 3 Year$ � '�
; �iP � SR# .��
C� ' I
, vf #
�-
`"'
WELL CONSTRUCi'ION ►ti
Distance from Nearest Property Line Distance from Source of P-�'
Pollution �;
Total Depth: FG Yield: �GPM Static Water Level Ft. �
Water Bearing Zones: Dep �r� Ft Ft. t
Casing: Depth: From � to �� Diameter: � Inches
Tl'PE: Steel Galvanized Steel'`�
If Steel, does owner approve:'Y�1� No
Weighr. Thiclrness: a H�Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No '�.,,
If "yes" give reason: - � �
Grout: Type: Neat S dLCement Concrete
Annular Space Width � Inches
Water in Annulaz Space: Yes No _��
Method: Pumped Pres Poured
Depth: From _� to Ft.
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
ff mixture (sand, gr ve , cuttings) - Ratio: to _
ID Plates: Yes No ►d
4 x 4 slab Yes v No �
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCO ANCE XJITH RE LATIONS SET
FORTH BY THE PERSON COUNTY H�'I�I�$Ag�tENT. �
of
Sanitarians Signature
Sketch well location on reverse side.
V Date
�
Date Issued
Date Completed
•' NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
+ supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
�" at later date. Note location of water supplies on adjacent lots.
1
(1) (2)
05/15/2008 13•14 3365977808 PERSON COUNTY ENVIRO
PAGE 03
11�plication Uate: 9�0 �� �ap: �3Z
Amount �aid: � 50 . c� Paxcel #: I Z 7
Receipt#�: c� �o t �
�-'�" ��3 ���� �.�. ������4
T` ""�^ � � �.T�'J,��
7���sa..rits.raa�rv,_ana.a'�yn. �.dn,Il 3�"`3l�e�e�71�.f:7ln.
A,p�licadon for Serv�ices
Se tic S stczns and VJells
Services �t.� uested
❑ Imp�rovement Permxt (Site Evaluation) Cl Construction Authori�
$ZOG.001$30U.00 if> C,04 d Fee is d endent on the
Mobile Home Replaeeme�t or Bu;Idimg Addition ❑ Permit Revision
_ _ $I50.00 (ifsite visit requffed) �75 on
eat)
�225.00/$125.00
�
No Char e
af
Septic Systeim
Iraportant: lfrhe fnfornuuion i,� the applicatian jor an l,npvrovcme„t Pennit is fncorrert, fals�, or the site is alterer� tleen the
Lrrprpvernent P¢rmit wed �he Autlrorfzatton to Canstruct ,�hall become irrvalid
) SenTices Rec�nested by_ I
Name: A /�� cl�LL Phone #(home :�/'/ I G`i�/-1 ySU
Address_ ' I= ,- (work/cell): 415 6 �g - 8�/S' �
E /s ..fc 2 y
2 Name and addxess of cuR'xent owner (iii'different t�sn �pplicant):
Name: R r+r. ���� rc �,(�—
Address•
_ u ✓ C /Ll�Y�S { NC� 2i5�L„
� 3) Pro�erty Descri�tio�: � T�ot Size:
Address and/or direct�iRns to Propez�y: �
O� fd /��A�Ndf E�rdLE c�_ �� . :
r
4) Px'oposed Use d�'y�e of Structure;
�esidentiai � Busine,55/'�'ype: Qtj7�er
Number of bedrooms � / Number of people served (seatsJemployees): �`
Basement: Yes No �(with pluntbing: YeS�Ivo � Garbage disposal; Xes No ��
A pro�r,iumate �ze of buildittg �oandatipp�: I,en�th �(o wiafh �_�
! Water Su 1 :
� PP Y
Privatc Well � (Proposed $xistirlg ^,
Comnaunity Well: Public Watex System: ,_
Are there wells or� the adjoining praperties? No�� Yes
#:
(please show l�oatian on site plan)
Note: ,4 com I�ted lication must atso include:
➢ A,plar/site pran of t�ie,prvperty that slaows property dimensions and the size and lec¢tion of all
pro,posed strudures.
➢.� signed copy of the `,�,at Preparatio►t' form verifying that the,property is ready to be evnluated
� am snbmittio4 t�is applicatKon to reyaest servi�ces from tb�e Persoa Coun�ty Healt6� Departmeo�� '�'he inform$tidu
provided is accur�te. I understand th�t if a�y site i,� altered or the intended use change,q, al� per-mits shall become
Signature (Ownex/Legat Representative): �M�.�� �$,��,t,�, bate: S S 0
11/07 Person County Environmental Health, 325 5. Mor�an 5t., Sr,ite C, Roxboro, NC 27573 (33Fi-597-1790)
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�3aai�ding Additao�s/ lb�o&�iie �o�ne Repl�ceanents
Tax Map #:�_
Approval Requested for:
Parcel#: Ia�
SL' Mobile Home Replacement
Building Addition �
Applicant Name: � M i�4 C
Address: " � ' P.d
urd -e 1a� �►.�c a 5� I
Phone#'s: Q1q,t��t�{- Iy� �IQ�Co�9-`��l�
Permit Located: �_ Yes No
Installation Date: ,���4� . Design flow: 3�0� (gpd)
Current Contract with Certified Operator on file (if required): �,1I�
Water Supply: �_ Well Public or Community
Wastewater system shows no visual evidence of failure on: �� �� J �Q, (date)
(Applicant's signature if site visit is not required)
Ad�atioa�epgaceanent Appr�ve�
�.��� ��
Environmental Health Specialist
11/15/OS
�i����
Date
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IE ��a s� aaat�rn..@ aa. ��.11 IC� �.m ]L �776tn
SITE PLAN
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Name �Qmm:, �� �Ch2�� Tax Map #_� Parcel #��
Subdivision Secrion/I,o #
��.�,� ; a ��� 5� 3c� 08
Authorized State Agent Date
System campanents represent appmsimatc conmurs only. The contracrarmusrtlag t6e system pnor to begJaning thesasra/lation m
insure tfiatpmpergrade is mainrained
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