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Per.san County Haaith Cer:
�25 S. i�10!�8(1 Stf��#
Rox�oro, �N.C. 2i5?�
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mprovements Permit.(Estab(ished/Recorded Lot) �_ Reinspection of Existing System (Loan Closing)
_ ImpFovements Permit (Unrecorded Lot)
_ Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Repair/Replace existing Septic System
Permi[ for New Well
_ Replace Exis[ing Well
Permi[ requested by:
�wner/prospective o
Address: E�S I l Fa
ome Phone #: `�' I�i-� -`�'i - S-�i �O
usiness Phone #: �119- e�'_7- oZo1'ot(o
I�Iame and address of current owner:
. Property Description: Lot size:
��
7. Dimensions o� Proposed Structure:
Width: �
Depth: 3 �' � ,
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
rVvn��
9. Water supply t5•pe:
private �j . public ❑ community ❑ sprin ❑
Are any wells on adjoining property?Yes � No �.
If so, identify location: Co2N�r D� GhA,e%
/h �„ k �►- �lu�„ is�� �-
. Tax Map#: F1�- 3� L-L- �� 10. Type of structure/facility: Proposed: �Existing: Q
Parcel#: !-of .l � 7 �o�� `� Type of dwelling:
Township: h�� � s�To�vvs�, /�1�eu�'0t'' House:� Mobile Home: C] Business: ❑
. Directions to property: State Road #& Road Type of business:
tames,�tc. � Number of Employees:
S.� t��les �1ork► � l�w� s� on (��.,�y /�Numberofbedrooms:�_
5o s�l� l�ey 6h� Chr��1►a lk�,,,K lq� . � Garbage Disposal? Yes ❑ N9�'
�.�n� �► i, n_� -r r.. n«- .at � T Basement? Yes ❑ No� If so, # of basement fixtures:
6. Number of occupants or people to be served: �_
CLEARLY STAKE ALL CORNERS OF T PROPERTY AND THE CORNERS OF ALL
SED STRUCTURES.
hereby make application to the Pei'Son COunty �ealth Department for a site evaluation for the on-site
sewage disposal system for the above deseribed propercy. I agree that the concents 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. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
�e site by the Health Dept., this application s�e.c.�me void and all fees paid forfeited.
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PERSON COUNI�Y ENVIRONMENTAL HEALTH
' y PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #:
� V Q� Parcel # r � �
Zoning Township F_./ / F�r(�.�
Applicant �� v " 1 �
�� � `
LocaUon• �
Subdivision: (/vJ/ Section: � Lot �_
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Well �ermit
TYpe of Water SupplY:
Re4uirements:
Individuat Community Public
��o..r�-� e.n.c-� J�,�y�.. l2- �o^�\ L-�S
� p \ ac2� <cA' cc �: �„e� . ,
Site Approved by (� s�.�.�,,,, o� �,�a.y u� c-�' °.�"� ��
Grouting Approved by /D a OC�
Well Log S D a- �O �����
Well Tag C SS ►s -�, - � � b��a�
Air Vent CC"s� � � -�► - � �
Hose Bib C�s ,a-��-�,
Concrete SIabC_35 �a-c�-��
Well Driller: � � —
Weil Approved By. c�a.�
c�wn¢s- i-t�ak `r' Q- ..� e.?� �
s�c.5 t� c,.Z rC� �ou.r- c�
nv.�.J 5�0.� . �� �u o� d. S\ct� �03
C rc.c.Sv..�. G,,... w,� s; a.�. kv iC..� v�.e,- .
Date: 1 a-�- o �
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
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PCHD, �ev. 11/29/99
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PLEASE SEE ATT,
Tax Map #: n ��
Zoning /1 �/�G'��TL
Applicant: �N ��C�
AND SYSTEM LA
Parcei # !O� ���
Townshfp � �h� �r�S T h+NS�1��
Location: �G�E..S�S iP0 f' Cl�/�L/E �%%Q�� /eQ-
Subdivisioo: _ Section: 1 Lot: �
Improvement Permit
A buildincl permit cannot be issued with onlv an Improvement Permit
New �Repair _ Addition _ Type of Structure}i��Water Supply ��V�'J� W(�
# of Occupants� �x' # of Bedrooms 2 Other •
Basement? �+� Basement Fixtures? �o
Projected Daily Flow: 2�a g.p.d. Permit Valid For: �Five Years ❑ No Expiration
Proposed Wastewater System Type: �hv��hal ���
Pump Required? Yes ✓No ��
Permit Conditions:.�YI.S� I � �i� �� ��� � ��e� �
� s f GoGP-T D/v
� Owner or Legal Representative Si ature:� Date: <<- �-� 9
Authorized State Agent: Date: �� 6
/
The issuance of this permit by the Health Depart t in no way guarantees the issuance of other permits. The permit
holder is responsible for checking with appropriate governing bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Cade.
Type of Wastewater System
Facility Type: �7�f�
Basement? 0 Yes �o
Wastewater Svstem Requirements
Septic Tank Size: �� gallons
Total Trench Length: o��a feet
M�mum Soil Cover: � inches
Other:
Permit Expiration Date:
Authorized State Agent:
Wastewater Flow: �g.p.d.
New �Repair DExpansion ❑
Basement Fixtures? 0 Yes ��f4"o
N��
Pump Tank Size: �_ gallons
Maximum Trench Depth: � inches Aggregate Depth:�� in.
Trench Separation: -/ Feet on Center
Date: �� �
The type of system pe�mitted �es � d�s not differ from the type specified on the application. I accept
the specifications of this permit.
� Owner/Legal Representative Signature• Date: �J '
PCHD, rev/ 10/12/99
Application #: 0�0�1�
Tax Map #: ,¢-32
Parcel #: ,�o� /�7
� Person County Health Department
Environmental Health Section
SITE SKETCH
�bN �ICF�i �o����y /I�ead'ows �°t�J
ApplicanYs Name Subdivision/Section/Lot#
- � �- ,� �� �
Au oriz State Agent Date
System components represent approximate contours only. Tlie contractor mustflag tlie system
nriar to beninning tl:e installation to insure tiiart proper grade is maintained
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Scale:
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PCHD, rev. 10/12/99
P�c,
Person County Health Department
� Environmental Heaith Section
Tax Map #: � �a Parcel #: %�> 7
Zoning: Township: Q S�iv FDrK
Subdivision: O in C0.��(,� Section: Lot: -�-
Applicant: ��r1 l,� i C�
�ocation: �u-�s R� �'Charlic (�1fln K (Zc1,
�peration Permit
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AU ORIZATION
�I��j i� ^/a ` �O
Authorized State Agent Date
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L�n� 2 � �D I
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Tax Map #: � Parcel #•
45"
P��
PCHD, rev. 10/12/99
Person County Heafth Department
Environmental Health Section� �h
Zoning: Township: /'7L�1, y �o �X
Subdivision: � � G0.c� aC�S Section: Lot: �
Applicant: 1'� dr1 �.�i Gh
�ocation: l��e�SS IZoac� c{'�C�rlie (�'lOnk i�ocid
Operati�n Permit
1. LOCATlON AND SEPARATION DISTANCES /
A) System meets .1950 setback requirements r/ , , t�{ �
B) Distance from system to any wells W Cl l not in5iutccd d ur,i+�, , n S(' ��
C) Distance from septic tank ta foundation �'
D� Distance from system to property lines �c�'
2. SEPTIC TANK ✓
A) Visually inspect the exterior walls and top of the tank
B} Visually inspect the interior wa11s, baf}�e, tee, filter, riser, lids, air vent,
bottom, and water tight outlet j�
C) Date of tank manufacture �-1 `I`afl
D) Tank seria! number ST6 14a
E) Liquid capacity of tank I000 gallons
3. SUPPLY LINE TO TR CHES
A) Grade (1/8 inch per foot minimum)
B) Material suppl� line is constructed f�om P �[:
C) Diameter .,
D) Length ' ���,
E) Distance from tank to drainfield/distribution device
4. DISTRIBUTION DEVICE(S)
A) Type �j / Fr
B) Is Device water tight
C) Distance from the distribution device(s) to the trenches
D) Is the device on a level foundation
E) Does the device perform according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth ��_ inches �
B) Trench width 3(e inches ,
� C) Distance between trench�es q
Dj Number of trenches
E) Length(s) of trenches 1 �� 11 �'� q D�
F) Aggregate depth la inches
G) Aggregate material and size
H) Record septic tank outle levation
I) Trench grade � (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth ✓
b. Proper rise over step d n�_
c. Solid pipe used _�
d. Elevations of step downs ✓(Record elevations and show on as built)
S�ee "as built" plan on attached sheei.
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� � PCHD, rev. 10/12/99
Date: �Z�l� '
Owner. �o��--�
Location/Directions: E
-ri.., �w --,�_ .� ., l
Subdivision-Name:
Drilling Contxactor:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
� SR# ' � �
T—r�–� ' , .
L.00 ##
WEL,L CONSTRUC'T'ION �
Distance from Nearest Properry Line 1 c1 Distance from Source of
Pollution ( G a
Total.Dep.th: ( Ft. Yield: GPM Static Water Level a..f' Ft.
Water Bearing Zones: Depth,�X .__Ft.BC� Ft� Col �. Ft� Ft.
Casing: Depth: From 6 to �(2 Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Yes No
Weight: Thickness:� � HeightAbove Ground: 1�/ Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason:
Grout: Type: Neat Sand/Cement / Concrete
Annular. Space Width Inches � �
Water in Annular Space: Yes No
_ .. Method: Pumped _ Pressure . Poured � . _ . .
Depth: From C'� �o �,2 C� Ft.
Materials Used: No. Bags Porcland Cement Weight of .1 bag lbs.
If mixture (sand, gravel, cuttinas) - Ratio: to
ID Plates: Yes � No � �
. 4 x 4 slab Yes � No
DRILLING LOG �
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C^vui�rI'�c' HEALTH DEPARTMENT.
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1 ��
gnature oF Contractor at�