A32 215Appli,cation Date: � �l (
Amount Paid: �00 , O
Receipt #: ^ �
�i4-S�� . _.
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
Mo6ile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
\�, j,�� �����1 V
.r,' �-�����
I-�" nn�au-�mm��v:n.�mIl ]Hla3ei.lL�.1Ln
Services
for Services
Tag Map: �3 �
Parcel#: �
Coustruction Authorization
ee is de endent on the e of s stem e itted)
Permit Revision
$75.00
Repair of E�isting Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: G� @ o� t� Wa 11 A� e .
Address: � s G.e � Eo,� Rw�
�'�.Y.�Q��nF'.P /�1C �nsu3
2) Name and address of current owner (if different than applicant):
Name:
Address: _
Phone (home): -� 3 b�' �Q � S � � ` `
(work/cell): 33F�- 5 0`+-3 8.5.5 � � ,
Phone:
/"`` r�A ��l �
1v` �
1'0 M�
1
°[ 1�—�6" ���s�
3) Property Description: Lot Size: a��`I Subdivision: 3yr � s Cr�t K. Lot #: �
Address and/or directions to Property: Q�� d's Cc ee K s
N�;a�e M;11: ,'Ut a�syi
❑ yes ❑ no Does the site contain any jurisdicrional wetlands? M,,� � ��'h Sq �� �� Q�Ynct � �� COt��
❑ 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 agency7
❑ 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 '
� New Single Family Residence Maximum number of bedrooms: �-i / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats: _
5) Water Supply: � New well ❑ Existing Well ❑ Community Well ❑ Public Water � Spring
, Are there any existing wells, springs, or existing waterlines on this property? � yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ �y
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
%��,�„�, W �,�°�`
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
y - Ig- I �
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `LotPreparation' form must accompany any application requiring a site e.valuation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
�� (� ���� �� Tax Map: �j 32 Parcel: 2t
� , � � � ) S�abdivision Ge _ �
- �'� � � � � � � Phase/Section/Lo # �
).C�s�rnwa�-�aca�*-�m �gn��.Il. IL-�ae.m.Il�I�n
Permit Valid for: Five Years ✓
Type of Facility: ' '
Number of• Bedroo �/ Oc upa:
Proposed Wastewater System: �
Proposed Repair: firc,rnk� r�,� 1�i
Improvement Permit
Non-expiring
�l ' New _�Addition
/ Employees / Seats:
Permit Conditions:�Fj,,.} �,,�„ �,�, ,�htd ��T
_'-���-� LL Sti�aCk4_ _ ---- —
Authorized State AgE
��) Owner or Legal
Water Supply: Y✓2 � �
Projected Daily Flow: 1�� gallons/day
Type:
Type:
Date: � /g-! 7
Date: f���-/`�
The issuance 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 aze 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
nr:rl Rules for Sewape Treatment and Disnosal Svstems'(154 NCAC 18A .1900). Neither Person Couaty nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water sapply will
remain potable.
Authorization to Coastruct Wastewater S stem
See site plan and additional attachments ( r/ .
Proposed astewater System: A�� �% �i3?, Q�;a, �s{�,,,) (*)Type � Design Flow ��D gal./day
New � Repair _ Expansio—�� 5oi1 LTAR: � 3 gal./day/ft2
Type of Facility: ' ' Basement: _ Yes _ o
(*) System Types Illb, II18g, Iv, and V, require pzriodic system inspections by the Person County Health Department.
Wastewater S3�stem Requirements
Tank Size: Septic Tank 1,�p0� gaL Pump Tank �'_ 000 gal. irease Trap --gaL
Drainfield: Total Arza f� � o sq. ft. Toial Length Do ft. Max. Trench Depth Z�_ in.
o•C.
Trench Width �_ ft. Min.Soil Cover � in. Min.Trench Separation �_ ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold ✓
S
Au�horized State Agent:
Issue Date: S j8 l7
Permit Expiration Date: �-td-22
Tlie system permitted is: Conventional /Accepted-7�'� / Alternative / Innovative . I accept the conditions
ra'nd specifications of this permit. ^���r '�
��(X) Owner or Legal Representative: Date:
��
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
Site Plar.
Tax P�1ap: 32
Parcel: ��
���.( / ��j� ���T Name: ��W �Address:
7J ll4. 1V - � 1
, ,�- �����.� Subdivison: � aS %eeK Lot:_� EHS: `
]E��sm�ffi��¢mIl ]E�emIl¢� Date: S 18-1i
��►,; v��y ,"'�� s-� �
I
�i nS�,��.�Q a��� pJ�.
C� S .5��`�'.�'
System Type:�6.�
Septic Tank: o00 � gallons
Pump Tank: /, o0o gallons
Total Linear Feet: �f Ub
Max.Trench Depth: ��"
n�.v5
�� . �� S .
v°'
.
Y V UO� �
,de�� .
�5�� �
�: �� lt_ �
���m^• ��, L.„
.�• .��. ,,4:-,��`� 4g�
� :, ,� �c , \° �uSQ.
^ ' 25 �
^ Qf �o° ,a;
� Z c!(���eWa�,/ J��vr�5
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Scale: f �� = 100'
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Health with any questions (336) 597-1790.
Additi�nal Commencs: I i► r
��`�. � �1��.����
-- ������
1Em���.., -� ���.�t ]�[�.�.,1,E� Ovvner- c� cic L�
Tax Map: ��, Parcel #: �I � ate: �-I l� I c�
g.aYte 'I'�� ia� (Sc9g) Tap �lo�v L�e ��� �ow / �oot
# I�i�net��(�) . { yn) ��: ft) ,
�. ' � �-( - 1, I t�o , -7
� ' I �f �� �. ► /c� . o
3 ' i 4 , i �� , ��
4 � I �E_, `7, ► 1� ��
5
6 �
7
S
9
1� . .
�Z ft of line x 65 gal. pLr 100 ft=� �1� : 100 =�_ gal
75% x� ga1= �.9;�. g�1 pe� ai�se ��_ gai per minute (gpm) =�'lov� ��
�riction �ead
L�ss: 1, 7E3 ft per 100 ft of supply line x 3.,L o_ ft of supply. line =100 = e,�_ft
�,� ,3 ft x 1.2 =_�_ ft of friction head �. .
Ii�iani%idt Siae: �^„ Force �Iain 5ize: a " PVC
'�otaI Dyataffiic ffiead. = 1�� ft of Elevation head + a ft of Pressare head + 3 ft of
Friction Head = /� TDH
P�p I2e€�uirr�e��: �_ GP14I @ l5 . ft of I�ead
�3rawalowaa: 1�g�I per dose ; 21 gai per inch =_2_ inci� drawdown per dose
- ,. . . ;n �,. ��� : � � � � � �.� � �: �:
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Lwllmarea
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� 9rmasmet
. . . . . _ , . "�'j.' OW pCi i�7�
S�i�-z :Y.farerial r�o:v Gl'sI �
-• " Sclied 80 �•j
; :;cree�110 % 1
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1 � � � ��� Ji
��a.�v-n�c-��ra�rncn�aa�a�.Il �'�a�asn.���a
Sloped To Shed Water
6" Cover •
t
..
Inlet From Septic Tank
4" SCH 40 PVC Pipe
NEMA 4X Simplex Contzul Panel
4" X 4" Pressure Treated
12" Separation
Electrical Canduit =
T�x M��� 1 . Parce.l # .
Su�hci�ivi�sion �_ � -.
Ph•�s•e Sec�t�ion Lot � �
�� Du,ct SealHoth
�� Ends OfThe Coruiuit Concrete Risex
24" Mu�inaizn
� � . � �" Separation
Threaded Gate Valve •
� . . • � • : . • : . • • - . , Union . , , .
` Access Cover• ' ti ; %� „y;;1'
' � ' � r' --
r• - r • �
► ' � � : ,i:
�,. Opening Filled With ` � Zip Cord
Anti Siphon Hole T�1
Portland Cement Graut �� H�) I �
Check .�.Nylon
• Valve Rope
, H�gh Water Alarzn Level
, (b" Separation�
,. High Level - Puxnp On
„ ;' �VapozLock �,
Hole ♦ �
•1 �Drawdrn�rt �Up Hi71) �
1
• Lcnv Level -Pump Ofi
; . �7
' Pzecast Concrete Tank 4" Cozurete
;•; (MaterialStzength}3500PSIj Black
• � ..
' �•`;• . . . • � ' . ' , . „ ,' • : . � 't
Supply ' '
Line + • �
F1oat Wires . < �
.i
�
- Floats , ,
�Rem,ovable • •
Float Tree �
�
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. ' �, � , 1 �, ' ,,
/(� GALL�lY PUlVIl' TAlYK
f�321d COIlCT@t@ Ci70ilt
Mastic - - :
� Opening Filled With
Portiasud Cement Cmrnit
�_ Outlet To Dutnbutioa
2" SCH40PS7C Pipe
���.sf ���.���
�--�- � � ����
IE��.� � ��m� ��.Il IE3C� � Il �1�.
WELIy PERMIT
(New�/ Repair_ J
Tax Map: ��Z Parcel: ZIS
Subdivision: S .I� Lot: �_
Applicant's Name: ���
Mailing Address: �
j n�er���e . NG 9."158�
PhoneNumbers: '33(�_s�(.�srS, qIR-�roo-/3's'IlMtd1,;,1
Location of Pro erty: I�ur.� �( i Il S d.—� �� e� C r�,•ss �1. ? OO or, R„ roJs Cr�.e� 7
l�f o� �
Permit Condi[ions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potabde water supply
OtherConditions/Comments: �I�i.rf��:, al! S,Pl�iac�.'S
Permit issued by: Date: � �Q-/7
Tew WeU:
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
E�} S/Date
.�/ I�tU-tY SS
Certificate of Completion
QLiner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
Well Driller: �a�p,�}4P License #: �
Pump Installer: License #:
Approved by: Date:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Rnvl+nrn N/' �7573
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
„�o�/,o
Jan 16 18 03:44p Barnette Well Drillinglnc
Vti`ELL C�NSTRUCTIdN RECORD (GW-1)
1. \Ycll Coatr�cior Informatioo:
�o�vN� � � �R�� �
'�eG Con�actor Nama
3376-�
NC Wal Conttactor CcrtificIIion Numbec
Barnette Well Drilling, Inc.
Company Narne n ,�,
���
2. Well Coastruction Permit #: � �
iis: ali app:icaole welf eont7nrctron �ennits (i.e. U.'G; Covnry, State, f'arra�ce, ctc.)
3. V1'ell Use (check wdl use):
Water Supply Wclf:
�Agricultural
�Geothermal (Heating�Cooling Supply)
�In dushiaUGommercial
�Irrigacion
Non-Water Supply WeIL•
uifer Rccharge
uifet Storaac and Recovery
uifer Test
perimental 'fechnoioay
oohecmal (Closcd l.00p)
�htunicipal/Pub3ic
x�Residenflal Watec 5upply (single)
�Residenrial Water 5uppl}• (shared)
�Groundwatea Remaiiation
�Salinity Barrier
�Stormwatet Draioage
�5ubsidence Control
[�'F�acer
�{Other (explain tuider #21 F
4. Uare Well(s) Compicted: �'��d '"� O Well iDti � J Z"
Sa Well Locatioa:
�2L�a%��vo�Rt! 1�7�i1uGc� L-•c�`l"'�
Faci'.it�•Adwna Ivamc Facility mtJ {if applicablo)
Q 4/ R�� C.2� e 1� L. a�` 9' ax� rQ . ��
Plicsical Addrtss, Ciry, aad 2ip
�� /C � d /� � %.5
County Parcel Idenrification ho. (PTN}
5b. Latitude aod Ioogitude in degrees�minuies/seoonds or decirual degrees:
(if,rell 6eid, one ladlong is sufi"icicntj
3G- Z.63z9 n�� f� 32.97 w
b. is(are) thewell(s)�ermaoent or �Temporary
;. [s this a repair to sa exisdng well: �YGc or l�No
I,flhis is n repoi� f:ll am known wel! ronstruclio� informaliarr and orpirrin the not�uc of �hr
repeir under �� 21 mmarks sectrrirt or on �h.e back nf this fo�m.
S. For Geoprohc/DPT or Llosed-Loop Geotherma! Well� having the same
coruiruction, only 1 GW-1 is needed. Indicate TOTr1L NLJMBER of wells
dri11eQ:
9. Total we(1 depth below fand sarface_ / O a (fk)
Fo� mulfipfe wells iist af! deprhs ifdr�'erarsl(exanepie- 3Q2W' and ��f00')
10. Static rvater levd below tup ot psiQg: 25 (�•1
f,�wcrerl�veitsa8m�r. casrng nse "+"
336-598-9275 p.1
22 Certificadon:
r��;� � � �� �- � �
Signa�ure of CMified Weq ConKaCta Date
Ny signrng this for� I hereDy ce�lifr tha[ [he wefl(sJ wa� /wereJ cnnrtructed in accor�/cnce
witF. !S� NCAC Q�C .0101 a� l5.91Y'C.4C �K .0100 t�e!! Constn.c�inn Srmrclardr rmd �hcu a
copv olfhie recnrJhcu 6eert provided so rhe well owner.
23. Siie diagrsm or aJditionsl weli details:
You may use the back of this page to provide additional we][ sitc details or well
construction detaifs. You may aLso attach additiona� pages if necessary.
SUBM[TTAL INSiRtTCI'[ONS
24a. Fo�11 Well�: Submit lhis fonn within 30 d�ys of campietion of weil
construction to the f011owing:
Division of Water Resourcrs, lnformatioo Processing UniG
1fi17:VCai[ Servicc Ccnttr, Raleigh, NC 27G99-1617
12. Sorehole diameter: b {in.) 246. For Iniccdon Wells: In addition to sending the form to the address in 24a
Air rotary above, also submit one copy of this fotm within 30 dsys of comp{ction of w�e[l
12.1Ve�1 construcdoo method: construction to the follrnving:
(i.e. aug_r, mtary, table, daa:t pu=_h, c[c.)
Aivision o[Waicr Resources, Cndcrgrnuad lnJection Cantrol Program,
FOR WATER SUPPLY WELLS ONLY: 1�i6 Mail Sorvice Center, Rale�gh, VC 27699-1 b36
13s. Yidd {gprn) �� hlethad oitesh BIOWE.'{� ZO i1Al�]_ 2�C, For Water Sanolv & lniadon WeUs: In addition so sending the forzn to
che address(es) above, also submit one copy of this form within 30 days oY
131� Disi�f�ction type- CilIO(If1G Amount• �f4 Cup completion of well construction to tho wunty health deparmlatt of the couttty
where consWctcd.
Form GW-1 Nuth Carolioa Depa�tment of Environmental Quatity - Dieision o: Water Resources Rcviced 2-22-2016
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