A32 30Applicatian Date: '���
Amount Paid: 7 a�
Receipt #: 703 � 2�
�,12� G G(�
G Improvement Permit (Site Evaluation)
C Mobile Hame Replacement or
$150.00 ifsitevisitrequiri
Well Permit (New/Replace ei
$3Q0.00!$200.0 75.00
��,?,)f �11'a���� TagMap: �3Z
....._ �.,,,r- � � ���� Parcel#: ��
IE:�Z zn-�o�+�-•e�.d.aIl 1H[�SHn37.
tion for Services
Services
L� Construction AathorLzation
(Fee is dependent on the type of
Q Repair af Existing Septic System
�1 N eJ�-- Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: �aL�n t�irn �i.v�-�f Lc� ; 2c_.�c�� �
Address �i �: r '-1 i �. �,-�;
,�c� x� �� G ��S 7N
2) Name and address of current owner (if different tl�an applicant):
Name• % �
Address: �t '
�
3) Property Descrigfion: Lot Size: Su division:
Address and//oJr d�irection�sj to Property: aa/:
%'�u -/S C. ,'( /J. ��,lC �fi�c_ f I / C /�'°l�%!. .
Phone (homs): �33G �'�2- " �3�-�L
(work/cell): �'���) 5���' G�;3L
Phone: /33(0) 3 G �/ — � � S�
#:
❑ yes ❑ no Doe�the site conrain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
0 yes ❑ no Is any wastewater gaing to 6e generated on the site other than domestic sewage? }— �
❑ yes � no Is the site subject to approval by any other public agency? lGL l�
❑ yes ❑ no Are there any easements or right of ways on this property? O y.� � ��� (
{if `yes' is checked, please provide supporting documentation) C �
�
�d) Proposed Use and Type af Structnre:
OResidential
❑ New Single Family Residence Maximvm number of bedrooms:
CJ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repairto Malfuncctioning System Will there be a ba�ement? ❑ yes ❑ no With plumbing fixtures? U yes ❑ no
❑Non-Residentiel
Type of business: Totat Syuare footage of Building:
Maximum number of employees: Ma3cimum number of seats:
� vVater Supply: � New well 0 Existing Well ❑ Community Well � Public Water � Sprino
Are there any existing tveils, springs, or existing waterlines on this groperty? ❑ yes � no
6) if applying for `Anthorization to Construct', please indicate preferred system iype(s):
❑ Conventional 0 Accepted 0 Innovarive 0 Altemarive 0 Other ❑ Any
I eert� that tlxe inform�tion provided above is complete and correct. I also understund that if the InfoPmaiion pt'ov�ded is
inaccurate, or if the sy,� is s�bsequently altered, or the intended z�se changes, all perrttits and approvals shall be irevalid.
Representative*`)
"' Supporting documcntation required.
-��-�y
Date
Permits are valid for either b0 months or are non-egpiring �vhen accompanied by an approved plai.
A compteted �Lot Preparation' form must accompany any application requiring a site evaination.
!1(1/i 11 AE•rcnn ('nnntvFnv+rnnmPnts�� T�t►a�ti� �'3S .C' Mnraan Qfi �nitof' Z?nv},nrn TT�` 77S'72 lZZ�_Sa7 t7oM
���,S.f ���.���
`_- � � ����
IE �rn�v n u- � � a �r�n � �ra �: �m.Il IF3C � �. � �:l�a
Tax Map: �3� Parcel: 30
Subdivision:
WELL PERMIT
(New_ Repair�)
Lot:
ApplicanNs Name: Jor��l. ���► �+�a- �^+�S>
Mailing Address: �10�°1 V��.b�u�A Rfl
1�3vtW � 1�C a`15`1'i-
Phone Num6ers: 33b�J83' bb3� _
Location of Property: qy� CH�Y.U�6 hD�1L Y�Q (,wEu-- Ac.�.sl �� `Ycr�tO, _
Permit Conditions:
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 potable water supply
Other Conditions/Comments: L1t�2 Q �'
Permit issued by: ��C�ca�. � • ���\
�iew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date: $ a'1 �
Certificate of Completion ��' ��(
�L,iner: I S �,PN�
EHS/Date
Depth: `L�
Grout: �S - � �
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
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