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A32 36A� n� . PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map #%� 3 Z Parcel #_� �� Zoning Township _ C���'--��- ' �r�zl'L Owner/Contractor ���- Date %/-/ � — �-S Location/Address -��. %'��r%�-�..- � � l�u=�- �,�, 0�- i ��-� s.R.# l� d/ Subdivision Name Lot#, •� �' �. ��� --� � ��� . �� i �� r ' � � s -�- / _ „ , • • � .�r . � " �''_ i ' .�. • � - / � � ---=�-� .�' (,� ���s�'e �'.�.e�. SEWAGE SYSTEM SPECIFICATIONS epair Lot Area %-�-� Size of Tank_ FD Mobile Home �� Size of Pump 7 usiness J� # of Bedrooms-!�- Nitriiication Li Max Depth Tre Permit Void after 60 months. Permit Void if not in compliance with zoning r gu a i . Permits may be voided if site is altered or intended use c�anged.� Well and Septic Layout by ,�e-�, , ,�-��Z � w ,�Q-.Q ,Q -�-�,,,� , Comments: f � �i i � Date — 7� Installed by ►20�'����'�.._> Approved by !�U .�� ��--t-�-v*-„� ., _ � �- � , ell Permit ite Appro� Jell Head �routin� A WELL SY$TEM SPECIFICAT10NS Repl -Pu Date � Installed by Required S1 _ Air Vent Required ell Log Well Tag pproved by, This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.1.0 0 ''t. . � •. . .. Y. . .... .K . .. .: •F}= ' � .: . . � : -�-, • ' 7• . t t • { • ��`�. t. ;; � �� � .".t�-�...�^�..�... ,-r .. y: � :�' ..� . _ _ � Y i. ':,"►..�:•� .. - � � :�.. � � •��•' ��' ......,. �, �. .. .�,.. . . M1a,� • '� M; � +, ,,,.�. : :w.:::•::• ; • .... ..:� .... ,; k,.: . ••: a . . .. ��•�`:�...,_��'�� . . . �pw:�m���:.�ri�'^��A�w:�Y:ww�:��j�n��Y�!'1� ��� '.,�'�'� �!7��w.:������� . � . . �aMY4vwWiGaC•�i�.+w��r!�`�^��w� �l�4�� s ��j���� . � ��iY.J�iY • . ♦ . ��� � ��� ��Y . �� � � �3 �� • Tax 14�i 2 P #,��_ r 'I`o�+mslup: Applican� C I e ar�►'.ed � Sui,division: Lot # � Location # //250 � � . : . . . �'pg�e oi'V�a�,Snp�efly: -1/ Individu�l. Commnnity Public �q���: �. . � Sito Approved By: � Linoc . . ��ronting Appmved By: � - 2-o c� . ' 7netalled by: " Woll Lo� � .' i7epth se� I�l 0' � � . p,�n Ta�: ' - � Grou�: w�u T�: � � n�• � � . ._ �v� ' � � . . � = �� e�� � . w� s�e: � ��� � � . c� s�: � � � �v�u n�: � �ss u� . � - Well App�aved by: .� Date:. - , . ��**9ee �ttac� 5ite 3�cetdt�**'� � i Welle must be 10 fe� from pmpedy linea. � - � Wells must be 1U0 fe� from s�ptic systems. � � .. � �Tells must be at leaet 2.� fe�t �from any build'mg fo�datiam. � , . Other canditians• �, . - . ` . � 0 PC^� rev Ol/'?7104 �.`���; �� �1! �1�� �1 S.. � �--- = �_ . c� �OO ��1 'IC`� �]Lb'�Il]I`��rnir�r-n�OSb�.rL.� 1L1L�C��1�� �l13 n� �. U�����. Name (/har���a��e►� . Tag Map # A32 Pa�cel #.�_ Subdi ' - n r Section/Lot# �-20�d1� Authorized St-ate Agent Date Systesra co�onents re�iresent a��r�xas�aate�cmnt�aars only. T'lae caratazrc��rr r�sa�st�%ixg tlae s�rs��a pa�r t� beg�sataing tlae z�tstaZlatr.�n to i�as�ar�e �dac��ir�o�ierg�rrle as �raaantcazaaec�, 3;y �¢ e� � r r� Q b4nd on P °� � ,���I v� d � ;��' 'a`� �.r ���a� ' �i' � yt7c � � �� ��� � ���� � �� .. c .,� . x �� ��� .'7'i. . �m� a� i1�7 �9 ' i7 � � �, ; � � i,,'3e n �„ �� � ;� � � �- ; � � t��� � . ������� � ,. , � ; �'��� R� �- � ,� � ::� ,� �- �-� � �. � �� F � '�rr.� �, � »,��. a�. �.SC� xE,=€.- �U� � ���� � ��- � �:� � �. � �� F . .. . . fi �_ � f� � � � ��- �; n.� � � � �� � e� �� ��. �� �- � ,. s �"� � `��` �� "�' � � � �. � •� � � ' � �� � � ,. �� � § � � � � � �k�. �: � � � � .���� .�� � �`,_ � "� � � � ��°�� r�z� �'�� ' �� �� � ° � � � w�� y ���,3 � � � j ss"�, ;�; �+ ` '` �a�, �� � g ¢ ��� � � �����g ,� ,� s- , ��M ��. ,�-' ��� . ''��� ` r � � �� �� , � _.---- -- �a� �� �'£��;Ff, �.t-"�"... f : -�.<... .�_... .,. . _. .... _. Scale: l� 'S2 ^� �'f � �r � `�,��.,, ��_.�+ "'�' /''�,�, .�. '�� �'"� k ° 4 �� .y��%. ! ,�`, � ��,��� ,�'� �� . ��` 4 � � ;;� �a.,, � �� � ��� � � � ;� � �u � � n � � i.,� ' o3tiyY . � � y � �. � �,;��� ����� � :. r �: Y F � e �.,T'ff.��' f � _ � � ', �. � a(+' �. � � � `.f j �n 9 �e, i�2 Y y '���� ��- �, � ' � � q�� .- s�'�;. ��'� o�� ���_ � � �� � � ��' � �� ���` ' '' � ��� ; t� ��� � �r � �Y��� � '�� �� , E i } � a ,� � . _ �� � � .����� i �� �. �• v� • LL M 1 North Cat�lina - Departme� of Ernironme�t, Health, and Natural Resources Division of Envito�mentel Management - Groundwater Section P.O. Box 29535 - Rateigh, N.C. 27626•053� Phone (919) 733-3221 P. �G � oFFlce us� o�t.x OU/W. N0. SERIAL NO. . ldt __,,.__ ��+0• � Minor Basin WELt, CONSTRUCTION RECO�tC? Ba;.+n code DR1LLlNG C�NTRACTOR: /I/c+��, S/� a n�// �c SS��t� t�ea�t Ent. t3W-1 Ent STATE WELt CQNSTRUCTION bRILLER REGISTRATION NUMBER: � t' �� _PERMRNtfMB�F�:_ � - ,3 � ���• �r l �2- _ 1. WELl� LOCATIOfd• Show.sketch of the lacation below} Nearest Town: ��0� d �''' E' .— Couniy: �� �^ � v- - (Road. Gommun . or Subdiv�sion and Lvt No.j OEPTH 2. OWNER �q %� f /V ,^ r,�_S' Ftom To ADDRESS �'� ��r �� � _.., !'? � /�s � <L_ _,_..— — {Sueet or Aouto No.) �ur�l /{ s��!/ �t1 �' d / S' city or Town state rp codn �� '74s' 3. DATE DaILLEO '�7 �� USE OF WELL Sror e �j. TOTAL DEPTH � aS- "— $. CUTTINGS COL�EC7ED � YES ❑ NO�' • �--�—�---�---- — 6. DOE8 WELL REPLACE �XiSTiNG WELL? YES [�' NO[] � ---- '7. STATIC WATER LEVEL Below Top of Casing: � FT'. (Use ".�` if Above Top of Casing) 8. YOP OF CASINO lS � F't. Above Land Surface� Casing Torminated aUor tHbw land 6urfaoe !s ittegal unloss a vprianoe ts Issuod in accordance Wlth '1 SA NCAC 2C .D118 ,p 9. YfELD (gpm): � METHQD OF T� �.1> ��'' t0. WAl'ER ZONES (depth)_ `� �a _ DRfLLiNG LOG Fortnaoon Desaipt�oo %��,/ ,C%,�,�r _ � •�r `�' {� . CNLORINATION: Type ���� Amount Z�" If additional space i� needed use back of fotm !2. CASING: - D@pth Diameter From.�S'�.'io � Fi. � From To Ft. �rom To Ft. t3. GRDUi': Wa►1 Th;ckness �OCATION SKETCH or WcighvFt. wtatcrial (Show direclion and distance irom at le9st iwo State � YO G� f✓.-«�� Roads, or aihar map refarence points) Dept� Matesial Method Fram To Ft. From To F1. ►4. SCREEN: D�pth Diameter Slot Size Material From To Ft in. in. `,F,� Fr�m To Ft. in, in. L From To Ft. ih, in. ,�i� � 15. SANDIGRAVEL PACK: ''�+ Y GS � Depth S;ze Materia� �' � `�` �,` `� From To Ft �� �� -�4 ` Q�, .a � � .�- �rom To � Ft, . .� �� _ �, t(.. REMARKS: • r �z'` � G.�z�r .: n Gv� l/ l�f�"iir jl, � <<�, f ' Gd.f�.� – �� �"D Gc�-1 O i�je �r.y �,�,s .c.-, I 00 NEREBY CERTIFY THA�'THlS WELL WAS CONSTRUCTED iN AGCORDANCE WtTH 15A NCAC 2C, WELI CONSTRUCTION STANDARDB. AND THAT A COPY OF THIS RF(:ARn HAS RFFN PAf�VIh� 7h THG WFI 1 nwt�tFR %�� ��-��'l���J�' Application Date: �ZI�1��, Tax Map: - `�2, Amount Paid: rv J� Parcel #: 31D ,l� Receipt#: ��� /+� 1 �� �� �� ` � ������ ��awau-a�aa�� ��sn�aC-..�n.11 IE3Ix�.r�.,Il�]L-n. Application for Services (Septic Systems and Wells) Services Re uested O Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 if> 600 d (Fee is de endent on the e of system ermitted) ❑ Mobile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired) 75.00 ❑ Well Permit (New/Replacement/Repair) epair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Services Requested by: yf�.� Name: G� �; s�?, �C �� ��,�.� �ou„ ��� .Sl�°r r Phone #(home): 36Y-Z goU - Address: ii2 t-v 1/�i�/1 .�, //s /Z �. (work/cell): �, // 33G - 5"� i/ - o� v i ,,���/. ti. /�� �yG 2 7Sy/ 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: 2.5����t Subdivision: Address and/or directions to Property: #: 4) Proposed Use and Type of Structure: Residential Business/Type: �v-1v�-, : �•, < < Sr�� Other Number of bedrooms Number of people serve�(seats/employees): c--� /./.�_, Basement: Yes No (with pl mbing: Yes �� No � Garbage disposal: Yes No � 5) Water Supply: � Private Well �/ (Proposed Existing _) Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A completed application must also include: ➢ A platlsite plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the properry is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. . Signature (Owner/Legal Representative): � Date : • 2 z-/a 10/08 Person County Environmental Hea(th, 325 S. Morgan St., Suite C, Roxboro; NC 27573 (336-597-1790) � �r