A34 117�� �
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�'��i.a.���.a�arn�.mrn.��n.��.� �c�.�n,�.��n.
Building Additions/ Mobile Home Replacements
Tax Map #: p �
Approval Requested for:
Parcel#: ,[j7
Mobile Home Replacement
_� Building Addition
Applicant Name: /�F' �
Address: �.oq ► f�.L/ l�P��C � •
Phone #'s: �4�d
Z' � :
Permit Located: ✓ Yes No
Installation Date: 1cs ( Design flow: tZS (gpd) 5 ��,����
Current Contract with Certified Operator on file (if required): ►•1h .
Water Supply: � t/ Well � Public or Community
- Wastewater �system shows no visual evidence of failure on: �D /I �r �b �t (date)
(Applicant's signature if site visit is not required)
Comments:
-�! � �"�-
. , ' =uS ' . . . i�--.��C.�
:. s��� � -����� ��� ��rf-� ��-+��g QN ��-�-� ��-������ 5�,a
-+�N� '���Co�J�1��o�S �'�wtil'6i �` �io2 'To i3c71 L� i.,�� '�l t1�
' � Addition/Re lacement Approved � �1s`j ��o �r
P
Environmental Hea th pe ' ist
11/15/OS
►o �
Date
0
�� l ���� ��
�`�.� 4: � . . .. . . ._
.:.'�� �'.�.���.��
�71.�;�Y717C�O7C]L��'TM'�� �3[71.�..�II:� , ���.��.� .
WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map � Parcel # 1� � T wnship:
Applicant: , i S'
Subdivision: Lot #
Location: ' -
.�
.,��i �rl���►���% / ' � � �1�
Type of Water Supply: � Individual _ Community Public
Requirements:
Site Approved By:
Grouting Approved B :
Well Log: 3�
Pump Tag:
Well Tag: '
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Well Approved by:
♦'
Liner:
Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
****See Attached Site Sketch****
Wells must be 1.0 feet froin property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date: �(� � 9_
PCHD rev O1/27/04
'�
i
� 01/02/1995 07:32 8044547843 BENNETT WELLDRILLING PAGE 02
,p r , � �e rs � �J lY. �2
��,� � > > J 11. 11.�1r�bJ �1. V � � � •b�' � ,�'� /,
^r"t"^r~�^ � � �lJ � � � ry �� n � // �r, I � .1.n c .
]��v a�`o x�, x'ye'a �ora�..et� ���r.m.A �G�'x. LA� � 4-�j • QS
C wner: �:� �
i ocecion' .� k��Q r z
5 abdivision:
�i['OQ� LO$
!3 � �., �5 - Tax tKap � Parcet # �
Lot # '
WeA Const�ction
C istaace From naarest �raperiy Linc (Minimum 14 fcet)
� istaacx from Scpiic Sysoem (Mininnnn b0 fat) �
I�� �p�: �S�' --- ft Yield: ,� GPM Static Wstet I.cv�el: 3� ft
v'ataT Bearing Zo�a�s: Dcprh �oo ft.x,,,�, ft oe fi � ft
C �:
�
C epth: Frnm „_,� . _^ �d �� .. R. Diamctar• � /S� in
x ype: Galvaniud Stec! �
Weight: _/� Thiolmcss: �� �_--- HeigUt abov�e Gco�md: J.�„ ... � Yes � No
� Rvc Sboo: � Yes No Ar�y problems �bered whilc ae��B aas�tB`� �.. —
Ii "yes" $ive rcason� __ .�.__
C r�t+ni:
Neat: � Sand+Cert�t ,,,,,� Cflncrate GTavtUCern�at ,,,,,
Annular Space Width _�- inches Wata in Affitxl�r Spsae Yes t�° Ft.
Mtthod c� Omu�: Pumped �� Poiuzd �P� ��
H accri�l.i Used:
No. F3sgs Portland ccment ` WciBt►t of t Bag �„ Po�mda
If �rrixture (sand, gravcl, cuctin�s) -- Ratio �,., to �
ID platcs: ✓ Ycs �,_.. No 4 x 4 slab ,,� Yes � No
L ner: C3roat: (natalled by: M
DCpth: ^ __�___ Date lztstalled: �„^
Drilllr� Lag
To lo.i s po�t�tioe
� –� e ��
� 3a b
3D 35 ^ ,�roul n r
� ,� _r � � rcc�
..... ..... _ - ----1--,..^
Iaocabior� Aravving
1 l�ereby certtlj' tY�� t,he above informallon is cotrcxt and tl�at this v�+cll was construoted in accozdance with regulatione set fatli�
b� the �erson Caux�ty Hcalth I7�partrnent.
� � � �A� �� Date b� � 3 "4S
gj �wre of Coutrxctor ,�� � _
� Pa�,np Inata�lment
Pt mp Installation Cvntractor: State Regiatration �Iumber• �---
Pt mp Depth: . . ti St�tic water Levet� ,,,., � .
p� mp Make & Modei: �,,.,^���_ � Pump Sitie aitd Rating: 1�P --__.—_ 8Pm
�� �
� . �
��1 ~~' � � `L-.i' �.,;� � .il.
11..:f�i�iL��u...7i�i�i..�.�i.�.�.11.a�.� .2l .t1�cLQ.��,ll.�l.
Building Additions/ Mobile Home Replacements
Tax Map #: /T _] I Parcel#:� Address: � o� � Ca K i rcr• � l� �
�— —�
Approval Requested for: Mobile Home Replacement
�Building Addition
Applicant Name: � �
Address: 6
Phone #'s: �',:�- S9 `I- �,S'$$
Permit Located: ✓ Yes No
Installation Date: �-1D - n �
Design flow: (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: " Well Public or Community
Wastewater system shows no visual evidence of failure on:
(Applicant's signature if site visit is not required)
(date)
Comments: !� ��e`�,-f —a, ;•� L,S � �i-Y;�w� �c/�� � �o' �arv► � 1 ��
G �_ '� s � s
Addition/Replacement Approved
nvir nmental Health Specialist �
7-/��-�9
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-�97-1790/ Fax: 336-597-7808 w�v�v.personcounty.net
���. s� I�I�I�.� �� . .
_ . . . . -- � � ���� .
��.���.� -� ���. � �o���
SI'TE PLAN
Name ' � ` 1� � � ✓`' �� Tas ;�Iap # , / J� Parcei # /� %
Sub ' ' Seaion/Lor#
%l ' C' _...o�'
Authorized State Ageat Date '
System companeats reprrsear appm�m contorra mlp. T7re coatacmrmust9ag rlre sysum priar t+o begmaurg the ias�aoa to
iusure thatpmpergndeiamamniaed
�
�±I�
l� 5►� 4rct,�. roeK � �l'�� �la��..
� �. � � .
� . _. . _
_ s���
1.� - ^' C�s., �'
�_:
■
0
, .
Te ����� �a ���s��
saiC r/1 o�t-�
--�-
rcxn, �: ���2�oi
- " Person County Health Department
Environmental Health Section .�. 1 � -7
Tax Map #: � Parcel #: �
Zoning: Township: �'
Subdivision: Section: Lot:
Applicant• �
Location• �
Operation 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 �}MPROVEMENT PERMIT AND CONSTRUCTION
Ald��d.ORIZATION. „ , /I J% _/A!
d
�
.
Agent
�
��1� -�(� 1
Date
Map#: � ���
�
��
�
�
Parcel #: ��
PCHD, rev. 10/12l99
�
, Application Date:. ����� v�� Tax Map #: � 3 / �
Amount Paid: l •00 � Q� �' �
RecB! t • �,9' � � Parca! #; r�"/
�����.�� 1�' ��� �� ' �
---' �C � �T11�T'ZC" �' � e, � � �
�s:avaa-awa�s-"---�- .oa�_�m.]L 7�---ZLav.w.Il.�1�a �
Improvements Permlt-�750.00
(Mobile Nome RepiacementlAddition)
APPLICATION FOR SERVICES
$150.00/5200.00
-�s- 1 a��e,.A .
A� (l 1
/�
owner. S��i r� �' C� �- i S�I-
3j Propecty Description: Lot size: Township:
Directions to the property (Including road names and numhers):
4)
5).
Subdivision: Lot #
�
���
�
proposed Use and Structure Description: answer each of the following questions:
a) Proposed . Existing , Type of Structure: Width: � Depth: •
b) Number of Bedrooms: Number of occupants or people to be served:
c) Basement YesJ No Will there be plumbing in the basement?
d) sar�age Disposak Yes No _
�• �i � . � �
Water Supply Type: Private (new � or existing '�. �Public_, Community_, Spring _
Are any welis on adjoining property? Yes_ No _ ff yes, piease indicate approximate locatiori on the
'site plan.
6j Does your properfy contain previously identified juPisdictional wetlands? Yes No�
� '. �
PLEASE NOTE THE FOLLOWING: .
➢ A PL�4T OF THE PROPERTY QR S1T� PLAN MUST BE SUBMITTED WffH THIS APPLICATION.
9 PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. •, � �
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STA�D OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE POR AN EVALUATIOPIBY THE�HEALTH DEPARTMENT
� STAFF. � �
I hereby make application to the Person County Health Department for a site avaluat(on for the on-site sewage disposaf
system �for the above-desctibed property. I agree that the contents of this application are true and represent the maximum
fiacilities to be placed on the property. I understand if the site is altered or the intended use changes, the' peRnit shall
become� invalid. .
or Legal Representative
� — 5��
Date
PCN�, rev. 06f27102
o.
Aooilcatl� Dai�: � � "��-0d
Amalunt f�aid: O .
��Ld
�� �7��
Person Counht Heaith Det�artrneet
Emrironme�al Heaith Sectton
' APPIJCATION FOR SEitVICES
�� �o �: ,�-��
Paresi #: '� •,�
IF THE INFORMATION IN THE APPUCAl70N FOR AN IMPROVEiiIlE�1T PEiiMR IS FALSiFlED. CHANGED. OR THE SITE IS
ALTE�iED. THEi�I THE IMPROVBIAF�IT PERMR AND AUTHORIZATION TO CaN3TRUCT BHALL BECOME INVALID.
1 i Asmdt rgqt�sied bll: (Ow�tarla9ent/ProsP�dtvo o�t C� �� S�a P h e � C' 1- e.,e
HomsPhona 33c�- S`5� -�s r� � ao � o o�� ��..� �
BlJS� P�10�9: �d'�f -�( [� �7 c( f� a X I J o ra N.4 ..Z i S" 7 3
2) Na�tis and addr+ass of cw�e�rt awnsr. �o(�; e /Je..P lo.� g .
'i?�J l�,ro ✓vS.., �-7 S' 7 3
3i PfoPutY D�fptlan: Lotsizx S<1cteT� . .
Di�bor�s fio ihe ProP�Y (���9 road names and ncurd�s): ch� b� a r�e 2J
G 2 �e ,2d�
4) Prapo�ad Use and Structure DesqiQllon: answer' earh of the following que�tion�
� e) P�p�ed �6as�ng a
b) Stldc Bu�t q ModWar �. Single Wide Q Double Wtde ❑� e el b�. ld� w S • � -
c) Niunber of Hedrnoms: - � � Number of aa�pants or people to he se�ve�
e) Basement Yos Q Na � lf yas, # of basentettt �arex � w ���`� '�
fl Gerbage Dtsposai: Yes Q No �� . �� �` U y,. � V� S t tJ �=`• �
� DM�s af Propoaed Stn�dure: Wtdth 3 S Depfh: � C7 �'� i c1 .
� w� �PPht TYPe: Private Q(ne+�� eodstlng�Pub�c q Cammundy 4 Spdn9 ❑
• � Are a�ry w�ells on adloinin9 p�op�tS/f Yas � No �j/es, locatlon
��s Indica6a D�ired Syatsm Typs: (ayatems can bs ralload tn onier of Yo� P�e�)
Carnettlo�ml �,,,Mo�#ied Corrvert8onal _ JAit� In�rovative
.Dtlw {spscity): � .
' CLEARLY STAKE ALL CORNEitS AND llNES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PI.EASE ATTAC?! SURVEY PLAT �R S1TE PUW TO TH1S APPLiCA710N
I hereby make appi[catlon- to the Peison Cou�ty Heaitt� Departmerrt for a site eva�tion for the on-si�e sewage disposai system fer
the above-d�ad propaKy. 1 ag�ee thst the conteMs of this appQcaHon are true and repceserrt the mawrtu�m faa'�S to be
placed on the properiy. 1 understand if the site is aitered or the intonded use d�angas. the permit sh�l become irnraBd. I under�nd
that as appitcatrt, 1 am �onaibie for ideN�yin9 ��9 ProP�Y �, comers and maldng the si6e � fior the
personnei of the Person Ceturty Heaith Depsrtment io candud thetr evaivationa I uttder�nd that i am responsibie for no1H'yin9 the
Heai�t Departrnent if myl AroP�Y ��Y wetlands as de,signated by the Army Carps of Enqineeis, ,
� � � . • � bcf �. UC� -
'' . WIIC!' 01' �8� RBQIES8flt8�11E . �S�
PCS-!D. tev 10f1?!99
� \ �.. �
v ) �
\ �
�
. i .,
Appilcation #: _
� . . Tax Map 1�: � .
Parael #: _ 3.3
� Parson County Hsalth D�psr6ner�t , �
Environmental Health 8ectlon
� 81T� E C ..
________.
Subdivision/8e�tlonll.ot#
( 2 �c � b 8 .
ate . � � '
ir,pre.qe�t r►pproalntata codloura ani(y. Tlie conlraclar mrrat JI'��g tlia syafsm
ye Inalalletlon to ln�ara fhat propar grade ir n�alntained
Syi�em �
arlor M
�
6oale:
R��±Iu111 rs*v_ 4f1/'12/A9 • .
n
, ,
_. PE�SON COUNTY EiVVIRONME3VTAL MEAL-TH �
_i - PLE�ISE SE� ATTACHE� PLAN FOR SOlL AREA AND S'YSTE3IA LAYOUT
T� � �: !�- 3 �f �� .� I t �
Zoning Tcwnship ��'J .
� �p��,c �'�� r{'s n I�P � 1.Qe_ ,..
t.ocauce: __20 � I ��4� %�ha v� l�o/. -- o
subdivblon: S�ctlon: Lor
—��erl5a+� �,
Improveme�t Permit � .
A buildin4 aermit cannot be issued witt� only an imarovement Pertnit
New ��Repair Addrtion Type oi Strudure �5ihe5 Water Supply W C�I
�►^plWees
# of C�e�s ��4 #•of Bedrooms ''" Other ��ee5 �x. �
BasemeM? /1/u 8asemerrt Foct�ues? N'D .
Projeded Daily Flow: j�,.rg.p.d.
Proposed Wastewater System Typ
Pump Required?� Yes ,x
Propased Repair :('r� r v P� fi�
Pem�itConditions: /�Qe�� sys�
Permit Va(i�d Fa�: � Five Years ❑ No Expiratlon
: CGOn v�r( f* bn:c �
��
Owner o� Legal Repres�
Authortzed State Agerrt:
r��•
Date: �-" l 7— a O
Date: / � i-g � 0
The issuance of this permit by the Heatth DepartmeM in no way guarantees the issuance of other p�rrnits. The pemtit
halder is responsible for d�edcing with approprtate goveming bodies (n meeting their requirements. This site ts
aubject to revocatton if the site plan, plat, or the ittb�aded use cl�anges. The Improvement Permit shall �ot be
affected by a change in ownersttip of the site. This pertttit is subject to compliance with the provisions of tha
Laws and Rules for Sewage Treatment and Disposal Systems of the North Caroiina Adminlstrative Code.
Authorization To Construct Wastewater System (Revuired for Building Pennitl
Type of Wasiewater System('b{2 vB�ft, io 1�a% Wastewater Flcw: ��.d.
Fac�7ity Type: l�7� S!n �55 � Naw �' Repai� pExpansion p
Basement? � Yes • �asement Fuchues? � Ye�
Wastewater Svstem Reauir+emeots
Septic Tardc Size: o Q�0 gaUans Pump Tank Size: �'— gaqons
Tetai Trench Length: � feet Maximum Trettch De� �_ inc�es A99�9�e DeP�l� �-
�,�fm�h, ' C�
5al Cover. � ind�es Trenct� Separatton: ` Feet an Center
' ottlP.f: �� /� (� o/`L CrJ l!e i i''P � V°� o(� %� 'Pn l 1 �/j0 S L'�7�t ('i �( i�l�i' i'
� Perrnit Expiration Date• �` �` L 0�
Autho�zed State Agen� � d�; % oZ-9 0'U .
The type of system permitted Q doe� 0 do� not. diife� fram the type specified on the appiicatien. I accapt
the specificaticns of this permit
OwnedLegal Representative Signature: X� �-'%°?^��%Cyc�L- C"�-Da�: /— /7 — cc)
PCHD, rev.11/18199