A34 42Amount paid � �,D��-
Receipt �t jn�v I
. . c.�, �o � �.
��/�.�.UO. 1%_30"c�% 7 3 Date
�� -�
Improvements Permit(Fstablished/RecordedLot) _
Im�ovements Permit (Unrecorded Lot) —
. Improvements Permit (Mobile Home Replace) V
Improvements Permit (Addition)
Reinspection of Existing System (Loan Closing)
Re�air/Replace existing Septic System
foc New Well
Existing Well
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1, permit requested by: .
�-n� Y Si11�1,501� 7. Dimensions or Proposed Structure:
�wner/prospective owner/agent: NAN��( kos(�'. Width: �O �
• lSaS QAk 62p�E �nA D _. Depth: l� r
Address.
' � 120 X�D.�D N � 27573 g, What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is��intended to serve?
Home Phone #: 9 I D 5'97 - S8 ��/
Business Phone �: �l1 °1 483 �"��5'g�
Name and address of current owner: 9. Water supply t}'pe: w�
sA�11�_ � private� public❑ community ❑ spring❑
Are any wells on adjoining property?Yes � No [� �
If so, identify location: oN CLA�EN�� C A s
Property Description: L.ot size: g9 �f f�c P-.CS
Tax Map#: /� 3 �
Parcel#: � z�
Township: _� � c� n�5-!>A ��
. Directions.to property: State Road #& Road
ames,�tc.
. s �. #
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10. Type of structurelfacility: Proposed: �lExisting: Q�
Type of dwelling: i
House: ❑ Mobile Home: �,Business: ❑ �
Type of business: '^ '
Number of Employees:. -
Number of bedrooms: �
Garbage Disposal? Yes � No,�,
� Basement? Yes❑ No�If so, # of basement fixtures:
6. I�Iumber of occupants or people to be served: �_
CLEARI;Y STA� ALL CORNERS OF THE P�tOPERTY AI`ID THE CORNERS OT ALL
PROPOSED STRUCTi1�2ES•
I hereb make application to the Pet'SOn COunty T:�ealth Depaxtment for a site evaluation fon ahe o�el``�
Y
sewage disposal syscem for the above described property. I agree that the concents of th�s applicat�o
._ . and represent the maximum facilities to be placed on the property. I understand if the si[e is altered or the
intended use changes, the permit shall become invalid. I understand that befoce an Improvements Permit can �-•
issued, I must present a survey plat of the property to the Healch Dep[. I understand that in the event I have n�.
delivered a survey plat of the property to•the Health Dept. wi�in 60 DAYS afcer the date of the evaluation of
the site by the Healch Dept., this application shall become void and all fees paid focfeited.
W,
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z Signc wner or Authorizcd Agenl
�errni[ Issued ❑
�ermit Denied Cl
?]at ObservedD
Signature
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��-�rnn��tvt�ATIONS/COMMENTS: -
SZTE CLASSIFICATION DIAGRAM_(Include: Soil:areas, property lines, roads, streams, gullies, wet areas, Fill
areas, weUs, water bodies, slope pattems, etc.� C.1AMfPRG.DOCSV�PPSEGSt�� FWANCEPC
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'� Improvements Permi�(Established/RecoTded Lo�)
_ Impsovements Permit (Unrecorded Lo�)
_ Improvements Permit (Mobile Home Replace3
Improvements Permit (Addition)
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ate
C/1�2u1 �� '
of Existing System (Loan Closing)
Repair/Replace existing Septic System
Permit for New Well
_ Replace Exiscing Well
Permit requested by: . , .
ner/prospectiveowner/agent:L�>��/fuDe�s� -
Address: �/o/'
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7. Dimensions or Proposed Scructure:
Width: �.��
�Depth: /`��
o�7ta�3 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that [his sewage disposal system is intended to serve?
ome Phone #: �/9�s/V -59��
usiness Phone #: �/9' �g� "3i5�
. Name and addre ;
A/��
220 G�
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�, Property Descrip
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Parcel#: �
Township:�
of current owner:
�S �ra-d , ,� i v�
,�,� �7s � 3
on: Lot size: 8% y�Z�'S
. Directions to property: State Road #& Road
lames,�tc.
s� �-f33y . 182s �1�
I�Iumber of occupants or people to be secved:
9. W ater supply t}•pe: �`f.�1 e � l)
private�j . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes � I`Io Q
,If so, identify location: � C'/��� C4r �
10. Type of structurelfacility: Proposed: [�lExisting: Q
Type of dwelling:
House: ❑ Mobile Home: � Business: ❑
Type of business:
Number of Employees: 3
Number of bedrooms: —
Garbage Disposal? Yes O No �
B asement? Yes ❑ No �' If so, # of basement fixtures:
CLEAR�Y STAKE ALL CORNERS OF TT3E PROPERTY
PROPOSED STRUC'TURES• .
I hereby make application to the PersOn COUI1iy �ealth Department `ents of th s auali� tion ahe �rue l�e
sewage disposal system for the above described property. I agree that the con PP
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use ctianges, the permit shall become invalid. I understand that before an Improvements Permit can b
issued, I must present a survey plat of the property co the Health Dept. I unders[and [ha[ in the event I have nc
delivered a survey plat of the property to-the Health Dept. wi�in 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become vo[c� and all fees paid forfeited.
AND THE CORNERS OF ALL
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`
Permit Issued ❑
permit Denied
Plat Observed ❑
��'� C�°t
Signature � _ Date
SOII.TFX1'URE (12•)6IN.) •
�1NDY, LOAMY. C1JIYEY. NOTE 2: t Ml7
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RECOMMENDATIONS/COMMENTS: ' �
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SITE CLASSIFICATION DIAGRAM (Include: Soil areas, properly lines, roads, s
areas, wells, water bodies, slope patterns, etc.) ��
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PERSON COUI�TY
PERSON COUN�1�1' HEALTH DEP�ARTMEt�IT'
325� South Morgan Stir.et
Roxboro, Nonh Czrolina 27573
(910) 597-2'3.7.1
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C�j� �U Je�So,�� N�N� R�J� .
To �dhom I t May Concern : G� T� �� �
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Based upon our e�raluation of your lot on Q�� v� ��-� l�X �� � 7
�� �A S n� �' "�� -/ �a -�,r t S , kTe f inn that your lot is- unsuitable for 11
�� types of ground absorption se�rage treatment and disposal systems, mound
systems and lo« pressure pipe systems. �s �R � Y �"s %�� �
If you would like to inquire about a discharge system, you need to
contact the North Carolina Department of nTatural Resources � Community
Development, Division of F�vironmental Management, P. 0• Box 2�68��
Raleigh, I�Torth Carolina 27611. Telephone T: i919)- 571-4700.
Sincerely,
C�� � �°�-�
Environmental Health StipertTisor
Q������� ,),
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En�ironmental Health S�ecialist
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Da[e: �U-13-47
Owner. �
Location/Directi
PERSOH COUNTY ENVIROIIMENTAL HEALTH
WELL LOG
Subdivision IVZme:
Drilling Con�ractor:
Distance from Nearest Property Line ��c� Distance from Source of
Pollution (oU `
Total Dep.th: �3cr� Fc. Yield:�_ GPM Static Water Level 5" �=t.
�zdater Bearing Zones: Depth � 10 Ft. � F� Ft� F�.
Casing: Depth: From�_to�_Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel �' '
If Steel, does owner approve: Yes No
� Weight: � Thickness: /� HeighrAbove Ground: <�% Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No � �
If "yes" give reason:
Grout: Type: Neat Sand/Cement �/ Coricre[e •
A.nnular. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped � - � �Pressure � � � Poured_,/ � - �. - - •. - : - .
Depth: From O to �. � Ft. . . .
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes ✓ No � � •- � .
�� 4 x 4 slab Yes�—No �
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH �3Y-THE PERSON C�Uia'I'Y HEALTH DEPARTMENT.
��� _.
�Signature of Con�ractor Date
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A lication Date: a.� S'� �
Amount Paid• ��
�ecaipt #• � �,
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�srson Countv Health Department
IEnvironmental Health Section
APPLICATION FOR SERVICES
Tax iVJao �: �-��
ParcQ! #: ��
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IF THE INFORMATION_IN THE APPLICATION FOR AN IMPROVEMElVT PERMIT IS FALSIFIEQ CHANGED. OR THE SITE IS
ALTERED, THEId THE iMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (OwnerlagenUprospective owner): `
Home Phone: ���� --�3-0,3�9�/ Address: ,�
Business Phone: - � �
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2) Name and address of current owner: _� �ji ,>ro;,/f
3) Property Description: �ot size: �_�wnship: AJ/7 , Sd,d�.c
Directions to the property (Inclyding.road names and numbers): �
4) Proposed Use and Structure Description: answer each of the foliowing questions:
a) Proposed 0, Existing �
b) Stick Built ❑, Modular ❑, Singie Wide 0, Double Wide ❑
c) Number of Bedrooms: d) Number of occupants or people to be served:
e) Basement: Yes 0, No �7 If yPs, # of basement fixtures: �
fl Garbage Disposal: Yes 0, No ❑
g) Dimensions of Proposed Structure: Width: Depth:
5) 1Nater Supply Type: Private�(new ❑ orexisting ❑), Public 0, Community G�, Spring ❑
Are any welis on adjoining property? Yes 0 No � If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
� nventional _Modified Conventional _ Altemative _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
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I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for
the above-described property. I agree that the contents 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 as appiicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsibfe for notifying the
Health Depart ent if my prope contains any wetlands as designated by the Army Corps of Engineers.
( �' � nC �'— �C�/_� �
Owner or Legal Representative Date
PCND, rev.10/12/99
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # f'1 ✓' `1 Parcel # � 2—
Zoning Township �?C,pC� _ _ _ _ � _
Owner/Contractor ` Date R /a �14�
Location/Address � g 2 (��1 K i�',-rD v e �� _
S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area g•R �C Size of Tank I���
SFD �/ � Mobile Home�_ Size of Pump Tank N
Business # of Bedrooms 3 Nitrification Line •y pZ} ` X 3'
Max Depth Trenches / $'�
Permits may be voided if
Well and Septic Layout by_
Comments: }�,2-e,p SP c;
�..,-, �,-��
Date/o�b-�i7
� �1-t �-!0 ,l,�l"�'�5 : ;��
is altered or intended use changed.
Approved
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual ✓ Semi-Public Required Slab _�
Public Replacement Air Vent
Site Approved Required Well Log
Well Head Approved Well Tag
Grouting Approved 1 b -1 � • °1
Comments:
Date
Installed by
Approved 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.l.l
� ----•• -.- - -.... ___._...___ .._ .
P�t9��4 Ci�unty i�eait�a. Depae�le�
� �eeir+�nmen�d Haslth �ection T�� �� #; ./�'3 y
. � � P�rrcai � �
_ - - : $i�'� Si��C�i � . . . . _
T
_ . .._ ��S ..�� M 1'h ln - .
3 iV8R18 S1J��ViStO�(�Ofl/L0�
, a� ap �p � -
. Autt�ori�ed State 0� � � �
,yy,� ��►�* npr� QFp�audem�e r�m,os o,.1y. T�rs c�� mr�r, fYap� rbe �e -
• p�r m b�q� 1�irs ��� l�at pr+�S►�!e �t �
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PE3�SON COUNTY E�IVfROH1ME�T�1- wEALTH
P��+,SE S� ATt'AC�IED P�AA1 FaR WEil. SiTE tA'
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zodna � .
`77� ,qti�a c �.vi„ ,z%� D h s .
�oe� �— - — - -
� - � • � -
��� P9TR11� . � �
Tvae of Water Suaalv: L� Individual Communi[Y . Pubtic
-- - ' � � . '
Reauiremenis: . .
Sit�e APP�ed bY --� � � � . � .
Groufin9 p►PProved by. , a �
Well Lag . _
We(t Tag � " �
Air Vent ' -
Hose eb
Cortcretie S1ab _ •
Well Drilier:
Well Approved By: �'
� �tiact�ed Stts Sia�ch*`
9
' We11s must be 10 feet from propett�l lines. .
� WeQs must be 100 feet from septic syst�ems. . '.
UUeUs must be at least 25 feet from arry building foundation. .: ..
Other co�diiions: � �
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PCH�, rev. 17/29/99
Barnette Well Driiling Inc 335 598 9275 �3/�Z/01 06:16P P.��l
P�RSON COUNTY ENVIRONilENTAL HEALTia
uELL LOC
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Date: � :.� �4�' ,
4wner. �m s %����� � — - SR# . . �
Location/Directions: _ �� r��c rd. , '
Subdivision �Name: ._._ __ . �.,ot #
Drilling Contractor: ,� < � �.�� ��� � ��nc
� WELL CONSTRUCFION
Distance from Nearest �'roperty Line � c3 Distance from Source of
Pollution ( G' o
Total Dep.th: yA0 Ft. Yieid: Z GPM Static Water Level a.s"' Ft.
Water Bearing Zoncs: Depth �2��Ft-_�1�Ft Ft, 'Ft.
Casi,ng: l�epth: From� o_,_.ZZ_..__ �• Diamet,er: �,�Inches
TYPE: Steel � Galvanized Steal �—
Yf Steel, does owner approve: Yes, No
� WeighG�'�hickness:�_ Height�Above Ground:� Ynches
Drive Shoe: Yes ./ No . ` �
Were Problems Encouncered in Setting the Casing? Yes No � "
If "yes" gi� e xcason:
Grout: Type: Neat Sand/Cement / Concrete '
Annular Space Width � Inches �
Water in Armular Spacc; Xes No
_ . Method: Pumped � Pressure � Foured f � - � ' ..
Depth: From O :o Q Fc.
Macerials Used: 3�10. Bags Porttand Cemenc Weig,ht of .1 ba�_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
�D Plates: Yes /� No� � �
4 x 4 slab Yes � No
I HEREBY C�RTTFY THAT THE ABOVE INFO�tMr1TION IS COR�2ECT AND THAT
THIS WELL WAS CONSTRUCT'ED TN ACCORDANCE WITH REGULATIONS SET
FORT� gy.THE P�RSO�I CO�i�TY HEA�.TH DEPARTME . -
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Sign ture oE Con ctor 1�a«:
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