A34 91�
P�rson County He�ith' Department �
• Well Permit �
Date: i i- I�-5 � This Permit Void Af r 3 Year I�?/ �
Owner: 1�►� • � � SR# /�.?� (�
L � a�o�' tions:
� �
Su ivision Name: Lot #
Drilling Contractor.
WELL CONSTRUCiTON ►b
Distance from Near t Property Line�S �/u Y Distance from Source of P-�'
Pollution b d u-`� �
Total Depth:� FG Yield: GPM Static Water Level �% � FG �
Water Beating Zones: Depth �FG FG F� FG
Casing: Depth: From �_. � � / i Ft Diameter: _ _ � ; , Inches
TYPE: Steel � Galvazuzed Steel `� �
If Steel, d�s owner approve: Yes No
WeighG 1�— Thiclrness• Height Above Ground: � Inches
Drive Shce: Yes"�_ o
Were Problems Encountered in Setting the Casing? Yes ;' 'No �
If "yes" give reason: 't7
GrouG Type: Neat Sand/Cement �' Concrete �
Annular Space Width � Inches
Water in Annular Space: Yes No ���
Method Pumped Pressuze Poured v� _
Depth: Fmm � to �Y� FG •
Materi Used: No. Bags Portland Cement __�___ Weight of 1 bag
lbs.
If mixture (sand, gravel, cuttings) - Ratio: _� co �__
ID Plates: Yes ✓ No .ti
4 x 4 slab Yes �— No �
De th
L - - .�
I HEREI
TI-IIS W
FORTH
Sketch weii iocauon on revei�G ��u�.
r NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
a
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
' at later date. Note location of water supplies on adjacent lots.
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Application Date:
Amount Paid:
Receipt #:
� 6 "02 � "� 3 ��� ) � ll ��� ��. V Tax Map: � 3 �
�� ,._,'.� • ��-- � � ��,�� Parcel#: �l I
IErnnwna�rc�snvxaaes.aa�l-aa.Il. �L'"�I��s..II.�.lLr.
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit requ'ved)
❑ Well Permit (NewlReplacement/Repair)
$3 00.00/$200.00/$75.00
tion for Services
Services Re uested
❑ Construction Authorization
Fee is de endent on the e of
❑ Permit Revision
pair of Exis ' ep � stem
Application. No Charge/ A$150.00 or $300.00
1) Applicant Information:
Name: �
Address: t
s..� �. �1�� �
2) Name and address of curreut owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
---_
Phone (home): � � � /�LC�'�'S`�
(worklcell):
ca � � -� °
Phone: � ��
Lot #:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ 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 agency?
❑ 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 5tructure:
❑Residential �
❑ New Single Family Residence Maximum number of bedrooms:
❑ 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 We(1 � Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? � yes � no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided above �s complete and correct. I also understand that if the information provided is
inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
� `%Yl M- � o--•-�sL,., 11J � �,� l a � Z�1— � �
Signature �wner/ Legal Representative*)
* Supporting documentation required.
Date
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
Owner.
��r�on�=County Health Department
�wage System:_;Improvements Permit
�� Tlus.Pecmit'�y oid;After $ Years Permit #
�T"a rn P s` 1�f -.. .�� 1 t�� r��G���t-l�' SR# i� 2�
'. Location/Directions: � � / u � "-:''"
�rJ � •�v
. �f� t— " r.�
.SUb(�1VIS10 8' i�f •'.� .n t . � � r _.�
Lot Size: �' � Type of Dwelling. ; U a�
Water Supply: Private: Public: Community:
Bedrooms: � Garbage I3isposal . _
Basement Basement Fixtures ,��,e
IIVF'OxMa� ` �,l �/�I�..�BY . .It _ �Y1C.:,�.�,—� c�-r CR-t�
Q�nit�ri�n• f i��i �i// /�./ O OC ICSQ/i3i1VC
REPAIR:U" � REEVALUATION:
Size ofSeptic Tank: � gallons � o �np Tank:
Nitrification Line: � � •,'
Depth of Stone: 12 inches
Max Depth of Tienches: � �
Altema6ve System: Conv. Pump LPP Pump
Remazks: ' _ _ . _ n
� � � � � �� � � � �� � � � � � � � � � � � 3�r
Date Well Approved:�1�%'� Well should be 100 ft� from any sewer system
BY Sanitarian
Date S S ved: �-
BY itarian
v �,r.�c i ir3y,r� i� vr � vinr� i ivl� �
Contractor. �e .r n .� � C'.�i� �e
— — — — — — — — — — — — — — — — — — — — — — — — — �
Sewage System location, installation, and protection must meet state and local �
regulations. Sepdc tank should be pumped out every 3 to 5 years and shall be maintained
by owner in sach mannet as not to create a public health hazard. Septic tank and •
nitrificatian line must be inspected and approved by a:member of the Person Counry
Health Departrnent before any portion of the installation is covered and put into use. If (�
the site plans or intended use change this pcmut is subject'to revocation. �
(G.S..130 A-335F) �
--S)
Location of sewage di�osal sewage system sketched an back.
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