A35 41CApplication Date: — S��
Amount Paid: 2�0.
Receipt #: Z 1
� �o ���,�f 1L �ld���l V Tax Map: �
150� Parcel#: 4l �.'-
g' �a3��� ' c� � jCTI�7C�
���4 Z.1,3 I -C�.�cao+na-�cuan_mcaco.znb:m.11 1[�I�,�.�ld,lLn
n
Services
0 Improvement Permit (Site Evaluation)
$Z00.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 if site visit re uired)
Well Permit (j�tew�eplacement/Repair)
$3 OO.OQ($200.0�/$75.00
for Services
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
_ _ $75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: ;5.4�oI/�� �C���oi✓
Address: a��'j SE'�rns i�12 iP�
flox.By��o �� a �s7�
2) Name and address of current owner (if different than applicant):
Name: S/��"/1�'I (/' L'�fi/lor✓ �
Address: ��D �S'«�S iG-2 .r1 e�
R�x�,eo �v� a�s7 f
Phone (home): 3:31� S�17 �?fi'3 7
(work/cell): 3c3 � �-� � — y 93i�
Phone: 3j� 5�'?� 0�$3 �
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: aS,�' S�'tary,S 7'�2 R�. Rox �.2a ry� � 7S7 �
❑ yes no Does the site contain any jurisdictional wetlands?
8'yes 0 no Does the site contain any existing wastewater systems?
❑ �es Plno Is any wastewater going to be generated on the site other than domestic sewage?
Clyes ❑ no Is the site subject to approval by any other public agency?
❑ yes e'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 Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
H�Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business: Total Square footage of Building:
Maximum number of employees: Maximum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on � is properiy? ❑ yes f�no
�
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. 1 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.
Siguature (O er/ 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)
Application Date: ("" 2 3�� 5
Amount Paid: �
Receipt #: ,
♦
A
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if > 600 gpd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
��� S� ������T Tax Map: 3 5
,�:.,,Y. ,�,,,,,�- '� �� Parcel#: �
,.
������
1'i'.annwun-aca�nunaR:ua�mIl �Hl+r.m�4:�in
Services
for Services
Construction Authorization
(Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: SA�� - .4. CcA i .,i
Address: � SG-'A✓r� S T�2 ��� .
�� �iSnfl o /�%C �7s 7 `%
Z) Name and address of current owner (if different than applicant):
Name:
Address: —
Phone (home): .�� S-9 - �
(work/cell): � 316 �-S.3 - y9 3,�
Phone:
3) Property Description: Lot Size: �. �SAC. Subdivision: Lot #:
Address and/or directions to Property: �SS �S�'qm S Tc--� �P�
�ax���� ,,�G a7�7'�'
❑ yes �'rio Does the site contain any jurisdictional wetlands?
❑ yes 0 no Does the site contain any existing wastewater systems?
❑ yes C� 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 CI 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 Structure:
C�Residential
❑ New Single Family Residence Maximum number of bedrooms: �
❑ Expansion of Existing System If expansion: Current number of bedrooms: �
E(Repair to Malfunctioning System Will there be a basement? ❑ yes C� no With plumbing fixtures? ❑ yes �no
1CI�1� on-Residentia l
Type of business:
Maximum number of employees:
Total Square footage ofBuilding: � r��� ��\����7 ��ri'l
Maximum number of seats:
5) Water Supply: C�New well ❑ Existing Well � Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no
6) If applying for °Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other � Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccuratel or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signature (dwner/ Legal Representative*)
* Supporting documentation required.
.1- �. 3-i.�
Date
• Permits are valid for either 60 months or are non-ezpiring 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)
����� ) f ���� ��
� � � ����
?.�sna-Yna-��ra;ra-n��a.��.Il ���.am.11�Ila
Applicant:
W'�c P�'� �-G cnu��r.Es h.v..tL,p -'�
Taz Map: A3� Parcel: �1C
Subdivision
Phase/Section/Lot #
Improvement Permit
Permit Valid for: Five Years 7�. Non-expiring
Type of Facility: �Sc Nsw _ Addition _ V4'ater Supply: I�avr`t� �.Y�u�.
Number of: Bedrooms �/ Occupants �'"^'�/ Employees / Seats: Projected Daily Flow:3'+c�'0 gallons/day
Proposed Wastewater System: Type:
Proposed Repair: A�.,c�.�.0 w�5`1a � TYPe��6
Permit Conditions: ��E.Qfl\j�'� +�A� �aoet� L-�c�5 t��'4 1`��- `�
"rt ; �a���o�. —
Authcrized State Agent: �11.
(X) Owner or Legal Representative:
Date: 9-ihi`�
Date• �'� //�/,�_
,
The issuance of this permit by the Hea(th Department does not guarantee the issuance of other required permits. lt is the responsibility of
the applica.ndpr�perty owner to insure that all Person County Planning and Zoni.�g and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvemeni is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Luws
�r�rd Rules for .Sefvag� Treatment and Du�nsal Svstems'(15A I�1CAC i8A .i9U0). Neither Person County nor the Environmental
Fiealth Specialist svarrants that :he septic system will c�ntinue to fanciioa satisfactorily in the future, or that t�e water supply wiil
remair potable. ____ _
Authorization to Construct Wast�water System
See site plan and additional attachments �_).
�
Proposed Wastewater S,ystem: Accz�tp t.. o'�5?v �� (*)Type�� Design Flow 3b� _ gal./day
Nev� Repair � Expansion Soil LTf�R: �.�S gal./dayJftz
Type of Facilit-,�: 3�3EA�G� �S� Basement: _ Yes i� I��o
(*) System Types Illb, lllbg, IY, and V, require periodic system inspections by rhe Person County Health Department.
��ss -
Wastewater System Requirements
Tank Size: Septic Tank la'0� gal.
Urainfield: Total Area 14F5�0 sq. ft.
Trench Width �_ ft.
Pump Tank " gal.
'fotal Length 3e� �.
Miti.Soil Cover �_ in.
Grease Trap "" gal.
Max. Trench Depth l8 in.
Min.Trench Separation 9 ft.
Distribution: Distribution Box� / Serial Distribution� / Pressure Manifold
Snecifications: 5�.�►S�Fh.I. at, ��U�.V� : M�a�h�'l� S� � Sdv
�
; Ztr �1.s:e�h� A
��
Authoriz.,d State Agent: AC�RWC�.. f�. St�� Issue Date: y-il \`�
Permit Expiration Date: �-►1-1�
T'he system permitted is: Conventional /Accepted x/ Alternativz / Innovative . i accept the co�iditions
and specifications of this permit. /�i �/�/�
(X) Owner or Legal Representati ����� Date:
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NG' 27573/ph: 336-597-1790 (rev 5/12)
� ���� s�-� ���.� ��
_ � � ����
���s��.���¢�.� ��.����
r
SITE PLArT
� Name �1'1t'�`( �lik`lZo � Tax Map # A� Parcd # y ��-
I Subdivision Section/Lot#
, ►�-�tRic�, �4• 5. �it� 9- Il• 1�
i Authorized State Agent Date
ISystem components represent appmadmate cantours only. The coatractormuse llag t6e system pdat to begianirig the insta/laaon to
� insure rhatpmpergrJde is maintained.
�
�76
�T
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W�v.'
..
40'
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R�4���
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�3 �b`3 �i,, 1rC.
-�, N►.a,�►� s� � s�,... ���
w���
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p�rP�'� t�a�
��� �i. S.�►s�+�. �a ��°�i�
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` �� ��p W � �:�s�'v�S
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��.s.s-.-. _"m'� ..m�...... r `+..< .n
2G��5
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:;<� t� ��,� i 6U FQet :
� >e,-,,,� �-. ., ..��,, ��,�.-r�
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�3m�]l,c�ill.'���.�1. J1..1L��O.JL�JL�.'
Buildirg Additions/ Mobile Home Replacements
Tax Map #: ' 3 5 Parcel#: ��C- Address: 25 �''t's,�'� �
v XbcA- v �(/C ? S?
Approval Requested for: Mobile Home Replacement
_�C' Building Addition
Applicant Name: � � a
Address: �f� o .�, S �
t�,�b� a/� ,�'?s7�'
Phone #'s: 5 tn'7 �� �7 �� 3' Q p 3`�
Permit Located: Yes � No
Installation Date: U ��'w'� Design flow: G�K`��"� (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: (�o�� (date)
(Applicant's signature if site visit is not required)
p ,
Comments: I Q r�'"i' S 5 r °'� � �I k ► � �0 � � ( 6 � �t �� ��.
Addition/Replacement Approved
l� � ��' �`✓'
Environmental Health Specialist
(- �3-15
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.�ersoncount .�net
k�a� l
Tax Map: �
Subdivision:
���.sf �I��.���
�---�- � ������
IE ��n u- � � � � � �.�.Il IHC � �.Il �l�
Parcel: y� C-
WELL PERMIT
(New i� Repair _ )
Lot:
Applicant's Name: Stat���l C�,�+a`t�oa
Mailing Address: a�o0 SGAths:�R. 4.�
Ro�C� � �Jt. ��15�t�4
Phone Numbers: 33t,-5�'1- �B3`1 33i�-533- 9`138
Location of Property: C;+�wO �v�E Ct0 7� Co�a�Nt w�4 ��
'i�Ci -��c .�� t,n � :..a,�.F � r�.w � � S•�rstES� 'QA . 4�e
�n�
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and Counry 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:
Permit issued by: �c-,P�R1GL f\. St'�i�}:
�1ew Well:
EHS/Date
Location: �-\q-�1`�
Grouting: •�
�-Xo 4�,-�►�Vell Log: �aS g-�q-1�
Well Tag: -�`�r
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by: � �• -
t��
Date: �- �a���
Certificate of Completion
DI.iner:
EHS/Date
Additional Comments: ����,r ' �n i�r�i�L 2�'�
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: -\`�- \
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
Barnette Well Drilling G�� 3365989275 p.1
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WELL CONSTRUGTiON I2ECORD Fofletemaf lfse PDILY:
I�tis form can h c uscd fa singlc er muldp!a o•cUs
l. Wdi Contractor laEormalion_
i:.�C-° �� F �' . I I..t_ i
w�u ca�� *��
.� � r -� �
Nc wai cw��c�r�s;� x��
Barnette Well Drilling, Inc.
c�yN�
L We(1 Constructioo Yertntt�: `� �S
L+rt d! appheablc �•rFI c.oasuuu�n per�nits (t.a CaaexY. Sta0. Veri<wrs. uc�
3. Wdl Use tch�ckwdl use):
����1 Olvitu�icipaUPu6lic •
❑Geothecmai(Heacin�JCoolingSuPP�Y) QResidactial.4YatcrSa2F�Ytsiagle)
pfndusniaUCammcrcial �Residcntial Wata Sapply (sivved)
No�-watcr Scp{�ly'1�+d1:
�Aquifer Rxharge ❑CNnundw�tter Rrmuliatian
£3 Aquifer Storagc and Rxovcq• �Salinity Barrier
❑AqssiferT�: QStocmwatrrihainage
DE�rcrimental Tecf.nolagy OS�4uidance Con�oi
QGmihexmal CClatcd I,00p) ❑Tracer
I�c` r� �S- � ! N f
�7c "' /�c.• �'- ��.s?',a 2..3' 7 y<�`� �rG /5
QGnothcnnal (B�atinpjCooling RcNm) i70thet (explain unticr fF21 ResnarL�s7 1
4. Datc R'eU(s) Compietcd: ��� �
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FaciGtyfOo�ct _ mC FzuliSp mN (if ippSitsLt�)
2c��� 1�,�,}�S�F2 �c� R��Xh�,:rr�..'�_.
Plrysi.r�l Addcus.�CitY. �d Ziv -- �' 1� "� Y
��F �' SC^�L
Couary Paiu[ Ideati6catiooTFo. (PiN}
56. I,afitude andX,aneitude In degrces/miuutssfs�eovdser deriroal dcgr�es:
�ifirell 5el�ooe 1tNong issaf�aicnt)
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6= I4 (srt) ihe weli(sj: qP'rmaamt ar QTempocsry
7. is [his-a repafr io an exis6ng.welL• OYes or �3"Co"
Ijthls [s a rrpotr, /'t!1 out Aav++r+ rc!( cortvraulon �'waicffon armGapitaiathc romlg of�he
rcpa'v r.nder �Zf rs�narkc secrhm onan lJx 6aaE ojlhis fom�-
&. Nu[nber of'wells eonstructcd_ /
For mrLFple:njeeGon ur rmnaveler sWjply weUs OiYLP witB 1he aene eanst�u�diup•Y� °m
ruymtt or+e;orne
9.'fatal'wdidepii. beZo+vland soeface: �-� � <<k)
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gisnawraaf Cettifixi Wdf Goatru�tor Bau•.
Sy ris+�� rht� jorm, f hcrcby arrfh' +F�c+ t7r u�eR(aJ w�s C+w'^�J cerurrucud'rn eccardm+� ,
,efrl, lSil NC.�C 02C.Of�O vr JSA NGi�O �Q��Wd1 ConsvvatioreStaredurdeartd thdta
�opy�fl8rs rccv.dhas�bcc�,,p+sryfdad.
2;, S�fe diagrim orsdditioaiIweU details: '
1�0U m8y tlsC tlfc 68C1c Df thi6 pagC UO �770YtdC. &�SLiOI18l.� wcn. SiSc aChd7ls Or WC� 1
i�qnstrudia�delsils. Youmayal3tl.aCaehadditionalpdgts:ifneocsiary.
SUHJhII7'CAL INST'IJCTIONS
24a For Ai1 Wdlr. Submit this.�ocm w+�t in 30 days of wmplc[ian o£v�dl
��s� �P� il�� c�on fo tbc foitowing
1'or rtr -veAs ttstal! ,rs (erm�+l'l�^3Q2 0 e
�i _�'� ��� Divisios► af Wxtcr Quaiit�. infarmaiiou Pco�g U�4
i0. Staiic waYer levtil bdovr tvp af �iog: 1617 LYLaiI 5�c'�!ice. Centcr, Ralci�b, I�C 27699-i617
Ifwater ieWel is above rn.tra� �ce '* "
7Ah er Io'ection. tlle_ Tn additioo to'seoding the %im tb tke addtrs in 2�a
il. Borehok diamerEr_ � �a-) abore, also �bmi[ a ccPY of this iatta witkia:30 days of campisi� b�"'wdl
k�, � �pn,yhucticntotttetollowi�lg:
12. WeII constrndioamethud: f%(�� � � �� �� y
(i.c. avg�.��]'. v1�te. dinxt pusl�. ar-) Drv�ision aCSinter Qnalil3'. liRdergroaad.Tajecti�u Couarol Program,
1� �ail g�'vi�7e Cra�ter, Italciek, iHC Z7699=1636
FOR WA'�'ER SiJPPLS"4VELLS UNLY_
� C� Method oTmt B���20 M� 24c �ar Nater Saob�V 8c Tni+rtfot� Wdls: (n add� Eo ?��� n 30 days of
13a�Yidd (gpm). -- ti�a addi�s(es) abovo: a[so svb�it oac wpy
oonaptefian of wcti eoasWdiau to d�e wuafy hr,d7dt depactrsait of the evunty
13h A'�sinfecBon type. HTH Amoon� _,_, � f 2 C� p whce constri�tud-
F'oam GW-I
Nofd� Grotina Departraeot afTiavimo�nt sad Natimlitcsovrr.es-Ikvafoa oEWaterQaiGry
R�;sed 7an_ 7A13