A35 3Additional appliances to be used: Disposal, dishwasher, washing
machine �V Q�1 �"'
Recommended: Septic tan
Nitrification line: r ��� ' � ��
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line mus� be inspected and
approved by a member of the District Health Depariment staff before
any portion of the installation is covered.
Date Approved: � — j � -' �9 �
Signe�
Sanitarian
By' �r� v -..:,s✓ rr � ,#r
%
r O. David Garvin, M.D., M.P.H.
�
District Health Officer
�'
r Countersigned
, (Over)
�r��,
i ��� �� 1����
��"'rVQTE: Make sketch of installa"tion showing location of house, septic tanks, privies, wat }�p ies on:
„.� ,,,, ,�„a
�� ��"�'"�� adjacent property, etc. Write ,i,n measurements. in order that installations may be located at later "
t������{�� ,
4 date. . . � �� �
y y �
�;� SUGGESTED INSTALLATION (DatP � �� � �� FINAL INSTALI.ATION (Date )
� (Road or 3treet) • #�— (Road p�St reet) -
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Site Evaluation Application
Fee Collected YES `�
o �
� d a,�`a,�" ��� ��
{� e �%•�'�"° .� 1�1 �
l`J�'
Date:
NO
APPLICATION FOR ZMPROVEMENTS PERMIT
1. Permit requested by: ownerf�rospective owner: ���%(�
agent : '�
Address: x `f3l
Home Phone ��: � / Business Phone ��:
2. Name and address of current owrier: �/� �j �C�i
3. Property Description: Lot size: ,�-.5 �/�i�C
.� c�.d � �°�- � m� a f
� �\lo��� P 1n �� �
iS� C/��C,
4. Tax map ��: � Township: wOO.��Q6}-�
Subdivision Name: Lot ��:
5. Directions to property: State Road �� & Road Names, etc.
�.,..�, _ L .t.P I �J I�
Lo�
z
�
Y•
b
6. Permit requested for: New Installation: Repair: ./
Additional Renovation re-using present system: l�
S
7. Number of occupants or people to be served: /�v
8. Dimensions of Proposed Structure: Width: J� Depth: v �
9. What type (if`any) additions, expansions, or replacement is anticipated to the struc-
t re r facilit that this sewage disposal system is intended to serve?
�l ° �5�t , y
�
�
w
10. Water supply private? public? community? spring? �
Other source? (Specify):
Are there any wells on adjoining property? If so, identify location:
11, Type of structure or facility:
Type of dwelling: House: _
Type of business:
Number of bedrooms•
Basement? Yes � No __
Proposed: Existing:
Mobile Home: Business: _
Number of Employees:
Garbage Disposal? Yes ro
If so, number of basement fixtures:
12. Clearly stake al]. corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system 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.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 13 A-335(F)
Signed 0 er or Authorized Agent
r
0
r.
m
�d
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K
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rt
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Permit Iss�tee! •,'`:y
Permit Denied
Plat Observed
' : • ,
•�
i�ACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 ARF.A 4
S S S S
1. SLOPE (X) PS PS PS PS
u u u ;,T
2. SOli. TEXTURE <i2-36 in. ) S S S S
(Sandy, Ioamy, clayey, PS PS PS PS
Note 2:1 clay) U U U U
3. SOIL STRUCTCTRE (12-36 in. ) S S S S
(Clayey soils) PS PS PS PS
4 . SOZL DEPTfi (in. )
5. RESTRICTIVE HORIZONS (in.)
(Impervious Strata, rock)
6. SOIL DRAI2�IAGE/GROUNDWATER
(�cternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
U
S
PS
U
S
PS
u
S
PS
U
S
PS
U
S
U
S
PS
U
S
PS
u
S
PS
U
S
PS
U
S
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
U
S �
PS
U
S
PS
u
S
PS �
U
S
PS
U
S
g. OTHER (specify) PS PS PS PS •
u u u u
9. SITE CI.ASSIFICATION
(See below)
SOZL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECOP4�NDATZONS /COMMII�ITS:
S?:TE CLASSiFICATZON DIAGRAH (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas, c�ells, c�ater bodies, slope patterns, ete.)
A 0041
� � ,
r-- . - . �
• PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION Il�ROVEMENT PERNIIT
Tax Map #_� � SJ Parcel # �! `�1 � ^
Owner/Contractor����M-�-; Z; L�� [�� �y Date �__� c'� -- �"-i.$'--
Location/Address
e+l o � � 3 � �j'_ S.R.# _
Subdivision Name Lot#
�
�
U
�
a
�1
M
�
Permit Void after 60 months. Permit Void ii'not in compliance with zorung reguiations.
Permits may be voided if site is alteyc or i en d u e changed.
VVell and Septic Layout by �
Comments: —
Date .,2 . Installed by � L � �,w �� Approved b /
WELL SYSTEM SPECIFICATIONS
Individ al r mi-Public Required Slab
Public Replacement Air �Vent
Sit. Approved Required Well Lo�
Well Head Approved Well Tag
Grouting Approved
Comments:
�
',7�- �rInstalled by f ��/ ��� � Approved by.
This report is based in part on information provided the homeowne�or his/her representative in the application submitted for this permit. The
environmental health specialist is not responsible for false or misleading infortnation contained in the application The env'vonmental heatth specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tank systetn will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�permitsam O1/95 rev.1.0
ORIGINAL
�
Application Date: � �3�"� 3
Amount Paid: j 0. 00
Receipt #: S y 4 9�}Q
� /I° � o o �
�� j) f ll �11�1��� Tax Map: � 3�
.._,.,." �.;.�,�- � � ��,�� Parcel#s �
]I�.�rmm�n•a> an.v.xa�.3a.C:.tn..11 lI�[�,.s.1l�::La.
ilication for Services
Services Reauested
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d) (Fee is de endent on the e of s stem ermitted)
obile Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
�
''1) Applicant Inform tion:
, Name: � � , Phone (home): 3 3� —SJO �} — 4 0 �-i 3
Address: � (work/cell):
2) Name and address of current owner (if different than applicant):
Name: Phone:
Address:
3) Property Description: Lot Size: Subdivision: Lot #;
Address and/or directions to Property: e tJC� e �- —) 3 3S
❑ 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 Structure:
❑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 ofbusiness: Total Square footage of Building: � S���/�
Maximum number of employees: Maximum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spri� b��� �
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes � no�� �(e j/
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 is complete and correct. 1 also understand that if the information provided is
inaccurate, or if tl�q site/�s subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
5ignature (Owner/ Legal Representative*)
�` Supporting documentation required.
`i-3o-13
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)
�` :.� �: �- �; ) �' ): ��,' � �:'�
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���,�,s.:z.�-�.�.�_��.��:��.-�.,.�: ���!1 �.I-����.�.. �.. �
�a�a�d��a3 ������m��/ I���bn�� �I�a�� 3���fl����a���5
Ta�Y IVIap #: /4 3� Parcel#: $ 9 flddress: �At� 6��wv'z Ma� Z��� �Q
. C�r �. v�..�t �ac�
Approval Requested for: Mobile Home Replacement
_� Building Addition
Applicant Name: O�0 M�c . 2�vr.� i�4rsf' C�tU�.c#1 �, C�Yq� ���ss>
Address: ___
Phone #'s: �3b- soy- 4�4�
permii Located: X Yes Tlo
Tnstallaiion Date: 'L-'z..�� 9�5 Design flow: ? (gpd)
Cunent Contract with Certified Operator on file (if required): �_ .
Water Supply: %� Well �ublic or Community
Wastewater system shows no visual evidence ef failure on: ta � a� �3 (date)
(Applicant's signature if site visit is not required)
�omments: �E's'�cr�"�UU ��. 3� � X�` A�Arrc►r.� ��i �c� 3� Ct�-u.Ks.-i�►;
(;�atJ�R. P�P w���. F� ifA►ux.�o �' st�ci�.� t'�rd �r� �,x�rna�.
_.p�ur�.a�r1,�o oa��x g��. •� sv?s� -�iti � . .
�tr1������//���������e�at ��p�-����1
d0�.,,.� a- �,
Environmental Health Speciaiist
to a ��
Date
Person C�un�i Environme�tai ;� eaith; 3�5 S. tiiorQan �t., Suite C; Ro;�baro, NC 2 i�; 3
Fhcne::;�5-�97-??9C/ra:: ���-�9�-i�OU � 1-��:.^,v.�,ersoncoun�tv.i,e:
Application Date: `�� � � � � �
Amount Paid: ���
Receipt #: 8 �-1 `�' ��
�'- q �v
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 end)
❑ Mobile Home Replacement or Building Addition
$150.00 if site visit re uired)
Well Permit ( ew lacement/Repair)
$300.00 200.00/ ,75.00
�`�yj.)� ll 11�����. V Tax Map: !�3 S�
� � ��,�� Parcel#c �
��m�aa-�,.,,,.,.,,��.��..n i��r��..u�.
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
�pplicant Information: a�� �'• 2'u`�`�
Name: � N�iL �o,p�.� S� �u V e.�n
Address: T� �� ba(t �'���.u,� /t+,� Z�'aw
C� ., ��1.
2) Name and address of current owner (if different than applicant):
Name: C. l�,dQ e-� �� S 5 �
Address: � ,- Q �av�.5 pc�
�o�urd N L 27s73
Phone (home): 33G - S19 -� Q 7Z
(work/cell):
Phone: , 3 3 4-�d y�� y�
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property:
❑ 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 supporking documentation)
I Q� f=,w� S�1a s► C.
SO� Ft�.x� �i�ES
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:
❑ Repair to Malfunctioning System Will there be a basementT ❑ yes ❑ no With plumbing fixtures? ❑ yes � no
ONon-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 Well ❑ 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):
CYConventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I certify that the information provided above is 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.
�'ignature (Owner/ Legal Representative*)
* Supporting documentation required.
- �� .Zl1/
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 apptication requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
�.����1� 11e�� ��
� � ����
I IE��ns���.a��.m.]t lE3L��]l�Ila
� SITE PLAN
Nasne �� �T- Z-�Ow� C.N a�ci\ Tax Map #� Pascel #$9
Subdivision Secdon/Lot
iJ�Rs�c1� A,. S�r� 1
Authoiized State Agent Date
Sysrem companents represent appmadmate contours on/y. 77re conrractormusttlag t6e sysrem peiot to begianing the installatfon m
tnsure thatpropergradeismaintained.
Tax iVIap: /��
Subdivision:
���,S.f ���.���
�..: � c������
7�:: mt.�n�r � �n n-irn. ��n��n.Il �r �.ai..11. �1�n.
WELL PERMIT (New X Repair___) ����`��
Parcel: g`�
Lot:
Applicant's Name: a�p Moy�r Z-�. ��sY C��,�
Mailing Address: 111� 0��. C�.o� 1�.� �,���� �.�
oc� 41�CC �`�s`l�
Phone Numbers: �31�-5qR- 8o`la 33b- 58�} -�} O`�3
Location of Property: ,�c -�E vti(�.� 6aA or QA�t. 6��� l�cc Z�o�� Rs�.
Permit Conditions:
1) See attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply.
3) Permits expire S years from the date of issue.
Other Conditions/Comments: t�t��.�t A�.ac�a�. F��mab wE�
Permit issued by: �DE�.ica� �•�� Date: `� 1� 1
CERTIFICATE OF COMPLETION
New Well Inspection:
EHS/Date
Location: �S � �iy
Grouting:
Well Log: �} �3 �
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: �(3a►R�� License #: �3`lb- �
Pump Installer: License#:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date:
Date Results Mailed:
Phone: 336-597-1790 Fax: 336-597-7808
8/1!08
WELL CONSTRUCTION RECORD
This form can b� �d for sm�l� ac multipte wdls
1. Well Contractor Information:
�P,,��; � �= P L i-f-f
w�u contcactor N.m�
�3 76 --�
NC Wcll Conhauor Catification Numbcr
Barnette Well Drilling, Inc.
Con�any Name
Z Well ConstructionPermittl: !���T._Q ��
Lis1 a!! applicnble wzll corutruuion/rermru L� Cormry. SrotG Yarinnce, etaJ
3. Wdl Use (c6eck well nse):
❑Agricultural
❑Geothamal (Heating/Coo(ing SuPP�Y)
❑IndustriallCommercial
Non-Watcr Sopply Well:
�Aquifer Kect�arge
OAquifer SWrage and Rocovay
❑Aquifa Test
DExperimental Technology
❑Geothamal (Clased I,00p)
l9fi!'unicipaUPublic -
ORcsidential WaterSupply (single)
�Residendat Wata Supply (shared)
❑Groundwatet Remediation
❑Salinity Barrier
�Stortnwa[cr Drainage
❑Subsidence Contcol
OTrdcer
�lain under #2I Rema�s
4. Date RTe[1(s) Completed: Z3 � dl ID#
Sa WeD Location:
o r� M? Z�'� cK �
FacilirylOwnerName Facility I[?S (if apPlicable)
/1 �� �!1/e GRc �e l�rou�� z ;oN �-
Physical Address. Cig', �d Zip �Zb � /�'!�L • L 7!`j !f
�e2�'d� P�I���/ f�9
c�cy w.�t ramas�uo� rro. (Pn�r�
56. istitude and Longitude in dcgre�c/minnteslsa:onds or decimal degrees:
(ifwell field, o�w lat/loug is safficicnt)
�� - Z 7-�3 N%g - O O-- y�8 w
6. Is (are) thowsll(s): �rmanent. or �Temporary
Z Is this s� repur to an ecisting we►1: �Yes or 4iPIo
Ijthis !s a repair, fil! oW lmown wef! constructiort fnformauon aad �p1a:n the nature oJlhe
rrpa'v arder ¥Il rem�la sectian or on Ihe back of [hlsfo�m-
8. Number otwells eonstructed: `�'
Fo� mv(tiple injection or nou-warer supply wells ONLY wi/h t/u same eoulrucffon. you cm�
submil one form.
For (demal Use ONLY:
22, Certificatiou:
n �
(�v�� �.��.�.�c�� � �Z�' l `f
st�c� orcaus�a w�u cooa�� n�.
By signing rhis�orm. / hereby cerr� that Ihe xzl!(s) imx (were) consurrcud !e accordvnce
with /SA NCAC OlG .0100 or ISA NCAC 02C A200 fYel! Constructton Standards ru+d that a
mpy �thts reaord has been pmvtded a the well oxrter
23. Site diagrsm or addi6onal wdl details:
You may use the back of. this page to provide additional weU site details or well
constnidion details. You may also attach additional pages ifnecessacy.
SUBM[TTAL INSI'[JCI'IONS
9. Total well deptl� below land snrfacr _,�u � (ft) 7•4a For All Wdls. Submit this fiorta within 30 days of compldion of wetl
Far multip[e wc/!sli31 nUdepths if ttr�ermt (�ple-3QZ00' and 2Q100� tonstruction to the f011owing:
10. Sta6c water level 6elow top of casing: Z S
Ijwnurleve! ts above cnstn& use "+'
11. Borehole diameter. 6 (in.)
�ft� Division o[ Water Qrulity, Iaformation 1'roeessing Unit, .
1617 Mail Ser►ice Center, Raleig6, IQC 27699-1617
12. Wdl constrnction method: R � R 1Pa �/e ��
(i.a auger. mtary. wble. dicect PustS eoc.)
FOR WATER SUPPLY \VELIS ONLY:
13a Yield (gpm) 2- � Meihod of tes� B�own20 minute
136.Disinfectiontype: HTH A�,o�� 7/2 Cup
24b. For Iniection Wells: In addition to sending the fortn to the address in 24a
above, also submit a copy of this fornn withirt 30 days of ibmplecion of well
construdion to the followin�
Divisiou of Water QuaGly, Undergronnd injce6on Coutrot Prognm,
1636 Mail Service Center, Rale bh, NC 27699-1636
7Aa For �Vater SuonlV & Iniection Wells: In addiNon to sending the form to
the addrcss(es) ebave; aLso submit one copy of this form within 30 days of
campletion of wdt conswdian to the county hcalth dcpartment of the county
where consVucted.
Farm GW-1 North Carolioa Depacm�ent of Fuviroement aad Na4aa1 Resoiaces — Division of Watu Qualiry Revised Jan. 2013