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A40 219��1�,� l�-t�U �`C-�2 Person County Health Department Well Permit Date: �r y.� � Thi Permit Void Affer 5 Y�ars Owner. ,,�� 'Z � L, ��,_,L T� SR# � Location/Directions: Subdivision Name: • 4 Drilling Contractor: WELL CONSTRUCTION Distance from Nearest Property Line Distance from Source of Pollution Total Depth: � FG Yield:� GPM Static Water Level Ft. Water Bearing Zones: Depth Ft�� Ft F� FG Casing: Depth: Fmm�o � L Ft. Diameter• Inches TYPE: Steel Galvanized Steel If Steel, does owner approve�No WeighG Thickness: Height Above Ground: Inches Drive Shoe: Yes No Were Problems Encountered in Setting the Casing? Yes No If "yes" give reason: Grout: Type: Neat Cement Concrete Annular Space Width Inches Water in Annular Space: Yes No Method: Pum d �r�( e Poured � Depth: Fmm � �to "`' Ft Materials Used: No. Bags Portland Cement ' Weight of 1 bag_]bs. If mixture (sand, gravel, cuttings) - Ratio: to ID Plates: Yes ✓ No 4 x 4 slab Yes�No �d � � � �C � z I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT � THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET � FORTH BY THE PERSON COUNTY H e��.T EPA MENT. � � 3� z4 �Q� i� Da[e Issued GtJ-G��.�u �__ 3—��/S Sanitarian's Signature Date Completed Sketch well location on reverse side. NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water su plies, etc. Note special problems existing on lot. Write in measurements in order that installations may be 1 ca at later date. Note location of water supplies on adjacent lots. . ) ' (2) ' � � � � ( �. � ( � I � � � �'� � � � I � � � � '��■�� , � �. :� � � ' • "'Person��ounty 1-1eal�h� Department � � Sewage: S�►s#em lmpravements. Permit , . �ar� - t • ; . This..Pe�ic voiaa-,�ttier.�..Y P�nit # . ' � r' o . owne�: ' i , 'e `� Is � I.ocatioq/Direcfiions: . . So u-1 � f ...f . sabdivi�a�, Name: ,.—; � � VPY <..� �� • �.oc # L;ot Size:.; �:�: -� Type of.Dwellin� , Wa�er 5uPP1Y= �� Public: Community: . ,- g� 4�._ c�arbag�e Dispo�l . . �Cat �1XbIf?S IN��ORMATTON.C.ERTh�lED BY . EFtviro�memal Health Speciafls� r �'�: � REEV ATION: . '� Size of Se�ruc Tanlc � Y Size of ^ Tanic ..._ —.. Nltrification ian� -7�� p ��,•Sr, �(� , Depth of Sto�: 12 uiches ��T' � Ma�c Dcpth of TYe�ches: . . . .. Aliernative System: Ca►v. Pamp LPP Aanp - Re7nffiic3: _ � n� wev A�a:� so-�s wen �a t� ioo �. �, �.� � sY ° . Enyironmenral7E%alch specialisc Date Sewage Sysbem'Ap�rqve� _ 3-:':� S�-'�3- BY w-ri�-2 .fl ----_ Enviro�imental Health Specialist , � �BRTiE�iCATE OF COMP�'IZON H Conhac�or. - �c ----.__.��._�------------._..r.._._,� � � $CWSgC $itE� �10(�OD,' 1i19L3i�8h0R� � p1�DLCCU0II:�1IIi1St•�Ii�CCt Bi8tC � ffila IOC81 � IBgll�Shollg. $�C f2n�C SbOA� bC �{3Y1I� OOL CV��3 � S yCffiS 8� 8118� b6 fII81S1ti1itCd � OWOGT IA�SOC}1 �CL.BS IIO[ m.CI63tC 8':�}lC il�t�l b8Z8I+d: SCptLC �Si1�C 2nfl nitrificatioa lme mvst be inspected and�approved by. a.member of.the:�e�son County . Health De�ne�t before a:ry portion oP the installation is covecrd and;put �w use. If : tlie aite pIans or i�,ue-change t�us pemiic is siibjeor�w revodaao,r. ... .. (G.S. 130 l�335F) � • , �_ I,oc�ou of aewage d�sposal a�wage system sbetched on bacic. . .. . b ' (O�)' . . . _ . .- -.-.-� Ap�ication Date: � Am�unt Paid: __l�� Receipt #: _g 1 b N i.}� 3��i� . �� ° ��e �� S f � �� 67�i.2! ~'��' `�; �'�II7 L�7T'I[� ; � �I.y.ilfll'IlII•�fD]L?L:RIY�.K�2T.Q;.L'Lt� JL-1CQ.�.81.�IA:.�I. �� Apulication for Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 d) lobile Home Replacement or Building Addition � 150.00 (if site visit required) � Well Permit (IVew/Replacement/Repair) $3 00.00/$200.00/$75.00 Services Re uested ❑ Construction Authorization (Fee is de endent on the type of ❑ Permit Revision $75.00 Tax 1�Tap: Parcel#: ❑ Repair of Existing Septic System Application: No Charge/ CA �150.00 or $300.00 1) Applicant Information: Name: � i�7 � ��_t,1.�� Address: ��cJ�b , �l �?�74- 2) Name and address of current o�vner (if different than applicant): Name: - Address: Q Phone (home): ,�(p• S�j7-�3� (work/cel l): Phone: ��Z - �11� �j - �75DC.P 3) Property Description: Lot Size: ��3 Subdivision: � ��.�. �,,-��,ot #: t�� Address and/or directions to Property:-��y}�,��//g �� r�S �Q�(_ —� ��'1�� ` r; f�1�c;.t Ciro�n� ��-Q.P ��ril- cr� �e/tee l.l� �'} or�o�h'!N�n (b+�- ❑ yes o Does the site conta�n any�urisdictional wetlands? ❑ yes �Lno Does the site contain any existing wastewater systems? ❑ yes �. no Is any wastewater going to be generated on the site other than domestic sewage? O yes �o 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) Praposed Use and Ty e of Structure: �esidentia—1 �� l� It�!�� NeLJ �v Single Family Residenc�e�� taxiV'm� nu be dT bedrooi�ts: J ❑ 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: Nlaximum number of employees: Total Square footage of Building: Maximum number of seats: �) Water Supply: ❑ New wel( �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): l�Conv\n� ional ❑ Accepted ❑ Innovative � Alternative ❑ Other ❑ Any I cef•t� that the if fof�n3atiojt provided above is com�lete and correct. I also zrnderstattd that if the ittforr��ation provided is inaccirrate, or if the site is sarbseqarently altered, or the irrte.nded arse changes, all perjnits and approvals shall be ifzvalid. Signature wne�eg� Representative*) * Supporting documentation required. [-?�-?:r�� Date Permits are valid for either 60-�nonths or are non-expiring ��•hen 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. iVlorgan St., Suite C, RoYboro, NC 27�73 (336-597-1790) ��.s.f �'��..�� - = � � � ��-� IE��rn�vua-�rnRnnan�c:un�:.zn.� IE�C�.en.��n_ Site Plan Worl:sheet All annlications must include a site nlan. The site plan shows the preferred location of the house, driveway, and any other proposed structures. The proposed location of the septic system and well may also be sho�vn. You will be contacted by an Environmental Health Specialist if the proposed site plan needs to be adjusted to accommodate the �vell and septic system. The site pinn nrtrst incl�ule t/re followi�ig informntiou: �Dimensions of the property. (Existing or proposed). Proposed size and location of the house. The exact footprint of the house is not required as long as it fits within the proposed area. I�4easurements from at least t�vo property lines to the proposed house location must be shown. ✓ Proposed driveway location. El�: �^�p Proposed location of the septic system and well (optional). E��iir� Location and size of additional structures (Proposed or future additions). This includes sheds, garages, �vorkshops, pools, etc. Locations of �vells or septic systems on adjacent properties (if known). Location of easements (access, power lines, or others) on the property (if kno�m). Proposed Site Plan (Note: The site plan does not have to be to scale, but must include the information listed above.) 3�4 n j �� 3�( � <� s� � 23� I�uW 5� �� l43 -�� I(�•� �55 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790 Fax: 336-597-7808 PHYSICAL ADDRESS: 92 RENEE LN ROXBORO, NC 27574 ZONING: RC SETHACKS: FRONT 25' SIDE 20' REAR 25' CURRENT OWNER: APRIL B. BRYANT D.B. 525 PG. 745 P.C. 6 PG. 76-5 PIN: 9994-00-51-0384.000 TAX MAP . A40 219 TAX REC RD�: 19223 \ PIPE ' FOUND � �WIWAM JONES / D.B. 838 PG. 610 �SHED � Nw N �� OLD HOME � \ TO BE REMOVED ,ao �\�� ` 22.21' SYLVIA BRAGG � D.B. 622 PG. 128 � < IRON PIPE � � FOUND• \ PROPOSED SITE PLAN FOR 92 RENEE LN ROXBORO, NC 27574 PROPOSED NEW HOME (28'X'56') DRUCILLA ALLEN DEBORAH ALLEN D.B. 260 PG. 58 \ 29.92' Civiltek East REPRESENTATON � THE PROPEF2TY DE�Sc.�iem�rEi s�r.��o rm�oioo s�ndia.io� o..is� pgm BOOK 525 PAGE 745 AND S710NM AS ALL OF LOT riRw o-z000 +� IN PLAT CABINET 6 PAGE 76-5 PERSON CWNTY 602 EA57 NASH S7REET (y52) 4�8-5005 SPRING HOPE, N.C. 27882 REGISTER OF DEEDS AND THAT ENCROAqiMENTS. IF ANY —MaIP NIX�k�a�tOsmDa man.�om AT 7HE 11ME OF 7HE R SHONTI. i1LE: t�O605.DWC � �. ��I� � s. �a►�Ms. mausawN. wRv�roit �-sns CURVE TABLE CURVE LENGTH RADIUS BEARING CHORD *�� ISS • IRON STAKE SET CI 74.09 2538.00 N75'S0'33•W 74.09 op o oasnNc �Ron Pi� /�c � oasnNc a�c r+u� IRON PP <n, Pow�tt vo�E PIPE pEo � PHONE PEDESTnL �ac. � _ FOUND vrM � wATER MEiER � CORNER ERIN DAYE � �25, S6p. CAMILLE DAYE EXISi1NG �� S�7�E, D.B. 872 PG. 92 SEPTIC SYSTEM � � \ I (A POR�ION OF THE DRAIN UNES ARE TO BE ABANDONED)\ ��99• \ EXISTING PARCEL� � LOT 41 TOTAL AREA: W 3 47,649 sq. ft. _ � 1.09 acres N -'� ?S� AREA IN R/W: I ,r�`�i S9� � 7.156 sq. ft. Im o 0.16 ocre N �n � NET AREA: �N � � ��, � m 25' � � 0,49�93�ft. I � � �'\ � � J � �! 0 �i IRON 1 PIPE �23 53' � FWND � ,RE N>>� . �� R/W RIGHT OF WAY qiE OVERHEAD ELECTRIC �..�� w000 uNE IRON � g �Pu�n PaN7 PIPE � � FOUND ♦ FUC (ns DEscRieEo) ;ORNER / � / / z _ _ ^ � �``�� CARO��O, ., � e a ;�� oFESSipy �'Lq �; � W � - e� SEAL 9� _ S y"� ; y L-3976 0 ; o�o :�o��,,; s (_ X��`� IRON '''��'��uii�� PIPE �'� � ��,� 'OUND (/" ' � \ NE� T� 3 sa-w �11�T � S10'12�19'W Flat River Toumship ` E� ('�• 3o.ts' Persan Cou�.fy, North Caroltina ' `gLIC R/�y `� Yap Racordad In Plat Cab{not 8 At Pagr y6-b. �_ so o u so too 200 � � � R �W :o c� rn v � � rn � � �I ��, sf �� 7:C�e�rn�n.u-�zca�•-+,-„ ��.Il IL��.Il�II� Tax Map: �� Parcel: 2(� Subdivision �(aF R;v:,� �la�-�a-E,av� Phase/Section/Lot # Z� Improvement Permit Permit Valid for: Five Years � Non-expiring Type of Facility: �S� a' w' New �Addition Number of: Bedroom� �/ O cupants / Employees / Seats: Proposed Wastewater System: Coriti�e-r��;��,z� Proposed Repair: Cm„�.e�v,{�a:�a( Permit Conditions: �� Si �z- SIY��" Authorized State Agent: (X) Owner or Legal Re Water Supply: ' � Projected Daily Flow: 31�o gal ns/day Type: .�a Type: 1'La Date: 2 -1? (!o Date: �-�-Z�r � The issuance of this permit by the Health Department cioes not guarantee the issuance of other required permits. It is the responsibility of the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revoca�ion if the site plan, plat or the intended use changes. The Improvement is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws a�rrl Ru[es for Sewage Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic system will cantinue to function satisfactorily in the future, or that the water sapply will remain pota6le. Authorization to Construct Wastewater S stem See site plan and additional attachments (�/ . Proposed Wastewater System: �.n� �� (*)Type �a Design Flow � gal./day New Repair _ Expansion � Soil LTAR; , 3 gal./day/ft2 Type of Facility: S,� aw�,l� �� ,j(i — 3� Basement: _ Yes _No (*) Sysiem Types III6, Illhg, IV, and V, require p�riodic syste�n inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank f10 gal. Pump Tank �— gal. Drainfield: Total Arza 52,� sq. ft. Total Length 1�� ft. Trench Width �_ ft. Min.Soil Cover _� in. Distribution: Distribution Box / Seria( Distribution V/ Pressure Manifolc Specifications: Authorized State Agent: �rrease Trap gal. Max. Trench Depth 2g in. p . C. Min.Trench Separation � ft. Issue Date: 2 - /7-/!n Permit Expiration Date: 2-i 7- Zl Tlie system permitted is: Conventional t/ /Accepted / Alternative / Innovative . I accept the conditions and specifications of this permit. / (X) Owner or Legal Representative: ( Date: �" �{� Zp ((, Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) �� _ ,. �� ]E�vasom►�a�e�.EmIl' 1FF�om�Il�76. SITE PLAN � • Name .1 Subdivis on i� > Authorized tate Agent Tax Map#�Paroel# 2l9 Section/Lobk ldl _ Z Date I Syslem componenls represent apprarimale contours only. The conlrac�or mus�Jlag the system prior to beginning the � j rns�alla�ion to lnsure thal propergrade fs maintained I Note: An Accepted system may be used in place oja conventianalsys�em wi�hout permit aulhorization or modification • � / ss�bS �SHED � N �� OLD HOME � \ TO BE REMOVED No � � . _: . :%�% :;;% L � PROPOSED NEW HOME (28'X'56') � E i-�1.er iaec r�ew t-anK ar reloca� Q„�"s{,n`i �,K. �'i�l� �Ce, t+'tu5� I ns�ct {-anlC I r� 2if1+¢Y 5`��cc,. �'► �d �—(�j� CoAv�,v��oY.a� pv�i'a -ehci o� 2aciS�i-�ncZ � J Sl�s1�w� ( l30' �c�� ' � 2�� i`renc� �� . �(( � Su�e. }� QI�Nv�a:� �cisf�n� tine IZ'- IS' bacK �'onn l�h�• ��- will sfc� ar► US�• �acK s�ii b�cK ;h a�j,ahd��ed sufi�s. � 29.92' � �2j� � � , �� 1 S6 \2s• G � Se � � � \ \ \ rl ` � �' l, i �►e. �.�c�Qi115 ��oY1 —��' ��A�Ci'1 �%Xi�lY1G� �If1C P� K � � R¢.�v►ove, Ar�� bacK w( ��(can" Soi� �� ,Qpal�i � ��899, . / / •.� \ / \ . � / 0 3 � �� . � � ' 2S� � � ►,�°°i � Se� � — �u�i � \ � / � � � � / . �s�" �N � Q-�� \ 1 � � � �,� \ 25'��j ° 1 � � o` 1– � � o �, = � , - � -J w�,• � � � �o �o � IRON �23 " 1 FOUND �3� R/�y � R�N�,�, N7%V3��8�W (/\ `\ ` � w q I - S10'12 � 9 W ` �N�' _ s�, � 3o.�s' � _ — , 1°U'BLIC R/� ' � ,_ �, Coc�o`v� ' _ .. � ' �w �t� �c�— wr' o�n sfi�s 33�- �q� l��o SC��E � I'`= Sb ` �ue � ��.sf ��.�� I��.�a��,r„-„ ��.Il I�ZL��.IL�7� Applicant: Location: System Type (From Table Va): Type V& VI Expiration Date: Operation Permit Tax Map �� Parcel # 2 � Subdivision F1R-� ��Pr Pla�fa{i�,i Phase/Section/Lot # # of Bedrooms 3 Product (IIIg): ��' Type V& VI Renewal Date: This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. 3—IS-1(� Authorized Agent) (Date) � i KP ,P��t. ^� (Licensed Contractor) �j�JO �'luu5�. Ur -Y un�a}1on R�' -f-irn�. a� i�s�e��ur� Scale � �' PCHD 2/14/12 on s��e., �� i �b��e ' � � .� i , `�., ��52 S� �' � �-,,, 3-is-1 (Date) i' 9 �3 �g � �q �JeW 7 L�n�, .� , q Star�FS �,er�, 1' q 7 �OD , rev. � ��JQ � t - P� �►� e, L►� u�� xis�,'n L� ne Aba�lo �d Se��-; d,�s ►J�ew L�ne Line Length 1 .�0 � D' Total a ' Tax Map: � Parcel #: ��Q Septic Tank System Checklist (Type II-I� System Type: (,�2) Se tic Tank InitiaUDate State ID & Date: 5- 32�i � -15- - 2- l�a Capacity: _ Tee and filter Baffle Vent ,/ Riser Outlet boot Perm. Marker Distribution D-box (levels set) - Serial Pressure Manifold LPP Notes: Pump System Checklist Pum Tank InitiaUDate Staie D & Date: Capacity: Riser 6" min. NEMA 4X Box Model: Piggy back plug Hard wired Alarm functioning Mounted on ost Above grade (12") Conduit sealed Pressure Manifold Number of ta s: Size and sch: Contracted Certified Operator (Type IV Systems): Notes: Application Date: Amount Paid: Receipt #: 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) $300.00/$200.00/$75.00 �� Tax Map: �_� �� • � �� Parcel#: �L f _1 � �� IEasva a-oaa aaao aa�al II�c�,al��a ilication for Services Services Requested Construction Authorization (Fee is dependent on the type of Permit Revision $75.00 Repair of Ezisting Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: IC�YS � Address• 2� �.�OI -e� (� Gre�-I�J�a. N�. �,�t-101o 2) Name and address of current owner (if different than applicant): Name: f��.'7Y'1 � �ri1 Q,h �' Address:�2. IQ�XI��. DY ��t bm o 1�1G 2"1 �'l �-1 3) Property Description: Lot Size: Subdivision: Address and/or direcrions to Property: Phone (home):�j��0� �30�� I (work/cell): Phone: �j3�lp ' 32Z ' d�J(C�; Lot #: ❑ yes �'no Does the site contain any jurisdictional wetlands? ❑ yes C�no Does the site contain any existing wastewafer 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 Q�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: �kesidential ❑ 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: O New well �Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes D no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): O Conventional ❑ Accepted ❑ Innovarive ❑ Alternative O 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. �� Signature wner/ Legal Representative*) Date * Supporting documentation required. • 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) Perso� County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)