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Persor� Cau��y Nealth Depar�meni
� _ Weli Permit
Lacc, ��' Pcacni: jG9�d Aftec 3 1'ears SRtJ �j�1�
Ctiwner• (1'
i,..�tionlf) irections:
Subdivistan I�t:3n7C:
D; ill ing Contrac tor, ��^�"� •^^' ""-'—'� ----
�=r�i t C�NS'1'RI�CTl4N_
Ls�anc�: irorn I�zarest Propcny Linc Distance iron� Sourc� of
��llurion _.._ ZQ Gy� 5L9tit S�Yutcr Lcvcl ,_ F4
Tacx Dcpth: �c. Yicld: __,_�_ .
tiYa�cr Bearing 'lones: Dep�h F[. Ft. • Ft. F�.
^��g; �epth; �rorn to Ft, Diamctcr �n�n�
;'1'�E: S�r,cl Galvanized Stecl 'j _
If Ster�. docs o•�vne� approve: � No
l'lcighr Thiclmcss: 3-leigl�t Abovc Ground: inchu
J?rivs Shoe: Fes ._r. Na ----
Wcre T'robtems Enoowteced in Setting d�s Casing? Yes No
If "yes" give resson: " `
Grour. Typc: �tcat =+S�aSUCemenz Concrete —
An��tar Spn:.e.Width j � ' ��«
1Yatcr in Armular Spacc: Yrs N0 Pourc�
I�•ieihoci: ' i'urnp0d � r�,��,�--�
s Depth: From � ��5•�--- r:.
�ria�eriais Use3: No, �3ags Portland Cemeni ,_._.__. ��?cighi of 1 bag -
1bs.
If mixture (sand. Sravet. cuttings} - Raao, �- � --
ID Plotrs: Ycs ,____T_ No � �
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:3�EKEBY C�Jt'I'IFYTiiA7'TEIEAIIOVEB�FORhtATIUNISCORREC'FANDTHAT �
;] t!S �VELL WAS CONSTRUCiED II�i ACCORDATICE �i'TTN R lfl.P►TIONS SET �
:Y?}2TN II1''Ii�E PEiZSQN CJUPTI'Y 7'� EP �� EMJ', � I� �
Si nu� (.`� trectc r T�sie I
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Saniwriaiis Signat� c �ate Issued I
Sa�utuia�is Signatuce Dn:e Compicta!
Skctcb v:ci� lccauon.ori reve �e side.
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pa=e�u( aq dstu auo��Ellelsut �ei,� iap�u uc s�uatussaseaw uc a�es� ��
�a�err, 'safnf.�d 'sxu�:� :,�;das �asno�{ so ut�l;8�oj 'ade�{s�-pe•a^3'zjs^
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loi bucnnoi{s uoi;e�te�s�i� jo ya�axs a:�ei.q :��H
Application Date: L ���.5� ������ Tax Map: ��
Amount Paid: 0•d �: "�.r- �����•� Parcel#:
Receipt #: I 7 % ( 7
Il:.aavaa-caa�anac:na�esl �f�r.ulfii�n
' ����� 7 Annlication for Services
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 if> 600 d)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Welt Permit (New/Replacemeat/Repair)
uested
❑ Construction Authorization
(Fee is deaendent on the type of
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Aonlication: No CharQe/ CA $150.00 or
1) Applicant In p�� aYon: �� S
Name: � �
Address: �
1 �.
2) Name and address of cur nt owner (if different than applicant):
Name: �
Address:
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3)
Phone (hom )
(work/cell): �, , n , _� �7� _
Phone:(��n��� � J�-� r
Property Description: Lot Size: •`iC1 Subdivision: �.rC- l`�Y' Lot #: "tOI�
Address and/or directions to Property: r-, n ,
❑yes r►'� Does the site contain any jurisdictional wetlands?
C�d"yes Does the site contain any existing wastewater systems?
� yes �� Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes L�]'g o Is the site subject to approval by any other public agency?
❑ yes L9'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:
❑ sidential Z
ew Smgle Family Residence Maximum number of bedrooms: , / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedr ms:
❑ 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:
Maacimum number of seats:
5) Water Supply: ❑ New well L`�f" Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicat�ferr� system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative Other � ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is sa�bsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�'��c� ��,�. 21C�I1�-
Signature ((j'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 `LotPreparadon' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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PERSVN' COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IN�ROVEMENT PERNIIT
Tax Map #_� l�f'j Parcel # � � ,�
Zoning Township �'��� � ,' V � ✓
Owner/Contractor o ►� �, K{,� Gi 4% o n_S Date ��
Location/Address , � �c'� �a ' �' �
S. .#
Subdivision Name Lot#�
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,Y,
A 0043
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SEW�GE SYSTE� SPJ�:CI�ICATI�I�iS . �
�.epair _ Lo+ �`,r�a � � : � ^Size of Tank .� _
ISFD Maoile Home�/ Size of Pump Tank
;Business _#� of Bedrooms V� Ni+.rification Line l�,
L � Max Deptn Trenches • _ � �, � � ^
i
Permit Void after 60 mor..ths. Permit Void if not in compliance with zoning regulations.
Permits may be voided if s:
Well and 5:.pti� i,ayout by
Comments:
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9
Date 3— �--�I� Installed by � � ' ApprovPd by_(��� �-�r.t�wr..
. � nG..O
,� �,J{,C� y;,,«' f'vVELL SY5'�EM SPECIFICATIONS �_ _
Individual ,/� Semi-Public Required Slab
Public Replacement Air Vent �/
Site Approved Required Well .Lo� �/
Well Head Approved We11 'i'ag �/ __
Grouting Approved �
Comments:
DateiS���_ Installed by ��c`,� (.� � l� ia.,.,,S Approved by���
'Ihis report is based in part on Wormation provided the homeowner or his/her representative in the application su m�tted fo is peimit The
environtnental health specialist is not resgonsible for false or misleading infortnation contained in the application. The enviro�unental health specialist
is also not responsible for concealed conditions on the property or for statements in Lhis repoR that may have resulted from false or mis]eading
statements provided to him in the applicatioti Neither Petson County nor the env'soc�nental health specialist wartants that the septic tank s;�stem will
continue to function satisfadorily in the future or that the water supply will remain potable. c:�amipro\perrtritsam O1/95 rev.1.0
ORIGINAL
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Suildiag Additions/ Mobile Home Replacements
, Tax Map#:�� Pazcel#: ��3 Address: (� K� -�� �''t�
2S?
Approval Requested for:
Applicant Name: � � �
Address: 3
Phon� #'s: 5 7 -
Permit Located:
Installation Date:
� Mobile Home Replacement
Building Addition .
f�vr ��P s— P1`5� a°t o
_DG�I�a,� ►�
� ,v� �7���
� Yes
-1 �- f q �
Design IIow: 3 � � (gpd)
Current Contract with Certified Operator on file (if required): Gr Q
Water Supply: _� Well Public or Community
�«��— ��,�� p�a�;����
G�-� �o�h
Wastewater system shows no visual evidence of failure on: �-� 3�( (date)
(Applicant's signature if site visit is not required)
Comments: / ��J �t
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Ca � t��` '��k ( al>lk
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on.. w�e l l •
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�1� l�+` O�h�l C 1%riP�rcv�Qr+,,e.�'+S vl-f-Pp��
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Additioai/Replacera�ea�t Appr6ved
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En ironmental Health Specialist
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Date
Persan County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-17901 Fax: 336-597-7808 www.nersoncounty.net
Pe�on Couniy Environ�ne,ttal He�
325 S. Morgan Street
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February 6, 2017
TaxParcelPublishing
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PersonCountvisnotresoonsblefatheuse misuse orm�sinteroretationofthisirrformacon