A40 259Appiication Date: � ► �7
Amonnt Paid:
'�: vp
Receipt #: 9b0
�—.�,:, � �� �`i.yl�
� = �:�� ��
?L�ayas-vaa���ad.gD I [a:.a.11�:��
for Se�vices
❑ Improvement Permit (Site E ,v,���ation) � � y . ..Of�Constn
$200.00/$300.00 if> b00 d • '� '� 4` �� : �'- ee is �
D Mobile �ome Replacemen�-,br Building Addition ., Cl ]Permit
Tt G(► AA /:F...a.. .....Lr........L.:.,.Il � � � @�7G 1111
Well Permit
�ag 1VIag:
Parcel#:
Auihorization
ent on the tvne of
•❑ Repair of Eiisting Sept[c System
Anniication:INo CharneJ CA $150.00 or $300.00
i) Applicant gnfqrmation: � • �
Name: C.
•Address� • �
2) IVame and address of current owner (ii different than applicant):
Name: s ' 2� '
Address: �
� '
3) Property Descrlption: Lot Size: �•O Subd.ivisioh:
Address and/or directions to Property:
Phone (home):33�A .32'Z-�q,�_
(wor cell): 33G�S$-�i.y �.�.:� �
. �F ♦
Phone �
#:
� 0 yes ❑ no 1�oes the site contain any jurisdictional wetlands7
� yes ❑ no Does the site contain any existing w�stewater systems?.
❑ yes ❑ no Is any wastewater going to be generated•on.the site other th domestic sewage?
0 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 documentado )'
4) Proposed Use aad'I�pe of Structure: "
C]Residential '•
C! New Single Family Residence Maximum number of bedrooms: Occupants:
� Expansion ofE�cisting System If expansion: Cucrent�number ofbedroom�: -
❑ Repair to Malfunctioning System Will there be a basement? � yes ❑ no V�Vith plumbing fixtures? ❑ yes L7 no
ONon-Residenttul
Type of business: � Total Square fc
Maximum ntunber of employees: Ma�nnum nun
S� V4l�ter Supply: ❑ New well ❑ E�cisting Well � Community Well ❑ P��
Are there any existing wells, springs, or existing waterlines on this property?
Please note any laiown ground water restrictions or sources of contamination:
;e of Building.
of sea�s:
ic Water ❑ Spring'-.,
yes � no
6) If apglying for ��Yuthorization to Construct', please indicate preferred s9stem type(s):
❑ Conventionai 0 Accepted ❑ Innovative ❑ Alternative ❑ OthEz --. l. ❑ Any
: - ' �=' - . .
I cert� that the infonnation provided above is complete and correc� I also
inaccurate, tl� site is subsequently alterea� or the intended use changes, all
� ,�.�-.� - - �
Signatare ( er/ Legal Representative*)
�' Supporting documentation required.
a Permiis are valid for either 60 months or are non-e,�piring when
o A cornpteted `iot Pre�aration' %rm must accompany any applic
rxid that �the inforsnaiion provided is
and approvals sliall be invalid.
� � - 4�11 'I?
Date
op�nied by an approved pla�
requiring a sIte evaluation.
• — — — - --- -- ---- -- — — • t — • -------- ---- --- ----•
:�
r
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADIS�N BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name af Owner or Tenant Arru �_. �
Address � (� R�. � � County �
�¢
�
Collected By SS �
Date Coilected 3"2(o-lg Time Collected �dr'3S
Source: �'Well ❑ Spring ❑ Other
Location: ❑ House Tap �'Well Tap ❑ Other
❑� No Charge �harge Re �Sa�,��e,.
■ � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � / � � � � � � � � � � � � � � � � � � � � � � � � � � � � � / 1
*ak****�F******okleiir*�k�k***�F**�kit**7t*9t****�Ic**9t*****it***k*�k******ik**vt***74�F*ie**ir**#*
Total Coliform
Fecal/E. Coli
Results
Present
❑
Reported By
Date Reported � a� ' �
Report Called �YES o NO
Called To T[`�.ri�,tS?_S1Q-___
Absent
�
►�
fi
�
i
n
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant _��,o��� :�-���
�
Address ) � �`i �.� �1. _ County
�
Collected By SS
Date Coilected /o-2u-I-( Time Coilected //%Sd
Source: r�llleil o Spring ❑ Other
Location: ❑ House Tap �eil Tap ❑ Other
❑ No Charge �arge
..............................................................................�
**,�***********************************************************************�*
Total Coliform
Fecal/E. Coli
Resu Its
Present
�
Reported By
Date Reported ����5 �' �
Report Called �i YES o NO
Called To � � ����e � �"G"�e�
u
Absent
C■J
�
�
�
A_Yp:iz�tioa Ja:e: � � 7
Amount Paid: �
Receipt #:
0 Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 if site visit re uired
Well Permit (A1ew/RgpZaeeu�eqt/Repair)
��,�.�� �I��.����� �
~� ������
�Sa�nso��a�aa�mIl ��mIl�a
Taa 11^�ap: � u �
Parcel#: ��
F_M0.I
ilication for Services W c�°I
Services Re uested
0 Construction Authorization
(Fee is de endent on the e of s stem ermitted
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Appiication: No Charge/ CA $150.00 or $300.00
1) Applicant Inf rraation•
Name: �tibi c �� � �GLI(`� V�
Address: o Ot
6 �D
2) Name and address of current owner (if different than applicant):
Name:
Address:
I —�- O
�' � i La1^cl�
Phone (home): 33 � • J�-1 . ��0 �
(work/cell):3� - . 3
Phone:
3) Property Description: Lot Size: Acr� Subdivision: N%/�' 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 0 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 pubiic 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: / Occupants:
❑ 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 Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If apptying for °Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative � Other ❑ Any
I certify that the information provided abov is complete and correct. I also understand that if the information provided is
inaccurate,lke�te is subsep�itly,Rlt¢t� , or the intended use changes, allpermits and approvals shall be invalid.
�
�wne�(Legal Repre's�nt,�ttve*)
documentation requiredG
�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.
(]0/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N�27573 (336-597-1790)
���, sf ���.� ��
�- � � ����
]E��a,���,��.,�.��.Il ]F3C��.11�l�
Tax Map: � `� Parcel: �
Subdivision:
WELL PERMIT
(New _ Repair �
Lot:
Applicant's Name: .f �
Mailing Address:
.7 �
Phone Numbers: -3 �
Location of Property:
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing consiruction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.J Issuance of a permit does not guarantee a potable water supply
Other CondiNons/Comments:
Permit issued by: o; ' Date: �ti %
Certificate of Completion
�tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller: � ��( �i71i�1��
Pump Installer:
Approved by:
Additional Commen�s:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
iner:
EHS�ate
Depth: 20'l7
Grout: ,������
QAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
WEL�, CQNSTRUCTION RECQRD
This form cnn bo used for cinglc ot mulliple wcils
i. Netl Contr etor [nformatlon:
��/iyG �yir/G�
�Vell Gbrucscbor tJame
y3T�-�
NC Wcll ContractotCc7fiHcation Num6cr
UVi�T✓ CiK �{�'� S ,�<
Company Nams
Z. Wet! Gbastruc@on Petmlt #:
Glst aUapplka6ls xr!lprroilu (i.a Cousry; Stote Yartaice, LtJecttvn, rre.J
3. Well Use (check weU use):
DAgricultu►ai QMunicipaUPubGc
ClCieothermal (Heating/Cooling Siipply) �identisi Water Suppiy (satgle)
�IndustriaVCommcrcial aResidentia! Water Supply (shared)
DAquifer Rechazge I7Groundwater Remedia6on
OAquif�r Starege and Recpvery OSalinity Barrfer
❑Aquitcr'[�est t75tomiwater Drainagc
QExperlmontal Technology OSubsidence Control
OQeothermel(Ciosed Loop) OTracer
4. Dnte LYell(s) Completed: Q'aa'� 7�VeU ID#
5a. WeU T..ocation: �
�a�iA/a'!f�''�/�� cv��' /T�C'r�
Facility/Owner Nnme FaciUty ID# {if applkable)
%�107 ��/t�f , �u4�� vG �
Physical Add�ess, Ciry, and 2ip
/���
C�'ty Parcel Idant{Gcadon No. (PIN)
Sb. Latttnde and Longitude fn degrees/minutes/seconds or declroal degrees:
(ifwell Retd, one latriong is suliiciera)
�6�6 � �-,?�'�� N ��'1 °/ �.D�SI, y �� w
6. Is (are) tke well(s)�rmanent or OTemporary
7. Is tfils a repair to an extsdng well: �s or ONo '
IJthlr ts a repetlr, JJ!! out la�ou�n n+el! cantlrucl on lnjorn�ation aird exp(atn !kt nature oJlke
rept+lr urtder #21 remarks sec!!o� nr an the back ojrhls form.
$. Number of weUq consh'uMed: �
For niultlple lnfecl/on or �wn•xrrtersupp/v �rells pAZY with 1he snme constntctlor, ynu cnn
su6mU onejnrnt.
9. Total well depth 6elow land surface: __ _ �"b�-� �7� I Eg,�
Foi mufttp/e u�eUa Ifst a!! depths tfd7(J'eronr (example• 3 r�i 1�0' a�rJ IQl R0�
�^ i
!0. Static water tevel balow top oi casing: �i/ (ft.)
Ijknrer level is atw�r castng, we "+••
i
11. Rore6ole diameter: � � (in,j
12. Well construcfiva method: �� i�� /
(i.e. augnr, mtary, cabte, dlrect puth, etc.?
Forintemel Use ONLY:
ia, wa7r�u zoxEs . .
��� fl' /�o.�ft' i� .
_.L,Z. �
�. ��
�S.a �� �
F TO . p{,1METER
v' iG ou tG !A.
l6. INNER CASING OR TUB(N(3 ( eother
Ro_ t�r, _ nun�reR
ft. !L !a
tt. f4 In.
7. SCREP.i�F- '
RObi TO AAfETER 9 �
tt. tt. t9.
ft. R tm
SrGROUT •
ROM TO ' 1tiAT£RIAL
U su � rr. �
R. ft
fG Jt.
9.3ANDICRAVELPACK Ua 1}eabls
R01j 'j0 biATERIAL
c� R.
ft. ft.
h. it
fG fG
tt. ft.
R. ft.
n. R.
n. ri.
ic. Et.
22. Certlti�tlon;
G� 1/�rf� c 9 ao-�7
Signa Ctrt cfl Contractor Ihte
B�� s/ g thls ,! hereby cert{j}� thar rhe x+¢!!(s) nru (werel conttrucled ln uccrordance
x�th /SA NCAC 02C .0I00 or l SA NCAC O1C .0200 lYell Corarn�cda� Srandards m�d that a
rnpy ojthts ncnrrt has beett provirted to �e arll ouner.
23. Stte d[a�ram or additional well deWils:
You may use tha back of this page W provide additionat �v�fl site details or wel!
consuucdon dGails. You may also attech additional pagcs if necessary.
SUBbIITTAL IIVSTUCTIONS
24a. For All Wells: Su6mit this fortn within 30 days of completion of well
consduction to thc following: `
Divislon of Wnter Resources, Infotmation Processing Unit,
1617 Mall Servfce Ceqter, Rale[gh, NC 27699-I617
24b. For In)g�jjon Wells ONLY: In addition to sending the form to the address in
24a ebove, also submit a copy of this form within 30 days of complction of �vell
construction to the following:
Dlvtston of �Yater Resources, Underground lnjection Control Pro$ram,
FOR WATER SUPPLY Si'ELLS OM.Y: 1636 Mait Senice Center, Raleigh, NC 27699-1636
13a. Yleld {gpm) �����%'� hiet6od of ttsC i�/j1l� Z��- For �Vater SnDp1Y & tn(ecNon Nells:
� Also submit one copy of this form within 30 days ofcomplarion of
13b. Dlslnfeetion t�pe: _.,�r� Amount• /� C�� well consaucdon to the county health depanment of the county wbere
constructed.
FormGW-1 NoRh Carotina I3epartment ofEnvirorsmcnt and Naturel Resow+ces- Dlvisbn of Water Resouras Revised August 2Q13
0
PERSON COUNTY HEALTH DEPARTMENT
, WELL A�1D SEWAGE SITE, LOCATION IMPROV� ENT PERMIT
Tax Map # f� �' � Parcel # aJI �
Zoning Township �=-E� ��"�-
ll��mnr/(��nfrnnf�r aiif�rw._ /1L//`� narP. ��rZJ�y
Location/
Su
ision Name Lot#,
�/
Y
a
/�`
¢;
i�
�-
SEWAGE SYSTEM SPECIFICATIONS
S.R.# � �
�p vj�
�7L
7Z
g3
C��f03
Repair Lot Area_/�-u-� Size of Tank Ilt�'�'
SFD [/` Mobile Home Size of Pump Tank N��'
Business # of Bedrooms�_ Nitrification Line S�D� �X 3 '
Max Depth Trenches , , . -.�-1�%
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.,
Permits may be voided if site is a�tered�intended use changed.
Well and Septic Layout by
ell Permit
Installed by �-1 � �-P'`�'t-� Approved
a1 ,�� qa� �—r3-97
SYSTEM SPECIFICATIONS
idividual ti` Semi-Public Required Slab _
ublic Replacement Air Vent
ite Approved 'V Required Well Log
�ell Head Approved 1' Well Tag
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The
emironmental health specialist is no[ responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or
misleading statements provided to him in the application. Neither Pecson County nor the environmental health specialist warrants that the septic
tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0
� .�
�
L'I;N;UN COIIN'I'Y I?NV1.IZONP;::N'I'l�I. II1�AL'J'I1 • ' ';'-':�'�
' ";t: �
� �+ IJI;I,L I,U(�
Da te: . � �� � �
Owner:
...
. . _.._ ._. . _.. SR#�,
Location/Du-ect ons: ��-�-- _ �d �-�.::�.��,.� �l,�e --��.�r.l .
. - —._.. _..
�uv,_'�vision Nair�c: - _ ...__._ '. �
-- ----
Drilling Contractor: � _ _ . ...---...___...__....._ ..----- ot #
. -��-��-------�t/�:-Jl— � �:t_�-�- —___ .
Wl;i.l. C'ONS'I'RIJC'TI�N � .
Distance from Nearest Pro��ci�ty Liri�:__,����,�� __ llistancu .from Source of '
Pollut�on . 0 J /u.,r
Total.�Dep.th: a Ft. Yicici:�� p__ __ �;�>M Static Water Level
Water Bearing 'Lones: Depth _%� I��. � � - 'FG'..
Casi,ng: Deptli: � From � to---__�-��� _�'t•�Ft. '�t,
I' �- Di amc tcr: � Inches
TYPE: Steel � G.ilv,lnilcxl Stecl
� . .
I� Stec;l, does owncr approv�:: a'e;;; N� . ..
�Weigh[:' / ") rrJllC[U1�'S�. • ' •
��*---�-- '—�. Hc�ghr Above Ground:�i7nches:: ,; `
.l�rive Shoe: Xes_ r � N�_ _ �. _
Werc I'roblems Eiicountcrccl in Scttinb the C:,sin�7 Yes �� � No �
„ -
If 'ycs give rcusori: =' :�
Grout: Type: Neat � ��� - . . . . "�'°�''�
. S:�r�ci/Cc,licnt_� Concrete � �'s�`f�
A�ulUlar.Spacc Widt�� .� ----- • ''�._�
___. I� ichcs
Water in Annular Spacc: Y�:s � c.i � I
0 1
Mcthod:� Put1Z�xd,;. ---._.__--- 1'rc:::;urc; � 1'c�urccl �' ... � .
. ,,: . �:
Dcpch: From—._.�__----- tu -�-�--I'�• _� � . . -•�
Materials Useci: No. �3a�s Portl�uid Ccincnt -- �`'=:'
If mix - .-:!�-- Wci�t o,�.l�bag ��''_ '�lbs:3�
[ure (sancl, gravc;l; cuttins�s) - � �R:���-
[�No " Ratic�: to :;:��
.. .
�ITJ Plztes: Yes _ � � . . .: ;..::.;j
...
.. . ,,..:,
_ __ _..._ _.,_.. _ , ,
� 4 x � slab Xes �.--- No_...__.. --- - � .:.
------------»I:II,I.INCT 1.(?C ;
��Cp[11 --- -- �
l�ormation Deticr;
---�'�=� c{�. ��. �
�
. ��—��___ �
Z HEREBY CER'ITFY T�-IAT TI-IE AI3pVL 1NFURMt�TXON ZS C4RRECT AND:'
. T�S WELL WAS CONSTI'.UCI'ED 1N ACCORD,A,NCE WITH REGULA'I'�ON
��RTH B Y�T�-1 � PERS ON CO UNTI' I-I 1;A I_,TI-I DEPA I�TM EN"I' �
i,/`
..__ . . -�/Z -4� �;"��
.�ibnatt�r� c�f C�r�����:tvr
�
;:
Datc �j