A40 262�� Person Courty tioalth C�p: ��� �•��
325 S. Mo.►c�an Stre�t �
R e c e i t t p l� i d )�• Roxboro, N.C. 2?5� P 6''�� . � 1 I— 9
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�0� Cqurier �02•�3-15 � a6 e D a t e
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' � �3 � APPI,iCATION FOR SERVICES 3 �
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Improvements Permit. (Established/Recorded Lot) I_ Reinspection of Existing System (Loan Closing)
�mpFovements Permit (Unrecorded Lot)
lmprovements Permit (Mobile Home Replace)
Improvements Permit (Addition)
_ Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
l. Permit requested by: . �, 7. Dimensions or Proposed S[ructure:
owner/prospective owner/agent:s �Ot�it) �j. S�C�t/US Width: ��f -- S�
Address: . i' �S _ � �y� Si►'� � �'If ►�� _ Depth:
S � ocQ.4 � C- a 3 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
Home Phone #:33� -S/�7- 5�G � 4
usiness Phone #:�9._- 933� o� '
2. Name and address of:current owner: 9. Water s�pply t}pe:
G�4�t1 : C'7J�^�l/ private f�� public ❑ community ❑ spring ❑
/ � ilii✓ Si� � r� � Are any wells on adjoining property?Yes ❑ No �.
$�t,�►� A- it/ C- o�'� 3 3 If so, identify location:
3. Property Description: Lot size: SJ. G��-�-
. Tax Map#: �4- �F b j�� 10. Type of structure/facili[y: Proposed: xisting: Q
Parcel#: �. ��. �� Type of dwel i g:
Township: � . - � J � House: �obile Home: C'�Business: ❑
5. Directions to property: State Road #& Road Type of business:
ames,gtc.
Number of Employees:
`- �- `C3 X.55 � � \�.ft-tii � L O. Number of bedrooms: �
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No�f so, # of basement fixtures:
6. Number of occupants or people to be served: ,.�.
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COunty Health Department for a site 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. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have no[
delivered a survey plat of the property to the Health Dept. within GO DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signccj Owner or Authorized Agent
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B 2949
, PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # A �U Parcel #_
Zoning Township _
Owner/Contractor �o�� �-�c�e�s / � l e��
Location/Address J57 ,S vN e,�' / �
Subdivision Name -
�� °2 G �
= �a �'ve
e�e�r��ate��
c- JaMCS �%v.
S.R.#
Lot# -
� ,5;�,� SEWAGE SYSTEM SPECIFICATIONS
Repair P np Lot Area $. �� A� Size of Tank 1U00
SFD � Mobile Home ✓ Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line '�00 `x .3 i
Max Depth Trenches 2� ��
Permits may be voided if site is tered or intended use changed.
Well and Septic Layout by �� 1f
Comments: Q ,,,r •� i.:�t cr� iG !' .� �•v� O�v r� rou �vrh,
Date � 14 - 5' 4 Installed by J• �e w� S Approved by .O. �
ell Permit Paid
ite Approved
Jell Head Approved.
�routing Approved_
Comments:
Date
WELL SYSTEM SPECIFICATIONS
_Semi-Public_
Replacement
Installed by.
Required Slab _
Air Vent
Required Well Log
Well Tag
Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not 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 Person 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 O1/95 rev.l.l
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lv�ne Gle�� �-�-eve� �
Subdivisio
Autho d State Agent
s��. ��.���:
'Tax t�tap # . � � ;Farcel # � 6 �
Se�tion/Lot#
�
� ate
system ar�onessts repr�rent a�,roximate�r�ni�urs osly. The contrnctor must,,#lag t3ie .syste�i prlor io
begrnnbsg the isrstcrllutson to insr�re that�iimpergrrxde is maintained :
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WELL PERMIT �
�LEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map 0 D Parcel #?.�7.► Townslup:
Applicant: 1�/S
Subdivision: Lot #
Location: /5'? 5. �.r/ L�a�l� �3�./e.�G
'l�pe of Water 5upply:
ltequirements:
✓Individual _ Community Public
Site Approved By: �,� �'�� �.o
Grouting Approved By: C�1 �'�� ( oc�
Well L.ag: �
Pump Tag:
Well Tag: _ �
Air Vent: ' .
Hose Bib: �
Casing Height: �
Concrete Slab: �
Well Driller: ��GiV'ne�P
Well Approved by: �
****See Attached Site Sketch****
Liner:
�Installed by:
Depth set: _
Grouted• _
Date:
Wa#er Sample:
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
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Date:� �
PCHD rev O1127/Q4
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Owner: I e
Location:
Subdivision:
• Grout Log n
Tax 11�fap f'f ��0 Parcel #Z�o�
GiyflG'� �Uv�'rn _
Lot #
. - Well Constrnction
Distance From nearest Property Line (Minimum 10 feet) 2(.�
Distance from Septic System (Minimum 60 feet) �_
Total Depth: `2.7 � ft Yield �_ GPM - Static Water Level: Z� ft
Water Bearing Zones: Depth � ft ft ft ft
Casing: L�
Depth: From �_ to �_ ft. Diameter. a� in
Type: Galvanized Steel ✓
Weight: Thiclrness: �� Height above Ground: / Z in
Drive Shoe: �� Yes No Any problems encountered while setting casing? _Yes ✓No
If "yes" give reason:
Grout:
Neat: Sand/Cement
Annttlar Space Width �
Method of Grou� Pumped _
Concrete GraveUCement �
inches Water in Annular�Space Yes � No
Pressure Poured t/ Depth to Ft.
Materials Used:
No. Bags Portland cement � Weight of 1 Bag���_ Pounds
If mixture (sand, gravel, cuttings) - Ratio to -
ID plates: ,� Yes _ No 4 x 4 slab � Yes _ No
Liner: -. ,�
Depth: Date Installed: Crrout: Installed by:
Drilling Log
Location Drawing
From To Formation
2 �e�u a � � %
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. 157 S�/��,r�je �;11S�i,
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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 Health D partment. �
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Signature of Contractor G�s� ID# 37�� Date 2�2C- O� .
Pnmp Installment
\Pump Installation Contractor. 3�►��e-}I-� We �� ��i'� I�� ^cJ �i�, State Registration Number. �� 2 G�
'� Pump Dep t h: % S � ft Static Water Level: Z S ft
�?ump Make & Model: 1 e Z ��e �- Pump Size and Rating: ��� hp � gpm
\ereby certify that this pump was installed and the well head completed accord'mg to the Person County Well Rules in effeet
�is date and that a copy of this record has been provided to the well owner.
` �� �- 2-2r-��
�,Installer Signature .11- �� Date: PCHD rev O1/27/04
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