A40 266�
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B 1296
PERSON COUNTY HEALTH DEPARTMEN'I'
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT 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 # f[ yo Parcel # ,z� �
Zoning L�� t,.).Q►,� �.,� CT�°wnship 'c.4 T i�
Owner/Contractor Date io z
Location/Address y95 Tlc �nr nroaN �.ov�� �-,/c a.� �AYN�S
i Av�iPnl �D � v �-s�cc ostL GFr= % S.R.# //yZ
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
epair Lot Area S 9 7 A c Size of Tank �aoo c;,o �
SFD �/ Mobile Home Size of Pump Tank io n o 4a `
Business # of Bedrooms�_ Nitrification Line �/ov' �r.3'
Max Depth Trenches �o �� - zs� "
Permits may be voided if site
Well and Septic Layout by�
Comments: �v.�-�? s ��
Date 3-25-99 Installed by
altered or intended use
w . l !
- 'foo'
Approved by
ell Permit Paid [t� W�LL SYSTEM SPECIFICATIONS
iividual t% Semi-Public Required Slab ''
blic Replacement Air Vent �
:e Approve� Required Well Log ✓
ell Head Approved ✓ Well Tag �
outing Approved 3-/G -99 fl�. ��ose �j, 6✓
Comments:
Date 3-�S"-99 Installed by ,Ev�.%� Approved by
! : �e r �c i c.q
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 in%rmation
contained in the application. The enviroamental 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.1.1
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PERSON COUNTY HEALTH IDEPARTMENT
SUBSUR�ACE �VASTEWATER SYSTElY,� NdONITORING REPORT
��� �-�.S-f�Qq �b � �
Date of Inspection System Installation Date Type Tax Map Parcel #
1/l[� ��,�oe �l�,iPvv, � IC��1r.vo .UC, .��1�')7'
Property Address
Instructions: Check yes or no far appropriate items and explain insgace provided for remarks and
camments. If an item is not applicable, indicate by "NA". If an item is not or cannot ba evaluatea, indicate
by "N" and explain. Nota thai this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in t�e permit are tv be carriPd out,
INSPECTION RE3ULTS
�OLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infiltration and surface water diverted 7
�eptic tank needs pumping ?
�Inches of solids:�
Septic tank fiiter cleaned 7
FFFLUENT DOSING SYSTFM:
Required pumps present & fucctional ?
High water alarm operating properly 2
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ? .
Eff�uent free of excess solids ? ,�
Inches of sblids(pump/dose t •):�
Elapsed time raadings 7
Counter readings ? a
Drawdown rate:
YES / NO
o � ❑
a°%oa
❑ / ❑
►
.
❑ �
❑
■ •
DISPOSAL FIELD:
Evidence af efiluent surfacing 7 ❑
Evidence of effluent ponding in trenches ?❑
Surface �3 ater e�ectively diverted ?
Di��ersioas/swales pro�srly !nai.n#ained ?
Vegetative cover maintained ?
Protected from frafnc/unauth�rized uses ?
Distribution devices in good condidon ?
Fielu free of settted or low areas 7
/
/
/
/
/
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/
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REMARKS
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C�, � Su (�� i v�� s yS�e�-, �
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�rnv�P��-P�-�- vc�-�- 5 a ►�w -
PRESSURE DISTRIBUTION SYSTENi:
Tumups/cleanouts/valves/taps intact &
accessible7 � � ❑ fss�•l� "`"`-'
Pressure head properly adjusted ? ❑ � ❑ nlGt � �D �a� � �
COMPLIANCE:
Compliant
Non-compliant
�
Needs Mamtenance ❑
A.U17i i i0lvtii CONM�ivTS: �Q'�-e %lr� �� k a L4 ��-, �� � I �l�l�� �l,��l�
sS�e�- �� �` i�or-►., ,�.
EHS
��
Application Date: 11 '_��
AmountPaid: 7� �o
Receigt #: 9 3� _.
�� � 03 �( �
�
� Improvement Permit (Site Evaluatfon)
.�2ao_aoi�3ao.00 (if> 600 �ndl
Mobile Home Replacement ar
�150.00 (if site visit requir�
eIl Permit (New/iteplacemec
$3Q0.00!$200.0�
�-.�?, � 1L 11'�J��.��1� Tax Map: �
�" � � � ��,�.� Parcel#: ��.-�-
3E��,-i��-»^8�� 7H[��.D�.
for Services
G� Cvnstruction Authorizs
(Fee is dependent on the
G Permit Revision
L� Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1} Applicanf Informaiion:y��,�f_
�aI[16' �GLty7 f%d'�n �W��f � r 2L..'�� �
Address• n. ts •�:r :li,��. �
• �-�'iif.��'i, Z �"%S %"
2) Name and addr of cnrrent owner (ii different thau agpIicant):
Name: '
Address: i � c, 7� ✓�r c%
3} Property �eserigtion: Lot Size: Subdivision:
�ddress and/or directians to Property: 1�'L��, ��r
�.rn .,, -1 - - .-'r l_.�
Ci yes ❑ no
0 yes ❑ no
❑ yes Li no
❑ yes � no
[7 yes ❑ no
Phone {home): ��(� ��� ' ��LL
�WOI�iICeII�: /�'7��5^�' �� �1���
Phone: �336 � S`�7 ' 3`�l9
: #:
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Does the site contain any jurisdictional wetlands?
Does the site contain any existing wastewater systems?
Is any wastewater going to be generated on the site other than domestic sewage?
Is the site subject to appraval by any ather public agency?
Are there any easements or right of ways on this properry?
(if `yes' is checked, please provide supporting documentation)
�) Propased TJse and Type of Structure:
❑Residential
µ✓r: ,.
❑ New Single Fatnily Residence Maximum number ofbedrooms:
0 Expansion of Existing System If expansion: Current number of bedrooms:
0 Repair to Malfunctioning System Will there be a basement? ❑ yes � no �th plumbing fixtures? ❑ Yes ❑ no
I7Non-Residential
Type of business• Total Square foorage of Building:
Maximum number af empIoyees: Maximum number of seats: _
5� VYater Supply: ❑ New well !� Existing Well � Community Well � Public Water Q Sprino
Are there any existino �vells, springs, or existing waterlines on this praperty? � yes fl no
6) if applying for `Authorization to Constract', please indicate preferred system type(s):
❑ Conventional � Accepied ❑ Innavative ❑ Altemative ❑ Other 0�Y
I cert� that the informaiion provided above is complete and correcL 1 also undetstmtd Ihat if t�te Infot'mtufon prwided is
inaecut�ate, ot� if the site is s�bseg�en�y altered, oi• the intended zcse changes, all perniits arrd approvals slzall be invalid.
Representative�`)
� Sunnortin� dacumentarion required.
y-�y-i�
Date
a Permifs are vaIid for either 60 manths or are non-egpiring ti}�hen �ccomp�nied by an agproved plat
a A compteted `LotPreparation' form must accompany any appiieation reqniring a site evsluatiou.
,, ,,., „ n,._.,... r-�..,,..,�, T?..«mr+rnPntal �Tt�.alth_ �75 4. �UlorgSll St_ S111tE C_ Roxbaro. NC 27573 (336-597-1794)
Tax Map: �
Subdivision:
���.sf ���.���
�- � � ����
IE��n� � ��m��.�,Il IF3C� �.11 �:1�
Parcel: �_
WELL PERM�
(New_ Repair )
Applicant's Name: T�1' � � i
Mailing Address:
G
Phone Numbers: 3� (� — S9 7— 39(R
Lot:
Location of Property:
�
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.
4.) Issuance of a permit does n t guarante a potable water su ply
Other Conditions/Comments: __��Y r� t�P.� -�o � h S-i��; l� /i�► �✓
Date: �/— Z7'� �
�1ew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Certificate of Completion
iner:
EHS/Date
Depth: `15, 7�.2,$-l�;
Grout: t/` �_�
DAbandonmeat:
WellDriller: �n1�.Y �/1117�it'd5
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
il/26/13
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Owner: � �
Locati . �-�.�.Q._. . _ .. . . _ ._.------ -- - S�#� � . .
on/D' ectzons: L . --. - -
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Drillin ----� _ /
� Contractor: _ :...._....._ ..__....__ .----� ot
�i!-�'i �..__..I.JL.. �/f .. J,��',=�_f.l�n_. _G__ r�.c.
WI;I.( C'C)Nti_C'RIICI'[��N ��
... . .;', i
Distancc from Nearest Pro1�ci��y Lii��:.__�- ���_ llati�;ln�` ��om Sollrce .
Pollution_�o � ,d /� � � �f � •
Total.I�ep.th:. �- Ft. �'iclu. >
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Water -._ �-d—...--- �'� M .Static WaterLevel %Z `.'
Bearing Lones: Dc, t11. , �Ft;`::
Casin . . 'P _7�=---�_1 t._..�Q._ _�'t•��_Ft.�-�-.-
g: Depth: � From �t. .
TXPE: Steel �----�0._..6�._..__�'�. Uiamc�cr: ' � Inehes
X.�Stec; , _...Galv:lnizcd Stccl � . • :�°,;
1 does owncr approv�:: �'�:; N� . �� �
' Weight:� rr��CAU1�.J�. /Ir LI 11� ( 1�(J ^
Drive Shoc: Yes_ ✓Nc�__.__. , � Ground:��_�lnches�:��:��
Were Problems E�icountcrcc( in Scttin�;- t11e C;,sin �� Xes �� ��
IF "ycs" give rc.isvii: .fi • ----� No z---�� �,�;
------,-;:.:
Grout: Type: Neat ` ---....--- � � :�::.�:�
S:�,id/CCi]1CIll 4� Coricrete ' ' � � =�;��'��'
Annular.�Spacc Wielt�� .� - ..ta:,�
...__.. _ _ T� �ch�s '",�. ;
VYatcr in Annular Spacc: X�:s .---- .
Method: �uni c ti , -. _--...__ fVo=�
P� �.----_ I r�:::;:ucr 1'c�urc:cl � .. ... .. � � . •�:u
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Dcpch: From ----- ----- --- .,,'� �
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Matei-ials UsccI: No. k3.i�.s ,l'or[(,�rid Cctnc t -,����
n_. 1� W cight of 1� ba .
If mi�tui-c (sancJ, gravc:l; cuttir���ti) - R•i[ic�: _� �=-`�1b�;4
�D Plates: ,. ` -- . �
Ycs � No . �� � . . .. ��`Y����"w,
� x �� :lab -- . _ ..._ .. . ��;;���;
: Yes_____�No - . ��� �;
_. � a,
--------..._.-----»[:I.l,[,INCr �.CX� .,.:;'.
l�e tl� ---- -----
To —
Fr�m I . -----_
�. — � � 1 urrnatlon Dcscr�pt�on
f- �------ -_...___ ----
. � . --. __ - --. .. _.—�..____ .
Z HEREBX CERTTFX T�-IAT 1'I-IE �,I3nVL 1lVFpRMt1'I'�ON IS COR
T�S WELL WAS GONSTP.UCI'ED I(� ACCORllA,N�,� y�rZTI-I REGULr'
FORTH B y.T�.� L P�RS ON C'0 U.NZ'�' I�I 1;A 1.,Tf-I DEPA 1�'i'M .-, A
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Sibnaturc c�l�Cont;,�::tc;��
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