A40 33The District Health Department
Orange, Person. Caswell, Chatham, Lee Counties
Water Supply and
IMPROVEMENTS
.� . . � _ L
Owner:
Sewage Disposal
PERMIT No.�
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Contractor:� � �"'Nc�:�
Water Supply:.Priyate � ;,_ •- Public
,
. . 4 . �,
Sewage Disposal Faciliiies: No. �bedrooms Dishwasher, Disposal; '
.. ; .
washing machine, other autoriiatic appliances
Size of tank: %� d� Nitrification line: �v
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMB�R OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:_I��— 77
Well: �
By:
,` ' �
Signe t"- �
� Sanitari
Counter-
signed
(Owner or his representative)
Certificale of Completion ., �
r;)
Date Approved: ���� By'
. itarian !
(OVE
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Wrste in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
Apalication Date: 6� I�� Tax Map: #: ��
Amount Paid:. � - �
Receipt#: 6 �. � Parcef#: 33
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� APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT
SHALL BECOME INVALID.
�' I Z ` t,�/ 'l
1) Permit requested by: (Owner/agent/ rospective owner): � � � �f � � �/ x � �
Home Phone: ,� 3�- S� R— 5�1 �� Address: _� u �c- l l(� �� �
Business Phone: � � � � 5 '73
�
2) Name and address of current owner: ���� �� ��� L, t� t�,�e_. �aX `�,�-
� e � � l s � � , �� �:-
� ' S�3
-�r— �� � �
, � �- �
3) Property Description. Lot size: ��� Township: �v� �' Subdivision: Lot#:
Directions to the property (Including ro d names and numbers)• �
r� � 1-�u �� ( e >l/t'� ( �s ( �
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed _, Existing _, Type of Structure: Width: Depth:
b) Number of Bedrooms: Number of occupants or people to be served:
c) Basement: Yes _, No _ Will there be plumbing in the basement?
d) Garbage Disposal: Yes _, No _
5) Water Supply Type: Private V(new or existing �, Public_, Community _, Spring _
Are any wells on adjoining property? Yes ✓No _ If yes, please indicate approximate location on the site plan.
6) Does the property contain previously identified jurisdictional wetlands? Yes _ No �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. 1 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.� n n ^ � > �
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Owner or Legal Representative � Date
PCHD, rev.10117l01
•Application Date: �.' �
Amount Paid: 7 `��
Receipt #: L 8�� a� 7
�e� r�s� .
O Improvement Permit (Site,Eyal�atiQn)
$200.00/$300.00 ( f> 600 �nndl -
�'1 � �.�'`s
�� l, ) f �11��� �l V� Tag Map: u�
y.,. ,�.��- � � ���.,.� Parcel#:
;� �'21'q11`lDII�]33SSitZ'�All �HIQ:e3LL��1.
ilication for Services
Services Reauested
�; .. C� Construc�,on Authorization
�' '` �.- `� (Fee is denendent on the tvne
O Mobile Home Replacea�en�tnr Building Additiun �,
$150.00; if site visit re uired ''
Well Permit {New/Re cem�n epair
� ��nn nnie�nn nni� S n . - -
I❑ Permit Revision
• ❑ Repair of
1) Applicant In�ormation: �
Name:. �+'��l �-4ex�' 1 Y ��AX�[�.S SnCr
Address: r '
h +�.r� n.1� �7
Z) Name and address of current owner (if different than applicant):
Name: � ' � "
Address: ��
2'1 �
Septic System
aree/ CA $150.00 or
Phone (home): '�i��-�y22=4���
(work/cell): 3��$ � C�f�3�o
. �
� � � ��� �+�`/l�I�1I�J
3) Property Descriptton: Lot Size: ,�_ Subdivisioh: Lot #:
Address and/or directions to Property: �cJ l� }-1 lifC�. [e� M�\ l S 1��
❑ yes ❑ no Does the site contain any jurisdic6onal wetlands7
❑ yes ❑ no Does the site contain any existing v�asi�water systems?.
❑ yes ' CI no Is any wastewater going to be geneiated�on.the site other than domesric sewage? �
❑ 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 documentation) ' C l0 �i
.. . "
4) Proposed Use and Type of Structure:
❑Residentia!
e
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
� Expansion of Existing System If expansion: Gtixrrent:number of bedrooms: -
O Repair to Maifunctioning System Will there be a basement? I� yes � no With plumbing fixtures? ❑ yes � no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
M�imum number of seats:
.
� Water Supply: ❑ New well ❑ Existing Well � Community Well ❑ Public Water ❑ Spring;
Are there any e�cisting wells, springs, or existing waterlines on this groperty? � yes � no
Please note any I�own ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional � Accepted ❑ Innovative � Alternative O Other -_ ❑ Any
�- • . -
I cert� tha the information provided above is cornplete and correct: I also understand that if the information provided is
inaccurate�he site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
gnature �wner/ Legal Representative*)
Supporting documentarion required.
_ a •�.3 -l'7
Date
• Permits are valid for either 6Q months or are non-ezpiring when accomp�anied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
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,11IC, I I SITE SKETCH .
Name �Ai i ��� a� �� 1 Q�2 Tax Map #� Pa.rcel # 33
Subdivision Section/Lot#
l/��4-fl 1
Authorized S te Agent � Date
System components represent approximate �contours only. The contractor must, flag the system prior to
beginning the installation to insure that propergrade is maintained
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Scale:
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/12/01
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WELL PERMIT
PLEASE SEE ATTACHED PI.AN FOR WELL SITE LAYOUT
Tax Map #: � Parcel # � Township ��CL�' ��VZ°,�
Applicant• V v i � ��� M �/�% ► �G� �
Subdivision: Section: Lot:
Location: N U, ('l,i �E'_ � i� l S � C�3 �1 � Q.Ci'�5S �� Q;�-
�� � i�� an �,-�� a� � �' � ( �
Ty�e of Water Su��ly: ✓ Individual Community Public
Requirements•
Site Approved by
Grouting Ap oved by � —� v�
Well Log �
Well Tag;
Air Vent
Hose Bib
Concrete Slab
Well Driller. �\PQk�
Well Approved By: Date:
'�See Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building foundation.
Other conditions:
PCI-ID, rev. 09/07/01
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Tax Map: �d Parcel: �
Subdivision:
WELL PERNt�
(New_ Repair_)
Lot:
Applicant's Name:
Mailing Address: �
Phone Numbers: S'99- �b 77�
v^�-�--r-a
Location of Property:
Permit Conditions:
1.J See attached site plan for proposed weil location.
2.) A�l �pplieable State �d County regul�tiorrs governing c�nstruction ayid setbac�rs apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potabde water supply
Other Conditions/Coraments:
Permit issued by: � Date: Z
Certi�ic�te of CotnpiPtio� ��`' �!l �ari�b�/�•v/�
�Tevr Well: � r , � /`�C��� �2i���'h�
i��C: �
EHS/Date �' ��� �� EHS/Date '�'�
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air �Ient:
Hose Bib:
Casing Height:
Concrete Slab:
�, } alvvny ���
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Well Driller: 5,/��s�
Pump Installer:
Approved by: � �
Additional Comments:
Date Saniple Collecteci:
EHS:
Person County Environmental Health
325 S. iVlorgan St.,Suite C
Roxboro, NC 27573
Depth: '� `
Grout:
��l�
QAbandonment:
Date: _
Method/Nlaterials:
License #:
License #:
Date: 3y���s��
Da�e Resuits Maiied:
�hone:336-597-17�0 Fax:336-597-7808
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