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Applicatiau Date: � o?� / �� y�� �� ���+�� ������T Tax Map• '4 � �
Amount Paid: ,G1p c�.�0. ,,,,_ �- �1 ��
Parcel#:
Reccipt #: 3 37� �T 10 � �� ������
(��re �•}.L (Q�l�:na•vnn-csuaaaat�na�.nH )�-3�ou�+L-Iln
� � - -
, �� �� �y %� yN�Application for 5ervices
! � - ., _ � � Services
Iui ov t Pcrmit (Site Evaluation)
� 200.0 $300.00 if> 600 d
Mobile Home Replacement or Building Addifion
$150.00 (if site visit requtred)
Well Permit (NewBeplacemeut/Repair)
$300.00/$200.Q0/$75 00
uested
Consiruction Authorization
(Rec is dependent on the type of
Permit Rcvision
Repair of Existing Scptic System
Appltcation• Na Charge/ CA $I50.00 or $300.U0
1) Applicaut Iuform tion: / /
l / %
Name: -� Gt/ /1 �� � �� �i2 � i �
Address: � ,�
% 40 g
2) Name and address of current awner {if different than applic�nt):
NAme:
Address.
Phone (home). '��� 9 9 � - C�.�4�
(work/cell): - �
Phane:
3} Property Description; Lot Size. �oJ� ubdivision: Lot #:
Address andlor directions to Property: � , L��
� , �
yes ❑ no Does the site contain any �urisdictionai �vetlands�
L7 yes no Does the site contain any e7cisting �vuste�vater systems?
❑ yes '�no Is any waste�vater going to be generated on the site other than domestic sewage7
❑ yes !$'no Is the site subject to approval by any ofher public agency�
Cl yes �'no Are there any easemenfs or right of �vays on th�s property?
(if `yes' is checked, please provide supporiing documentat�on)
4) Praposed Use and Type of Strucfure:
❑Resideniial
�Iew Single Fam�ly Residence Maxin�um number of bedrooms. �
❑ Bxpansion of ExisEing Sys[e�n If expansion' Current number of bedrooms:
�J Repair to Malfvnctionins System Will there be a basement7 0 yes �'no With piumb�ng fixtures? ❑ yes 0 no
ONon-Resideutiat
TyQe of business.
Ma3cimam nvmber of emplayees•
Total Squaze footage of Building
Maximum number of seats
5) tiYater Supply, �New welI ❑ Existing Well ❑ Communify Well O Public Water ❑ Spring
Are thare any existing wells, springs, or extst�ng tvaterlines on th�s property? ❑ yes ❑ no
6} If applying far `Authorization fo Construct', please indicate preferred system type(s}:
❑ Conventional 0 Accepted ❑ Innovaiive O Alternative ❑ Other ❑ pny
I certify that 1he ir fo�7nation provided above is co»lplete and cor�•ect 1' also unde�stand that if tlie inforntation provided is
inaccurate, or if th�te i subs qttently alt re , or the r►rte�rded r�se chmsges, allpermits and approvaTs sha 1 be invalid.
� �o l,�
Signature (Owner/ Legal Representative*) Date
* Supporting documentation required.
• Permits are valid far either 60 montl�s or are non-expiring when accompanied by an approved plat.
• A completed `LotPreparntion' form must accompany any applic�tion reqviring a site evaluation,
(10/11) Person Caunty Environmenfal HeAlth, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
49
PAYNES
TAVERN
K
,5�
' A�AP
JAYES 0. TERR'/
0. e. 621, P. 318
EXIST)NC 20'
ACCESS EASEMENT
P. C. 14. P. 2�8
CONTROL
CORN£R
6RAY-MORTON
CE4ETERY
0. 03 ACRE
O.B. 5G7, P. t91
P. C. 14, P. 208
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J�NES D. TERRT
D.B. 627. P. ]�B
5. 67
ACRES
0. & 283. P. 887
P. G 11. P. 67-F
P. C. 12. P. 550
PROPOSEO DISTURBEO �REA
�� � T 7. 523 71 50. R. TOTAL
� � -231.94 SO.FT. E%ISTINC DRIYE
i' \ 21.291.77 50 F7. 70ThL
��� INCWDINC�
�` ORAINFIFID: 4,952.8 SO.FT.
:` .'
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it1 PROFOSED �'
I ` DISTURBEO
� AREA /
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f /�\ '
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� i..�" '\ %.
� � � 4952.8 Sq. Feei �/�
� ORAINFlELD � �
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EXISTING
DR1VE
Ealadnq �,a� �. c�n• ���.., �o�
Exl�tlnq ]ron Piv� (7/s' unt�s� ne
l/4' Iron Pfp� S�t
Ea��tlnq Nell
Noll S.t
Cairyut�0 Polnt
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/ � � / � NORTH CMOLINA PERSON CWNiT
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JOMN J. JENN�NGS �RTIFT THAT TMIS
_!_ I ,' S...CAR��••.,,
SURVEY l5 OF AN EXISTING �ARCEL (OR GMCRS) .•� N O
-��' � �1�� NITHIN PEftSON �OlIN77 AS RECORDED IN DEED BOOK ; O�.' ••SS/ ��'�•�
/�� ta 28� . PAGE �BZ. AND/OR PLAT Sc3 1l� PAGE 67-f .�. c� !/ 7`.
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�� JOHN J. .1ENNINGS CERTIF
VLIIT 11A5 DRAWN UNDEA 4'1 SLPEAY[
AN ACTUAL SURVEY YADE IPAFR YY
PA��.@L �ETC�(07HER�TNATB
NO7 SUNVEYED ARE ttEARLY 1NOICA
iRQV INFOftYATION fOUND IN BOOK
1� TMAT TIIE NA710 OF PNECIS
CULA7FD l5 1: �4� �� ' 7H�17
iftEPARED IN ACCORDFNLE WITH GS
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I���a-�������.11 IC-33L��.Il�1�
SITE PLAN
Name�� M5 Tax Map #� Parce #�
Subdivision Section/Lot# �
thorized State Agent Date
System components represent approximate contours on/y. The contractor mustJlag the systemprior to beginning the
installation to insure that proper grade is maintained
_
—
__ _._ ,
.1.ni�i S� 5{�yh
J
. — 3t� o� d� 3 c� 2
— 3(�0' �cc �(
____- ________--- . _ __ �P'�
,
�� (� ���� �� Tax Map: �yQ Parcel: ZS�
��,,, � , ) Subdivision
� �`'� (� � ���� Phase/Section/Lot N
]E�����-��� ��¢�.Il IE���.Il�II�
Permit Valid for: Five Years
Type of Facility: �
Number of Bedro�
Proposed Wastewater System:
Proposed Repair: ���
Permit Conditions: �
- �.1�1%1�-�(e�e�--5� t
Authorized State Agent: _
(X) Owner or Legal Re�
Improvement Permit
Non-expiring
�T� New �Addition
� l� / Emalovees / Seats:
Water Supply: �e I j
Projected Daily Flow: 3f�0 gallons/day
� 'I'ype; �
Type:�
Date: _ 9-/�-(S
Date: l-s �i�
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in comptiance with t6e provisions of the North Carolina �Laws
n�:d Rules for Sewage Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water sapply will
remain potable.
Authorization to Construct Wastewater stem
See site plan and additional attachments (
Proposed astewater System: ���� �2s� Q�k�{,a, �(*)Type � Design Flow 3�o gal./day
New Repair _ Expans- ic�^� � Soil LTAR: . 25 gal./day/ft�
Type of Facility: — Basement: _ Yes _No
(*) Syslem Types Illb, Ildng, Ii�, and V, require pzriodic system inspeclions by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank 00 gal. Pump Tanlc —� gal. ^vrease Trap gal.
Drainfield: Total Area �•� pKp sq. ft. Total Length 3(aD ft. Max. Trench Depth 1� in.
Trench Width �_ ft. Min.Soil Cover _� in. Min.Trench Separation
Distribution: Distribution Box ✓/ Serial Distribution / Pressure Manifold
Soi
Au�horized State Agent:
�
p,G.
ft.
Issue Date: _ q-/�{-/�
Permit Expiration Date: Q-/y- Zp
The system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: ��_( Date: %� S-� -�
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
���,5� J.�'J�1�.�'C���
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I �Gna.wna-�n��an.��n.�:�.Il IHL��.Il�]En.
_ _._. _ - :.__ _ _ - -,-- - ------. _ __,____._ _ _�___- --- -
SITE PLAN � - -- -------__—_ ----- -_ . _ _._ . _ _ ---- . __ _ _ __
Name ry�5 Tax Map #� Parce #�
Subdivision Section/Lot#
thorized State Agent Date
System components represent approximate contours onty. The contractor must flag the system prior to beginning the
installation to insure that propergrade is maintained
._�_. .: _. . -- ._.
. ..1._ n��t � S �f Si�Cw1.
', Pfe- i ns� l I«{��o� Me�e�h�n � ` 3(� o�� d l 3� R
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IE�.�a���TM,.-„ ����.11 IE-3L��.IL�I�
Tax Map �{i � Parcel # 2�_
Subdivision �1�,4
Phase/Section/Lot # n1
# of Bedrooms 3
Applicant: . Ed,
Location: ( � , � �
oas�- � t�3l�
��err�.��O� }�e�'�it
System Type (From Table Va): Product (IIIg): ��-�.
Type V& VI Expiration Date: A- Type V& VI Renewal Date: 1J
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatm�nt and D:sgosal, antl �ll conditions of the Imprcvement Perm:t antl Cons�r�ction
Au�horizaticn.
� � ub�
(Authorized Agent)
�i2�EraG Lewi s
(Licensed Contractor)
A N�
'. n�'
"1-2�-14
(Date)
1 � 1.0 -�4
(Date)
Scale
PCHD, re•r. 1�/14;12
�'Gynts IAv2trh �
Line Lengih
2
3 g
Total 35
Tax Map: A yo Parcel #: Z$
Septic Tank System Checklist (Type II-I� System Type: �
Se tic Tank InitiaVDate
State ID & Date: Z„ �, _
-t ,/
Ca�acity: P 5- l000
Tee and filter
Baffle ,/
V ent
Riser
Outlet boot
Perm. Marker
Distribution
D-box (levels sei)
Serial Tg _ o_
Fressure Manifold
LPP
Notes•
Nitrification Lines InitiaUDate
Trench Width: 3 ft. �/TS �- zo -t
Trench De th: in. ,/
Total Le�gth: 3� ft. ,/
Minimum s acing: ft. �/
Rock de th/ uality h! }�
Dams/ste downs ,/
Grade < .25" in 10') �/
Cover (6" minimum) ,/
Setbacks
From wells N r• ' e
Pro erty lines _Zo-�
Foundations/basements �/
SurfaceWaier ✓
Other:
Pump System Checklist
Pu� Ta�k InitiaVDa±e
State iD oc Date:
Ca a
IZiser (6" ' .)
NEMA 4X Box
�Iodel:
Piggy back :u
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure Manifold I I
Number of ta s: �
� Size and sch: i
Contracted Certified Operator (Type IV Systems):
Notes:
Tax Map: �Q
Subdivision: _
��� s ���.���
., f
�--�= � � ��-��
���.a����m�.��.�. ���.���
WELL 1�T
(New Repair _ )
Parcel: 2�_
Lot: ___.
i ,,r I I /��
Applicant's Name: � -�' 6e��o �� � ��
Mailing Address: I 3� I ���_ � Qn�S
i�..._s��vrll�.,_._ _- q►q-XIS-29�q <c)
Phone Numbers: � OLyq �'�SQ-�� Y
1,) See attached site p�an Jor prupwYe ► ja�o� govepning construction and set6acks appry•
2.) All applicable State and Counry gu
3,) Permits expire S yeaYs fr'om the date of issue.
¢,) Issuance of a permit does not guar'antee a potable water supply
Other Conditions/Comments: . L_ �_ � I i � ��. ��
,
�
Permit issued by:
CerNficate of Completion
�Tew Well:
EHS/Date
Location: � .� _ Zq_ I 4
Grouting:
Well Log: `D!�
Well Tag: �—
putnp Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer: �/��
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Date: 9–/y /� —
OL,iner:
EHS/Date
Depth: —
Grout: —
QAbandonment:
Date: —
Method/Materials: _
License #:
License #: �—
Date: !�
Date Results Mailed:
Person County Environmental Health , Phone: 336-597-1790 Fax: 336-597-7808
325 S. Morgan 5t.,5uite C
11/26/13
WELL CONSTRUCTION REGORD,
This form tan bc.used for sinslc or �itiple wctls
L Wdl Contracto� Loforcna6oa:
fR-CS 1� /t' ! l� �• �(,�— ��
w�u co�� N�
�J �f� `'�
NC Wdl ContracwrCatification Numbcr
�arnette Weii Drilling, inc.
Compaay Name
2,Wdl Canscraction Pcrmitlt: � / ��
Us1 af! appllcab4 x�e(! corcuruuron pernriu (f.e. Crumty. SrnrG Vorrar+ce, etcJ
3: Wdl Use (check wdl use):
waw�s�P►�wdi:
QAgticuittual O�M��unici aUPuhlic-
�Gcothumal(Eieating/CootingSuPP�Y) �+�idrntial.WatuSuPP�Y��P�e)
�Indust�iallCommercial Oitesideatia! Water Supply (shazed)
Snpply Wd1:
E7AqtiiEa Rscharge OGrolirtdivaterRertiediation
❑Acjuife� Stoiage and Kecava} �Salinity Bartia
OAquifaTest L]StotmwaterDraimge
OF�perimentaLTuhnology �SutuidenceContmt
❑�xCQTf1CClI�2� (C�OSCd �.00P� ��'dCtl
QGeotheiinat (Eieatin�/Coofing l�m) OOther (ezplain nader #2I Ri�atks)
d. i)atc FVetl(s) Comptcted: � 2g "�� WdI.ID# �/ 7��
Sa. `R'ea Locatian:
�c��.c�f�,�����'vP_�/�/ ��""S
FaciGty(QwneENwie --T FacitilpID#(tfappliable)
0 �1.� /IJ�S �Ac%2N ; u-5 f ��s-r $'��
�.� �cy. �a tia
' �F�Sa�
Camtv Pa�cci Idcati5wiioa 1Va CpIM
56. Lafitude aad LongiEndc iu.dcgr�ts/au�uttslsa:oeds or deamat ikgra�
(ifwtp 6dd. aie 1sNoag is m[fici�tj � -
3 6. 3`� ��'� rr 7� - a. 2. 6�3 vv
G"Ls (ue) &� wtll(s): Ctlircrmanent. or �Temporary �
7_ is ihis srtpair to an tzisfipg,weU: OYes oc �
IjJris ls c rxpatr.ff! out�brarm wr,tl aunstnauion i�an med�a dre raaQt of `d�e
++epa'vrmder �2I trmar:a scction or o� thai�ofililtfamr.
S.:Namber oPwdls consirudcd: �
For rm�hiple iryettion or rton-wawavqi[y wdls OKtPwtih lkesamt caxsA'ra�iios: )orr.can
rubrnuwxjorui.
7 Tota! welt depi� below taad satiat.t: Z� � (ft)
iForwudirpld iae¢s tlstd!ldepthx iJdr&+rra (�le-3�200'andZ�tOG')
For [otemat Usc ONLY:
-��d iV[Z£R711NFS:: � ... . � . . �. � . � . . . - �.....�:>� .
Z./6 t'- Z Z�' �� G
st r�
(� � 3CS� � 6%'°' � St�(�2t ��°�G
Ct fL �
ft {L �
SGREEIY
,UM .TO DUMEtER. � SL
� n �
Ft [�. 1O-
: GItOU'�' - -
:OM TO MAITRfAi� � ..
� fL �Q � �ment
ft ft
R K
S,e►fi[fl/G1tA'�EG:i'A� _fi I�btc .i
:OM ro MA�+�
tc rc.
it fL
:DRiGi�P1G"�AG`� t�eEr:�sd�ti�_,,,;�sfii
;OM � 1'O � P��N
C� _ rc _.�_ rc _n11�- c�
��ZsFt�
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,� tt 2� O r� y�'
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ff. �
rc a
22. (:'ertiiicaBon:
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.�. .-� 7-�����
s;��o�c.a�� warc� D�:
qr �mG+g ildrinnn. f l�nby «.r�y dxu ,ho+xplsj �nT f�+�l oonror�ed 6i scowrdance
vfthlS�I NC•4e 02C.OIflO-ur JS.i NGAC OZG _0200 FYd! Cons�ivcti6aS[ai+d6rrlr mtd Ihola
�?Pl'afd+ts xau�thosbe�+Etmvided m'die �eeit ovrter.
�3. �te'dirgcim oCaddifioualwel! dttaiLi:
YoU m�y us� 8ie �k af th'cs i�$t � P��+de: aaditiaiaZ wcll. sitc defails tic wtll
t6ii�7aa dda�s. 1'on ma}+stso.attarhedditiocial pages ifi�siy
SUBM�ATAL IlVSf UC�7ONS
24a. For Aif �3'tIC� Subsnif this�Sotm wi�hin 30 days of canpletibri of w�ell
o�Ystiudioa fb the foilowii►�
10. Static lvater fevel bdote top of casing: �� S tr�7 n�oa ofw3c«�Q�uc�, Infurmatioo Yrocessiog IIui4
!ji«aterleveGtsabove castrr& rar '+- 16171VIatl Service Ceater, Raleigh,NCi'769�-1'617
11_ Sorehote diaineter. � �n:) 246. Fbr Ioiectioe VKdls: In addition W s�@ing the foiin to the addcess in 24a
abpve, also sttls� a cApy of tf►is foint withirt.30 days of bompktion uf aell
� canshu�tiari to tiie followQi�
12. Well construction.mettrad: /`�r � [�,� /� /P `�
(ic au� , cotaiY. cabk, d'uod past� erc.) j�y j��ori ef Water
Qualit9. [T¢dugruaQd.Injection Conhd Pingnm,
Fali Wi1TER SUPPLY R'ELIS ONLY: 1636 i►�ail.Serviae Center, Rafeigh, N+C 27fi99-1636
i31 Ydd m, 31i 1►ict6od oitak BIoWn20 minute 24C �ot'iirlta.SgdW9 Bc.Iniedioi� �Vdis (n addition to sending 1he forin td
(SP ) the add�e.st{as) alloves aLso submit one oopp of Biis foiin within 30 days of
compidian o€ wd! constNctioa to the ca�unfy hca1W dcpartmart of the county
x3n.v�f�aaa�: HTH �a�� � 1�'�i Cup ���.
Fam GW-1
Nad� Caroliaa Dcpa�tnwt.afFnvicoumcnt ud N:h�nl Rrso�ecs—Div'sim of WaterQiraGty
Rcviscd.Jan. 2�13
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