A40 292. � �o• oo . .
. . . . �'o� C��-� � �9 �'ed V� , �
Aooiication Date: �-�-D� G����� Tax Mau #: �f �
Amourrt Paid:
Recc��ot �: � !/e�e l � � �251 p�, #: a 9 �--
� �� S ���� �� `-� i � �
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APPIJCAT]ON FOR SE3iVIC�S • .
1F THE iNFORMATION iN THE APPLICATION FaR AM iMPROVEAAENT PE3�MIT 1S INCORRECT FALSiFiE�
CHANGED. OR THE SRE IS ALTERED. THE3V THE IRAPROVEME3�IT PEiiM1T AND AUTHOROZATiON TO
CONSTRUCT SHALL BECOME fNVAL1D.
� � ��
.1) remut requ� by: (Owner/�qentllrospective ovm��: .
Home Phone: 3 !� �-�(, � Address:
Business Phane• '' '
,
2) iVame and addr+ess of current owner: � ��j� ��h�
� -�'f SS -
. �. � 3 ��1 a�o�i
3) Prc�erty Descriptlun L.ot size: `� g5 Trnnmst�ip: '� � � Subdivisyon: � � � /�CP;s �{ #�
Directions to the'n�erty (ln�u�ing roa� names and numbers): a� i�� ,
4) Proposed Use and S#ruciure Description: answer eacf� of the foilowing questions:
a) Proposed . Existtng , Type af Struc�ue: � 8� X l� Wldth: ' De�th:
b) Number of Bedrooms: � Number af �pants or peopie to be served:
c). . Basemerr� Yes . No � Wiil there be plumbing in the basemerrt?
d) �arbage Dispasal: Yes . No _
� Water Suppiy Type: Private _(new �ar e�astinc��, Public� Commuraty . Spring
Are any wells on adjoining property? Yes_, No _ if yes, piease indicate approximate ia�tiori on the
.site ptan. �
6� Does your propeity car�in previousiy identiiied jurisdictionai rn�lands? Yes_ No `!
PLEASE NOTE THE FOLLOVYfNG:
➢ A PU4T OF THE PROPEiZTY OR SiTE PLAN MUST BE SUBMCt'fE� W1TH THIS APf��..1CAT10N.
➢ PROPE3tTY L1NES AND CORNE3ZS 11�UST BE CLPARLY MARf�D{�• ,
➢ THE PROPOSED LOCATtON OF ALL STRUCTURES MUST BE STA�CE� OR FiAGG�.
➢ THE SITE MUST BE READILY ACL'ESSIBLE FaR AN EVALUATION BY THE HEALTH D�ARTME3�lT
STAF�. � �
I heteby make appiication to the Person Courrty Health De�artment for a siie evaluation fnr tf�e o�-siie se�nrage disposal
sysiem for the abov�desixibed property. I agree that the cantents of this applic�tion are true and represenf the ma�dmum
faciC�ies to bey�iac�d on the property. I understand ifi the siie is aitered or the irrtended use ct�anges, the permii shali
became ir�vafid! - � _
�
or Legal Repres�ritative
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D�e
PCi-ID. rev. �61ZTIOZ
Application Date:
Amount Paid: p
Receipt #:
0 Improvement Permit (Site Evalnafion)
$200.U0/�300.00 (if> 600 gpd} ____�___
C Mobiie I�ome Replscenjeni or Bu:id;ng Add;tion
�150.OU {if site visit required)
U'JVe[i Permit (New/Replacement%Repair)
$300.00; �2C0.00/$75.U0
��� �f ��ll��`iyl �y Tax Map:-J��
._,.; � • � Parcel#c
������
TE-�:.,�ca-a-na-m�* �.*-* a�satiall IL-3re,,o.�i��.la.
Services
for Services
❑ Construction A�thorizatioc
Fee is deFendent on the type oi
� Pe� mir Re� isiou
Applicati�n: No
1) Applicant Information:
Name: Mar�c� �e���'G 1�
Address: � ��1, ���S,�M DYc
�o y,..�n C o N C, �� S 7
2} Name and address of :.urrent awner (if �ifferent than appli�ant):
Name:
Address: �
3) Properiy Description: Lot Size: _ Subdivision:
Address and�'or directions to Property: _
$150.OQ or 5300.00
���..t'�Ar�.�i
Phone (home):336' S�2' �3`�i �S
(work/cel l): 3 3 6- s� a- 2���
Phone:
c���l �.-� � -��.5
i.-o�-- ��-I�
Lot #:
�LL..
"�EFo2.�
Y'tS i'r"
� yes D no Does the site contair. any jurisdictional wetlands?
0 yes ❑ no D�►es the site contain a��y existuig wastewater systems? y,,�� `p�
❑ yes ❑ ro Is any w:�stewater gcino to be generated on the sitc other than dornestic sewage %
❑ yes Q t�o is th� site subject to approval by ar.y �ther pubi:c agency? �
❑ yes ❑ no E1re there any zasements or right of ways on this property? a�v �� •'�"(
(if `yres' is checked, please provide supporting documentation) f�i� �L1.1�� ef/K.`S
4) Froposed Use and Type of Structure:
p �, — 3 i.��'� S
❑Residential . /
❑ I�iew Single Farriily Residence Nlaximum number of bedroems: o ��� � 11 C�c:iL --�a�.�
C Ex�ansion of Exist ing Sysiem If expar_sion: �ureut n�.ur.ber of bedrooms: �� '�j � i �-�-�-5
❑ Repair to Malfunctioning System Will tl�ere be a basement? � yes O no With plumbing fixtures? (� yes �7 ne
�Non-Residential
1'ype of business:
Maxiniuna number of empiuyees:
Total Square footage of Building:
Nl;iximum n.amber of seats:
5) Water Supply: ❑ New �ve11 ❑ Existing Well ❑ Community Well ❑�ublic Water ❑ Spring
Are there any existing �vells, sprin�s, or existing waterlines on this properiy? ❑ yes ❑ no
6) If applying for `Authoriiation to Construct', piease indicate preferred system type{s):
O Com�en±ional ❑ Accepted Cl lr,novative ❑ Alternative ❑ Other ❑ Any
I certify that the infornzation provided abave is c��mplete and cotrect. I also understai:d tltat � the infvrrncztiorr pr•c�ti�ided is
:naccurate, or i; t/�e site is subsequently altereci, or the ifitendad use cr'tanges, all pes•Y:its and apr:rov�ls sltall be� ii7VQllCil
�
Signature �Owner' Legal Representative*)
'� Supporting documentation required.
6-�G-`Zat3
Date
e Permits are valid for either 60 months or are non-ezpiring when accoinpanied by an approved plat.
� A completed `Lot Prep�ration' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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I���aa-�mm �-�-�. ����.7L 1�33I��.Il�II�
Applicant:
Location: I
Permit Valid for
Type of Facility: �
# of Occunants�
Five Years No
�
# of Be ooms
Proposed Wastewater System:
Proposed Repair: __��
�1
T��x M��� Pa.rcel # - �
S�uhct6vi.s�ioro � .., G�t-
Fh��s�e�Sect�ior� Lot u
Improvement Permit
u New �C Addition Water Supply UG.
�rojected Daily Flo g.p.d. �
—�"� ` �� czs � Type: L a
`— Type: �
Permit Conditions: j�Pirx ��1rn�. n�r� �%s�f� sr�'.k�-. v� C�� �h�h-A:r �f
�-,..�e _ . .
Owner or Legal
Authorized State
Date• �-»-ac�
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Peison County Planning and Zoning and Building Inspections requirements are met This
Improvement Permit is subj ect to revocahon i# the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). 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.
Autho.rization to Construct Wastewat �CIII Reqnired for Building Permit)
* See site plan and additional attachments (_�. � :__
Proposed Wastewater System: �9.s,���.,.�,Y e� c. Wastewater Flow �.p.d.
New � Rep ' Exp ion Soil LTAR: ,�-�S g.p.d./ ft 2
Type of Facility: � —� Basement Yes � No
p_ � � Wastewater System Requirements
Size: Septie- i .� gal, Pump �anl • al- =, Grease Trap: � gal
.J , . ,+ � � ,
field: Tota1 Area: �i'��� sq $� Total Length'" Mazimum Trench Depth � 1&'' in
eh Width i ft Minimum Soil Cover: �( _ in Minimum Trench Separation: � ft
�G Distribution Box
Specifications:
Serial Distnbution Pressure Manifold
Authorized State Agent: � f �
Permit Expirahon Date: s-
The type of system permitted is �onventional
the permit.
Owner/Legal Representative:
Date: 5��3��/
Innovative Alternative. I accept the specifications of
Date:
PCHD7/�0/2002
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�7]LYITOTMT��Cb.�J9.� �Oa.l�
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Natne ��„��-}c�l�� Tag Ma.p # i��iv . Parcel # o�9c� .
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Subdivision ��c� � ��' Section/Lot# �
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Authorized te Agent . � Date • . �
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� nen � resent a roxlmate conto � onT . e.contractor must fYag tbe ���� �
sysrem compo ts rep pp Y
system �prior to� be�lnnin�► the �nstalla�lon to inskre at rroper �ra is maintained. � .
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WELL CONSTRUCTION RECORD
.
North Carolina - Department of Environmeat mnd Naturat R,esources - Divisian of Water Quality -(3roundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) �-� �' � CItRTIFICATIOli N awa 3
WELL CONTitACTOR COMPANY NAME S\� P� Q- f� .r o�' .: W t�� � C�. ti1'. �S �nc. •?RONE N{���1) Sa.`�' ���
STATE WELL CONSTYtUCTTON PERMI'T�I�A`� o�P A�"t C� ASSOCIATED WQ PERMITN QQ`� ee-� �°� �"
(if appliceble) (if epplicable�_
1. WELL USE (Check Applicable Box): Rcsidentia� MunicipaUPublie ❑ Industrial ❑ Agricultucal ❑
Monitoring O Recovery ❑ Heat Pump Water Injection O Other O If Othor, List Usc
2. WELL LOCA'iI0 • p"� Topographic/Land szttin8/
Ntarest Towa: 0 ,�,_ County_„�.,L_f�_ ORidge OSlope OValley ,A�Fiat
�o� k�; ti a � A c r_,r L �`fi' �� � ufi u►-� n D r� (ebect +ppropsiaee bw�)
(Street Name, umbee, Commuairy, Subdivivaa, Lot No., Zip Code) I.at1NL�C/�OAgitll�e Of we111oCStion
3. OWNER: �� tA t1 �`Z.� i101'nC�' �' (�m�'000°�i)
Address �O a- Cti���� � _ Latitude/loagitude aoUrce:OdP5[7Topographic map
(suvet or Route No.) �� b07��
_�,X�'c�c c�. � C... a-1 S� s DEPTH DRiI.i.ING L-OG
�1�C�ry w rown sua zip Code From4 � f To F`rmati o�I�escription
(�.J__ � 3 - $ °� �`! o s 1
Ara codo- Phone number � < <� �' 1°�
4. DATB DRiLLBD� � �" � ` � S � � `X
S. TOTAL DEPTH: � �j a:S� � aC�O � `'
6. DOES WELL REPLACB EXISTiNti WELL? YES ❑ NO �d
7. STATIC WATER LEVEL Btlow Top of Casing: �_�FT.
(Uw "+^ itAbove Top of Cuiay}
8. TOP OF CASING tS �_ FT• t�bove Land Surface'
'Top of culo� terminated ador below iud iwfaes require� a
varianu la aceordanee w�lt61SA NCAC 2C .Ol la.
9. YIELD (gpm): �.._ �THOD OF TEST � � �
10. WATER ZONES (depth): �� �
� , � nrp�pN SK.�FTCH
11. DISiNFECTTON: Type 1�'� � Ataount C U Show direction and distance in mitea from at least
12. CASING: Wall Thicirness h�'� S�� Rosds or Couaty Roads. Include the road
(� pcpch D�iamSe� r or wa�ht/Ft , Matcrial n mbers aad common road names. Q,u,�`�a ��
Fro��L._ To� �t. �- ,.� �S a1V . �' 2.�� Q,,
From To Ft �`�'�
From To F� ��,�\ � !�o'�
13. C3ROUT: Depth • Materisl Method �� ���,.� �
From�_ To�U Ft C,o � c.c �.�Cer �� � „�
From To Ft. — A�r'C.rM r. V�• ` S"'1
14. SCREEN: -- Dtpth Diameter Slat Size Maiaial �. J s� \ n��•
From To Ft. in. in.
From 'io Ft. ia. in. � ,,,,: � .
15. SAND/GRAVELPACK:—�
Ikpth Siu Material � V,�� �.�.
From To Ft.
From To Ft.
16. REMARKS:
! DO HEREBY CERTIFY THIS WELL WAS CONSTRUGTED IN ACCORDANCE WITH ISANCAC 2C, WELL
COPISTRUCTION STAND�e�S, A.N�'['�1AT�COP1'r(JF_Tf{IS $,ECORD HAS �N PROVIDED TO � � OWNER ,
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SIGNATURE OF PSRSO�CONSTRUCTIIdG THE WELL
Submit the original tn the Division of Water Quality, Groundweter Sectton,1636 M�il Servtce Center - Rite[gh, NC
27699-1636 Phons No. (919) 733-3221, within 30 days. CiW-1 REV. 07/2001
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��`P7Ic3::V0►''^'_"'""'" 4Q�CR��.� �Q��.��:.
WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �i Pazcel #�_ Township:
Applicant:
Subdivision• ,' Lot # 1 �/
Location:.�,.,�,. r�, is 1-���„ �� o�, 1-h,�i� � ��i �,., i�c,��.,, C�
�
e of Water Su ly: � Individual Community Public
�'P PP —
Reqnirements:
Site Approved By: 2-%.2�� ` Liner:
Grouting Approv By: ?- 2�-D� � �Installed by: .
Well Log: �^� � b Depth set: _
Pump Tag: � � Grouted• _
Well Tag: �/ � Date•
Air Vent: ✓ �' � �
Hose Bib: V`' ��iVater Sample:
Casing Height: � � ��1
Concrete Slab: �
- � - _-,.�� �.�
- •„ , w, , _ :l . �.��►11.�/
****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 any building foundation.
Other conditions: � �
Date: g– ZS' ��
�
�
I� sa F.� ��-...
i,�-.a Q �
PCHD rev Ol/27/04
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