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A40 342
� . ' � � a 7-� a �t��, o�: � � l�'d,�G � O �2�3°3� d �� � ����,1�,03 • • u -.� L! � : .� �ii _!i � ' r `1' � -� =� . �.� i . • ��L � 3i�� �i _ Pac+cel #: l�h+�Sy 1F THE INFORNIATION IN THE APPUCATION FOR �AN IMPROVE111ENT PERMIT IS FALSiR�. CHANGED OR THE S1TE 1S ALTERED. THEN'THE 1MPROVEiUIENT PERMIT AND AUTHORRATfON TO CONSTRUCT SHALL BE�OME INVALID � 1) P�tmit reqtwstied hy: (Ownafag�ltlprospoc.ttvo owiler�: .'�n ,.�., �, u k� n�<� k��s tiOtne Ph0�1et .'� l�,1-1- �.S l� -a • A�ddrosx �S 4_5' � N-� � rnl! � m 5 I!s /�I� 8tt�esa Ptlone: ►� " 02 „-��1. �, � n Z� Nam. arw addc�s a cur�r�t �ow�: .��,�, p 3� Prop�Ky D�scrtptioc� Lot sts� �, D�r Ta� �� Diradions ta tt►e property pt�q �d �acnea ��ba�sk c. � ���a � c. f"�4= 4) a1 Pcopos�d Ua� and Structun Doscrlptlan: anawa esd� af thn tdlaa�nq quea�ona: si �P�� t�E�q � b) Stlydc Suit 0. Moduia� �. Sicqle Wlde 4 Dcuble Wide �Y � Numbec ot eedcoonsa: �„ � Numbar ot oc�. oc p�i. m be s«r.d: y e) Ba�C Yea q No (3-tf yea. � of baaema�t 3xiucex A Gacba�e Dis�ak Yas q No cY `" QI 41�nensionsof Proposed SUvcttue: VVkith: �. Depttx 6a VYabr 9uppi�►1yp�: Ptivais q(t�ew Q ot aodatlng �j. Pubifc 4 Comn�dY Q Spin� 0. Acs acry weqa on adjoin��g pcope� Yes 0 No l'�lt'ye�, locatlon 6� PMas� Indicab Daii�d SYsmcn Typs: isy�a�ms can be rallo�d In c�r ot Y� P�l �'Coaventtona! Mod#ied Cottvfntlonal _ Aib�ttia�tvr �jnnovatlw O�hr �: -� � CLEARLY. STAKE ALL CORliER3 ANG L1NES OE THE PROPStTY. � 3TAKE THE CORNERS OF ALL PROP08ED sTRUCTUR�S. PLEASE ATTACi�I SURVEY PtAT OR SRE P1.JW TO TH�S APP�ICATION I He�abY mske a�B�on to tt�a Person Caunty Heatth DaQartmak 1bc a a� avaivatlon ior the on-siLs sew�qs dVPosai sYst� tha above�descsibed property. l aqree tt�at the contenb af this appli�on ace troa and te�ueaent the ma�dsunn i�ias ta ptecad on tteee proQecty. ! understand d the site ls alfasnd arths ��iended us� d�anpes. ihe pem� st►a�Y bec�ne inYeiid. l� ttmt as ap�Carrt, 1 am �aspons�e fa idaWlying and marbn8 ProP�Y iinea, c�neca and moki�tg tlie s�e a�s iar pecsonnd af the Pe�sott Couniy Hesqh Dapartrttent to canduc� tt�ir avak�attocu. I t�nd lhat 1 am t� t� �9 Hea�h if my ��c� any wetlanda as dai�0ed bY the Army Ccxps of Er�rs- /� . �,...� � a- � _ o" o� 1�1 R�c�tattve . Oatie � 0 Tax flAap �k /"�'/ � Puwl � " ' J� Z �- - Zoning Townshlp Ol, �ie � qpplipe� JGiWtYYLt{ AW k-��n $� . �ew�: — t,� i I� Q�.� 1,..� r�e • a'(�-'�� �� subd„►+s�on: �;t�r_c�1cT, I�t�s s.won: � � 5�' tmprovement Perinit A building aermit cannot be issued with onlv an Improveme�t Permit New ✓ Repair Addition Type of Strudure � Water Supply �l) e t( . # of Oax�pants #•af 8edrooms � Other Basement'1 � Basement Eix�ues? �! a Projeded Daily. Fbw: � g.p.d. Pertnit V�Id For: � Five Years ❑ No Expira�on Proposed Wastewater System Typa: �hVE�N�I701�lGf � Pump Required? Yes k No Proposed Repair: � 'T'�►„�a h�2-- C�a.��er' t � � n �.. e Petm'itConc�lons: �'Peo Sr�Sfei� S'�w.,w_ .�-r-ia. bu,%��K4 ,5vk /�an, k�vl /c� ti./K. Owner or Lega! Represerrta�ve Date: �li C� Date: !/ � •Ov The issuance of this pertnit by tha Health Departm\'e.nt in no way guarantees the issuance af other p�m�its. The pem�it holder is respo�bla for chedcing with , appropriate govemtng bodies in meedng thei� requirements. Thls site is subject to revocation if the siie plan, plat, or the irrtended ase changes. The Improvemec�t PeRnit shatl not be affeclsd by a change in ownerst�ip ot the site. This percnit is subJect to comptiance with the provisio�s of the- Laws and Rules for Sewage Tneatrner�t and Disposal Systems of the North Caroilna Adminlstrative Cade. Autt�orization To Construc! Wastewater Svstem (Revuired for Buildi�g Permitl � Type ot Wastewater System Conves..� o►za.� Wastewatet Flaw: �g.p.d. Fac�ity Type: 1 B� 1� S� L� e�v'fi� New� Repair OE�pansion ❑ Hasement? 0 Yes ��No Basement F�riues? 0 Yes,�3 No Wastewater Svstem Reauiremer� ' • - ' . � � �' :Sepf� Tank Size: �� ° gaUons Pump Tank Siza: '`-- gaqons �/��� � . • Total Trench Len �� feet Maximum Trendt De /� iru��es A regate Depth:! �\ ��� . gth: . . Pth' 99 �� dy� ��' �e.. �%x�� Maximum Soii Cover: � tnd�es Tr+ench Separation: / Eeet on CBnter - '%)-/I-�3 ' o��:`%`� � `` �a�,f oha/ So�'� Caver �� �c,',-�l�- � . Permit Expiration Date: /! - a-�- - O S v Authorized State Ager� Da�: -19 ���- • dU . F The type of system permitted 0 does ❑ does not differ trom the type specified on the application. i acrxpt the speci8catlons of this pernitt OwneNLegal Representative Signature: l�Ct'✓i. Dabe:/ I i6 � ' .* uL ya , u�� s� PCtiD, tev.11/18/99 . y,�. �t � V4. 9� � . . _ .._ _ . _._....._ _. ..__ ___. ... _ . _. . Person County Health. Departrnent Environmental Health Section Tan Map #• �� Parcel #: S�T� Sl4�TCH __ _ _ _ _- - �-� �}�w��s A pllc t's Name . Authorized at Agent Qa�1d r�s �-o+ 5y- rs Subdi isioNSection/Lot# /�- 3--a- • � o Date System cort3Pone�ds represent approxlmate cnnto�rrs oaly. The contraclor must Jlag the system prtor to beg�ie� tlie installation io ix�ure lhat proper grade 3s malntained - Q�a�--r��,��.�e. �j �b) � sef-f�� � ;''�`, C�GS�- "�� s I Tr v-�w�a� �� � � �n �x6a � b; /e �� �D�►°�IW � �% \�-�'� < f ' .i.f�-1. - + •�� [:� � � '�a'`�,.% � uIel��C� �r.��-o3 � � � \;� �� �� ^ —. _ ��1 � � � �-_.. .�, �_ `. �' �_. ...�_. �. � .. _ --_ __ _—� � o�cn, / �o fi c .�,'lCov�r ,i/ee�'�p/ TiJNaV hTi Ii E ChtP�M9�R 'K,��+�c#t R R�f}• � �- _ — � Scaie: _ f f` =1f 0� ��.� . - ro � � �� � ���� �� -�y�,i,i�� � � � ���� 7E��.s-�� � ���.Il. IF3L�.�.7i-�1}�. �1x ful�.� �/ parc��l r S�uhci;ivis�ioii � �, �I, r: Fh:�:Se'Secrt�i:a�i �Lot r � Applica� �c�. �n � Locafion: � s� � � l�; �z O L�.� � C� �, ��.��aQ � IS'' _ to� o.. t �-I � � . � �� �ra#ion: Pernnit . ., . � � System Type (In Accorrlance With Table Va): �L O� '' THIS SYSTEAA 6-lAS BEEW INSTALLED IN �COMPLlANCE V►IITH APPLIC�►�L.E NORTH CAROLlPlA GEPIERAL STATU'TES,. RULES .�ad� .$EW�►GE���T�►i"NIENT AI11D- �DISPOS�►L, AND Ai.L COWDITIONS � OF T�11� IMPf�OVEMENT � PES�IIflIT . AIdD CO1VS"6'RUCTiON . . .. . " . • .. _;.� �:lc?:-c�,. .� .. . ' . .Authorized State;A t , • � a5' . � • . . . : �Date . . . . . ln talied By. 4� � � . . .. . te: � \ � 1 � �c� ' � � . `,s��s . _ . .. .' , . �. . � ' . • . ',���� ' . ► • ' S " � � , - .. :.�:. �2�� .. . 's'�DYy ' . • ..��35 � , . .' .. --- . .. . • �o �� : . . . ._. �!7/a . .-'?llia --�. . : ' .... 1�-�-4:� ��. '. . .. .• �. . . . �� . . s��ra . ssh ' �� . � . t o5 • ZI�J • � • V ` ��,1' : jS �a . � 4�,7a %c7 . loT� S1 �4S'I� . s' � Sl . . 5"� ��--`'".'J , . 55��' , 4.�,�a 45� i 35' l�`7 � . oh . � _ �� . � 0 � " �i' Yr-1c��3 p-ss -a��o �i �3 -'�a �l i--iau.�- . -���, rev. G7/29IO2 S�3�i9C T�RiK (�J����'�iON C�fE��.I�i {'�'�p� t6 - - T�x Ma� # A� Parcel # 3��a System Type {Table Va) _s��� OwmeflAQpiicantSc�,� ���s . Subdiyision �c�k-r� c�Z � � AddresslLocation � Ser,lPhase Lo# # . Septic T'ank ra a�� o c�on aaes n�� t� . . St�te ID/date �-(Q-a3 S�r3- �� � Tranch Wid�th ft. ' 11- i�fo Capacity. �-lc�. gal. � � .�, Trencf�.De th f rn. ' , �.��.U� �• � Tee and Fiter �i��a Trenct�.Length � fi. �� ,r��a�3 Baffle � I-i Trench Grade . � Sealarrt - ,.o Trench S acing � . .� . � Riser ifi ap (icable . a-�3 Rodc De th and Qua(' � �,,., Tank Ou�et:Seal ,r-, -�z Dams/Ste downs etc. � ��. �� � PeRnaner�t Marker � �,,,a,�3 Pressure Laterais � � : P�� �Tank . � Hole Spaang . . . tate e � � o e. �ze .. - � . � � - . � . Capacity . . al. � Pipe Sieeve . � - - . � . . � . Waierproof /Sealarrt � Tum-u s}Ptofiectors ° � � � . Riser � � �4�equi� Se�ac9�s . . 1Naier Tight � - , From UVelts •. � � � � � ,.o . � . . Puov�p � Fmm Pmperty lines � . - . � �#aeck Vatve/Gate Vaive . , ., . : .Struchares/8asemertts.:: � �.� . - � � -siphon o e � � rt es - raina � e ays � � � � - � .� �ioats/�wiiches � � : � � � . - � . . . � _ : . � �Surface` Waters . . . _ , . _ .. � - .. _- . Alarm visable and audible ; Public Waier Supplies _ F�ectricai Componer�ts � Vertic�l Cuts (>2 ft . . ` ,/ Rate gpm � Watear Lin+es . Appr�oved Pum Model Vehicle Traffic ;:� � Biocic Under Pump Ad�acerrt�Systems � � • � � . � Pu Removal Ro e/Chain Easeme�rts/Ri � trt of 1tVa � �Dis�bution Systern �e� Serial Distribution '� Easemer�ts RecocY3ed �. ressure an' oi erator r�fiact Low Pressure Pipe • Tri-Partate Agreemerrt � Appr. Pipe IViateria! and Geade � Vaives . . � Coaninera�s� . _ pct�d rev. 31'13/�1 � ���.��- ` �'�I�� �� -., � � � ��°��- �SL'���1�^�mm-mn-n.�^LZ��.� ��..�.��� °/Y Y:+Y.�� ��$O1VS8 S �'�ASE SE� A'��Cg3EI) P�N ��It WEI.I. SI'I'� I.A�'OU'� 'I'ax Map #: � u� 1'arcel # 3�-�_ 'I'ownship �pplicamt• C��`'� Subciivisioai: See�a.on: �.ot• �L� --� �� ��. 1�,�HF iZz -� '�� �,-. w:�z �s� l� � bn C,�i , o�-tt,t,n.l.e. _ f`�- 7 -iy` iv �'-- �•, 'I'y�e of Water Su��nlv: ✓ Individual Community Public Res�u�e�aents• Site Approved by �55 11 � 1 a-�3 Grouting Approved bp CS`� [ 1�-la-�c�3 Well Log ✓ C-� ' � - ► 3 -�3 Wel1T ✓ t\�12- � Air Vent / i• z - o� Hose Bib i- z - 0 3 Concrete Slab ' L i- z - 03 Well Daifller. -- \11� Well l�pproveci ��: I�ate: i/ - z�- O 3 '�See Attac�eci Site Sketch'�` Wells must be 10 feet from property lines. • Wells must be 100 feet from septic spstems. Wells must be at least 25 feet from any building founda.tion. Other conditions: - PC�-ID, =ev. 09/07/01 Barne*Ye Well Drilling Inc 336 598 9275 �- ;�. s � ���� �� �.. ,�� � � �Ll'' �� '�' � �� :n-n�sri� •n-�rna�r�-n.ayat�tiG.�..�� ', ���<c+.e+t.�tE��a. Owner: �. �p�atiUn: _ Subdivision: 11J13t03 09:1SA P.001 a� oD �� � (�p�: � �l�E . .� � ��t� D� D��sl � ��- /� �o � �' ' ; Wel� Con5tru�ti0rt Distance From ncarest Property Line {Minirnum 10 fcet) /� ' Z7istancc from Se tic System (Minimum 60 feet) /C�C� Total Depth: � f[ Yield: ,_�.. G�M Static Water Levcl: •- r� tt Water $e��ing Zoncs: Dcpth / 5r ft ft ft ft Cas�,�g: . Dept�: From � to ��' ft. Dinmctcr: � in Type: Galv�►ni�ed Stcel � ' � Weight; Thickness: �_ Hcight above Ground: /�� in Ta�i�e Shoe: _� Yes No Any problems encountered w3iile setting casing'r �Yes �Na If "yes" givc reaso�• . Grout: .. Neat: S�ndl�ement Concr�te �ravel/Cement � Annuiaur Sgace Width '' inehes Water in Annular Space Yes No Method af Grout: Pumped 1'ressure Pouz�ed'._,�.._ Depth �_ to �_ rt. Mater�ials Uscd: ;• . No. Bags Portland ce�rnent� br.�^ Weight of 3 Bag s� Pounds If mixture (sand, gravel, cutt�ngs) — Ratio �_ to �. .. ID piates: � Xes _ No 4 x 4 s] ab � Yes � No Drilling Log Locatian Urawing F�� '�'� �armation . 7 ' �; �f ' ' 5 � -�= ' � .� � c� : �. .� � - f� � �` � � . � �� Y � ro � ..°' G '� J ��v�'�G� m I hereby eertify that the above i�nfo�tnation iti c�rrect and that this well was eonstnicted in accordance with re�ulation� set forth by the Person Colmt H- De artment. . Si�nature uf C��n �cta� .� . c ' - . � - , .-'� �'LL II? # ���� A�te �� � (� `� �3 • � PCHD rev 09J34/0� �, �. PERSON COUNTY HEALTH DEPARTMENT 355A SOUTH MADISON BLVD. ROXBORO, NORTH CAROLINA 27573 BACTERIOLOGICAL WATER SAMPLEANALYSIS Name of Owner or Tenant o �.J Address uq County PERSON Collected By � � Date Collected �{���{�(� _ Time Collected 1 v�� Source: ell ❑ Spring ❑ Other Location: ❑ House Tap ❑ Well Tap ❑ No Charge C�Charge [�Other ........................................................................� ************************************************************************ Total Coliform FecaVE. Coli Present ❑ C Results Abs�nt D,� � P Y ` T � �c.� /Y� [� ! J Re orted B .��.� r,�. .�,,, Date Reported `7 ' � � � / 5� Report Called Called To: ❑ YES � NO