A40 348r
q -a 7-60
��t�, a�.: ��
�mount Patd• l�o t.5 6. a�
��_��—
C'.P'-� 3 � 3 �
s
� .
i.. � _ • II .,.,#
• • u .: L� � : .� �ii _ii
` � o i t� � �l� �l!t ��� � .
. ;� • �� . . �:iL �i?=
IF THE INFORMATION iN 7HE APP�.1CA710N FOR �AN IMPROVEiIAENT PERMIT 13 FAL91Fi�. CtIANGED OR THE 51TF�,�
ALTER�. 'THEN THE 1MPROVElIAE'�VT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME 1NVALID
1) P+�rmit roqwated by: (Ovm�r/agwtUprospa�tiva ownec�: .� -n �-, N t� .. ,�„
Haifs Pttion� � l, �� - �,5 6 � � Ad� LK �t �S , Wu«-A t� m � t �c ��,
Bt�eas Pt�ot�e: � � � �4 � �-r.� �
Z� Mame attd addce�s of curractt owr�: <�� ��. r
3) Prcp��ty D�scriptiot� lotstz� �� r_:� Ta+�t� �
Dkadtons t�a the ptopecty (I� ro�d � and �tumba�ak
4) P�posad Us� and Structutr Descriptloa: anawar esch af the fo0�awi�W que�or�a:
� ����a
b) Stirdc Bu� 0. ModWac 0. Sin�le Wfde 4 Doubb Wids 6�'
� Number at Bedtooma: �- � Nucs�6er of ccxup�nb� oc peopla to be sarye� j
a) Basement Yes Q No L�`�yes. � cf baseme��t tbducex
' A Gacbaqe Okpoas� Yes 0. No 0�
� 4ir�eioctisai Proposed Scruca�ue: Widtt�:. `} Depttr _ r�?
61 �� �PPhf �= Priva►is q(new � or a�dsUn9 �. PubRc 4 Coaxn�a�dY 4 Spin� 0.
Aro �ny weqs on a�oina�g popat�? Yes � No 0�ttyes, iocation
6� Plas� Indtcab D�si�sd SYsi�m Tj�pe: lsystema can be ranio�d In cMilt of Y� P�+l
VCoavecrtional Yodified Caav�ntiasal _ �t�w �ovattw
01tw (sp�d[yj:
CLEARL.Y STAKE ALL CORl�IER9 AND L1NES OF THE PROP�RRTY.
STAKE THE CORNER3 OF ALL Pi�OPOSED STRUC7URES.
PLEASE ATTACl1 SURVEY PU1T OR SRE PLAN TO TH{S APPUCATIGN
I henebY make a�6ca� bo the Pecson Cou[rty Health DaQartri�ant ia a a�s av�tlon to� ths an-si0e saMr�e dtsPa�t sysb�n
tha above�asctibed propedy. l aq[ee that the conLentz af this appiiptton acs true and ro�t the mmdrtu�n fac�tles tc
piacad on the proQecty. I iu�do�tand if the s�e ls alt�eced ar ths iniecxied t� c�tanpes. ttte pam� shaY becane i�tv�Bd- I w�c�
that as apQBCatrt. i am �espons�te ta idaWfj�ing and rtm�iCin9 P�'aP��Y iinea, co�nec� and making the s�e a�e fiac
pecsa�nal of the Pecson Cotu�ty Heaqh Departrnent bo cac�dud their avakmtlor�s. l ur�atand ihat 1 am ���M9
Health D ff my �s any wetlanda aa desi�na�ed bY ��Y �� ��-
�
- -� �- a o
� R�� . o�
� 'ti
_. P��SON C011NTY E�1ViRONME�YTAL MEAG�'i-i
- � ��,.
Ta�t 51ap �k
_ ��_
APP�IeanC ,
Lncatlon:
�
Tor�hip
r
�
�
Su�ioa: �✓�b� �• s S�ttoa: Lot_��
� Improveme�t Permi# � .
A buildina �ermit cannot be tssued with oniv an Imaroveme�t Permit
N�w v Repair �on Ty� o� stNa�S'�D water s���y �� ll
# of Occupants #•af 8edrooms �, Other
Basemec�t? �Basem�t Foc�ces? ,�Q„
Projeded Daity Flow: � g.p.d. Pemut Valid Fa: Fiv Years ❑ No ExpiratJon
Proposed Wastewatet System Type: Cd'h dZt��Y�t� .
Pump equired?" Yes �� No n
Propased Repair :_ f;an v'�P�r�C /
Pem�itCcnd�ions:�e�o sc,s r• � m bN.�a�•�i -�vKnala�v� �� �O� �n.
0
Owner or Legal Representative
Autttorized State Ager�
1. /� Gt ("
Date: 4 �' D "�
pa�: /�' 2-d 00
The issuance of this permit by the Heauh Departrnent in no way guarantees the issuance of other p�rmi�.s. The permit
holder is respansible for chedcing with appropriate goveming bodies In meeting their requirements. This site is
subject to revocation if the siie plan, p1at, or the irttended use cl�wngea. The Improvement Permit sNail not be
affected by a change in ownership af the site. This permit is subjeet to oampl'�ance with the provistoas of the
Laws and Ruies for Sewage Treatrnent and Dispasat Systems of the North Carolina Ad�ninlstrative Code.
Authorization To Cons#ruct Wastewater System (Revuired for Buiiding Permitl
Type cf Wastewater System �,OnV��D ha. � WastewaUer Flow: �y,p.d. .
Fac�7iiy Type: `�► +'"J�''. S(i^D • Wev�,� RePair OExPansion Q
8asement? Q Yes � No Basement �? 0 Yea J� No
Wasbewater Svatem Reauiremenb
Sept� Ta�dc Size: / b0 d gaUons Pump Tank Sizs; �" gaitons
Tota! Trenc#t Length: S�d feet Ma�dmum Trench De�th: � indtes A99�9abe Depit� ��" in.
Ma�dmum Sal Ccver: � ind� Trench SeQa�aBon: � Feet an C+enter
Percnit Expiratlan Date:
Authorized State Agen�
�_i
'/.1.[IJ,�:lL/� ..��_ _ i v
i�/
�
The type of system pertnitted 0 daes C1 does ot. difter from the type specified on the applicatior�. I acr.apt
the specificatians of this permit
OwnerlLegal Represer►tative Signature: r Date• l-i =Z-0 Z— •
PC}-ID, rev.11/18/99
�
. ..__�—._ _.. .. .._...__..._._..._.__..... .. --- -
� �P�rs�� Caunty #ieaitDa. �Department t�
� Es�vironmeniai Hesith Section T���aQ �: �" 70 '
� _ . . � � Parc�1 #: 3 �
� S�'iE Sl4lETC� _ . . _.
�zlyh m � _._ .� G✓!� � �S � Yrl(� �
A llcartt's Name Sub 'sioNSe onlLot#
. Author�zed State Ager�t �ate
,Sy�in rompaee�fs npr.esent appruzl�ate cmeta�os oirly. The cn�tradar nu�t f1aB the syslrne
prior to � lhe i�csiarllartion lo iniure that pmPer grade it maintairud
v� � Q�W ,j $�.S � t � � I
�s-� ( I 5'e��+�c S� ys-�e�. a�
�r��e+' �r� ���ou�t� Cb�ou�
�v rt i'YtOljfl�VluN+ �� WtP�^
' �P,2� o�-� � �a�rtS �� SyS�w�.
� Yk i n�bv►.cd �h �-o r►,._ �O u i� ci �1�-q
J
�pu,r�c�a ``o� � a v� (o� �vi �1�. i vnc� r�
,�e � �DYb ��r�i� � � ►n,f .
1 J
s�-t �, 5 y s�.
�. y � �� ��d�
s�: t = s�'
� ' � . • ����i � J' J�Ji.. JJLi����� V ' .
� �� �
1 1 i /�• �
, �^ '•. �:�•�j��� .
' ' _ ""' -... . . _ . .. . �iim_�aa�o�s n,.�,. �@��n.n. ��s.��n.
Tax Map #: I I �� . Parcei #• � � �
Zoning: Township: l �a'� �' � tr
� S�bdlvision: ��Kri d� c f� C�c:�,; .;: ..�� Section: Lot: S�
` s
Applicant: �u-"'� n'`�f �� � lCc � _
Locatton: �S�cU-c. S ��.1 �
�peration Permit
d
. System Type (in Accordance With Tabie Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
' AUT IZATION. -
. : � s-C� -oa
� Authorized State Agent Date
.. • �
_-1 '�-Y
.� � \
� � ��
'o �
J ' �
. _,� .r� N
�, 6 <C c �' O
��d ` ,� a ;
�
�d� � �T' � � N
.� 1 N
J
� G
• O r,
�
7
0
-�
PE�tSON COUNTY ENVlRONMEAITAL HEALTH
PLEAS� SEE ATTACHED PLAN FaR WELL SITE �LAYOUT
T�e�� �� . �� 3 `� ��
Zoning ' Tnwnship G� � � � �%C/V
-t
-� %= K=!'�S
,�� �; r� m .
�,; I s7 .� �}'iu %�el �!/Y, 70� d� � c��r�r� , te
�+,�� �v��o � s.� ,.� GO
. Weil Penr�i# ' �
1 ; '� Ind'nridual Communii}/ . Public
Tvae of Water Suaa v
�
Reauirements•
Site Approved by ✓
Grouting Approved by _
Weli Log ✓
Wel1 Ta �
Air Vent ✓
Hose Bib �
Concrete Slab
�-OZ
� �-�?�--p 2
Wel! Dritler: �n I/1,�� �l �/���� (C�,��ti�1i
Well Approved By: • � �-{,1�L� i1. �
Date: �-� � ��Z
**See �Attached Site Sketch**
Wells must be 10 feet from praperty lines.
Wells must be 100 feet from septic systems.
Welis must be at least 25 feet from any building foundation.
Other conditions:
PCHD, rev. 11/29l99
�
���. S� ���.� �� �� o� � 23 0
' �� c� � � I�T � �Y C�or�p� a� .N I l�/�1�� �C
���s��.,,-�.,, ����.�. ��.�.n�� � D�o Dr��Ilod S-Z.2-aZ
Well Log 1`
Owner: S��l ���,J IC.UJ S Tax Map �"f O parcel # 3�I g
Locarion:
Subdivision: — Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from e tic System (Mini.mum 60 feet)
Total Depth: ��� ft Yield: GPM Static Water Level: ft
Water Bearing Zones: Depth ft ft ft ft
Casi.ng: Q
Depth: From
Type: Galvanized Steel
Weight:
Drive Shoe: �Yes
If "yes" give reason: _
Grout:
1
to __�j�_ ft. Diameter: �p ��i in
_ ✓
Thickness: • tgg Height above Ground: in
No Any problems encountered while setti.ng casing? Yes No
Neat: Sand/Cement ✓ Concrete GraveUCement
Annular Space Width �_ inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured ✓ Depth Q to � Ft.
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Rario to
ID plates: ✓ Yes _ No 4 x 4 slab f Yes No
Drilling Log Location Drawing
From To Formation ���
�
Z �
cu6� Ib-� S
a
� ��ti!
,�
I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person Coun Health Departxnen
Signature of Contractor ID # � � Date �'J" Z3 - � Z
PCHD rev O 1/ 16/02
�
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant � S ' ��_
..� _
Address � t �s�c� � I � � County ' � �
Collected By ��
Date Collected �-31- il� Time Collected �� 15
Source: �a'Well ❑ Spring ❑ Other
Location: e'House Tap ❑ Weil Tap ❑ Other
❑ No Charge e' Charge
..............................................................................�
*******�********************************************************************
Total Coliform
Results
Present
❑
Fecal/E. Coli ❑
Reported By � � �%���
Date Reported lD � �' � �
Report Called
Called To
o YES o NO
Absent
�