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1F THE INFORMATION IN THE APPUCATION FOR �AN IMPROVEI4AENT PERMIT IS FALSIFl�. C�WNGED OR THE SiTE !S
A�.TERED. TNEN'THE 1MPROVEiIAAENT PERMIT AND AUTHOR(ZAT10N 'T� CONSTRUCT SHALL BECOME INVAUD
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3) Prop�cty Dtscriptlo� I..ot st� I, o o Tawnatra _„��
06eWoc�s ta the proparty pncl�tg road r�acr�ea artid numba�sx
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4) P�oposad us. and s�r. oescrlptton: anawa � ot tha fa6owinq qu�ions:
a� ProPc�ed �.�0 Q
b) Sti�Cdc Bu�t q Noduiac 4 Si�qle W(de 4 Doubb Wide �—
d Nutnbec a� Badtoo�r� �, � N�unber at ocapants or peopis io be senre� `_
e) Ba� Yea Q No Q�If yes. � of ba�srt�ant fixtuce�
' A G�e � Yes q No �
� Q�iotsso! PraQoaed Strudtu+�: YVidtt�: �g Dapt� �
a1 ��PPhr � P�ivai. a(new Q oc mdsUno �. PubRc 4 Co�nnund�► o. sp�nq a.
Ara atry weqs on adjci�ing propat�? Yes 0 No t9�ity�, foc�tion
6j PMas� Indipb Daii�d Syatom'iYP�- (sysioma cas bs rida�d tn ard� of Youc �)
!�Caiventiooal Modifted Convuttlwtal _ /�w �
Ottw (sQ�diy):
CLEARl.Y 9TAKE /�L.L CARliERs AND L1NES OF THE PROP�RTY.
STAKE THE CORNERS OF ALi. Pi�OP08ED STRUC7U[iFS.
P�.�ASE ATTACtI SURVEY PU1T OR Sl7E PU1N TO THt3 AP4�ICATION
I he�'ebY make a�8� ta the Pec�on Co�mty Heatth Depaw�tlfor a s�s evakt�tlon tor ths an-site sawape disPoaal sysi�m
ttw sbove�dascrbed propeKy. t aq[ee that the conte�b a( thb applic�tlon acs tt�e and �sni the mmmrtunn � tp
ptecad at the prvpe�ty. 1 w�d�star�d if the sibe b aitec+ed orths ��Eended tx� ct�anpes. the pertn� sfiaiY becacne irsvaBd. l t�
tttat as ap�BCartt� 1 am c+espons�ie fa idautiying and marldn9 P�'oP�Y �. �� and maidng ttis aibe a�s '.ar
Pe�sonnd of 1�e Person Ccuniy Health OeparErttart io coctidud tha�r dvakmtlons. I�atand that 1 am r� �' �9
Hea�h D att tf my � any wetlanda as daiq�ed b�l the Acm11 �� ��.
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Autho .. Agent ��e � � �
,�y� ��n� �Pra� aPPr�ud�e ca�t°ws only. The ca�tra�or mr�t, flag t&e ay�tteee� ,
��n�iir ra b� en�g dlr� bi�oA �v in.iun that proper � is �ra�t�ed
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PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �G�n�� �i��s ��c�l.-�
Address � � � �Slt� f ���.�' � County P-AiSo;1
Collected By %��O[� / -�rr�
Date Collected / Z�/ 7�a � Time Collected / 2�-3.S
Source: l�Well ❑ Spring ❑ Other
Location: ❑ House Tap ❑Well Tap
❑No Charge Lc�lfrge
ther U v�-Sl�c. ���'�i'v �
J
�**����*�*�����*����*�������������*���**,��*��*�**��*�*������*����*�**���*�***�
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Total Coliform
FecaVE. Coli
Reported By
bactreport
Results
Present Abse
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❑ l�
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P�E�S�N Ci3l�IVTY ��V!!lR�NMIE�ITAL HEALT�!
Tax Map �: ,��_ Parcei #� j� Tbwnship � 1-.S."T' �� i 4�'� r2� PIN
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APP�canC '�.`.�''�z�`:��:'t. �as �i -�1-! ��T Subdfvision �'✓°�.� �"T�'f;" �C�e=�„ PhaselSectfon_� lotS�
�`�.. —fT''
Locatlon: �_r'�.}�' �-S i +°'�.�.:a..t t�
New �.t Addition
# of OccupaMs
Projected Daiiy Flow: _
Proposed Wastewater
Proposed Repair.
Improvement Permit
, Type of Structure �-�-i�� � Water Suppiy ���= � i_
# of Bedrooms ��- , Other System Type �
� g.p.d. Permit Valid For. ❑ Five Years o Expiration
rstem: f°���",�I _'�ea ; � r� �.; �--�— —
Permit Conditions: I.-i sn� � c r� �� ���� ?: c��t � css.4 !_'_ �..�•r� d�
�\
Owner or Legal Represe►rtative Signature: Date: ��`3� ��
Authorized State Agent /_ ,, Date: 1..� 0��� "'C�S�
The issuance of this permit by the Health Dep�a�tfnent in n�4vay guarantees the issuance of ather pertnits. The permit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subjeat to revocation if
the site pian, plat, or the irrtended use changes. The Improvemerrt Permit shall not be affected by a change in ownership
of the site. This permi� is subject to aompliance with the provisions of the Laws and Rules for Sewage �reatmerrt and
Disposal Systems of the North C�rolina Administrative Code.
Wastewater System Description: .�.s`�e��• Wastewater F(ow: ��- '
Faality Description: �c� �� �- _ IVew R�
Basement? a Yes C]�IQo Basement Fixtures? ❑ Yes o
lNastewater Svstem Requiremerrts
p.d. Type: �
Repair ❑ Expansion ❑
Tankage: Septic Tank size �� � gat. Pump Tank size -E2s' gal. Grease Trap size gal.
'�r�nches: Total length -y� ft. Tr+enct► Wdth .'�U, ft. Total Area ���C_a sq. R
Max. Trench Depth: ��.� in. Aggregate Depth:� in. Soil Cover. _� in. Trench Separation � ft, on center
Permit Expiration
Authorized State
*See attached si
The type of system permitted � does ❑ does not differ from the type specfied on the application. 1 acr.ept the
specifications of this permit
OwneNLegal Represerrtative Signatu . te: g�� '�� �
O�eration Permit
System Type �n accordance with Table Va) �
This system has been installed in compliance with applicabte North Carol"ma General Stahttes, Laws and Rutes for Sewage Treatrneirt
and �isposaf, and all conditions of ihe Improvemeirt Permit and Construction Auihorization. Issuance oi this permit implies no
gua e ttrat tfie syst instalteci wilt function property for arry givert period of time.
�8' 3� -� I
Au rized State Agent Date
PC�iD, rev. 03/07/01
Person County Health Department
Q, Environmental Health Section^,�.
Tax Map #: 1� � � Parcel #: �/ `3`��
Zoning: Township: r ��� le i J c r
Subdivision: �a K r( d gc �i C f CS Section: �✓ Lot• (� �v
Applicant: �JQrnr►'�V l��u1�r�'t5
Location• i��F I'� ,; � �S 7��t /, �
Operation Permit
System Type (In Accordance With Table 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
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State Agent
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Tax Map #:
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5� �{�dc�san
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Date
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9 �3 q'3 ,
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Parcel #:
,�
�a:
1 �a'
Z R�`
3 Ri'
9 � �'
9i`
cs, q�,
,
$ "� a�'
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57v 3a4
PCHD, rev. 10/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: �- s'-o► '
Owner. � �,M y
Location/Directions:
Subdivision �Name: __ e�k��_%
Drilling Contractor: �
��
Lot # � �
WELL CONSTRUCTION V
Distance from Nearest Properry Line ! v Distance from Source of
Pollution ( G �
Total.Dep.th:_,Zt�� Ft. Yield: / aa GPM Static Water Level a2.5—' Ft.
Water Bearing Zones: Depth 1�'��"�'�`F[. Ft� � F� F[.
Casing: Depth: From 6 to io a Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Yes No
� � Weight: Thickness:� '� Height� Above Ground: /�/ Inches
I?rive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
. If "yes" give r�ason:
Grout: Type: Neat SandJCement / Coricrece
Aruiular Space Width - Inches �
Water in Annular Space: Yes No
Method: Pumped - - Pressure � Poureci � - � -
Depth: Fr�m O to � O Ft.
Materials Used: No. Bags Ponland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � � � �
4 x 4 slab Yes � No
i�R1I_LTNG LCX't
I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH �3Y�THE PERSON C�vi�TY HEALTH DEPART .
� q-s-o� --
Signa urc of Co tractor Da«
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1
���dSt��9 ��31li�� ��9`�'�R��ME�1T��. ��,�..'�3i
���5� ��� .��'���3E� ��u`� ��1�'��..� Si�E ���13�
T� � �: � �� � ��� � 3 `��'
��g Tawnshlp
.l. , �.i L... J
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s�nan►� G� _ s�to�:
Well Permit `
Tv�e of IiVater Suar�lv: �ndividual Community Public
Requiremen�s'
Site Approved by i�� alro�
Grouting Appcoved by � -�`� �
Weil Log
Well Tag ri�� � -�! - o/ �
Air Vent ;�'� d=
Hose Bib �_ F-ai -ti
Concrete Slab ���a! - � �
Well Driller: ��'��
Well Approved By: ✓� ..� � Daie: ln ���8%
. ;
. **See Attached Site Sketch'"""'
Wells must be 10 fe.et from property lines.
1j�ells must be 100 feet from septic systems.
Welis must be �at least 25 feet from any building foundation.
Other conditions: �
PCHD, rev. 11/29/99