A40 355I°� . ��� �'�
0 9 �� •6 �
'� 10 �'J �r �a �a P�P ���ue J�o o�d JGu A wou aa 4�H
d� �03 v� � i �A A� 1 '� �1 �o� a4 ��0 �H �� �d lout�+ed
�011 �+e a�s �t �PI� Pue csaum� 'oauq l�{�oda�d But�ew P� �Pl � �� � I '3�de ss �til
�� u�nnv,ocaw oyl i� P� �� �A )o �� �R �be 1 '�i�dad� • Pac�m�a'p�anocle o�A
tua4sl�4 �!P � � � �l � � z �1t �4�0 yII�H �1�'J ��d �t103 �9�e v�etu J�qaotl I
NOLL1f'JTidd1/ S1H1 Ol Ntlid 3LS ZIO 11f1d 13I�21�1S 1�f11\/ 3b1131d
'S3�1fi1�f12iLS Q3SOdO�id'1'71f 30 S7I3NaOJ 3H13�tf1S
1li2Bd023d 3H130 S3In'I OI�1�/ S?�3N?]O� i'11► �f1S J�'�f3't�
=�i �i0
� �+►1�OIY — 1�13u�� P�MI 1�13���'J�;
l�� � m�Wo uI P�� aQ ��1 =�1 �S P�+F�O �IP�i �Id I9
�`�Ji� oN 0�A iJ�lmdad Bu�yojpe uo spa+M► l�ue ord
� O d�pdS b �'0 �94�►d'U7 � m D Nwta) 0 �l+d ���1 ��S �M (Q
Q ` �1K�0 �� �{3PlM �4S P�a+d lo �'l�Wb (6
�Q oN '0 �A �10 ��J �1 •
xom� tuou�o�sq �o �`adc otd b�1� �e io
C�� �►►� aQ �l � � Q� lo �4�N (P " -��Po910 �+N p
�PJ oPMh o14�� b oPlM �tS '7 �ry b 3ln8 �tS (4
0 �3� P�ad �
�b �1 �A}� � ��� ��AdF��O �S P� �f1 P���d �t
x����������
-� �i a�- �m, �,oad�•a �� te
����t�� �
� �� �--U . ► i :Qt�ocld �8
' �''D� s t ; � � J" � 5;:� , � � � `� 5�� - -r %�'.� �d �H
g v�.� c r� � Y� �.�,� :(�uNw a►Ii�ed�adA���O) �R Pn4�� �l�+d (�
'Q VfAN 3W0�36 iIVHS .L7 NQ� LL a0 V �Nd 1JW d IAF3A02idW13 . Hl
lSlVd d 1N3 dWl Nd�aQ� O�f�ilddl� 3Hl I NO OJ 13H1
– :., �
=c� ��!_ - - •_ • r •-
eWUOJ�
no� uosJs
����/� �
.�� �
�o
9 £ 0£ ##-�
�
00' �S��.
0
ov-�r b
r
r.,
�
�
�
�
�
�
�
N
W
w
W
Application Date• __�,1���0
Amount Paid: ? '.a 0
Receipt #: I 7��
❑ Improvement Permit (Site Ev�alpation)
$200.00/$300.00 (if> 600 gpd)
��?, ) f �11e�� �� Taz Map: � �
......,, t.,.�- � � �n�,�n�1 Parcel#: �L3�—
J• ��II.l�'iTmII�II33CII3�All. �jQ�11YQ:Y1
ilication for Services
Services Requested
❑ Mobile Home Replacemen4 or Building Addition
$150.00 (if site visit required) - '
�ll Permit INeedAe�eetn�nt/Reaair)
1) Applicant Ic
Name:.�
Address:
2) Name and ad
Name: J
Address:
Sif
�
y . Og Construc�t�,on Authorization
'` ��' (Fee is denendent on the tvne of
• I . ❑ Permit Revision
�7_5.00
❑ Repair of Existing Septic System
Aunlication: No ChazQe/ CA $150.00 or
e Phone (home): ,� • �' �
(work/cell): �
thanl �a,p�ph'cant): � � '
Phone:
3) Property Description: Lot Size: �_ Subdivisioh: Lot #:
Address andlor directions to Property: � ipoZ. Z�l�'. r�
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
� yes � no Does the site contain any existing wast�water systems?.
❑ yes 0 no Is any wastewater going to be generated bn the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation) � w
4) Progosed Use and Type of Structure:
❑Residential . ,
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expansion of E�cisting System If expansion: Current number of bedrooms: •
L7 Repair to Malfunctioning System Will there be a basement? ❑ yes � no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
M�imum number of employees:
Total Square footage of Building:
Ma�imum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well 0 Community Well ❑ Public Water C] Spring'�
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes 0 no
Please note any l�own ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please ilidicate preferred system type(s):
❑ Conventional ❑ Accepted 0 Innovarive � Altemative ❑ Other --. } ❑ Any
� . .
I certify that the information provided above is complete and correct. I also understand tlzat i„ j'the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Signattr�e (Owner/ Legal Representative*)
* Supporting documentation required.
- ��-,2g"�%
Date
• Permits are valid for either 60 months or are non-egpiring when accomp�anied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
��
P�#�SaN Gt]UNTY E�lV1RONME�ITAL t�EALTi-i
rax a�, � �- � v �r 3
Z01fI11Q �
AQpiicuiC _
l.oCation: _
81�irWoa:
Taw�uhie 1 KJ� l 'r1 �11 � r '.
Lot�
� Itnprovement Permit � ,
A buildinct aennit cannot be issued with oniv an imarovement P�nnit
New �RepaIr AddrtFon Type af Strucbure��D � Water Supply �� �.
# of Oxupa�ts (�0 ��^^1�� #•af 8edrooms .� Otl�er
Basement? ��8a�e�rnatt F'od�u+ea?�
Projeded Da�7y Flc�w: .�'�' °y.p.d Pamui Valtd Fcc: Fiva Y�s 0 No ExQkattan
Proposed Waste�ter�ystem'i�p� l�.�-nJd-�r,,�-��1
Piunp R�?' Yes � No .
Pemtit Can� - o,.� la�i u.w�a�v�. a .
l��.s �—� S�. �,� � !o w1 �,�,�t-�
Owner or Legal Represerrtative S�e:
AWttorized Statia Agert�
�: �'—�—� I
Date: 2'� �- �
Tha issuance�oithb pemu't by the H�h DeQaran�F �n no way �mrar��s ��s�mnce o� a� p�m�. t�,e �
holder ls responsi6te far d��fi9 � aPProP� 9�+�A bodtes t� meeting their r�dnernents. This sita ts
su6Jec! to re�roc�tion if the sitie plan, plat� or the t�t�edad ttss changos. The ImQrovemait Permit si�l not be
affecied ksy a ci�ange ia owno�hlp cf !he sita. This parmit 1a aubJed to comQlianca with tha provisions a! the
Laws and Ruies for Sewage Tr+eatrn�nt and Disposai SysLema of the Nocth Campna Adminlstntive Coda.
A�thorization To Construct Wastewater Svstem (Reauired for�8uitdina Permitl
Type of Wastewater Syatem �s�hv'� li o'�Ll YlFastewatec Flcw: �� .�;.�.
r-�i, ryP& . �'. � �^�1��7�'n j ��a�m� ❑
8asemenl't es J0'No Basemerrt Fbdures? o Ye� .
WasEawater Syatem Recuiremer�b ' ' -
. Septic Tatdt Size; /�On gailona Pump Tank Size: _,�_ gaQons
Tctal Trendz Length: l fieet Ma�dmum Trsnd� De�tk � inct�� Aggragaba Deptt�� in.
Maximum Soil Caver: � ind�es Tr�end� Separation: �, Feet on Cerder �
Otper:
Pecmit Exp�ation Date- �" / d` —O G
Autho�ized Sfate Agen� � DabD:��/ .
Tha iype o! sysbem permitted Q doe9 Q does not. diRar trom tha type specifled on the appllcatlan. 1 ac�spt
the speciflcattans af thts penalt
OwnedLegal Re{�re3er�taflve Signat�tre: p�-���
PC�-iD, rev.11/18l99
�
. . __�_.. ... .. .._... __._.._..._._._ .._ .. . _- �
'. ' ��P'g1�:1 �i�!l111J �':@8��, �6�7af'�'ip16� /�
' . � �ereronmera� Heaitl� seciion Z�c � �a�i �: � �+' �
� _ . . � � P�i �:
� � Si'i'E 5�4�"iC� � _ . . _. 3 5�
�
_... S��,y,�m ._.'� iJ�i n$ � c��✓; d� e I�res l�f- � 7
ilcant' me � S (visioNSedioNLci#
. � � �� _ a� -
. u�to�iZed Stabe ��e � ' .
sy� ���* �p� appraud�e �roa o,dy. T7fra caetrador mrmr, fYag rllts ,�ysha� .
� prior to 3�iur�r tli� installatioa ro i�e th� prnper gr�la fr era�x�
i �
. �
+ �
� �� .—�rA-' 4" ��l -� Q.�°``, � .
��
0
Scaie: � =�fQ�
� �
�(f �� �,
f �
�ls �
J_\
�. i
�� a� ' OO� ^ -
�+�..1�
� ' 1 3`S�
3�� �o � S`�
%' I� � �
-� L(.b p, ��� pv ��� o'►^`�
� - - -�,1�,1 �
_ ��� "� -� --
� __-
� �,��`�� s �� ����
" � ; ,� ,� `�'rr'� .
Q � _ - �,� ,lu�.. �
. �/ • ^ r
0
� �� ��� ra`
� P °`'r ��"�
-�K\
1
�,r�5 `� SYS��
��� �Il � �� ..�K���''i
� "r � -� M I��� � i ��5.
�� ��w -CQ� ��N. �� �
a� � LY��e�
�(�',��c�. a�
J�..�' " �, � �. ..�!V�'( -
�,`b�
r�'�Ow� � .
� -1- �
Person County Heaith Department
Environmental Health Section
Tax Map #: f%4�o Parcel #: j 3S
Zoning: Township: '
Subdivision: C�.�, !'��c�e /r�nas Section: Lot: �
Appiicant• 5�,,,,,....�.� ��l.,.r
Location•
�peration Permi�
System Type (In Accordance With Table Va): �'
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPUCABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
, �'�' ��'-,z�-oi �
Authorized State Agent Date
5'6% ��` " i vY
a. ;'a %s
S,� ..
S'ta9�'
4� 1��pN�
��
Tax Map #: /� �r7 Parcel #: 3 3.�
PCHD, rev. 10/12/99
Tax Map: �
Subdivision:
���,S.f ���.���
`^- � � ����
���nir�aan�ncam�ra�m�. ����.�.¢Ila
Parcel: �5
WELL PER1Vt�
(New_ Repair_)
Lot:
Applicant's Name: N� � L�..( ,� g_��� ,,����,ry
Mailing Address: 4�� - -" �
��L�, G 275� �
Phone Numbers: �Z���� ���`- �,� ��_�1/�� �/,�,�
Locallon of Property: j�v � /y/.�/}-�; Ti�i1 �,(� -
Permit Conditions:
1.) See attached site plan for proposed well location. --
2.) All app�icable Sta�e afTd Cvunty regulatorzs governing eonstructiofi art�sEtbacks apply.
3.) permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: �//�.L� Date: // - j
Ce�tificat� of omp ��n
�1V'ew VVell: ��,���� ���` iner:
EHS/Date L�'��,� > Jd � � � EHS/Date
Location: ''""� Depth: //7�'
Grouting: �iao l��y �, � Grout: .
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan 5t.,5uite C
Roxboro, ivC 2757"s
G�� �-
�`'�''�� ' �.�a��a,�
/?-� � lV�1�f
/S3� �����/
�
DAbandonment:
Date:
Method/Materials:
�
I,icense #:
License #:
Date:
Date Results i�laiied:
Phone:336-SS7-1790 Fax:336-597-7808
li/26/13
PE3�S�N COUNTY E�IVIRONME�i'TA►L HEALTH
PL.F.�4SE SE� ATTACHED Pl�N FaR N�i_L SiTE i�►YOUT
�- �� �# �� 3��
� �� � . T����..- �IVe.�(
zo�do� �
� �AcM. �����"s � � .
t�,.Q,p �j l2 � �--� � i •.
i.optlon: �'�` i t' ��` (%�Lt � a P V �,�c a a cs �^ �
� '�,�V�c, 2 � Y'�S � �-z�•
Tvae of Wafier Supai�:
.�
ReauiremaMs: .
VV@�� �9i1'111�
/tnd'Niduai CommuniEY . Public
S�ie Approved by ✓�� I o' I$ "o �
Gmutin9 APProved by � bt 10- ��- o�
Wel1 Lag `� � o - ��-oi
Welt T � ' �
Air Vent •
Hose Btb
Cancxete Siab _
Wetl Driller:
\
Well Approved By:
�: la�a9 --�r
*�'S�e =l�ttached Stfie Siaefich*'`
We11s must be 10 feet from property lines•
Wells must be 100 feet from septic sysiems.
WeUs must be at feast 25 feet from ac�y buiiding foundation.
Other conditions: �
�
PCHD, rev. 1�/29l99
.� � . . , ,
: �
Date:
Owne
Location%Directions:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Subdivision Name: i
Drilling Contractor:
SR#
Lot # �i
WELL CONSTRUCT'ION v
Distance from Nearest Property Line I v Distance from Source of
Pollution ( G a
Total.Dep.th: FG Yield: GPM Static Water Level Q2.r' Ft.
Water Bearing Zones: Depth �_F[. � F� Ft� Ft.
Casing: Depth: From 6 to �O� Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Y�s No
� � Weight: Thickness:� '� Height�Atiove Ground: /�i Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" giy e r�ason;
Grout: Type: Neat Sand/Cement / Concrece
Annular. Space Width � Inches
Water in Aiuiular Space: Yes No
_ .. Method: Pumped � - Pressure � Poured � - �
Depth: Fr�m O to �� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � =
� 4 x 4 slab Yes i No
I HEREBY CERTIFY THAT THE ABOVE TNFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET
FORTH BY-THE PERSON C�'vi1TY HEALTH DEPARTMENT.
� , + . ��-
S g aturc of Contraccor a«