Loading...
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«