A40 357a'7-6o
" A_�ooltcation oata: �
" Nnount Pdd: ��� 6� a 6
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� #- ,3a,3 �
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• • 11 ! � � !.= L'11L:lL
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IF THE INFORMATION IN THE APPUCATION FOR�AN IMPROVEiWENT PERMIT IS FAL31Fi�. CtiANGED OR THE S1TFz1,�
ALTERED. THEi�I THE IMPROVE�NIENT PERMIT AND AUTHORIZA'TION TO CONSTRUCT SHALL BE�OME INVAUD.
1� P�tmit nqwated by: (ovm�rlag�ntlproapoc.tiw ownec�: ��?n w, w. ,, � a �,k ►,� s
Homs Pt�ona _ 3 6�� -� .s�, � � A�d� � S ti.s . �J � �..r �. ,,, r �►_� F�t,
8l�sirlesa Ptr0�10: << � Rr,-w ��P..�
'� �iRl� ifld i�C�i Of aw��swa OWii�% ��G rn!
3) PrOp�tty D�scriptioc� Lo! sta� 1. (�o Ta�rRat� �'13_
DL'ect�ons to the prope�ty (l�q road �tes artid n�unbe�sx
4) Fkapos�d Uaa and Structu� Dsscriptlon: anawa esch of the foUawi�W que�ona:
a� PtoPc�ed L�E�d�tinq 0
b) Sti�Cdc 8u�t q Nodular q Slnqle Wlde 4 Da�le Wide �
q Nutaber of 8edroamx � � N�unber af o� ot paopia Do be sacva� �
a) Ba:ema�t Yea Q No Ci�tf yes, � of basement f[xtucex
•� GarbaQe Dis�a� Yes �. No p�
� 4�ansoi Proposed Strt�ut+e: YVidth: � Dapllx ��?
-� �I ��+PPb � Priva�s q(ne�w a or aodstlna �i. Pubic q Commu��ih a. sp�w 0.
Ars any wepa on adjoi��i�g p�opert�' Yes I] No C�yes, locatlon
s
6j PMas� Indicai� Daiisd SYamm 'typ�: (sy�st�n� can be r��bd in a� of Y� P�l
�'t`.aavenllo��atl ModiR�d Conv�etlottial _ A�a�v� �
_� �P+��fI�
CLEARLY 9TAKE ALL t�RliER9 ANO l.1NE3 OF TliE PROP�RTY.
STAKE THE CORNERS OF ALL Pi�OP08ED STRUCTURES.
PIEASE ATTACN SURYEY PU1T OR 9TE PUW TO TH{3 APPUCATION
I heraby makn app6ca�n to tt�e Person Cou�y Fketth DaQa� ior a siDs ev�tlon Yor the an-si�e sawaqe disPoaai sysi�m
ttw above�dd propetty. l aqcee that the cont�ents ai this applicatton ace ttus and �snL the moodrrunn fa�ias bo
pleced on the pnoQecty. ! undorstand if the sim is alt�ec+nd arths inEended usa ds� the pem� shaY becams inw�id-1 undess�
tt�t as appBCant, ( am rospon�e fa idati�iying and ma�kin9 Pco{�eCtY W�S, ca�e�s at�d maidng tbs aiEe a� �
persoand a� erson Ccturty Heallh Departrne�t bo wnduci their evdtmtloat. l t�and ihat 1 am t�° ��9
Healthh D i! my properly�co��� a�ry watlands as desi�na�ed bY tne Arm�l CotPs of E�pi�-
9_ a �_ �v
� �ea.�re . oate
Application Date: � $�2j'�'7
Amount Paid: "�3 , ov
Receipt #• t � a 6 �
._
�#IGBZ �n,
1
��,,�� 1� 1LeJ1p,��� Tax Mag: �_
r ��r^ �'arcel#: �,
- r�• � ����' .,
?L-±:nz�aras�an�rsz�t-.�.D _�Hi�ca.11�:{z_ ;
for Se�v�ices
❑ Improvement Permit (Site Ev��uation) �, � .� Construct�n Authorization
$200.001�300.00 if'> b0U d • ' � '� �` �� : �'• � � . ee is d ~r endent on the e of
Cl Mobile H[ome Replacemen�-;or �uilding Addition ., �]Permit Revision
� I S(1 M(if c;tP vic;t w.,,,;,n.il _ '. � ' �•fe rSn
Well Permit INew/BAeis�emm
• 0 Repair of Eaisting Septic System
�3qu.00l�zoO.vR/�75.00J • • ' ! Application• No Charge/ CA �150 00 or $300 00
1) Appticant ►nfqrra�ation: . . . � .
Name:. �'oln�, IA.I��W:zc3Y[i,c_ Z'r�C. Phone (home):33� 322-q355
�Address: T,j, �� �' -(; nd.Qd � (work/cell): 33L-583-In�e3G
^ox.�o�o'1�a.s �'Ig'1`�i • .
2) IVame and address of current owner (i€ different than appIicant): ' �T �•
.
Name: �Phln, e, 1��1+�f�+�.�ri �Sarr;es �ui�i�� e: �
Address• r ' �
_ ek r� �_ 2�S��F � � ' .
3) Property Description: Lot Size: l.l� Subdivisioh: Lot #:
Address and/or directions ta Property:10$' Zsa�aC Tre.:— I l�o e �e
� yes ❑ no I�oes the site coatain any jurisdictional wetlands?
O yes ❑ no Does the site contain any existing w,�st�w�ter systems?.
C) yes ❑ no Is any wastewater going to be generatednn.the site other than domestic sewage?
� yes ❑ no Is the site subject to approval by an}i other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documontation) '
4) Proposed Use and �pe of Structure:
�Residential
�
❑ New Single Family Residence Maximum number of bedrooms: I Occupants:
0 Expansion of Existing System If expansion: Cuirent number of bedrooms: •
❑ Repau to Malfunctioning System Will there lie a basement? � yes � no With plumbing fixtures? ❑ yes ❑ no
I�IVon-Residenttal
Type v€business: � Total Square footage of Building.
Maximum number of employees: Ma�imum number of seats:
. �.
5) Waier Supply: 0 New well ❑ Existing Well � Community Well D Public Water ❑ Spri.ng' i
Are there any existing we1L5, springs, or existing waterlines on this property? ❑ yes ❑ no
P1eAse note any Imown ground water restrictions or sources of contamination:
� If applying for `�uthoriza�ion to Construct', please indicate preferred system type(s):
❑ Conventional 0 Accepted L7 Innovative 0 Alternative ❑ Oti� •-� ____ ❑ Any
� � ' . '
I cert� thut the infonnation provided above is complete and correc� I also understand that if the inforinaiion provided is
inacq�rrate, the site i.s subsequently altered, or the intended use changes, all permits and approvals sliall be invalid.
�2gna re (Ownerl Lega� Representa.tive*)
�' Supporting documentation required.
� _ g1�3-;J�
Date
a Perffiifis are v�alid for either 60 months or are non-egpiring when accomp�nied by an approved pla�.
A . A completed `Lot Preparation' %rm must accompany any application requiring a site evaluaHon.
v
. , Q
F�#�St3N CL3llNTY E�iViRONME�ITAL MEALTi-i
Tax �lap tk �,�i/ Pu�d�
r '.
�3.
911�OIC � CC- . . , `� ,i�plC . �.00 V �
� Itnprovement Permi# � .
A 6uildino �ermit cannot 6e issued with aniv an Imarovement P�nnit
New�Repair Adddion Type of Strudure �,��
# of Oa�pa�s �kof SedrooR4s � OU�er
8asement? ��-9ase�nent Fod�ues? ill0
Prcjaded Da�Y Fiow: 7 a-v 9.p.d. Pamui Valtd
Rroposed Wastewater Syste�n Ty�: r,'vE
Pump Requued?' Yes �Na
Proposed RePaic :- /'� n v e n h� �
Pemtit Cond�iona:�en �215 w� __ 5 '
owner or Legal Represarttattve
a,mo�a st� a��
Yeers
� �r��� n
� Water Supply �
❑ No Expi�atlan
�fi-'o.,� �.,..�.�' �. �
Date: / - -2 3-- o �-
aate: � � �� —� /
The issuance cf this peanit by the H�ttt Depactment Tn no way gtmra� ttte issuance of otllec p�. Tha per�n�
hcWer is respor�le for checicing wrth appraprtate gaverninp bod[es in mee�ng the�r re�q�.drernenb. This site ts
subJect to cevoc�tlen if the siae plan, plat, or tha tnteeded ase chatpos. The ImQrovema�t Pemilt shall nat be
affecied by a cfianga in owneiship cf ihe aite. Thie pomiit is subJed t� campliancs with the provision� of the
Laws and Ruies foc Sewage Treatrnent and Dispasal Syatems of tho Hocth Cacoiina Administratfite Cade.
A�thorization To Construct Wastswater Svst,em (Requifed for Buildina Permitl
Type of 1AIasLewater System ���t V'Gtr r`r�i � Wae�awaier Flaw: �g.p.d.
Fac�tty Type: � GGSl61 �il l0� New D�RepeirQExpansion ❑
Base�neni? Q Yes o 8ase�nent fb�hues? 0 Yea � .
Wastewat� Svatem Reauiremer� ' ' -
-. Septic Ta�dc Size: D fl gallona Pump T�Ic Stra gaail�ans
Total T� Length: � feet
Iuiaxirtuun Soil Cover: �i ind�es
Ma�dmum Trend� De�tf� _`1, �dt� A99reS� ��� �-
Tr�et� Seperal#on: �, Feat an Cantec
Ot�ter: � ,
Pecmit Explration Date: � � ,- —�
Authodzed state Ager� p�; �- � 2-b .
The type af systiem permittad Q doea Q da nut. diRer icam the typo specified on the applicatlan. ( ac�pt
ttta speciflcatlons of thts permit
Owned resentative Si �/V - 2 - v� .
� � 9� oata: / 3
PC}�iD, rev.11/18199
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� •
��rs�n �aianty �ealtDa. i�eparisne�rt
��e��nmeniai Hasith Secfio� '��c' illap �:
_ . . . � � �s� �: 3� j
� Si� Si�iC� � _ . _.
. �ct�r�dc�e �ctZS � (,d� � 1
$U��VISIONS6C�011/L0�
a - � � --o( . .
Da�e � � �
S!'� ���' nP�� aPP� r�atoura only. The ca�trw�r �rr�rt ftas the sys�ras -
prdor to b�� 1be inslallalion io �a�e lhat pmper R'�'�e is mabrt�red .
.�1s-�►�( �- Prc�er
a ��be�� 116w'� ��
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C,o �,�'o us:
Sr.aie;
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. . . . ,. .
. n� a�rsr� �us e�t wsrau� ut co�wutc� wrrti a�c� � �.
� CAIiOLlt�iA O�RAL STATLTfES,� RULES FOR SEiNAOE TREJITI�N'[ ANC OISP09AL; � �
. ANfD ALL CON�i10N8 CF TI� IYPROV�El�IIT P9ZINT � AND CONS7'RUCitON
ii1lTiiO Ti0 � .
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i
�. PE�SON COUNTY E3�IVIRONME�iTA►L HEAL• TH
PLE4SE SE� ATiACNED PLAN FaR WELL SiTE �LAYOUT
���
: �¢ ��° �.,� ����` �`�7
• 7� ��a� I��veY
zomoa .
� 1
J6'�f')1/h�. �A'[N' ths
� ..�— -
�,SG►a c_S � {�ti � � � �vLC�✓�f i��°i �P -
�,pCi�00; r
�,�-,'d e •��S � g
� D � . '�:��- -
Tvae �f Wafier Su�� .
.�
Reauit�emenis: .
� wen Psrn,it � • �
�d�ra{ _C,ommuuniiyy Public
_ Site Approved by ✓31+ 3 -� ��
Groutin9 i°►PPr'oved by ;ls�+_3 ac�-a�.
Well Log ✓5N� 3 aco-oa
Well Tag � ' �
Air Vent �
Hose 8�
Concxefie Stab
Weli Driller:
�
Wel[ Approved By: _ �' ' -
*+See ktiacfied Site Siaafich**
Welis rrtust be 10 feet from prope�ty �ines•
Wells must be 100 feet from septic systems.
Wells must be at leasi 25 feet fram acry building foundation.
Other co�ditions:
0
�
0
9
<:
� _:
�
� . . PCH�, rev. t�l29/99
� . �. �
��` ; , �� ���� ��
. � � ����
I��ca�n�roaairnam�radam.lL IE-1L��fl�l�a
WELL PE�
(New_ Repair ) �� '�� �
Tax Map: l.� Parc 1: 3
Subdivision: 4 K Lot: �
Applicant's Name: _��i�i e��6�,4�� C��� l�4 d�✓ �i 2a�S
Mailing Address:
Phone Numbers:
Location of Property: �D g
��
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicttble State and County regulatiorrs governing construction and 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:
QPTew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved 6y:
Additional Commenls:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
�
Date: K � �F ^
Certificate of Completion
�ner:
• EHS/Date
Depth: / n 7 ,
Grout: �c � ac(_ ��
,/ � .
QAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
WELL CONSTRUCTION RECORD
Th�s focm can bo used for iingic oc muitiple wclls
1. Weit Contraetor formaUon:
C�',Q�G �y.���
Weli Conuactor Neme
�37�- �
jVC Well EontractorCestlficatioa NumLez
# !�/�i'�� Lf/zr�A.� .��.
co��y �m�
z. weu Glowhvction rermtc a:
List ad applrca6le »e1/ pern�ir.r (f.� Cous¢; Sto[� Yarrance, Infectfar, etG)
3. We11 Usa (chech well use):
DAgricultumi ❑M cipaUPublic
[7Geothermai (Heatin�/Cooling Supply) � entisl Water Suppty (single)
DlndustriaVComme�ial ORes�dendal Watet Supply (shared)
Non-Water
QAquifer Rechnrge IIGmundwater Remediation
oAquifer Scorage and Recovery ❑Ssliniry Berrier
OAqu;fcr Test OStmmwater Drainage
❑Experimentai Technology OSubsidence Control
QGeothennat (Clased Loap) OTracet
❑GeoWecmal (Fieatiag/Cooling Retum) ClOther (explain undec#21 T
4. I}stte Well(s) Completed: •��Z Well ID#
Sa. WeU Locatlon: '
�Ayfi�S ���i�/
FucilitylOwner Nnme Facility IDJt (if applicable)
���—�� ,� �.�N� .
I �
Physipl A mss. Ciry, and Zip
G�
C�+�+�Y Parccl Idencificadon No. {PQJ) �
5b. Latitude and Longitude tn degrees/rolnufes/seconds or deciroal degrees:
(if well fie►d, onc Iatllong is su8icient)
.��° o�i�,�3���R►�N 7�°�'a�.�q3�y�' w
6. Is (are) the well(sj:�ermnnent or �Temporary
7. [s this a repair to an extsdng �eA: �s or ONo �
./jthla fs a repatr. JJ!! aU tnotiti� uril conatruc !on iqjornra�ion a,rd esp(uin tTre nature oJ�Ge
repalr m�der #1 / mma�ks seclton or on the Gack of thts jorm.
8. Number of weUs constructed: .�L-
Fnr mu(dple inJectron or �ion-wa(er supply urlLs OAZY Krth Ihe same conrnucNan, ynu rnn
submif one jorm.
9. Total weil depW below land surface: __ � ���0 , �n,�
Far multtple nt/!s lfrt aIl dopt/u jjd�erent (esample. 3CaI00' and IQ100�
20. Static water level below top of casing: �� � (ft.)
!f warer levef is a6otir caring. u,te "+" �
!1. Borehote dFameter: _, G /� ([a,)
12. Welt construcdon method: O
(ie. auger, rntary, cabie, dicect puch, ate.)
For Intetnai [Jse ONLY:
22. CerUiicadon:
,
��� y-/ 7
Si c11 oaunctor Dato
B}� s thir ! Gereb}� cerr(fy lhat 1he k+eli(s) H�as (were) consrructed 1n acrnrdance
x�th !SA NCAC OIC.a1Q0 or ISA NCAC 01C.0200 fi'efl ConstrncNou Standard.r ard that n
cnpy ojrhls record has been provided fo the xr!! viti�er.
Z3. Site diugtam or adtlitional well deta!!a:
You mey use the back of this page to provid� additional well site detaifs or woil
consuuction details. You may also attech additional pages if necessary,
SUBMTfTAL IIVSTUCTIONS
24a. For AII Wells: Submit this forra within 30 days of completion of weU
construction to the following: '
Divisbo of Water Resources� lnformarion Praceasing Unit,
1617 Mail Servtce Center, tislelgh, NC 27699-1617
24b, For Iniect[Qn Wells ONLY: in addition to sending the form to ihe eddress in
?Aa above, also submit a copy of this form wlthin 30 days of complction of �vell
construcdon to thc following:
Dlvlston of Water Resources, Underground tojection Control Program,
FOR R'ATER SUPPLY SYELLS ONLY: 1636 Maii Servlce Center, Raleig6, NC Z7699-1636
13a. Yteld (gpm) �� �� Method of test• /fl L'" 24a For Water SaDD1Y & ln�ecdon �Velis:
_-Q Atso submit one copy of chis form tivithin 30 days of comptetion of
13b. DisinfeeNon ty�e: _���_ Amoant: /� C!� we{1 conswcuon to the county hcalth dcpartment of the county whero
consiructed.
Form OW-1 Nocth Carolina Departmcnt ofEnvironment and Natucal Resourcu—Dlviskn of Water Raources Revised pugust 2013
����,5� ���� �� D�� �D � ���,��/ l
`�' c� � ��T'IC� � � [� rr�.�,�.�:�-�1.��/ ���:
����-��,r,Y,. ����.� ��.�.a�� D�o � .���� ��
Well Log
Owner: �Z�-,� ✓h c.� et�,iJ���'� S Tax Map�ljl� Parcel #�S�'
Location: �� �� � c %��.'/ .� F L'�u cir��� � �
Subdivision: �, ��^i'� ��rs �, Lot # ��
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Se�tic System (Minimum 60 feet)
Total Depth: d`�� ft Yield: -D GPM Static Water Level: �� ft
Water Bearing Zones: Depthl.�'s ?' � ft ft ft
Casing:
Depth: From C� to JD_S ft. Diameter: k' in
Type: Galvanized Steel �cs
Weight: Thickness: -%�g Height above Ground: %5'^ in
Drive Shoe: t/Yes No Any problems encountered while setting casing? Yes �
If "yes" give reason:
Grout:
Neat: Sand/Cement
Annular Space Width
Method of Grout: Pumped _
Materials Used:
Concrete GraveUCement
inches Water in Annular Space Yes No
Pressure Poured Depth to Ft.
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log
Location Drawing
From To Formation
D E���t � `�..�
� .sf L:� �-c
� i�v -«, ,-�� �c
!-��`� �
��
,
, . �,� �,:,�, r�� ^ �
��. t
.�
��'
���
I hereby certify that the above information is conect d that this well was constructed in accordance with regulations
set forth by the Person County al Dep e.
.
Signature of Contractor � ID#��� Date ��5���
PCHD rev O1/16/02