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Improvements Permit.(EstablishedlRecorded I.ot)
Im�ovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
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Date
_ Reinspection of Existing System (Loan Closing)
Repair/Repiace existing Septic System
_ Permit for New Well
Replace Existing Well
l. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospective owner/agent:_CJ���les �Pe�'�I/1%5 Width:
Address: •� 2 � �j �,ia� .� a� Depth:
� 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facili[y
that this sewage disposal system is intended to serve?
Home Phone #: 336 ���'( - �1 �1 �
usiness Phone #: � �i°�� � 12 �
2. Name and addre�s of current o•xner: 9. Water supply t}'pe:
� 'ut/S private � public ❑ ccmmunity ❑ spring ❑
� Z ���� : iV,�� , Are any wells on adjoining property?Yes ❑ No j_].
If so, identify location:
3. Property Description: Lot size: f� ,G3
. Tax Map#: � 10. Type of structurelfacility: Proposed: DExisting: Q
Paccel##: Type of dwelling:
Township: House: � Mobile Home: Q Business: ❑
5. Directions to propercy: State Road #& Road Type of business:
ames,�tc. Number of Employees:
:a- - ,,. � �:.�� ; >>,,.�-; r� �Pa }:�' �".,,,-; °�, �r����� Number of bedrooms: 3
v�,�_ �.r I � .,4,,, i ,,�� . �,>, �4:,r*.;; �:, � Garbage Disposal? Yes ❑ No �
t-;;� '�:-,„ �'. si ,,, g.,.�-� � Basement? Yes ❑ No�1 If so, # of basement fixtures:
, 6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pei'Son COunty T�ealth Department for a site evaluation for the on-site
sewage disposal system for the above described propercy. I agree that tlie concents of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invaiid. I understand tha[ before an Improvements Permi[ can be
issued, I must present a survey plat of the properey to the Health Dep[. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
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Signc� Owner or Autt�orized Agent
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PERSON �OUNTY HEALTH DEPARTMENT
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WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map #
Owner/Contractor
!� � � Parcel # �� 3 6 �
Township
Date /e -�-
Location/Address d.v %��, v�' J��y�.s /auc�.. /�ol. ue
:�'ro�.. /575. S.R.#
Subdivision Name ' Lot#
,fl �,�/� SEWAGE SYSTEM SPECIFICATIONS
Repair Punp. Lot Area �. (0.3� c Size of Tank %!X}O
SFD ✓ Mobile Home '" Size of Pump Tank
Business # of Bedroom� Nitrification Line yU0'X 3'
Max Depth Trenches 2�/ "
Permits may be voided if site is al ered or intended use changed.
Well and Septic Layout by �. oti...._
Comments: .� ,' � ,�s � � _
Date -( 0'O� Installed by 'S �m m y L c c� i.S Approved by
;
Well Permit Paid WELL SYSTEM SPECIFICATIONS '
Individual Semi-Public Required Slab �' - �' �oa-
Public Replacement Air Vent �'- -��
Site Approved_ Required Well Log
Well Head Approved j������ � W lg 1 Tag ���
Grouting Approved �� % ��-,p Z �-�-o�� � �j
Comments:
Date �- � p� Installed by �jf�,rv� Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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PL A T CAB
FILED IN PERSON COUNTy �ANGER
---- DAY pF __________,R19ISTE� OF DEEDS ON TNE
'---- 0'CLOCI( __M
REGISTER OF pEEDs ---'-----___
`1AA1 q, WARREN JR.
•8• 276, P. 463
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Tax Map #• �� , : Parcel #• «� � � / .
Zoning: Township: �-� � cvc. r
Subdivision: � „_,�,_��:t- �: Section: Lot:
Appltcant• 1�1�G�� � �S Qt T��c v�.5 .
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� �vration Permit
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System Type (In Accordance With Table Va): -�
THIS SYSTEM HAS BEEN IN�TALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUT�S, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS O� THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTH�ATION. p - .
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State Agent
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Owner: �
Location: J
Subdivision:
Dri'lller I D # �
Com.p�ny Name � t _�.
D�te Dril!Ied +
Well Log
Lot #
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Tax Map�� Parcel # �
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: .,2ov ft Yield: � GPM Static Water Level: �,� ft
Water Bearing Zones: Depth � G ft ft ft ft
Casing:
Depth: From � to (� O_ ft. Diameter: (o �I in
Type: Galvanized Steel ��_
Weight: T7uclrness: . IS� Height above Ground: � in
Drive Shoe: �Yes No Any problems encountered while setting casing? Yes _�Io
If "yes" give reason:
Grout:
Neat: SandlCement i/ Concrete GraveUCement
Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured Depth to Ft.
Materials Used:
No. Bags Portland cement Y� �'� Weight of 1 Bag �5�o Pounds
If mixture (sand, gravel, cutting' = Ratio to
ID plates: �Yes No 4 x 4 slab � No
Drilling Log Location Drawing
From To Formation
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'I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person County Health Departr� n
Signature of Contractor � ID# D�- Date ��2�f -U 2
PCHD rev O1/16/02 �� �
❑PERSON COUNTY HEALTH DEPARTMENT
355A S. MADISON BLVD.
ROXBORO, NC 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of O�vner or Tenant J 5e S
Address $3(� Cau 5 1Q�Nrv� f��. County �Trsa�1
Collected By ,, S
Date Collected / y.� 2!'Oq Time Collected Z. %d5�
Source: ell
❑ No Charge
❑ Spring C��Well Tap ❑ Other
�'Charge
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Total Coliform
'Fecal/E. Coli.
� Results
Present .
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0
Reported By
late I �
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Absent
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