A40 367��3-t�
Application Date: � � 3 �e OQ ���.SS ������
Amount Paid: � 00 , O O �6, �,
Receipt #: �� � 72 �5 3 � � ����
IE��n-�rr,.,�,,,�,ad.�.Il IHI�,.�.Il�
�r�d.'�
rovement Permit (Site Evaluation)
$204.00/$300.00 (if> 600 endl
❑ Mobile Home Replacer�ent or Building Addition
$150.00 (if site visit required)
0 Welt Perrnit (1Vew/Replacemeat/Iiepair)
$300.00/$200.00/$75.00
1) Applicant L
Name: C
Address:
h/�
�lication for Services
Services Reauested
�
Tax Map: � �d
Parcel#i �7
�. aN�e ,1.A � �a�
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$�s.ou
�7 Repair of Existing Septic System
Application: No Chazge/ CA $150.00 or $300.00
Phone (home): .��`� o2-S���-'
(work/cell): S� 9 � ( �. 9
2) Name and address of current owner (if different than applicant):
Name: Phone:
Address:
. . . �R•d �-c- .
3) rroperty D�scription: Lot Size: ��� Subdiv�sion: �� � Lot #: 7 7
Address and/or directions to Property:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
� yes 0 no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other thar dnmestic sewage?
❑ yes rJ' no Is the site subject to approval by any other public agency?
❑ yes � no Are there any easements or right of ways an this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure: ,
❑Residential �
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of E:cisiing System If expansion: Current number of bedrooms:
0 Repau• to Malfunctioning System Will there be a basement? ❑ yes ❑ nu '�'ith plumbing fixtures? ❑ yes ❑ no
ONon-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property7 � yes 0 no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
C7 Conventional ❑ Accepted O Innovative ❑ Alternative ❑ Ot�'�er ❑ Any
I cart�� that the in,faj•mation provided above is complete and correct. I also understancl tlzat if the ifzformation provided is
inaccurate, c�r if the site is subsequen�ly altered, or the intended use chcrnges, all permits and approvals shall be invalid.
d
Signature (Owi�r/ Legal Representative*)
* Supporting documentation required.
� 3 �
Date
Permits are valid for either 60 months or are nou-expiring when accompanied by an approved �lat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Mor�an St.. Suite C. R�xhnrn NC'. �757� «Z�_So�_t �om
����,sf ���.� ��
- - _ � � ����
?E=�s �-yn � � ��.����.11 IF—� � �.11 �1�
� ��
Taz Map: � Parcel• 6
Subdivision ; ►.e.
Phase/Section/Lot #
Applicant; ��y 'w���S
Ad re . /,�,oc �on:
-����_� � � c ��-�=�� �.� _ ,____--�-�-��---�_= �_�_ c�.�= s4 �
Permit Valid for: Fiv_�
Type of Facility: 12
Number of. Bedrooms � / �
Proposed Wastewat Syste �
Proposed Repair: ��_
Improdement Per�it
Non-expiring
New � Addition
��mployees / Seats:
V4'ater Supply: �'P��
Projected Daily Flow: 3 6o gallons/day
Type:
Type:
Permit Conditions:� �/(%a���� ��p'� �
Authorized State Agent: y� _ Date: 5- 2?�! (�
(X) Owncr �r Legal Repr entative: Date: ��j, Zo(lo _
The issuance of this permit by the Healt�h Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site pian, plat or the intended use changes. The ImQrovement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Luws
mrd Rrcles far Setivag� Treatment and Du�osal S'vslems'(15A t�TCAC l8A .19U0). Neither Person County nor the Environmental
Heaith Specialist sv�rrants that �he segtie system will c�ntinue to fanciion satisfa�torily in the futare, or #hat the water supply wiil
remain pota5le. -- __--- _- - --
A�thorization to Construct Wastewater System
See site plan and additional attachmetTts �_).
�
Propo d Wastewater System: Cc P n�— c� S'� (*)Type � Desi�n Flow 3� a_ gal./day
New � Repair _ Expansion _ Soil L"ff�R� 2� gal./day/ftZ
Type of Facilir,�: �j �(Z /12e S, Bssement: _ Yes �C No
(*) System Types III6, Illbg, IY, a�d V, require perio�lic system inspections by th_e Ferson County Health Department.
Wastewater System Requirements
Tank Size: Septic Tark (� �� gal. Pump Tank `— gal. Grease Trap `- gal.
Urainfield: Totai Area [ g� sq. ft. 'fotal Length 3 3� ft. Max. Trench Depth � in.
i rench Width 3 ft. Min.Soil Cover �P in. Min:Trench Separation ( ft.
Distribution: Distribution Box / Serial Distribution �/ Pressure Manifold ____
SpeciGcations:
Authoriz;,d State Agent: I�r � i ��- Issue Date: 5-� ?���
Permit Expiration Date: S�Z? � Z(
T'he system permitted is: Conventional /Acczpted �/ Alternative / Innovative . I accept the co�iditions
and specifications of this permit.
(X) Owner or Legal Representative: �� Date: -
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC27573/ph: 336-597-1790 (rev 5/12)
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� '+ SITE PLAN "
Name ��l l", � Tax Map# T � Parcel# ��
Subdi isi i Section/Lot#
. �� — �_
Authorized S e Agent Date
System componon[s represent approximale cor.lo»rs or,ly. The contractor m.us[Jlag the system prior to beginning the
installalion to insure that propergrade is inaintained.
Nole: An Accepted syslem may be used in place oja conventional system wrthou[ permit authorization or modification.
3365975822 m hc783
10:16:13 a.m. 06-04-2016 2/2
� ""C'C_J �p �
OFFER TO PURCHASE AND CONTRACT - VACANT LOT/LAND
[Cnnsult "Guideliaes" (form 12G) for guidancc in completing this form]
NOTE: This contruct is intended fnr unlmpsoved renl ptuperiy thut Buyer will purchuse only for personnl use end does not havc
immediatc ptans to subdivide. It should not he used to seIl pmparty that is 6eing subdivided unlcss tha pmperty has boen platted,
properly approved and recorded with the tegiscer of dceds as of the datc of thc coatia�t. If SeIIer is Buyer's bullder and tlae sale invalves
the constiuction of a new single family dwelling prinr tn clasing, use tha atandard Offer to Purchase und Contract New Construcdan
(Form SOQ Tj or, if the coa9ttucdon is completed, use the Offer to Purchase and Contract (Farm 2-'1� with tha N�w Construcdoa
Addcndu� (Foim 2A3-'1�.
Far valuable consideratiun, thc receipt and legel sq�ciency of whIch are hereby acknawledged, Buyer o[fers to purchase and SeUer upon
acceptanee egrees tn seIl and convey the Propccty on the terms and conditions of this Offer To Purchase and Cantract and nny addendwn
or r�odific�tion inade in accordunce with its terms (together thc "Cnntinct").
1. TERMS AND DE�'IIVITIONS: Tha tenns listed below shall have the respective meaning givea them av set forth adjaceat to each
term.
(n) "Seller": oak Ridaa Acres LI�C
(6) "Buyer":I.inda Diana Daii
(c) 'Troperty": Tha Pruperty chaU inalude ali that tsal esiate described below together with alI appurtenances thereto including the
imgrovaments locatnd thereon. NOTE: If the Propeny will include m m�nufuctured (mobile) home(s). Suyer and Seller ahould
conside; including t}�e Manufuctured (Mabile) FIome p�ovisiop is1 the AddiGanal PcpviSians Addendwp ($tandard Facm 2A11-�
with thIs offer.
Streot Address: 77 Marco Drive
��y; Roxboro Zip; 27574
County: Peraon . Narth Carolina
(NOTE: Governmental autlioiiry over taze.�. zonirig, �oHbol distrlct5, utilitI�s and tsiail dellvery may differfroiri addre§s shotc+n.)
Legai Description: (Complete ALL applicable)
Plut i�eference: Lot/[Jnit 77 �, B1ocklSection , Subdivision/Coqdaminium Oak Ridcr� Aczes
� as shqwn oa Plat Book/Slide 13 at Puge(s) 67
T4e PIN/PID or other identificarion number of the Pmperty is: 9994-00-31-4802. 000
Otherdcscriptian:OAK RIDGE AC/PH5/L'I''77/VI,
Same or aIl of the Property may be described in Deed Baok 390 at Paga 340
(� "Pucchase Prlce":
$ 9,500.00
$
S
S
$
$
$ 9,540.00
paid in U.S.1]oliars upon tha folinwing terms:
BY DUE DILTCiENCE FEE mede payable and delivered to 5eller by the Effective Dnte.
gy II�ITIAL F,ARNES7' MONEY DEP05TT mnc3e payable and delivered to Escrow
Agent aamed ia Paragrap6 1(fl by ❑ c�sh ❑ peraonal check 0 official bank check
� wire transfe , EITHER [� with this offer OR ❑ within five (5j days oF the Effective
Dutc of Wis Contrac�
BY (ADDTTIONAL) EARNES'I' MONEY DEPOSI'I' mndc payablc and delivered to
Fscrow Agent numed in Pacagrnph 1(fl by cnsh or immediately avnUsble fuads such as
official 6ank check nr wus trnnsfer no latar thaa . Z"IM�s
BEING OF 1'H�s ESSENCE with �egartl to saId date.
BY ASSUMP'I'ION nf tt►e unpaid gtinciput baleace and s►ll obligntioas of SelIer on the
existiag Ioaa(s) secured by a deed of hust an the Property in accordance with tha attached
Loan Assumption Addendum (Stan�nrd Form 2A6-�.
gy gEr.r.F:R �A1�TCII�fC3 in accordance with the attached 5eller Financing Addendum
(Stnndard Farm ZA5 Z�.
BALANCE of the Pucnhase Priae in cash ut Settlement (some ar all of which may be paid
with tho proaceds of a new loan}.
This form joinqy apprnved by: Page 1 of 11 � STANDAitD FORM 12-T
North Carolina Bar Association � Reviscd 7/2015
TOR� Nosth CaroUna Associatlon of REALTORS�, Inc. ,K"�,�.1OY"0,,,,, � 71'1015
Buyu initials �_ Seller initials
w�tw�a.n-s�.�ns�nas�.,ricnw re�a�u-swa F,.: c9iswTsaso n�e.�
CcL Sm'all ProA�s�d with rlpFamK1 b7f sk�0� 18G70 Flde�n Wts fioul Ftwy A4fib�n 48W18 Ib00ELi�1Q�.G�
���. sf ���..� ��
������
� exn.�na-�n�n.n�a.��n��,Il �'�¢��.���a.
Applicant: Sq�'Li�,. y ��S,,Jxi
LoCatiOri: � , n n t /
�D�eration �ermit
System Type (From Table Va): �
Type V& VI Expiration Date:
Tax Map �� Par el # � �
Subdivision 4�r � S
Phase/Section/Lot #
# of Bedrooms �
Product (IIIg): �-. ��o W
Type V& VI Renewal Date: �_
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
Authorization.
� �r��
( thorized Agent)
1 -i. �' S
�2icensed Contractor)
Scale �5
PCfiD, rev. IZ/14/12
�q��23 ' � �O
(Date)
�'�3'��
(Date)
s � Z ` -�-v PlL
��
.�5�� P��
33 r
�
Cdr ✓�2 r
P'''
� � v�o r� 5pY5
Tax Map: �'1D Parcel #: 3 � ?
Septic Tank System Checklist (Type II-I�
1�'o�es °
System Type: ��` J � ��Z
Pump System Checklist
Pum Tank Initial/aaxe
State ID r3c Date:
Ca ac:ty:
Riser (6" min.)
NENLA 4X B�x
Model:
Piggy back lug
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressu�e Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
l�dotes:
���.sf �I��.���
- � � ����
IE �� � � �,� � �. �.�.Il IE3C � �. Il � ]�
WELL PERNIIT
(New� Repair_ )
Tax Map: �� Parcel: 3 6
Subdivision: q v,' ,�
Applicant's Name: �qrti,r�•� �'%&'l,� t�i K S
Mailing Address: �—
Phone Numbers:
Lot: �
Location of Property: �� �� �(,� �(CQ Q q� �C --� Qu q v�-2� S a� �—'t
- �t U'✓'C a
Permit Co�ditions: .
1.) See attached site plan for proposed well location.
2.) All applicable State and Counry regulations governing constr�uction 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: �
�ew Well:
� � EHS/Date
Location: � Cr ap
Grouting: i�
Well Log: ff
Well Tag: �
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Date: ��2? �! ip
Certificate of Compl�tion
DI.iner:
EHS/Date
Well Driller: l�i�Rd�L�'�
Pump Installer: ��
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Nealth
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 fax:336-597-7808
11/26/13
Jun 3016 02:59p Barnette Well Drillinglnc
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w�LL eoNs�ucrro�v �co�n
'llos fc+tm�caa 6c usaf for s�aglc oc mulripk wdls
1. Wcll Contractor loform��ou• --��
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V1'cl1 Contrauor Namt
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xc wa� co�c�,t;a�U� H�
Ba�nette Well Uriiling, Inc.
cnm�ay Name �J � �
ly
z.:�C��CODSfIUCtiO� eCrtUitih. ��
Ust alfapplimbfe weAcowtrnxioa�criwr�s �i.e. Cnrsuy, S� V'crim+cG uc)
�. wdi vu t�n��k ,��it ���:
Q/�j(�[qyy� [],i�iWUCIp'dl/P1l�J�lC-
QGtoQtamal(FieatingK'.00lingSnppLY) zcidariial,WaterSuPP1Y�sm��)
CiInd�aljCommrrcial i7Rcsidra4ia! WaterSupply (shartd)
s�Pp�YwaL
336-598-9275 p.1
,�� ������'
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Fa Irae�usl Ucc OPiLY: .
ElAqtti�'ts Re��+'8� ❑Gcotir[dwaler ReYriediation
L7Aquifet Stoiageand Rxovm OSalinity Bartt�x
CtAquifcr 7'aE OStoTmv.ater ihaicsa�e
p�immtal.Ttthnology �Suhsidrnqe Contmt
DC�4th�atsi (�lased Loop) a'IYaccr
CiGeotlximai(Hca�n�fCoolingRdum) OOlha( Ia;dnnQes#2[Remadrs
d.lht�i'Vell(Sj'Canpicted: "!�' �'PYd1�1#�'„��
5a. Wei[ Ianriau:
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e�7 /-�-Rc C� �J ►`11� �.�'r t� � ;-� � :PQ�-
Physiral Add�as, C:ry, �d Zip
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5h Iatitude aad Laagifade in.dcgreesJmisutcstsecoud�or deCim�tl i�e�r'��s•
(:frrc�i �ld. me Iatltoag is wFficicat)
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j/r/Jr ls n repalr, fil! omhrown +rel! eoruu�uaio,. F�orraarfan md a�4un the norare aJatie
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t�bmrr ox forr+.
9. Totstweil dc�t� below fand sottae� /�� (ft)
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T3. S'itt di�giiata'r uddihon.ilwdl dctmis:
You t�ry ase ttie back o£tbi� pa�e W pxevide: addiGara� we1l. �itD detai{s or wr�l
�on delails. I'on irraaX alsd.auach additian8t pagas�fne�ss'asv.
5UE1tii�I'A3.IlH5[UGTlON5
7.aa. For Aft FVdI� 5uhmit this.£otta wislun 30 days of aompldion of +�cll
oda�shudidn to thc'f0il6win�
Disisioa oLW�tcrQosiii}, InforusaUoe.I`rocas�og U�ui�
f6I7 i4fa� Se�Cv.ia Ceatsr, Raleigh.t+EC�76l9-1617
1L Borehoie dla�aeter: � f a) 24b. For Iteicctioo WdL�: Fn addirian to sending �hc fo�m to the addres.s in 24a
jJ abovq al�o.submit a c� bf d� foiut witkrin:30 days of complction ofwrll
LZ. WdL ceostRvctioa .aFdhad: ry( (,��. � ry�f%�� c�od ta ttie followin�
{i•a augc .�ota�Y. cat�te: d�cM P�� ct�•) Ikt�isioriaEVVnter QuatitY� Uud�maad.[njectioa Cou4ro1 prugram,
FOI� WATER SUPPLi' WELES O1�ZY• 153G NLait Seeviae Csnter, Rategh, NC 27fi99-t63fi
I3iYidd m. '� Btown20 mir�uie 2dcForTi'sftrSundY&.iu'Eex�aati_Y_dir [nadditiontaset►dingthe.fbrinto
(SP 1 �'� Mct6od oCtrst � a��(,a) abuve, slw subaiit one r.opy of. tliis foim wiihin 30 days af
compietion o€ cuclt whshuction to thc cou�ty hcaEiti dcpartrn� of �c oauaty
asb. v�iKaoo � HTN ,�o�t, 1��i Cup .�� oo�u�.
F�.,�, rU�-1 Noed� Cmolwa bcaartwmc af Fnoiranmrnt and N�+ul Resaazes— Div"sion ot�4'ater Qinfiry Revisod.Jan.1013