A40 372•' Appltcation Date: ��r���6� Tax Map #: � ��
Amount Paid:
Receiat #: 2— Parcel #: 3 7 Z
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� APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
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1) rermit requested by: (Ownerlagent/prospective owner):
Hame Phone: 3�4�- �S-�. SS 3$ . Address: S��o I�ru� �AN�^ lPc/
Business Phone: /7 -�Gh d�� /1 G. ��S 7�
2) Name and address of current owner: S�41MM�, ttfrc�J�.�.0 �
3) Property Description: Lot size: � AG�• Township: Subdivision: - �, Lot # gZ
Directions to the property (Including road names and numbers):
4) Proposed Use and Structure Description: answer e ch �jf t�e following que tions:
a) Proposed ✓, Existing , Type of Structure: j��o�.t'c.� —.� �,��r+�oo«�Width: Depth:
b) Number of Bedrooms: �_ Number of occupants or people to be served: Z
c) Basement: Yes_,, No � Will there be plumbing in the basement?
d) Garbage Disposal: Yes , No 1C
5) Water Supply Type: Private ,� (new ✓ or existing�, Public_, CommunityJ Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE. FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
i hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be place�on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid. // ,
Owner o� 'Legal Representative
�a-iz-�
Date
PCHD, rev. 06127102
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Building Additions/ Mobile Home Replacements
Tax Map #: � v Pazcel#: 312 Address: � Qu�r de �e. �,
Approval Requested for: �� obile Home Replacement
V Building Addition
Applicant Name: �t+ nv� � lYa ��
Address: Q� _/� �
Phone #'s:
Permit Located: � Yes No
Installation Date: — - Design flow: �l�� (gpd)
Current Contract with Certified Operator on file (if required):
VL'ater Supply: �/ Well Public or Community
Wastewater system shows no visual evidence of failure on: — Z' 3(date -
(Applicant's signature if site visit is not required)
Comments:
Addition/Replacement Approved
Enviro ental Health Specialist
1(-- I 2 �l3
Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net
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T'f33S SY5TE3i HA�s • HEi3�i INSTAL-"LE�] tNi CaNIPtJANCE. :1M'iH- APPUC.ABLE. NCRTH
C�IERAL-3TATtlTES, •RULE�� �� SEW,AiGE"FREATMF.i�iT AND D�.S�O'�L, .
piyD Ai.L CANDR'[t?NS� . OF : TI�� l�PRQVEIl�I�'1` PEi�l1iC AND. •CflNS�UC'�iR][ol '
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Applicant:
Location•
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S�u.f�cliui�ioai � _ i�
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P ia���S.c' S e c ti o �i, �`L.o t� �
�prmveffient P�a�t
Pe�mat Valid for �ive Y'ears. 1�T Eagira�on �� � �.-,"��('
Type of Facilit}�: �' i� ' New �t�ddition _ W�ter �upply --��,
# of Occupants �# f Bedroo 3� Projected I�aily�Flow 3�o g.p.d. � �
Proposed W �tewRter System: ' � ..
t .
Propos�d Repair: �' � �
Permit Conditions: '
Type: ��
�e� .ZT�.- .
Owner or Legal Representative i e- �'-"`�" ��� Date: �"�� 4
Autharized State Agent: ., � ' Date: – �
The issuance �f thia permit by the Health Deparhnent in does not guarantee the issua�nca of other permits. It is the responsibility of the
applicant/praperty owner to in sure that all Person Couni�► Planning and� Zoning and Huilding Inspectiona requirements are me� Tdu�
Innprovement Permit is subject to revacation if the sit� pian, plat or the intended ase changes. The Improvesneamt Per�it i� not aifected
by a'change in owner�hip of the property. This permit was issueai in compliance with the provisions of the North CaroLtna `Laws and
gules,for SewaPe Ti�eatment and Disnosal Syste�s' (15A NCAC.I8A .1900). Neither Person County nor the Envirorz�enta! Heaith
Specialist warrante that the septic tank spatean will coniinue to function satiafactority in the future or tbat the v�ater supply will �emain
potable. � �
�Autho,rization �o Con�truc� V�asteva�ter S3�stea�i ��tequired %r �ntilding fl'ermit) .
�` See site plan and additional attachments (�.
Proposed Wastewater System:1' .tv.�, .��n��� Type �,` Wastewater Flow ��.p.d.
New � Repair Egpansion 30� I,TAlt: • 3 g.p.dJ ft 2
Type of Eacility: 3�3I2 5;..���,'� ��s:����s� � Basement Yes t�o
J�
'�astewater System Itequirements
Siae: Septic Ta�: dU� ��1 ,. �p T�k: -�—� g�� Grease Trap: � gal
field: 'Total Area: �[,� sq ft Tota� Leaagt�n � ft 1Vlazimu� Treaac.� IDept�a ,3o an
�h'�idth 3 fit 1liiiniva�aan �onl Co�ver: ��., i�a Minimum Trench 5epazation: % ft
Distribu#ion: ✓istribution �ox Seri�l Distribution Pressure Manifold
Speci�cationa: ,jr:� s.'�,j✓�ari . � .
Au#hor�ed Stat� Agem$: //�,(/�--�– . /`� • �
Permit Expiration Date: /a—/ �o - �$'
The type of system permitted is
the pemut. '
O�rnea-/�.�ga� it�pa��se�tutave:�
Innoyative
Date: /.2 �% 6 �!�'�
Alternative. I accept #he specifications of
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PCi�7/3 I2002
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Name .�/h�ZL1/TCL�✓���
Subdivision / k�,b�e �r�
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Authorized State Agent
SITE PLAN b
Tax Map # �� Parcel # 37 `�
Section/Lot# �'%2. �/� �
/2�-1 fo� -03
Date
Sysrem components represent approximate contours only. The coritractotmustflag the system prior to beglnning che insrallation ro
insure thatpropergrade is maintained.
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1'I.�E SE� A'�"�'AC�ED PI..t1N FOIt WEI..L SI'�E �Y�gJ'I'
"I"ax YVYap #: .�6 Parcel # 3 � � 'g'ownship �%. � �'v�e:�
A�pplicanr .��t syr n�
Subdivasnon: /.� �t �^,'c��- � �r�� Secsi��: I.ot: ��
I.ocation• '
'I'�e of'Wat�r Su��alyr �ndividual Communitp Public
Rea�ui�ements: �
Site Approved by �
Grouting Apg�oved bp � " %/�'�
Well Log `tl
Well T
Air Vent
Hose Bib�—
Concrete Slab
Well I�riller.
Well �p�rovec� �y: y� ��� Date: �'' � �`� 7
'�°5e� �lttacfliesi Site Sketcia�`
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septic systems.
WelLs must be at least 25 feet from any building foundation.
Other
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PC�ID, rev. 09/07/01
BarneYte Well Drilling Inc 336 598 9275 01/23t04 05:18P P.002
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�rout Lo�
Owner: Ir�r�c•� � - - ----
T nrnFinn•
Tax Map %9�%D Farcel #���
SU�dIV1S1011. VC ���'lL�e n/ /7Cy''�C.� j.Ot # �.��C__•„�••—•—
Well �onstructio�t
Distance .From nearest Property Line (,Iv�inimum 1 Q feet)
Distance from Septic System (1V�inimum 60 f�et}
"C'otal Depth: �, ft Yield: �D -- GPM Static Water L�vel: �� f't
Water Bearing Zones: Depth �f ft �lft Ft ft
Casing:
Depth; From _____Q_ to � ft. Diameter: ___�j ';� in
Type: Ga�vanized Steel �_
Weight: T'hickness: .. /S3� �eight abave Ground: ��L— in
Drive Shoe: � Ycs Na A,ny problems encountercd wl'iile setting casing? �Yes �.�To
�f "yes" giv� rcason:
Grout:
�Teat: SandlCernent � Concrete Gravel/Cement
' Anm�lar Space VJidth inches Water in Annulaz� Space 'Yes Na
Method of �Cxz�aut: Pumped Pressure Poured � Depth to
Materials YTsed:
N�_ �ags Portland eement � Weight oF l Ba� r�D Pounds
If mixturc (sand avel, cutrmgs} — Ratia to
ID plates: es _ No 4 x 4 siab �� No
17rilling Log Lc�cat�on Drawing
Ft.
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I hereby ceitify that the above infacmation is correct � d that this well w�,5 eonstructed in aecordanee with re�ulations
set fvrth by the PerS�n County Health Dcp�rtmen .
Sfg��ture of Contractot' ID #�� Uate �r�� "'�`�
pCHp rev 09/30/02