A40 376Ap�slication Date: � �� 1 �
Amount Paid: , d0, bU
Receipt #: 1 3 OU
�� ����
r �1 � ��� Z �°d �`�a �� 1����� �
,� a a ���,s� IP�I�����
lq3TGr cC�jC71�T�C�Y
_ �� a 7 aawasoaaara�an�mIl �c�.Ild�n
C%F
Ao�lication for Services
Services Requested
�� �q3 �o �
Tax Mag: /��
Parcel#: 3 � �
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d) Fee is de endent on the e of s stem ermitted)
❑ Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 if site visit re uired $75.00
❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: •
Name: v / � w'�' IvS Phone (home):
Address: .��t (r J. F �.1- s 11� . (work/cell):
2) Name and address of current owner (if different than applicant): �r
Name: Phone: .3.� � � / � � � � �
Address:
3) Property Description: Lot Size: Subdivision:6A�' I� �,�Lot #: �_
Address and/or directions to Property:
❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on 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)
4) Proposed Use and Type of Structure: 3 �i+ ��L�lT
❑Residential �
,Z�yl/► �
e�0�1 w Single Family Residence Maximum number of bedrooms: �_/ Occupants:
❑ Expansion of Existing System [f expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? � yes �o With plumbing fixtures? ❑ yes �
❑Non-Residential
Type of business:
Maximum number of employees:
Total Squaze footage of Building:
Ma�cimum 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 property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If applying for °Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other � Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, he site is subsequently tered or the intended use changes, all permits and approvals shall be invalid.
� a,,.„,►�-� Q, �-%� � a °- �7
Signature (Ov r�r/ Legal Representative*)
* Supporting documentation required.
Date
Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
���.s.� ���.���
. � � ����
I� �raaa u- � �rnaa-a m �rn. ��.Il IF'7� � a.11 �llEa
WELL�'ERNIIT
(New ,/ Repair_)
Tax Map: 1 0 Parcel: 3'i V
Subdivision: _QaK R�dn._ J�creS
Applicant's Name: sQM«.� �IQWK;M.�
Mailing Address: �yKs �,j(,, �•���_
Phone Numbers: 334.- SAB- Zl29
Location of Property:
Lot: �_
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and Counry regulations 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: Mai��-��� all s,cF�.�Cs
Permit issued b • � �
(�Tew Well:
EHS/Date
Location:
Grouting: �I�l�
Well Log:
Well Tag: �
Pump Tag:
Date: _ 7-G--l7
Certificate of Completion
DL,iner:
EHS/Date
Depth:
Grout:
Air Vent: Z,-28'Ig
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller: �jp�� ..
Pump Installer: i� � �
Approved by:
Addi[ional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
o..,.ti,..., ntr ��c�a
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: 2 _2�.�g
Date Results Mailed:
Phone:336-597-1790 fax:336-597-7808
„�,«„
—7
���.�� �'��.���
�� � � ����
I��.�aa-��,�„-,. ����.Il IE���.Il�I�
Tax Map �0 Parcel # `7(�
Subdivision D '
Phase/Section/Lot # $(�
# of Bedrooms 3
eration Permit
System Type (From Table Va): / Product (IIIg): C�a►.,�
Type V& VI Expiration Date: N ik Type V& VI Renewal Date: �I�
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
.
��
( thorized Agent)
�� 3
� ��
� �-��Ul� �Gtl`�}1
;�I `U�
(� y�kLL
Scale
PCHD, rev. 2/14/12
� ,�a� � j�
Z-�- IS
(Date)
��_ g
(Date)
Line Length
I56'
Z s'
Total 300'
Tax Map: /�y0 Parcel #: �
Septic Tank System Checklist (Type II-I� System Type: �4 �1.h�F; �
�—
Se tic Tank InitiaUDate
State ID & Date: SS Z_ �_
�-30- ✓
Ca acity: ii$-�000 ,/ •
Tee and filter ' � ,/ � "
Baffle ,/
Vent
Riser
Outlet boot
Perm. Marker
Distribution
D-box (levels set)
Serial _ g
Pressure Manifold
LPP
Notes:
Nitrification Lines InitiaUDate
Trench Width: 3 ft. — „- r
Trench De th: in. ,/
Total Length: cd ft. �
Minimum spacing: ft. b.c ✓
Rock depth/ uality
Dams/ste downs ./
Grade (< ,ZS" in 10') ✓�
Cover 6" minimum) ,/
Setbacks
From wells 5 Z-4-rS
Property lines
Foundations/basements
SurfaceWater �/
Other:
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes:
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
D �t1ti � ,� 0 iQ �su �
Well ContractorName
.�3 7� --�
NC Well Contraaor Cectification Number
Barnette Well Driliing, Inc.
Company Name
2. Wetl Construction Permit #: �"/ �
List al! applicable we!! constnrctron permus ('�.e. UIG Counry, State, {'ariance, etc.)
3. Well Use (check well use):
'ater Supply Well:
Agricultural QMunicipaUPublic
Geothermal (Heating/Cooling Supply) �Residential Water Suppty (single)
IndustriaUCommercial �Residendal Water Supply (shared)
Noa-Water Suppiy WeII:
Aquifer Rechazge �Groundwater Remediation
Aquifer Storage and Recovery �Salinity Barrier
Aquifer Test �Stormwatcr Drainage
Experimental Technology �Subsidence Control
Geothermal (Closed L.00p) �Tracer
�lain under #21 Remarks
4. Date Well(s) Completed: ""�J l� �'eil ID# �
Sa. Wetl Location:
�A✓�7 /�� �%t � _ i �5`
Facility/Owner 23 e Facility IDik {if applicable)
� a-f �6 d � /�. .,� �9� ,� n �es
Physical Address, City, and Zip
�z �s dh> 3 �6
County Pazcel Identification No. (PII�
5b. La[itude and longitude in degrees/minutes/secoods or decimal degrees:
(if well fietd, one IaUlong is sufiicient)
�3� -�� 7 4� N��- 0 2 0�`�_.w
6. Is(are) the well(s) ermanent or �Temporary
7. Is this a repair to an ezisting well: QYes or QNo
!f this is a repair, fil! oul lorown wel! construction injormatiort and uplain the nature of the
repair under �Z! remarkr section or on the back of tlris form.
8. For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surtace: � L D �f�-)
For multiple we![s (ist a/l depths ijdifferent (uample- 3Q200' and 2@/00�
10. Static water level below top of casing: 25 (f�)
!f water level is above casing, use "+"
11. Borehole diameter. � (�n•)
12. Well construction method: AI� rOtBi�/
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELIS ONLY:
13a. Yield (gpm) J � Met6od of test: B�owed 20 Min.
13b. Disinfecfion type: CfllOnll@ Amounr. 1/4 Cup
22. Certification:
i
�2a�. �.; . �.�� --3� - �
Si�ahue of Certified Well Contractor � Date
i
�
8y signing this forn+, / hereby cerlify thot !he weU(s) was (were) constructed in accordance
wlth /SA NCAC O2C .0100 or /.iA NCAC 02C A100 We/! Construction Standards and thar a
copy of this record has been proviJed to the we!! ownei.
23. Site diagram or additional weil details:
You may use the back of this page to provide additional wel( site details or well
conswction detaiis. You may a(so attach additional pages if necessary.
SUBNiITTAL INSfRUCTIONS
24a. For All Weiis: Submit this fotm within 30 days of compledon of well
construction to the following:
Divisiou of Water Resources, Information Processing Unit,
1617 Mail Serviee Center, Raleig6, NC 27699-1617
I
24b. For iniection Wells: lIn addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
constiuction to the following:
Divisioo of Water Resources, Underground Injecdon Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
I
24c. For Water Suoolv &! Iniection Wells: In addition ro sending the form to
the address(es) above, also submit one copy of this fortn within 30 days of
completion of well construction to the county health departrnent of the counry
where constructed.
i
Fonn GW-1 North Carolina Depaztment of Environmental Quality - Division of Water Resources Revised 2-22-2016
��-�,�,�� ���.� �l�
� � ����
7C�o���-�����.��.Il IE���.Il�I�
Tax Map: � Pa: cel: 3�
�ub�i��isi�n ;
Phase/Section/Lot # $�
/ Improvement Permit
Permit Valid for: Five Years ✓ Non-expiring
Type of Facility: • � New �Addition _
Number of: Bedroom �/ Oc upants / Employees / Seats:
Proposed Wastewater System: �� '
Proposed Repair: ���,�
Permit Conditions: ����,,,�,� (,�,�(���� P�r
Water Supply: Lc.�/ j
Projected Daily Flow: 36a gallons/day
Type:
Type:
Authorized Sta.te Agent: �_ •. Date: '7- �- �-r
(X) Owner or Legal Representa ve: ���{� Date: 2
The issuance of this permit by the Healfh Departm r�cioes not guazantee the issuance of other required permits. It is the responsibility of
the appiicandproperty 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 plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in campliance with t6e provisions of the North Carolina °Laws
a�rrl Rules for SewaQe Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmeatal
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water sapply svill
remain potable.
Authorization to Construct Wastewater S tem
See site plcm and additional a#achments ([/ .
Propose stewater System: �-CGe�kr� �Z�?o R�cfY�h �,,sy��.) (*)Type _��, _ Design Flow 3(p gal./day
New Repair Expansio T Soil LTAR: -� ._.�.�i gal./day/ft2
Type of Facility: Basement: _ Yes �1Go
(*) System Types Illb, IIIbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank QOd gal. Purrip Tank — gal. ^vrease Trap ��gat.
Drainfield: Total Arza DD sq. ft. Total Length 00 ft. Max. Trench Depth � in.
0 , C.
. Trench Width � ft. Min.Soil Cover _� in. Min.Trench Separation � ft.
Distribution: Distribution Box �Serial Distribution � Pressure Manifold
Specifications:
t�'ba x �a�
Authorized State
Issue Date: 7-(0-l1 C/Z-2277 Q�eu,�P�l�
Permit Expiration Date: -�- �- 2 2
The system permitted is: Conventional /Accepted / Alternative / Innovative . I accept the conditions
and specifications of this permit. _ 2 /
(X) Owner or Legal Representative: /�Z�L..L-- 7 � C/ � Date: �� 02� �
�
Person County Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
�� (� �jC�, ���1� Name: �
��,,,) lle
� �.���,�� Subdivison:
lE������mm�Il lE�mmfl�
�
�
Site Plar.
��
Tax Map: Ayo
Parcel: ���
Iress:
I.ot:$crL � �
EHS:
Date' �-1�-1"L
10 � ... �1 � �' A '� � r�
i<ai. �+.. i
�
v
' �o
..�
;,.� -
(,X'i
� ` . !o
� .
._ � .
� 3�� � � �� ? Y,
N�w�e � " ``'
. 25� � � ,
. .—i�
. - � : �.
1 i f o,lt '
, �a � `, �
;
�c
; ro� �,`„� ,
� .: � � I.�
.. Y . �.. pp +� (� -''?' ..l
!Y1/ �J ;�.J�
�f1N�J�'� J���I�N�H .
.:=,3 � �� � .
System Type: �
Septic Tank: �Q�. o gallons
Pump Tank: gallons
Total Linear Feet: �OD,
Max.Trench Depth: �_"
�.
.... _ . �. ...`�� .. . <,�,,
`�� .
��
�
Scale: '� ,-50�
Noie: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to insta�lation.
2) Coniact Pers�n Cour�ty E�ivironmcntal Heaith with a�y Gue�ti�n� (336) 597-17S0. �i::
Additional Comments: `�