Loading...
A40 381Application Date: - y- a C TS �( uv �� Tax Nlap: �a ��� Amount Paid: a �O.O� � �0—«`� Parcel #: � 3 g Receipt#: J' 7�2 4�' %��`�7� ��0 1(�'(•�L �� Z�iZ�-�l C� � `__..,��� S � 1C' �1L�1� �J� ��.�3 ---'' �_ �����'� lC : u�i-n n ai .m �3 ,•-,•-„ <e� ai� �L-..-,-�.11 IE 3C <c--..-n.11 ti=1�a Applieation for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if> 600 d) (Fee is de endent on the e of system permitted) � Mobite Home Replacement or Building Addition ❑ Permit Revision � I50.00 if site visit re uired) $75.00 ❑ Wcll Permit (New/Replacement/Kepair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 No Char�e 1) Services Requested by: - ' Name: S �m �n y �RN+'�' /►US Phone # (home): .S ,3 { - 3� � '� �� �' Address: 3" �f SS v�p.� � /%I /�-�3 R!� (work/cell): 3 3�- o'� -�5•2 9 �o�X ��Rb �v c. a9��3 �' 1d' 2)Name and address of current owner (if different than applicant): Name: �'�m C Address: 3) Property Description: Lot Size: A� Subdivision: 6 qM �t' � v�Lot #: _�/ Address and/or directions to Property: 1'- o W i C o 6� �-A N= v�'� Q. R T_ o ni c� u� rz rF R r a-r,= , L E y�t 6 rv � E n/_s�. � Y.� ,� oT � w�Pr 4) Proposed Use and Type of Structure: Residential � Business/Type: Other Number of bedrooms 3 / Number of people served (seats/employees): Basement: Yes No � (with plumbing: Yes No _) Garbage disposal: Yes No � 5) Water Sapply: Private Well r/ (Proposed Existing _) Community Well: Public Water System: Are there wells on the adjoining properties? No _ Yes ✓ (please sho�v tocation on site plan) Note: A comvleted application must also inclirde: ➢ A plat/site plart of tl:e property t1:�t sltows property dintensio�:s and t/te size rrjr�t locatio�: of crll proposed structr�res. ➢ A signed cvpy of tlie `Lvt Preparatiori' form verifying tliat tlie properry is recrdy to be evc�lcrnted I�m submitting this application to request services from the Person County Health Dep:�rtment. i understand that if the information provided is incorrect or if the site is subsequentty altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representarive): ,�� ��-•�o l)ate : � � b 4' ° �' 10/08 Person County Environmental Health, 325 S. Ntorgan St., Suite C, Ro�boro, NC ?7573 �336-�97-1790� � �-.� ;� �.�I � �u ���.�.J �� , i �.�.—. 'y �' � 1 .. �' � � ���� �1n.-s-�r�o-�-�, -,�,-� «��.��. ���a.�,� �c;� ,� G`��c,^� � �� � �.° C�t �a �- � . �'���``�c�9'�i� `� �1 ��r�i ��lad ��r � Type of Fac�iiy: — # of Oc�upants ✓v+4 CL Propased Wastew �LOI]O5�t1 �731i: � _ �pra�we�aa� �?��mi� t�� �����g w� �� Type: -� Q Tn7�: Pezmit Conditions: � ,��,-,c?� Sr',{-2- S�(��� • - . ,--� . • � . :. . _ . � - . - �. .: � - � � . � - � �.1�'� �/_�/��/" . - � i 1✓l� � � % � ' ` a• -. ,r. c- �:i. ��� � �: - The issuanca of this permi# liy the Health Departmeut in does not guara�tea the T.CC7A'aT(`� of o�iaer permits. �t is the �esponsmility of the aPPli�aP�Y owner m in szue that aIl Pezsan. Cou� Pianning and Za�iug and Bu�ing Insp�tions reqa�a� are me#. 'I'laa� �pa-ov�snent �ar�at is s�jext #m re�oa��aon 9f t�e sa�e p��m;'pl:��'�� t� iaateside�t sase �'�a�mmg�. `�ae �g��e�es¢t �er�t is ��� as�'e�t� 3ig► � c3�m�gs iaa o�vae�i�np o�f #�a� progseriy, 'T�s p�s-anit v�as issuaed an c��lianca ��a t9a� �Sro��� of t�� I�T�� �C�rolan�, .� `��ovs asaai ISsales far Sesva..�e ?'re�tnne�at �� �sosal Svste�as' ('1�A I��� �� .19�0). I�aei�hes� �E��a ��un#�,r..mo�°'t��.`'� �aavsa-��aent� ��d#h Speci�tast warranis t�aat t&a� s��tic � sy� vviil c�sa��e tm f��oa sa#i�ia�a�a�y iri tflne f�atm�e�or:t�t� #�a�-�a�r suppsiy wiil remafn �Sotai�ie. � • � . �ua#�a�a��io�s t� ��ns�r+aet ��st��at�� S�s� (��E� ��r �aa�a� ��.,*��� � T. Ses szte plan and additianal attac}�men�r %�- � . � _ -. � , 6 . Pr�gmseri Wastewaxez syst�xn: l�) t�t/�t �' �t�i �( � �V�' I Ty-pe�Q Wastewater �lmv� 3�.p.d. New 1L RR.epair Ex�ansion ,,�j,� ' � So�i �T�38: • 3o g.p.d.! $2 . Type of Fac�ity: 3'���- S� � Basement ` Yes ,�„ No � �'�������� ��$�� �������� � . '�� �a�ae: �e�#ac'��' � �C� b�d �fi�dc �m�fl ��: �� s€� � �}� iamm�C: —' g�l �a�� ��p: g�d '.�o� Le�agt� n a � '�r.�� �d� 3 � �uoi� ��ver: �_ � ��baa#�on: � �i�a�ibaa�¢on ��� i� c�a�ai ��abn�flosa �p�iffi�tio�• �'f� ��'�X rl�r S �4�2 � �t.� � ��9aas�e� �ta-� Age��t. Pernrit Ex�i T�e tyne oi systern p�itezi �s P�mii- ��!-°..'P.3� ���gv.r.S...�����Q: Date: ' �� �� ��a�a �ie�� �_ � . . �t��a�m,�a ��e�a ����so� `� � �ress�e ��o�d. ;� a-l--, l � v,�_< Date: ?�/ > /0 A.ltersa�ve. I a.��ti�# t.iZe �erincaiions of the ���: / 0 - /6 -� ��� �V. 1'_%iQl��•- ° ,• .. : . . ,d . ���.s� I�I����� , - ,------ �-�- � � ���� 7�as.vaa-.m�+-�-�-�ca�m.7L ZL-3L��.Il�7la SITE PLAN N� � ( KS Taz Map #,� Parcel # 3g � Sub ► Secrion/I.ot# � O Authorized State Ageat te System componeats mpirsent appro=*m�� rnamurs anly. I3e contnctar mustll�g tbe sysrem pdor ro begiaaing the iasrillation ro insure �atpmpergnde is mamtaiaed ,�q;� �a%� � � � . � ►���n�q �. � �,�.,�rj 4 C� . � ".. ��.: i.:. .,�. HENSLEY AVENUE 5Q' R/W � N�7' 'Q9„E 15 . 4Q' � .5a � 1�1�L L �— Q��4a � .. � we �) .. !�� ,���-;a� � �°���° � � N � � N Cn -� O N CTi O �� � � "' Sa ' s��: � � � :.I: � ��� � 3s /O' '�, 158. 4Q' �o�� - ,(„JD /��� ��AY �; i �. 4Y _ �. . fJ�/y) /�//TlDI7. uCG(I"ih.J I Wef C?oi�c%.��s, � N � .v N � � Q N v �� / O ,� j''�''v� 1 • + ,v rcfm, tn.. a�/�z/oi a ���� �� ���� �1� ��.o b � � � ���-�� "1 11�� �����.�' � ���li.�� � �i�i � � J.L JL � t�. � �� �,,Q . Applicant: '� �`+� • �� ����' Location: � � ax M� � � �rc ' : ubdivision � � � ' j Phase Section; ot # � # of Bedrooms - . . �rati�n er o� ���,��- , System Type (In Accordance With Tabie Va): � TNlS SYSTEM H�.S BEEN INST�4LLED IN COMPL.I�.NC� WfiH APPLICABLE . NORTH Gi4ROL1NA GENER�►L STATUTES, RtJ�.ES FOR SEWAGE TREATiViENT_ AND DISPOSAL, AND - ALL CONDITi(�NS OF � THE lIViPROVEIVIENT PERMIT AND CONSTRUCTION AllTHOF�t ION. - . rv� �, 'W�/ (��72�0 � . uthorized Stat Agent Date i nstalled B: �' � Date: � � 2 Z 0 � .Y f O 1 � � 1 ' � 3 6� � i ��` �° � 3�i �.� pjc� p1 �- FCHD, rev. 07/29/Q1 ,; � ���3IG �'�,�K �PlS�E�'�30� �+�9E��b.1SS �l�pe 9@ � S� Tax Map.# ��� Parce! # 3�r Systerri Type (Tabie Va) OwnerlApplicant � Subdivision Address/Locafion Sec/Phas� Lot # _ Se��ic. �`an� Inat's�9/Dat� ii�a acataora �nes Ir State ID/date �� .S��e � Capacity lo-v-o gai. Tee and Fiiter � � Baffle Sealant ' Riser (ifi app(icabie) Tank Outlet Seal Permanent Marker Pueaap Tank . . Ca aci al Wate roof /Sealant Riser � Water Ti ht Purr�p Check Va1velGate Valve Alarm (visable and audible) Electrical Components Rate (gpm) . Approved Pump IViode! Bloc� Under Pump. Pump Removai Rope/Chain . ��Dis�a-ibu�ion;Sy�teen Serial Distribution Pressure (�an ol Low Pressure Pipe A�pr. Pipe I�liaterial and Gra� Valves � � ✓ Trench �dth s Trench Depth � � T,rench Length 3av Trencf� Grade � Trench Spacing Rock Depth and Qualiiy DamslStepdown� etc. Pressure Laterals � Hole Spacing - o e ize Pipe. Sleeve Tum-ups/Protectors Required� Se�acks From Wells � From Praperty fines u�tches lurainage vva� Surface Waters Public Vllater Suppiies �/ertical Cuts (>2 ft.) Water Lines Vehicle�Traific � � �Easements/Ri ht of W Other Easements Recorded ert e erator on Tri-Partate Aqreement Comta�en� ft. in. ffi. pct�d rev. 3l13/01 ����,�� ������ `� � I �'� � � � � J!. � I�.������a-����.�.1i .II�C�.�,II�II-� W�+ I�L P�+ RM��' (�1ew�Repair� Taz Map: � Parcel: 3 $ � � Subdivision: Yi Lot: Applicant's Name: � � �� i'1 lddailing Address: Phone Numbers: i�o�j� tion of Prope 7� Y� `'' i�� ��it� �- �% ff'�►�t � 7�2i.. ��� ts r�,., JP � � Permit Conditions: I) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply. � 3) Permits expire � years from the date of issue. Other Conditions/Comments: Permit issued b�: �--C IDate: �' ? d ��Ia'�'�'ICA�E O�+' COMPL�TIOI�t New Well Inspection: HS/Date Location: Grouting: �3 D�' Well Log: Well Tag: Pump Tag: Air Vent: � Hose Bib: � Casing Height: Concrete Slab: Well Driller• � Pump Installer: ,ti4 Well Approved by: Date Sample Collected: Person County Environmental Health 32� S. Morgan St., Suite C Roxboro, NC 27573 Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ License #: License#: Date• Z5� � Date Results Mailed: Phone: 336-�97-1790 Fax: 336-597-7808 siiios : % �,. SiATf;; .1'� �." yp.�,d w^J " '� �'• ,� .J� ;t s.:.. � :�. _'.; `.�.�_ ��: ,�.� � .�:��;;����� ���� ��s'� 4n�.x�ta � _ .Y� �Kap �-�� � "f p�ti.L� �� RESIDENTIAL v►�LL coNs�vcrioN �coRv North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR C`ERT�ICATION # , ��i I "- !7 1. WELL CON OR: ,�-y, �f /� � Q� � Y �i , Well Contractor (I ividual) Name Bamette Well Driilina Inc. Well ConVactor Company Name 6_ 11 Bamette Tinaen Rd Street Address Roxboro NC 27574 City or Town State Zip Code 3c 36 � 599-0015 Area code Phone number 2. WELL INFORMATION: WELL CONSTRUCTION PERMIT# OTHER ASSOCIATED PERMIT#(if applicade) SITE WELL ID #{itapplicaWe) 3. VYELL USE (Check Appiicable Box): Residential Water Suppiy ❑ DATEDRILLED (D� Z Z"OcI TIME COMPLETED �-3l'� AM ❑ PM f� 4. WEL LOCATION: cmr: �ro ' .vd�t � � co r�m��.- o'f � c r'c j (SUeet Name, Numbers. Community, ubdivisia►, lot No., Parcel, Zip Code) TOPOGRAPHIC / LAND SETTING: (cheGc appropriate bo� ❑Slope ❑Valley p'�tat ❑Ridge ❑Other LATITUDE 36 "�,• i�� • DMS OR 3X.XxX)o0o0cX DD �ONGITUDE �_',�• Z2.'� • DMS OR 7X.XXX)oOCXXX DD LaGtude/longitude source: �PS pfopographic map (location of.well must be shown on a USGS topo map andattached to this form if not usirrg GPS) 5. WELL OWNER SQ/hrol/ �.w 1�.� ^ � OvmerName �..o� R� diw.�../%dtqc AGr�Cf Street Address !,, .�'ai �i !�/��s U+� ��• 22,�� C�ty or Town State Zip Code c'� _��?— S'S38' , Area code �hone number 6. WELL DETAILS: / a TOTAL DEPTH: ��v � b. DOES WELL REPLACE EXIS7ING WELL? YES ❑ NO L� c. WATER LEVEL Below Top of Casing: �! FT. (Use "+• rf qpove Top of Casing) d. TOP OF CASING IS � Ff. Above Land Surface" � 'Top of casing tertninated aVor below iand surface may require a varianoe in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): �_ METHOD OF TEST BIOWfI ZOtll f. DISINFEC710N: Type HTH Amount 1/2 CUD g. WATER ZONES (depth): : Top �3J Bottom i 35 ; Top �S Bottom 1 j J Top Bottom Top Bottom Top Bottom Top Bottom Thickness/ T. CASING: Depth Diameter Weight Material = Top�Bottom 2� Ft. 6� 5�2t �c Top Bottom Ft. Top Bottom Ft. : 8. GROUT: Depth Materia� Method ; Top�� Bottom�� Ft. Sand/Cemenl Poured Top Bottom Ft. Top Bottom Ft 9. SCREEN: Depth Diameter Slot Size Material Top Bottom Ft. in. in. Top Bottom Ft. in. in. Top Bottom Ft in_ in. 10. SAND/GRAVEL PACK: ' Depth Slze Top Bottom Ft. Top Bottom Ft. Top Bottom Ft. 11. DRILLING LOG Top Sottom �i 3 i- �s— �_��� ( l c� �_.,(_Sr12_ / / / / / / / / : 12. REMARKS: Material F rmation DescripGon o r! _ y c I Dp HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 75A NCAC 2C, WELL CONSTRUCTION STANDAROS, AND THAT A COPY OF THIS RECORD HAS BEEN PRO D TO THE WELL OWNER. -- �- f 0 -� � 9 S RE OF TIF ED WELL CONTRACTOR DATE 0 n � f� PRINTED NAME OF P ON CONSTRUC ING THE WELI Submit within 30 days of completion to: Division of Water Quality - Information Process[ng, Fortn GW-1a 1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2i0s