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
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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�
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Type of Fac�iiy: —
# of Oc�upants ✓v+4 CL
Propased Wastew
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Type: -� Q
Tn7�:
Pezmit Conditions: � ,��,-,c?� Sr',{-2- S�(��� • - .
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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 %�- � . � _ -.
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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-
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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
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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
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HENSLEY AVENUE
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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 �
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FCHD, rev. 07/29/Q1
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���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
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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
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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—
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( 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