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Persoa Caurrtv Hesith Deoartmutt
Environmert�l Heaitt� 3ectiQn
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Tax Mao �k /� '�a
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IF THE INFORIIAATION IN THE APPUCATION FaR�AN IMPROVEiIAENT PERMIT 13 FAL9IFlED, C�iANGED. OR?HE SiiFilS
AI.TER�. TH�iJ'THE 1MPROVEiV1Ei�IT PERMIT AND AUTHORLZATiON TO CONSTRUCT SHALL BECOME INVAUD.
�) psnnit roquasted hy; (pvmechs�pacttvo owttarj; �'1-�M/ �iA ���f'• w�r .
• Hans Pttion� ��-f -� a- qd�ax .r� sr �e o<f /L> ic �s �D.
Btnneas Ptw��e: _���,�D ��e �� �
Zj Nam. and addrsss ot cucrent owner: SR-,e�i E
3) Proputy o�scriQtio� �oe� �� Tcwcat� �.�
Diredions ta the prope
T�
4) PcoQos�d Us� and Structitre Descriptton: anawa esch ofit� foCowicW qcte�ona:
� ProPoaed�Ex�q �
b) Stidc 8t�t 0. ModWat 4 Sinple Wlde Q Oouhl�e Nflda��
d Number at 8edroanx �_ � Ntus�ber ot ocapanb� or paapta to be sa�ve� �
a) Baaesn� Yea q No � 1! yos. � of baaecnart �cturox
• fj Ga�baQe Disposa� Yes q Nc,�
� G�rt�seiotvaaf ProQosad Str�tuo: V4iclw: �� Da�ttr S�
i��PPhf �IP� Prtvate �(new Q oc aods�n9 �. Puhwc 4 Co�nn�l o. Spin� D.
Ars arry wdla on �oining p�opert�(? Yes6�No 0 ltyss, locaticn
6j P{� Indlcati O�aii�d SYatam Type: (syamma can be rado�d in ord+� of Y� P�*1
�CoaveMlon�i Modttied Corn�atlonal _ Atbmaftw .�
Oth�r (sp�cicy�:
CLEARLY. 9TAKE ALL CORtiEFtg ANC UNES OF THE PROP9tT1f.
STAKE THE CORNERS OF ALL PRi0P08ED STRUCTU[iFS.
PLEASE A1TACt� SURVEY PtAT OR SiTE PU1N TO THIS APPt1CAT[ON
I tleteby rtiske app6cation bo the Pecson Co�u�ty Health Depactn�ant ior a s�s avak�ito� tor ths a�ite sawapa d4Posal sY�
tha aboue�dsscnbed propaty. l aproe that the cAnt,ents of this applk�ion ace tnss and t�ent the ��ea bo
ptacsd on the proQecty. ! tmdecstand if the sim is altec+ed cc the in�nded us� ctianqes. the pecn� shaY becatns irna�d. l undets�
lhat as a� I am cespons�bie fa idaWfyw�g and macidn9 ProP�Y iinea. co�ne� and rtwid�g ths ai�e a�e �'
H� ot 1he�Person Co�urty Hesqh D�arttnerrt to condud tt�ir avaktatlans. I ia�atsnd ihat l am tnap� foc noiuyin9
mY ProP�Y � �Y � �► �d blf � �m1f �Ps � �s.
��..� /-�o-a9
Ow� L�1 R�re . Date
� ��,�J �� ; 1 '�1���.� �� �
`-- � =-- �' � �-�T��i `��
�" �. �� ��.
! �'_, 33'�"27� �p �-„ -r,-„ <t� �3�.�.. � �.
�( �p ./ � � °r(�C�1 � 3 �� .
0 0��, � rrt �� P ���s
G�- o`� � � ��-- q a—
. �a�r�ve�ent �Ea�it ' �
�'�# `V�ad �or �'3ve �I� �u ��on �e'.
Type of Facility: �R S�F /� Nevv Addition °�ate� �aa�ppdy
# of Oc�upants �_ � of Bezirooms Proje�ted Daiiy ow 3 60 g.p.d.
Propose3 Wastewater System: u' �'v�. � a�i Type: ��
Proposed Repair: ` cv� "v-� Type: � �T
Permit Conditians: � F St �' S i CP�C �
�
Owner br Legal R�presentative
Authorized State �Agen� �
�
Date: �-J - 2 `� � / 1�
Date• 0���7fp �
T'ne issuanc� of this pemrit by. the Health Department in does not awaraniea the issuanca of other permi�s. It is the responsi`bility of the'
agplicant/property owaer to in s�e that a11 Person County Plannmg and Zc�umg and Bn�iding Inspections requirements are me� �his
�proveme�t ��rmit � sasb���t t� revoca4ion ii the site gLzn, plat oe tEte intended use c3�anges. Ti►e Yn�p�oveme�at �ermit is mot
a�fe�#e� by a c3�ange in ownerstup of the property. �3ais permi# was issued in camgfian�.vvith the provisions of the t�Tort9i C�roli�aa
`Zaws a�d Iiules far Sewage Treubnent a�d �isaosal Svstems' (15A 1�TC?,C 1�A .1900). �either P�on �County nor tiie
�nviranffieut�l �3eaitta S�e�ialist'�varrants tiaat the septic tank systeua will cflntiaue ta fnnc�aq sa�sfactorilp in #iie fuiinre or'ti�at
the wa#er s�Qply will remain: potable. -� --.. . . ' .
.
�aat�o�a�aon � Co�s#s�ct �as€ev��tea Sys�e� (Re�nir� fo� �wlc�ing Perffiit)
* S'ee site plan and udc�itioreal artachments %�- _
Propos Wastewater System: �� V P� 7` ! U,-, q f � ��� -�r Wastewater Flow _���' -.p.d.
�Few,�� Repaix Expansion � Soi� I,TA1t: O�'� O g•p-d.! $ 2 �
Type of Fac�7iiy: � 3� R S�� Basement _ Yes No � � ,
_ �a�t��a��� Sg�ste���e�aair��en� �
'�� 5ize: Se�tac'�anic:(b� � �am� iaa�c:l �/�� g� �Yease �a:a�:� "l � g:�ii
�r�a�eid: i�tai ��: � ��� s� � Total �.�g#]a yUa �t � �� �s�enc.�► 3)ept.�a `��' �
'��emc3a'bVid#Ha 3 � �a� Soii C��er. �O � in 14�iinimma�a '�a�e�c�a Sepas�tion: � �t � G
�ista-�aati�n: �as�u�oa �o� �Ses�ial �istri�ntaon �xes�re �fo�d
Spesi�fica$aons: �Sp� S►`�- P S� P }"�� .
�n#paoriz� �ta#e ���t �r'd
- Perrnit Exniration Date: � a
T'ne t��e of system permii*e3 i;��C�nv
peimit. .
i�ww3a�r/���1 ��pres���ve:
Date:
� �
Alternative. I ac��t ti�e s}�e��fications of the
Date: � � � - /�
P�D rev. 11/14/05
.��",.J� .�lU11l.�.� `lJl \y . � . .
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. . IE��y-m..�,,,.,,��� ��.�1� � .
SI'I'F S�TC�-I
Name �Q ^^'`'� �'� w/tt;� S Taz l�lap #��arce3. # � � �
�ubdivision O'Q �,` �P �-G/ps Section/Lot# �-�t 9'a.
1_!���� �z�� o! � v q .. _. - .
Authorized State Agent � Date - � �
sy�, �o�o„� �p,-�� ��,n,,�,�.��� ottly: The rn�stmctor »aurt, flag ihe'ysteml�rior to
begrnraitg the i».rtallaiz'on to insure ihat propereamda i.r maintained
: :,
..: �. :.
.�;
H�NSLFY AVENUE
5Q' R/W �
{�iv� I = I I o'
�N� �: � �o,
��N �. 3�.� i I 5'
��n���= ��'
! b7�L = 40o fEEr
Con�v tiv7'.T oivfjL
� 158. 4Q'
Must install septic system on contour.
Must not install septic system during wet conditicns.
Septic system must maintain all proper setbacks.
Any questions call Environmental Health Dept.
336-597-179�
���4LE�� 1�- � ��•
���,sf� ���..���
` � � � ����
I��.�� � �.,.-n-r m��.�.Il I�IL �.�.11�I�
Operation Permit
Applicant:
Location:
Tax Map ��� ar 1 #
Subdivision �
Phase/Sectoin/Lot #
# of Sedrooms '�
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.
System e: (In Accordance with Table Va): �l-�`� Product: ��
Initial: � Repair: Expansion:
__..---- _ . . .. _._ .__ . .. - - - --- �i - -- --- -
_ .. �. _ .- .
REHS/REHSI
� - (�wcs �1,,� j
Licensed Conhactor W �� 1
►-
Scale a'M-�
� 1�
_. . - - -- ---.. . .
. �f" 2? f�, _
Date
8�z� o
Date
� �, p��
�
Tax Map: � �� Parcel #• 3gZ
Septic Tank System Checklist (Type II-VI) System Type: ��0.
Se tic Tank nitiaUDate
State ID& Date: S-t�(3 3z ��
- � - �o ,/.
Capacity: S v �
Tee and filter �/
Baffle �/
Vent ✓'
Riser
Outlet boot /'
Perm. Marker ✓
Distribution
- ---
_ - -- _.__ _
—� —
___ ox_ e_v_e._s set :_. __ _
.._ _ --- -- ....
Serial
Pressure Manifold
LPP
Notes:
Pump System Checklist
Pum Tank InitiaVDate
State ID & Date:
Capacity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (if applicable):
Notes:
Tank Com onents InitiaUDate
Pum model:
Block (4")
Nylon retrieval rope
Float tree and attachments
On/Off float swing: in.
Ala�-m float (6" separation)
Anti-siphon hole
Check valve
Tllreaded union
Gate valve
Conduit sealed
Outlet sealed
Approved and secured riser
Su ly Line
Size and material: in. sch.
Length: ft.
�-���� �� ����..� `�J �
�..� " -,^ � �J � � � �
l���n.���n.��.��n.��.�. ���ll-��.
���,�, ���1VI��' (1'dTevv��Repair�
'�as l�Iap: .�cy v Parcei• � g a'
Subdivision: c�a kr� d�F A-c /`P S I,ot: � ����`
A�plicant's Name: ��` ^^ �-, „ �-« � � � '�S
il�iailing Address: Sy SS {���� P/� ! 1/S Rd.
!�-oy�.���, Nc a-?s7�/
Phone Numbers: 3 L„ �- 2� S��
�ocation of Property:
S/D -� � c��
�,G.-rc�
' S 7 •S —� � �f � �� r�4 � �
�
a
I'ermit �onditions:
1) See attached site plan for proposed well locaiion.
Z) All applicable State and County Yegulations governing constr�uction and setbacks apply.�
3) Permits expire � yeArs from the date of issue. /J
Dther Conditions/C'omments: SP? S ��'P ��P �'�-7 -
Pss�ni# issued by: �ate: �1�2- %�� �
��R��'��A'�E �� C�l���'�IO1�T
1`�ew dVe�9 I�aspection:
EHS/Date
�
Location: S �
Grouting: � S'l0
ulell Log:
WeII Tag:
Pump Tag �
Air Vent: L/
Hose Bib:
Casing Height: 'l/
Concrete Slab: �/
Well �riller: �G�-h . . .
Pump Installer: . � �
�ell Approveri i�y:
Date Sample Coilected:
Person County Environmental Health
�25 S. Morgan St., Suite C
Roxboro, �IC 27573
�
L�ner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Wefll �bandonment:
EHS/Date
Completed:
Metilod/Nlaterial(s):
I�acense #:
License#:
�ate: I J
Date Results Nlailed: ''
Phone: 336-�97-1790 Fax: 336-597-7303
siiios
RESIDENTIAL wELL coNSTxucriorr xEco�
North Carolina Department of Environment and Natural Resources- Division of Water Q�ality
WELL CONTRACTOR CERTIF'ICATION # ���� � �
1. WELL CO CTOR: / �
aa� �f A� �
Well ConVa tor ndividual) Name
Bamette Well Drillina Inc
Weil ConVactor Company Name
611 Bamette Tinaen Rd
Street Address
Roxboro NC 27574
Ciry or Town State Z�p Code
3c 36 � 599-0015
Area code Phone number
2 WELI INFORMATION: t1(,�0
WELL CONSTRUCTION PERMIT#� , n /T —
OTHER ASSOCIATED PERMIT#(itapplicable) PaY�� � ���' -
SITE WELL ID #(if applicaWe)
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED � � �l'� � �
TIME COMPLETED 2� AM ❑ PM L�/
g. WATER ZONES (depth):
Top��_ Bottom�( lS Top Bottom
Top 20 Bottom,J 2S ToP Bottom
TaP go{�am Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top�_ Bottom� Ft. ��_ �� .—�� —
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
-rop�._ Bottom�_ Ft. Sand/Cemeni
Top Bottom Ft.
Top Bottom FL
Method
Poured
9. SCREEN: Depth Diameter Siot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
4. VYELL LOCATION: Depth Size Material
CITY: / � �'t• !�s COUNTY �� ._ : Top Bottom Ft.
/� h L .� Z Top Bottom Ft.
I
(S t Name, Numbers, Community, Subdivision. Lot No., Parcel. Zip Cade) TOp Bottom Ft.
TOPOGRAPHIC / LAN9 SETTWG: (check appropria� box)
❑Slope ❑Valley p'�lat ❑Ridge pOther
LATITUDE 36 ^_ " DMS OR 3X.)OCXXXX)OCX DD
LONGITUDE �5 '_ " DMS OR 7X.XX�CXXXXX DD
LatitudeAongitude source: �PS pTopographic map
(Jocation of.well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OyVNER (f (
) � � IICiNJIGf;ns
Owner N me �
n lt �
�tree ddre
. � �'�� l�� . � 27s�U
City or Town State Zip Code /
36 S��g ga�r°y
Area code Phone number
6. WELL DE7AILS: � ^ ` �
a. TOTAL DEPTH: U
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Q�
c. 1N�1TER LEVEL Betow Top of Casing: ZS �-
(Use "+` if Above Top of Casing)
d. TOP OF CASING IS � FT. Above Land Surface'
`Top of casing tertninated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIEID (gpm): � METHOD OF TEST BIOWtI ZOtll
f. DISINFECTION: Type �"�T�"�_ Amount ��2 CUq
11. ORILLING LOG
Top Bottom
.� / Z
Z / 3�
�/ Z S
�_/ �Eo
/
/
/
/
i
/
/
�
12. REMARKS:
FormaGon i saiption
r �- Sa�.d
� �
�
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECOR� tiAS BEEN
PROVI� O THE LL OWNER.
. ,y,l�
SIG E F IFIED WELL CONTRACTOR DATE
� fl �1+� � �� � � al �/ ��'"1
PRINTE NAME OF PERSON coNS i rcu�. ING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Rerm�G�W-1a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300