A40 67Application Date: � 17'u%�� ���fs� ������ T� �p' -�—�—
Amount Paid: 7�0 U ._-.: �r- ������ Parcel#: _,�p�_
Receipt #: � i� �Cz,-, an �,„,,.k,� ;:,sIl 7[�[m.�l�
�� � 3 7Z A
� Improvement Permit (Site Evaivation)
�200.00/$300.00 (if> 600 gpc�
G Mobile Home Replacement or Buildin�
$150.00 if site visit re uired
�Well Permit (NewiReplacemen e a»
$3Q0.00/$200.00/$75.00
Addition
Services
for Services
Q Construction Authorization
(Fee is dependent on the type of
� Permit Revision
❑ Repair of Existing Septic System
Applicarion: No Charge/ CA $150.00 or $300.00
1} Applicant information:
Name: �ul►,-� n t,�%o-�cf 1.J � Zc..''d�S
Address: `� �%� % li.��. �
_ Jl ~ 4 / r
2) Name and address of current owner (if different t6an applicant):
Name: G �
Address: Z c �
�
3) Property Description: Lot Size: Subdivisi
Address and/or directions to Property: ���
� ye's ❑ �io
❑ yes ❑ no
❑ yes ❑ no
❑ yes ❑ no
CI yes ❑ no
Phone (home): /��f•� ��'� " G3�=LL
...�,s.z.s�
(work/cell): �33�� s"%3��" �/'�3�
Phone:
Lot #:
Does the site contain any jurisdictional wetlands?
Does the site contain any existing wastewater systems?
Is any wastewater going to be generated on the site other than domestic sewage?
Is the site subject to approval by any other public agency?
Are there any easements or right of ways on this property?
(if `yes' is checked, please pr�vide supporting documentation)
�t) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
Cf Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtuces?
❑Non-Residential
Type of business: Total Square footage of Building:
Maxunum number of empIoyees: Maximum number of seats:
� yes ❑ no
� Water Supply: ❑ New �vell �Existing Well ❑ Community Well � Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? 0 yes 0 no
6) If applying for `Authorization to Consiract', please indicate preferred system type(s):
❑ Conventio�al ❑ Accepted ❑ Innovarive � Alternative ❑ Other C7 �Y
I certify that the infot•mation provided above is complete and correct. I also ztnderstand thA'11f ihe 1nfoYmlltfon provlded is
inaccurate, or if the site is strb�equently altered, or the intended use changes, all permirs a�td approvals shall be invalid.
ignature ( er/ Legal Representative�`)
* Supporting documentarion required.
�% -i%- Z�i�
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed �Lot Preparation' form must accompany any application requiring a site evaluation.
r� nii � l PPrcnn C:rn�ntv Rnvironmental Healfih, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
���. sf ���.� ��
- � � ����
IE ��,� � �,� �,� �, �.Il IF3C � �.Il �I�
WELL PERMI�
(New_ Repair )
Tax Map: N b Parcel: ��
Subdivision: /J �� Lot: �
��
Applicant's Name: � LQ �
Mailing Address: � � ,� �,d,
_ �6)cl�n (o C� 2'1 �'l
Phone Numbers:
Location of Property � _ L/q � -�'7
_�
Permit Condi[ions:
1.) See attached site plan for proposed well location.
2.) All applicable State and Counry regulations governing consduction 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:
� I�/Vi f� iL,��LI � /i.n s�l�
Permit issued by�
QNew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additiohal Comments: �
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date: �Z � ����/
Certificate of Completion �.,�
tlff,iner:
EHS/Date
Depth: 0' 'S5 �; Z - �g-��
Grout:
DAbandonment:
�
Date:
Method/Materials:
License #:
License #:
Date:
r ,1, � ►' �'
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13