A40 84Application Date: �-!a Tax Map� i��
Amount Paid: �cxa .�'0 Parcel #:
Receipt#: �$�,q3
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Application for Services (Septic Systems and Wells) b e'� oµ► �
C
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Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit.�ew�eolacement/Repair)
,/�. Services Requested by:
Name: � /�C,�! /• IU Gl rkk`1.TU �
� Address: c a C.�O�ch,l� S�•t-�t-U� �+'L—
� �d t3 �� IL�-
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
Phone # (home): �� Sr! � �
(work/cell): � � — C l �6
2)Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: Subdivision: Lot #:
Address and/or directions to Property: l l� Go-lo f�l. �1�•C� �'z����
4) Proposed Use agci Type of Structure:
Residential � Business/Type: Other
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No i(with plumbing: Yes No �
Garbage disposal: Yes No �
5) Water Supply:
Private Well � (Proposed Existing _)
Community Well: Public Water System: .
Are there wells on the adjoining properties? No _
Yes �(please show location on site plan)
Note: A co�npleted anplication must also inc[ude:
➢ A pladsite plan of the properly that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the properry is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid.
Signature (Owner/Legal Representative): Date :g . � �a
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro; NC 27573 (336-597-1790)
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V���,� PEI2MIT (New�o �2epair�
Taa Map: -�� Parcel:
Subdivision: Lot:
Applicant's Name: C �� n
Mailing Address: 3�� �.ake 5 J�e �r
Phone Numbers: ,�� - 5�� 1
Location of Property: � �� (',�� �h'i �9 F'���
Permit Conditions:
1) See attached site plan for proposed well location.
2) All applicable State and County Yegulations governing const�uction and setbacks apply.�
3) Permits expire 5 years from the date of issue.
Other Conditions/Comments: -
Permit issued by:���Q �\�,� I�ate: �l � I r�
� C]ER�'�FICATE OF COld�LE'I'ION
New Well Inspection:
EHS/Date
Location: j 5
Grouting: o - z�- (a
Well Log:
WeII Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: �t �.So�l License #:
Pump Installer: License#:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Iiate:
Date Results Mailed: '�
Phone: 336-597-1790 Fax: 336-597-7808
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SITE PLAN
Name lD.`V 1%l l_41�u--t'tt�l" 1 Tax Map #��Pazcel #��
�division Section/Lot# _
'cti+r�Q. �C�. g � � I O
Authorized State Agent Date
System components represent appmximate contours on/y. The contractormusttlag t6e systemprior to beginning the insta/l�don m
instue thatpropergrade is maintained.
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T�ees
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W eN
RESIDENTIAL wELL coNsrRucrioN x�coRn
ItE
North Carol'ma Department of Env'wnment and Natural R�sou�ca- Division of Wata Qualiry
WELL CONTRACTOR CERTIFICATION # ��I _!_`�'
F-i l�c-�Sc� f� V�1 e. I I G'o. Z�1' C„ '
. WeH Conttaetor Company Name � •
� STREET AODRESS � ���«__��r2IJ ��
Al2[1�C��rt 77� -- - - �? �
�ry a Towt1 S e Zip Code �
�,-���7- _37�
Area cade- . n«,e number
.
2. WELL IN�aRMAT10N:
SfTE W'�:LL ID 11{if appiieable) �( v �Ll
STATE WELL PERMIT�M(UappticaWe)
DWQ or OTHER PERMIT �l{if epplicabie)
WEIL USE (CheckApplicable Box): Reside�tial Water Supply.Q7
DATE DRILLED_IC%'�9�Z�1 �
TIMECOMPLETED �; �C� AMp PM.�
3. WELL LOCATIO :
CITY: I'I�r�IG Y"►� I!S COUNTY J°�SU%i
�U ,
r � � c. ,� C'�� �r_ C
(SIn��Nams. Numbars. Community, Subdivislon, Lot No.�, Parc ,�)
TOPOGRAPHIC 1 LAND SETTING:
❑ Slope ❑ VaueY O Ftat ❑ Ridge ❑ Other
(chack nppropriab bo�Q
May be in degrcn,
LATITUDE � _ minuta, saond4 a
IONGITUDE in a decimal fortnet
Latitude/loagitude source: ❑GPS pTopographic map
(locatbn ol w�e/ must 6e shown on a USGS topo map and
attached to lhis form rnoR ushg GPS) �
4. WELL OWNER
OWNER'S NAME C � �j
STREETADDRESS .�C�� �� �,�D)/�r
City or Tcwn State Zip Code ._
��
Area coda - Phane numbe�
5. WELL DETAILS:
a. TOTAL DEPTH• I �IS
b. DOES WELL REPLACE EXISTING WELL? YES�O ❑
c. WATER LEVEL Bebw Top d Casing: FT.
(Use'+• H AboMe Tap d Casinp)
d. TOP OF CASING IS "�'� � FT. Abwe Land Sudaca•
'Top d caswig temiinated af/ar below land surtace may require
a variance ln accadance wQh 15A NCAC 2C .011H.
e. YIELD (gpm): � METHOD OF TE$T Q�/l
r. asu�ecnoN:
y. WATER ZONES (daptfi); �
From� To �'�._
Amouoc
From To
From To From To
Fram To From To
6. CAS(NG: �j �/ Thiclabss!
, ' DePt� ��� V�(gty_ Mat
Frnm�To Ft /� i.l� ��
�-�—T'
From To Ft G�
Fram To Ft •
7. GROIlT: Depth M�erial
F� a To �.'to Ft e�S
Frnm To Ft
Fram To Fl
P M�
8. SCREEN: Depth Oiart►eter Slot Size � M�erial
From To Fl in. in.
From To Fl in. in.
From To Ft in, in.
8. SANOlGRAVEL PACK:
Depth Siza NI��
From To Ft.
From To Ft
From To Fk
10. ORIWNG LOG
From To
D� rv
f v �70
,-7`� ��r
A"�( / �LS
11. REMARKS:
Fortnatio� Description
0
Ic
ls�a.� . �
i DO NEREBY CER7�Y THAT THiS WELL WAS CONSTRUCTEp N ACCOR W V10E YYITH
1SA NCAC 2C, WELL CONSiRUCTqN STANDAROS. AND 1}IAT A COPY OF 1116
aEcoen w►s� �ovnEn ro n+e wE� ow�ri
OF
Submit the original to the Divisio� of Water Quality withi� 30 days. Attn: Infonnatio� Mgt�
161T Ma(i Servtce Center— Raleigh� NC 27699-1617 Phone No. (919) T33-7015 ext 568.
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OATE
THE W ELL
F«m GW-ta
Rev. 7/OS