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3� Di� �on: Lot s� �..� G;,, Ta� T /i� . � � f .'L�.�� �� %� "J �%�
t�tiots 90 th� �roppty (� t�d. tt�mee �d rfu beta). ���'i� �c�� ""�^
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�) � .,... F�dsitnA _, �1'�Ipe cri S�aC � � �____M pepih -..�
b) Ntrt�6er � 8sdraatt� _„ (�mbar c�( o�rp� a people io be �erve�
c) ' 8ar�emenk Yas • Nn _ lA�t tt�r�e bs ptc��bbsg (n ttta b�asraant? • ..
d) C�rt�pe Df�tk Yes ,_, i�n _ .
:�} lili�t �'�YPx FrivaOe �. i� .._. d�' eod�tt$ �. P�udic_, �..,..� sWr� _ .
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�p � tl�. p�op�' coo4la� pit,.�y I�i�d i��ott�i wa�? Yas _ rto r�,/
t.
D� A PI.AY OF TF� �� g�T.E PU�N YU�i' AC �T7� WITi�i 'iHIS APPLIGATIDI�L
y�,o�tnr ta� �t� c� �r ee c�.�.� �.
�� et�oPos� �or�►�a ar� n�.,�.. �-r��� ��� cu�t r�.v►c�. �
� T�1E �'T� 1�q,J8i' E�: RE�G�,Y i�l� ��►N gl/ALl1A'T'➢i0N 8Y TfiE tgALTN DR�IIR77E�.'T giy1FF.
�' �Seb�t Reslo� � tio ttie P�aa C°uMY H�h De�rtrn�tt 1bt a si� � fi�c 11t� c�be - �
�Y�rn 1br tt� ab�� pR;p�, ��� tlteat th� c�a af tftbs a�c�tlon ar+e hus and represer�the ma�rnrKtm
�come t�v�iid. �� p . 1�ticber� ii tha � ia a� at tha i�herideQ t�e �1g� � p�� �
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PI::tD. taM�.lOtt?101
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�___-. -. --,` � � � � � �
I����a-��-,-,.-„ ��.�.�.IL IL-���.Il��
Applicant:
Location:
il ,� .—�
�'�rffiit qlalad �or �iv� Y�ars
Type of Facility: S :���
# of Occupants���of Be�
Proposed Wastewater System:
Proposed Repair: ��r, �%_'
Permit Conditions:
�x , �p . � ��r�:.� �# � �
S�ubd,iv �ion ! �
� h;as= Sect;ion:Lot r _
�
� ��apra����e�t �er�t G�� G-�. �{ ►� � 3�u.1
iadoExpara4aon � o"t��^v�. r�:'�,�.,,�,l�z
��s;�1�P�:.r��:_ New�'Addition Wate� Su��i� z.��i/
s���� Projected Daily Flow �z^ g.p.d.
, Owner or Legal Representative Signature: x
Authorized State Agent:
Type: �'.�
Type: ��'�
�
Date: a - /6 � � s
Date: �- �"'� �
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibiliry of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. 'This
Improvement Permit is subject to revocation if the site plan, plat or the intended use ehanges. The Improveffient Permit is not affected
by a change in ownership of the property. 'This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Systems' (15A NCAC 1��. .1900). Neither Person Countg� nor the Environmental �ealth
Specialist svarrants that the septic tank system will continue to function satisf�ctorily in the future or that the water supply will remain
potable.
Aut�or�aiion to ���s�ra�ct �asge�a�e� Syste�a (�2equired for �uilding Permit)
* See site plan and additional attachments (�.
Proposed Wastewater System: ( �.���-�.�'��a�;.�
New � Repair Expansion
T e of Facili � �'
YP tY� ��/" S:ie�:� /�_ ����-, � �• ��s� ���:.e1�
3� a- ��s-
Type � Wastewater Flow �g.p.d. ,
Soil I�T�: �.3 g.p.d./ ft 2
Basement _ Yes �-No
Wastewater System Requir��ents
Tank Size: Septic Tank: ' c�'Ca gafl Pu��s T��: �- gafl Grease Trap: �— ga1
Drainfield: Total Area: '�.sq ft Total I.eng� .� ft 10�Iagimuan'I'�encfla I3ep�n 36 an
g'reaach �'ad�► �_ �t l�anaianuffi �oi� Cove�: 6' an
I)ist�abut�on: ✓ Distribution Box Serial Distribution
Specafications:
S rA
Minimum Trench Separation: � ft
Pressure Manifold
Autho�nzesi State Agent: ���l���-� , 4��5'• �
Permit Expiration Date: � �
Date: � 5%' 03
The type of system permitted is � orlventional Innovative Alternative. I accept the specifications of
the pernut.
�Owner/�egal ���resentative: Date:
�-/.� -o S
PCHD 1/17/200a
���. � 11 Ji.a�� �Jl �1
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�c���-��.�.,a:��.ffi.n �.��.Il��. �
SITE PL�iN.
Name �i �s es' Tas Viap #�� Patcel # 3 9�
Subdivision Section/Lot# /O�
c g,� _�3
/
Authorized State Agent Date
System campoaents represent appmadmate conmurs on/y. The contrrctacmustllag tfie system prior to beginrting the iasrall�tion to
insure thatpmpugrade is marataiaed
i.:. "�: ' , �
.�: YELL! � �T4� DR! V� i
� 5t� R�1�' ._ � ,
- � $ �o,
�� ��° ��
L`�
we��
� 73—�y
;
�p� ' ''
. �¢ l'?D IJD �
�
�ial2 f%m� _ ,
� �
%�%d �� � v. f ia G � �S/ �� % �/t?.S . . �
L�-� / Gi �o;C, c.�
.�s slr.OcJr w �o - s,7; � �
..� b� � �
- :k.s�� 4 1 � ak- � � � fl ��j '
i � ��. w �u, � � , � ..
W � .
�-��c � � . : v ,
�
C� �-1?-05 �. .A n o ..
� �e�u�:r r�/'ea �
. • � �— ' . .
535 � �`oNv �%ne � 30 �'.yi�;�;Gt�rfo�ti :
��� �
. ���
3 b�- :''� �
�`�`v � � . � . �,S 1�/a7� r� �
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' �.���� � '+J� � i��. ,
.
. . . ��a
Scale:
I �� 5 � �
PCHD, rev. 09/IZ/Ol
���� �� ���� ��
`�.. � ' � � � �� Jl 1L
� �n.� a- � � a� � � ��.11. I�—� � �n.11. �1�n.
T�x M�p � / � Parcel # � �
Subc{livision / ' ! �. �
Ph�s•e Sect�i�on Lot # I �
# of Bedrooms
�, �'�
=.�: ' �° : : : :.' " ',�� : �
System Type (in Accordance With Table Va): 1�4
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLtPlA GENERP►L STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND COi�lSTRUCTION
AUTHORIZATION.
, . 3�zr /�S
Autho d tat Agent Date
I nstalled By: ���i -� Date: �/Zl �b S
io,7a
10.7 '
� ►O,i�•
� - ��6i
, ,.
, 4��„
._ T ���--s `�� ='-'Gc�K.
� �-� � �. a" <L
. ��
� �
I�t�Y1 u 4.G l �- yp - p,,,4
� /�" t'�'� � l DO p
/� 6 � `��"T r � `} Z
O. ��
PCHD, rev. 07/29/Q4
�E�TBG TAiVK IRISP���'aORI C�iECKLlST (TyPe. ll - I!/�
Tax Map #_� Parcel # Sysiem Type (Tabte Va)
Owner/Applicant Subdivision
Address/Location Sec/Phase Lot #
State ID/date ��� l�Z
Capacity � /��, c
Tee and Filter
Baff1e
Sealant
Riser (if applicable)
Tank Outlet Seal
Permanent Marker
Pump Tank
t,ct ctt:lty t�a�.
Water roof /Seaiant �
Riser
Water Ti ht
Pump
Check Valve/Gate Valve
Ant�-si on o e
Floats/Switches
�11arm visable and audible
Electrical Com onents �
� Rate m
A roved Pum Model
Block Under Pum
Pum Removal Ro e/Chain
��Distribution. System
� Serial Distribution
ressure ani o
Low Pressure Pi e
A r. Pi e Maieriai. and Grade
Valves - z�
; �z Trench Width -� ft.
� Trench De �th 2- o in.
T,rench Len th do �-
Trench Grade -
Trench S acin �
� Rock De th and Quaiii /
Dams/Ste downs etc.
� Pressure Laterals �
,� Hole Spacinq
Sleeve
Required� Setbacks
From Welis -
From Property lines �
Surface Waters
Public Water Suppl
Vertical Cuts (>2 ft.
Water Lines
Vehicle �Traffic
Easements/Righf.of W
Other
Easements Recorded
e e perator on
Tri-Partaie Agreement
Comments
�
pct�d rev. 3/13/01
: ���.��' ������
._...—�=�,� c� � �J���"
������� ���.�� ���.���.
w���. ����
1���� ��� ��"�'AG��D �'�l� ��� �I.I. SI'�E ����J'�'
'Tax 1@ida� #: � �' C Pa�c�i # J � �' '�owns�aip ���. �� .�i�'vr>r
Applaca�at: .�� s3� �:i � ��u�.��i
�
Subs�vd�noaa: � r� ;^,'cf�• � h`t.'r'��: Se�tloIIa• I.mt• �� 6
�ca�ioaa• .
Qo-• �nS�o..�.� � 2 -
Q
'�'�e of'Water Su��l� �ndiv�idual
Re��aia�e�ne�t�•
Site Approved bp � S � -7 -05
Grouting Apptoved bp �S 3-`7 -05
Well Log �S �-9-0�
Well T � 3 21 a�
Air Vent
Hos� Bib
Concrete Slab i� 3 -7' � _
Community
IL:) Ab
We�fl Drayfler.�crncZ�� 1�s�9.� �.\
W�ll Approves� � . Da$e: � '
'�Se� Ai��es� Site Sketc9g�
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septic systems.
WelLs must be at least 25 feet from any building foundation.
Other conditi
.p
�r p� �,
I�y (., �
PCi-ID, rev. 09/07/01
Barnette Well Drilling Inc �36 598 9275 03/08/05 06:23P P.001
��� S . � � OD � �l' �
...��,.4 � . ����� o fl c�Qt�,� ��
- - � �� : � �� ��� � � a�
]F.rsh�vu�-�.s.a�rna��cn.�{o.A' ��a��l[�Ila � ��� � � ���i�
Grout X.og
Owner: ,��C�.�kl1'I�l, �l'' �C—r��u� � Tax Map, f/U Parcei #� c��
Locaaon•
Subdivisian• �� t �t � `/C' G�
Well Construetiou
I�istancc �rom nearest �'xoperty Litte {Minimum l0 feet) l U
Distattce from S tic System (Minimum 60 feet) U
Total Depth: �� Yield: .��G� GPM Static Water Le�eX: �S � ft
Water Bearing Zones: Depth��� ft ft f� ft
Casfng:
Dcpth: From ��� to ��� ft. Diameter: � in
Type:�Cr.tiva�ized Steel .�/ �
Weigh� Thickness: ��Ieight above Ground: 1�� in
ririve Shoc: Yes No �1ny proi�lems encountezed wk�ile setting casing? _Yes /No
If "yes" givc rc350ri' �
Gmat:
Neat: Sand/Ccmcnt Cor�c;rete GravellCemerxt �
•. Annular Space Width inches Watcr in Annular Sp�ct Yes No
Mzthod of Crrout: Pumped �'ressurc .Ipoured DepCh _� to ,�_ k't
1V��texials Uscd: ,
No. Bags Yortland cemen.t � Weight af 1 Bag Pounds
If mixtiu�e (sand, gravel, cuttings) -- Racio to
A� plates: �,,,�es � No � a 4 slab l'Ycs _ No
Liner: ..
Depth: Date �itstalled: � Crrout: � Installed by: _
Drilling Lo�
�.ocAtion �rawxng
J�rom To Form�tio
`'� ' , L _. . �
t �P. � C ��f=' 7� Q �•
� �
O t^ `� cy . �J�, �
Gi � '-�J� �
'��y�� w
U �
. �
� ���
I hereby certify that the abovc: information is earreet and that this well was construeted in accordance with rcgul�tions s�t forth
by the Person Co�mty I�calth Aepartment� ��' .
Si�natnrc of
YD # �� Dute :�� � yC� S
Pnmp xns#allment
�P
lnstallation C;ontractor_ �LyL�.�� ���=� State Rcgisiration Numher: l�° y
pu.mp. Depth: � U ft S'c W�ter Levei: �� S ft
Pump Make & Model: - 1 Pump Size and Rating: �_hp � gpm
I hereby cCrCii'y that this pump was installcd and thc well read complcicd accordin� to the Person County Well Rules in effect
on this date and th�t a� of th;s rPcnr has been pro ' ed to the wcll owner. .
�'umu �stali�r Si�naiu� � ', .� . � " Datc: � � 7'C� � PCE�D revQl/�7/04
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant rJ�►'��� ►'Q %-� Ur/�u�
Address J�� ��/����� 1��Y� Lf'� County �'c5C71
Collected By�1� '�; ,
Date Collected o1 �4� � ��, Time Collected / 1' I"7 C���
Source: C�Well ❑ Spring � Other
Location: ❑ House Tap �IWell Tap .
�No Char e ar e
g g
❑ Other
/(�, � 3 ! co
V �.,
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Total Coliform
FecaUE. Coli
Results
Present Absen
❑
p �
Reported By ��1�� ���.J, rYl 1
bactreport
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