A40 398;=eb-13-02 04:15P
P.02
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31 i��t�jl Qisc�lptlon: I..ot a�,a: /� a Ta�eet�; �'� gubdiyi�on: ��1 /�/ � Lot#: /_„� b�
Dis�r,ctiorm bo the prvperty (Ir�ng tna�, c�n�e acd numbe�a): �
�) q*���ed�a snd� D�ai�tlon: ar�avrer � o! the ibliawk�g �or� o
`type oi S�'tx�ura� yyb�; � pb� � .
b) aurttber of 8edroarr� +�, Number c�f p�up�nts ot peoQle bD ba a�arva� '
c) S�ement Y�s ._. No _ WFiI thare be paanbing In it� baserneitt? � ..
d) L�t�ps D�k Yes r, Nu _ .
�� Yl/a�� �uPP�Y'�►P�c PrlvaOa '� (na�w _... or end�ir►9 ,J, P�a� C�xt�tY ....., s1�6i _ .
Ar�-aty ws� cn adjoir�g properiy7 Yves _ No _,,, lf Ye�. Pie�em ir� �PPn�ocht�aie lop�tan an 1t�a ai� plan.
� O�s tfi� propM�/ c�o�4Lo� pnnrtausN 1�antl�d j�tr�td �? Yea _ Mo �
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➢ A PLA7 OF T� PRC�Bt'IY O� SRE PIJ�N ��' �i,�Biifli�D WITEi 'I�lIS APPL�iTfOK
➢ P�tiOP�'A7Y 11NE,9 AtdD Ct��3 YUBT e! �RLY YA�,.
3'' TF� E'l�OPQS� I.00ATION O� ALL 9TRUC7U1�' 1/!�T 8E 3T�l� Ci� FlAt�.
y 7'HE srr� Y�cr e� R�u�v Ac'.Ct�rHLE �oR.�►A1 EVALu�►TpN e�r TMe r�►LtH u��R7�r s-r�.
�� �f m�e a�tlpr� � the Per�oR C°uMY He�i� pePartrne�lt t�a� a� evap�tion for th�
5'��Om fa' ths 8bo� ProP�l• ��'� U1at th9 CO�nia oi t�tbi �� �De �
� tio ba p on the ro �ri �'e b1,a and repreeetrt t�e mq�num
A ��under�nd if th� sibc ia si�ad ar �te ir�nded tma change�. thc pem� stiall
b�corr�e lnva�d. �
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Applicant:
Location:
��r �
T�x M�� � � P�r.r-el # :i! �
S��ahc1!ivi•s�ioi�i �1 //� � • ��
Ph•�•s�e Section. Lot � , �i :
Improvement Permit
Permit Valid for Five Years No �zpiration C/
Type of Facility: � New � Addition Water Supply �� (
# of Occupants r'�t�t � # of B ooms Projected Daily Flow � g.p.d.
Rroposed Wastewater System: ��t, �MA . Type: G
Proposed Repair: �/`� Type: �Q
Permit
d�.
/�� �/ ��� � •1 r�` I�f r�(� - ���;�+-�S• ! ° .
Owner or Lega1 Represe
Authorized State Agent:
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement 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 Sewa�e Treatment and Disposal Systems' (15A NCAC 1�A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
�Authorization to Construct Wastewat�r System �Required for Building Permit)
* See site plan and additional attachments (_).
Propos d Wastewater System: `_pl'�t/i�� �� Type �c Wastewater Flow ��.p.d.
New � Repair Exp ion _ Soil LTAR: .�v g.p.d./ ft 2
Type of Facility: � Ri� ; � Basement _ Yes yC No
Wastewater System Requirements
Tank Size: Septic Tank: l('�(9� gal Pump Tank: gal Grease Trap: gal
Drainfield: Tota1 Area: 1,�W sq ft Total Length ft Mazimum Trench Depth a`C in
. ��
Trench Width � ft Minimnm Soil Cover. m Minimum Trench Separahon: � ft
Distribution:
Specifications:
Distribution Box � Serial Distribution Pressure Manifold
� ��- ► � � � ( ( l �nes � �, c�.(--c�- sc�c c� �.�, <
Authorized State Agent: �{N
Permit Exuira�on Date:
Date: %�' �.—D �
The type of system permitted is �C ventional Innovative Alternative. I accept the specifications of
the permit.
Owner/Legal Representative: � �'Lf� ��' ��CG� Date: d/ I 1��.�-
PC 7/30/2002
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Applicant: S2��n �� �k/,�ns
Location:
1
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T��x M�p iTi P�rc�el ; �
S�ubd�ivis�ion ,� � �
Ph��s�e Sec�t�ior�i Lo�t � � ,
Operation Permit
System Type (In Accordance With Table Va): .r� c�
THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF T}iE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORI TION..
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Authorized State Aaent Date
Installed By: ��e;�rsn��
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Date: %� �� ��Z
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PCHD, rev. 07/29/02
SE��IC TAN9�C INSPE��'10N CNE�B�CLIST ('iype Il - I
Tax Map #� Parcel # 3 System Type (Table Va)
Owner/Appiicant ,;._ Subdivision '�.� : >es
Address/Location Sec/Phase ot #
Septic Tank n� a a itn cat�on �nes n�t�a ate
State ID/date -I � . �S-b�' Trench Width ft.
Capacity. a . gai. Trench. Depth it�. ��
Tee and Fiiter �;/ Trench Length � ft.
Ba�fle ./ �'/ Trench Grade � i
Sealant , 0 Trench S acing ./ �
Riser if applicable) n/ Rock Depth and Quality �
Tank Outtet.Seal,/ � Dams/Stepdowns etc.
Permanent Marker �1/ Q.- Pressure Laterais
Pump Tank Hole Spacing
tate ate � o e ize
Capacity gai. � Pipe Sleeve -
Waterproof /Sealant Tum-ups/Protectors
Riser Required Setbacks
Water Tight From Weils �:
Pump From Property lines
Check Valve/Gate Valve - StructuresBasements
Ant�-si on o e �tc es rainage ays
Floats/Switches � � . . _ . _ � . Surface Waters - �
Alarm visable and audible Public Water Supplies �
Electricai Components Vertical Cuts >2 ft. .
Rate gpm Water Lines �
Approved Pump Model Vehicfe Traffic ;
Blocic Under Pump Adjacent Systems -
Pump Removal Rope/Chain Easements/Right of Ways -
Distribution System Other
Serial Distribution ti \' Easements Recorded .
ressure an o ert ie perator ontract
Low Pressure Pipe • Tri-Partaie Agreement
Appr. Pipe Material and Grade �
Valves �
. Comments� �
pct�d rev. 3/13/01
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1��.�a-��n.aan�sa�.�n.]1 �3La��.71�I1a
WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
3� 8'
Tax Map #: � Pazcel # _�� Township
Applicant
Subdivision:
Section• - Lot• �
Tvue of Water Su�nlv: �. Individual Communitp Public
Requirements:
Site Approved by
Grouting Approved by C� ��- zs-�-
Well Log C,�S t t-�-s_D�
Well Tag �55 i►-zs-�-�-
Air Veat C5S � a- t�-��-
Hose Bib C�S � a-I �-�a.
Concrete Slab C.�S I 3' I�-v�
� �z� s�t.� .+zt�.. .,... �a-��-�
Well Driller. �c.fnQ.N� 1��� ��� �
�
Well Approved By: � � Date: 1�1- t �-��
'k*See Attached Site Sketch'�
Wells must be 10 feet from property lines.
Wells must be 100 feet frorn sepric systems.
Wells must be at least 25 feet from anp building foundation.
Other conditions: �
PCHD, rev. 09/07/01
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ZE�a.�na-o�a�+ ��a��.Il �L�.�.I1�1Ea.
ln � � �
-
Drillller I D #
Com��any N.�me ,
D�te Drillled
/ Grout Log ?
Owner: �-� ,�-Cv `h ll �� Tax Map � Parcel #,l �
Location:
Subdivision:
Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet) / I�
Distance from Septic System (Minimum 60 feet)
Total Depth: � ft Yield: 2- GPM Static Water Level: � 3� ft
Water Bearing Zones: Depth 2 3?'� ft ft ft ft
Casing:
Depth: From _� to �� ft. Diameter: � in
Type: Galvanized Steel
Weight: Thickness: � Height above Ground: � in � ��
Drive Shoe: Yes No Any problems encountered while setting casing? Yes �iPQo
If "yes" give reason:
Grout:
Neat: Sand/Cement Concrete GraveUCement �
Annular Space Width inches Water in Annul Space �s � No
Method of Grout: Pumped Pressure Poured � Depth c7 to cv 3 Ft
Materials Used:
No. Bags Portland cement .�� Weight of 1 Bag �i`1 Pounds
If mixture (sand, gravel, cuttin s) — Ratio .2 to �
ID plates: Yes _ No 4 x 4 slab X Yes No
Drilling Log Location Drawing
From To Formation
� � � � � �z �
� L/b �.� l c, � �
I�u�
C�
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�t�f,l�rri Mr �� �
I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person County Health Department.
� �/ �9
Signature of Contractor /��L� ID# 2 I%( Date `� `z Z d Z.�
CHD rev O1/16/02
Tuesday, December 21, 2010 2:21 PM Keith L. Barnette 336-598-9275 p.01
.�IESIDENTIAL WELL CONSI'RUCTION RECORi)
North Larolina L)cj+artatent ef Lnvirrnimeat aiid N:uural Rer.cwrces:- I.livi�:inn c�l' Wa►rr f,�uHlity
W ELL CONTRACTOR CCitTTFI('.ATIOIv #�"'Z � l rj
�.1tv��L. CONTRACTOR� G� /� / ` /
� � �_1 q/ran
We0 Convactor (II'►divi4u81 N�n�e
B�mette.Well brillina Inc.
Well Contractor Comp�ny Name
611 Bamette Tinaen Ftd
Strest AdJress
Roxboro NC � 2��
City vr Town Slatc Zip Coac
�� �s , 5ss-ao� s ^ .
Area coCe Phone number
z wF�� iMFowu�►�aa:
wFLL CONSTF3UCTION PERMIT#
p7}iFR ASSQCIATED PERMIT#(�t applltaWe)
91TE W�LL ID #1(�t t A�i�blcT
3. VVELL 113E (ChECk AppliC�Ul� kiCrx). ftesiileidi2l Watri Supply ftii'
DATE DRILLED_ I�—e4I 'Ld
TIME COMPLEf�D DU AM ❑ PM �
g. WATER ZONES (depth):
: Top�� �ortam eZ 7 b
: ToP�.�� Bottont_.t�
Top, _ �._� _ FiOltom
4_ WELL L CAT1�N: �
cinr: �nrb couN rY�t'�l�.�7 n .,
a �S���h�. .r Lkn.L , ,��..« [
(S��eet Neme. Numbers. C mu��ty. .,ttbdivrs+on. �l ot No.. arcw, Z Code)
TOPOGRAPh11C / LAND $E! 1'ING: (crtecx spproprlate box)
JSlnpe ❑V�ney [�iat ❑Ridge ❑Other �
L.ATITUDC- �s _ " DMS OR 3x.xXKXxXxXX UU
I.ONGI7UDE �$ ' ' " DMS OR 7X.xxxx7ocxxx ti❑ :
LatitUdeltpriyilucfe suurce; �PS Qfopographic map
(1ocsUon oI wer! musr De snown on a uS�S iopa map �npanachev co
ihis brm if not asing GFSJ -
b. WELL O R
� �Ffa� n
Owner Nsme
a y 1 r L�K�
str nddress
�O �
City or Town Sl2tB 7�p CsWC
c���.� �T71 aabr7y
Araa code hhone number
6. WELL DE7AILS: �f
a. TOTAL DEPTH: �Y� T� '
b. DOES WELL aEPLAC� EXISTING WELL7 YE5 �7 NO C�
c. WATER LEYEL Befaw Top of Casing: i F"f.
(Use "+� If AbovE 'fo of Casl�g) �
\
d. TOP QF CASING IS F7. Above Lanr1 S�rfar,x•
"Tpp pf casirtig tormirl�;ed at/or below land aurfaoa msy require
a variance tn accordance with 15h NCAC 2C .0118.
e. YtELb (gpm): ...''�Q METHOD OF TEST BI�WII 2Of7)
r. d�s�rv��cY�or,: �ry� FiTH a„d�tie 1/2 C,�d
A 3 `' �
/ ��/
1'op _,_ Bottom
Top t38tlotri, __
7op Dnuom
ThiCknQSgl
7. cASING: Dvpth Diamater Wai�Jnt Mate�at
Top�_ Bottom 6 3 r•r. _. ,
Top _ Einttom Fl
Top---•-••- Bottom.. _ F1. .
8. GROUT: Oepth Material �fetnod
Top B�ttom Ft. Sand/Cement Poured
Tdp Rqtlom Ft.
Top Bottt�m Ft.__._ ,.
S. SCREEN: Deptl► f]iameter Slot Sizc Materlal
'1'op Ho�tom _ Fl.. , in. _ _ in.
Top Hottom Ft. in. in. _.
Top Bottom Ft._.__ .In. . _ In.
90. SANDIGRAVEL PACK:
Dcpth 8lza Ma�rrial
Tap Qottom Fl. __ .
7Gp_ _ edttom Ft
Tap t3oriom Ft._ _ ,
11. DRILLING L�G
Top ortom
��� ��o
/ _.
17.. REMARKS:
F rm�tion I�s�nptiort
-- �.�n�{� / �Ma�hz.
I DO NEREBY CERTIFY 1"I IAY TH15 WELI WAS CONSTFtUGTED {N
ACCOR�ANCE W1TN i6A N(;AC 2C, wELI CONSTRUCTION
StAPtDARDS. AND THAT A COPY OF TNIS RECORD HA5 BEEN
PROVI EO TO THF WELL OWNER.
�- ra at-�u
S1G I URt UF `ER 1'I I WEt,L (;ONTRACTOR DATE
__V.P��__. a� i�n
YhlIN 1 tU NAMt U!= soh� �qN9rR CTING THE WELL
Submit within 3Q days of cnmpletlon ta: Division of Water Quality - lnformation Processing, Fom, �w-ta
1697 Mail Servioe Center, Raleigh, NC 27699�9&1, Phone : i919) $07-6300 Rpv. 2/q9