A40 408Aaplication Date: �- i 7 � �
Amount Paid: �
Receipt #: .- 6
0
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APPLICATION FOR SERVICES
Tax Map #:
Parcel #:
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iF THE INFORMATION IN THE APPUCATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED, OR THE-SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Owner/agent/prospective owner): ( Q�lY'�t ��"1M�'
Home Phone: 335-23'i%%y� Address: �79 , ���, .
Business Phone: .�3 � S�y r77/YCc�e� ���r'a- � �13 `� �
2) Name and address of current owner: �TuSfi�� p,, �(G�c� ���'r5
3) Property Description: Lot size: �2� � Township: �� �� Subdivision: n�5 Lot #�
Directions to the property (I�r cluding road name,�,and numbers�: ,�. �
_ V� d�f�� � �� `lf s �- J —/C � d ( � �Y_. , , ° �
wi'!�-
4) Proposed Use� a� d Structure Description: answer each of ��o owing questio s:
a) Proposed ►! , Existing , Type of Structure: Si' � ��}'�` Width: �� Depth: %�
b) Number of Bedrooms: � Number of occupan s or peo le to be served: 3
c) Basement: Yes , No ✓V1/ill there be plumbing in the basement?�_
d) Garbage Disposal: Yes _, No _
5) Water Supply Type: Private _ new �or existing_), Public�, Community_, Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No_
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. 1 understand if the site is altered or the intended use changes, the permit shall
become inva 'd.
r
- �7- �
Ow er or Legal Representa ive Date
PCHD, rev. 06/27/02
'. ���� �� i �����b...y � -_'... V �F3 � � � .� s� 1 dg
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�7�-'9.'��'L��"�"'"r'T+'1 �%3'Il_��.�L 1i 1LaL�:.l1� fa?
�'�rmnt '�Ialid �or � �
Type of Facility: �
# of Occupants �(;�
Proposed Wastewater S
Proposed Re�air: �
.� �rQ - �
Owner or Lega1 ]
Autharized State
3�ears
# of
Iffipr�ve�aaent �ermit
I�'o�� :piration
e n ,Pi New Addition
�s �^ _ Projected Daily Flow �
�,
�ate� Sa�piy -��
d.
_ Type: �
_ Type:
m
Date• / - % -U y
Date• Z-28 D(�
s�s�er�-
X
The issuance of this permit by the Health Department m does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that a21 Person Coimty Planning and Zomng and Building I�spections requirements are meL 'This
Improvement P�ra�it #s subject to revacation if the site. pl�n, plat or the intended use changes. The Improvemeut Rermit is. not
arffeeted by a change in ow�er.ship:�%the-groperty. �'his p�rmit �vas :�sued in_enmpliance with the p�ay}sio�s of.the.lvo�th��G�aralina �
.s+:�:::-.�:fLaws��.and A�tu�ps f�Y Se7u+�Se,� Tzeul�zaenl.unr3:._D�osal Svstems' (��A N±C��^1:SA .1900). iVeither Persan.�t„Toun�,�io�_„hthe:�;.:;,
�«a�n9ii-��une�tal �ealtiieSp.e�ia�is��r�=.�ar�;c�he.septic tank.sys�em mll:��'�nnpT��uc#ien'sati�factoriiy���sa�t:i::,
_;. .-the:�ater.supgiy will.remain..potai�ie.. � �:. .. _ .
_. _ . .
,...._._._.._._.. ,..:. � .._.. ; _;._. :
.._.-a2 z•.�.
,,�-- .,�4'�� � {i �:�. :::. � . Amtiiorization to �on'st�ruct �Vastewate� Syste� (I%qu�ea��f���Btulding Yerrmit)-' � -..- �- " .:,'
. * See site �lan and additionai attachments (_). . .. -
Proposed W tewater System: H��EQp �� �-lBut e� �iu�►vbP,�J � Type � Wastewater Flow �D g.p.d.
New �Rep _ Expansion Soil I,T .�s g.p.d./ ft 2
Typ� of Facility: ri va.fL " .S i�y� Basement _ Yes �
�astewater Syst�m �e�inireffients
'Tani� Size: Septic Tank:� Od0 g� Pnmp Tank: -gal �rease Trap.- - gal
I)rainfeld: Total Area: �� sq ft Total I,ength 3�e D it � 1l�a�mnm Trench Dep� /� an
�rench Width 3�t 11�inimnm Soil Cover. (Q in lblinimnm'Itireaach Sep�ration:
9 °� �
�istribnt�on: �is�trihntion �oa Serial �istn'bution Pressnae 19�ianifold �
t�ut9noa�i�eai State A�
Permit
�ate: Z"2�-/(
-�/
Date: 2 -
The type of sysiem permitterl is Conventional Acc�ted Alternative. I accept *.he spe�ifications of the
permi.t. - .
Q�R*3A�/��31 �E�1I'ESE��7�lV8: Daie: / - % ` O � X
' pCED rev. 11/10/OS
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Tag Map #�_Pa�cel # `���
Se�tion/Lot#
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Date
Systesrs com�or�ents re�ires�nt a�b�r�xas�aate�cont�aars only. �3ae cora�a-actorr �sass�j%ag tlae .�s��a j�azor t�o
be�inning tlae a�tstallatr.�n to i�asaar�e fhcs� pr�o�erg�e as nuxin�iner.�,
487.00'
rr
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Aaplicani
Locaiion:
�� �]�ar� � f _ ��uc �0 � � 40F�
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. System Type (ln Accardanca Wiih Table Va): z
THlS SYST�� 6��5 FE�� iNST.a,LL�� IIV CDi�IE'Llr��l�� V1/1i�9 �PFLICABLE . NORTH
G"A�OLIF�A G��1fERAL ST�TiLlTES, �i1�E? �OR Sct�iI.AG� TR�ATMENi' �f�ID D(SPOSAL,
Ai�D •�LL CONDITIONS O� ' T1�� IIViPROV�iVIE�T P��fll11 i AND CONSTRUCTION
AllTH�Ri�T1ON. � .
�
. � • � . /a- �-- aq -
� uthorized ate Agerrt Daie -
lnstalled.'�y../ / 3: �-•_� �u..c� - Date: /o -S_ oq . -
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Tax IV��Q � Q'{6 Parcz� ��) n�_ S�fS�Elii T�7@ (T2�7Ii' V2� � —Z
Ot,v�er;A�plicant � Jer"� i�w�k� ,r S�bd�vision
AddressJLocc�ion �I��,,� C�, �� . Se�IPhas� Lofi � �
���u��. �'�ra� ��i�aadi��� �o�a�a������o� g�� Ini�� da� �
� St�#e ID/dat� - - a- - � rencfi Widfh� � 3 ft. ✓3S. ia�-og
Ca aci - ai. � � Trenct� Depth 2-l5 in:
Tee and Fiiief - � Trenci� Len th �t.
� Baf�ie � Trencfi G�ade � �
Sealant Trench S �cin �
.� " Riser (ifi applicabie) � Roc�C De th and Quali
- - Tank Out(ef SeQ( � Dams/Ste dowr�� �#c. �
Perman�nt iVlar�ce� Pressure Laierals � �
. Psamp Tank � � Hole Spac�ng � .
� State D/date - . o e tz�
- � Ca aci al. � Pi e. Slenve .
� ' Wate roof /Sealant � Tu�n-u slProte�tors � �
Riser F�quir�d' S�t6a��
Water� Ti hi � � From� Weils � �a -s -09 �
��a�a� From.Propes�y lines � .
Che�ic ValvelG�te Vclve Structures/�asemenis � �
�� Anti-si on o e � �tc es / ramaae a s �
Floats/Switches � • � Surface Waters .
�larm visable and audible Public lNater S� iies - �
E3ectrica! Com onents • Verticai Cuis >Z it
� Rate m .. VVater Lines �
A rove� Pum fVlode! Vek�icle�Traffic ��� '
Bloci� Under Pum � Adia�cent stems � -
� Pump Removal Ro elCnain • ��asemenis/Ri ht of Wa s
. ''DBSI�'H�7�1�0l1: S�'�d�'1 . ��$'9�i'
� Serial Disinbution ib-s- Easements Recard�d .
� Pressure �8an�rol e' e erator ontract
Low Pressure Pi � � Tri-�'artate A reemer�t
Ap r. F'ipe 1lrtateriai and G�ad� - . .
Vaives �' '
. �c�ma�sen� . . .
�c:�d r��. 3113/C'1
: 3 � i+� » . .. .
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;.
�eq��ets: �. .
Sito Approved By: �
fro�ing Appm By.
� �VeIl Log. � S . �
� T� _"
�Vell Tag: .
Air Vent: • .
� Hose Bib: •
�g ��
Canc�eta Slab: •
�/ 3 l/D
���
Linar.
� �. 7ns�lled by, .
. �� ��
G�a:
Date: ' ' •
RTates Sample: �
�Vell Dr�lca: Ol �--�_ ..
Well App�oved by: C�
*�*9e� �t#ac� Si6a Ske#c��*** . .
Wells must be 10 feet from property li�nea.
W'elle mnat be 1�0 feet fr�m septic syste�ns. �
�Tells muet tie st leaet 2� fest �fmm any bniiding fo�mdatinn. �
Det�:. � - Z9 -/o -
. -�
�
. .
Other conditions•
�'G� rev 01/27I04
T� �i�,� �.�j a
�C�r� Z.( `�_
RESIDENTIAL «�rLL co�srRucrioN n�coRn
North Carolina Department of Enviroument and Natural Resources- Divuion of �Vate� Quality
WELL CONTRACTOFt CERTIF[CATiON # �"( � I
�. V1fELL COQFf TOR:
�\ l �^J rl
Well Coniract ind'rvidual) Name .
Bamette Well Drilling inc.
WeU Contractor Comparry Name
STREET AO�RESS 691 Bamette Tingen Rd.
Roxboro NC 27574
City or Ta�m Siai� Z"ip Code
� 336 � .599-0015
Area code- Phaie number
Z WELLlNFORMATION:
StTE WELLlD #(ita�l;wbte) N/A
STATEWELI.PERMIT#(dappucable) N/A
DWQ cu OTNER PERMlT #(if applicable) N/A
wEu. use �cn� �r� ��: �;a�� w�r s�,apN �
OATE DRtL1.ED l —3 J' � �J
TfME COAOPLETED /Uy � pp� �
3. VYELL TION_ . �
CITY. • O '` `� COUNTY e ,SD ✓�
�ca �-� �� ,��. ✓ �G, , ,�;/ _
_(Steet twme. Yumbera. Cor.r�tun4y, S�l:di�ision, Lct 3Vo., Ps'tel. ZP Code)
TOPOGRAPHIC/LAN SE771NG:
� S1ope O Vapey �❑ Ridge O Ofher
(��� •
May be in degrees,
LarrruoE 3 _ m;�,��. � «
LONG(TUOE ' "' a dtt""'� tor`°az
Latitude/longit�e source: pGPS pTopog�raphic map
(locati�on of we9 must be shown on a USGS topo map and
attached to fl►is form I not us'rg GPS)
4. WELLOWNER
OWNER'S NAME ( ( Z M�1 � ✓
S EET ADDRESS .� i V 2✓ C, O
_�O�o�o /!V �. 2�5��1
C aTown Sf�e rip(',ode
c� �� �- �o�(, -�.� � ��
Area code - Plwae numher
s_ wEu. oEra�i.s:
a T07AL DEPTtk � V V
b_ OOES YYELL REPLACE EXiST1NG WELL? YES ❑ NO p�
e. WATER LEVEL BebwTop af Casiing: 25 FT.
(Use'+• if flbou�e Top of Casing)
d_ TOP OF CAStNG IS 1.5 �_,�n� �„a s�r�-
'ToP d casin9 tema�ed at/a below la�d su�face may require
a raciance in aocadance witfi iSA N1CAC 2C .U118_
e. Y1ELD (gpm): �_ W ETHOO OF TEST Blow 20 min
f. DISiNFECTiON: Type HTH qmount .Z�J CUp
g. WATER ZONES (depth):
F�om�' C� To� From Ta
fran�� To ?- � e From 70
f'rom To From To
6. CASING. Thi�knesy
Oiameter Wei ht Material
From�_ To �+ ' FL__�
from To Ft. 'I� -Lt �—
From To Ft.
7_ GROUT: Depth Materiat
From� 7o Z � �t Gravel/Cement
From To Ft
From To Ft
Method
Poured
8. SCREEN_ Uepth Oiameter Sbt Size Wiaterial
From To F� in. in.
�%AFrom To Ft_ in. in.
F�om To Fl in. in.
9. SANDlGRAVEL PACK:
Oepth Size Material
From To Ft
NlAF� zo FL
From To Ft
10. ORIIUNG LOG
From To
� 2
Z_ `!�
� �3 Z G �
I1. REMARKS:
Fo�mation Oescriptan
^'I.V SJ!/
�l, �t � . �/
�� r�l �t c�
� oo r��avi ceanFv nar TM�s w�a�e, wns coNsravc�o w wccoRo�wce wcrH
15A NCAC 2C. WELL CONSTiiUC770N STANDAROS. hN0lt41T h COPY OF THIS
REcoao ras se� Paaov�o ro n+e wEtt ownER
_ �---.. 7 � ��
S! E OF CER IFI WELL C�NTRACTdR DATE
G, �, � � � .� �
PR{NTED NAt,AE OF PERSON CONSTRU TING THE WELL
Submit the original to the Divisioa of Water Quality withi� 30 days. Attn: �formation Mgt, F� Gyy_�a
1817 �Ilail Service Center— Raleigh, NC 27699-1617 Phone No. (919) 733-7015 ext 568. Rev 7ros