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A40 408Aaplication Date: �- i 7 � � Amount Paid: � Receipt #: .- 6 0 1 ���6� ,G� ,�7 �a,�r � ���_S�" ��I����T c� � � �T'I� � �a-a�aa-ox��-^-^ vaa�m� ���rn..n��a APPLICATION FOR SERVICES Tax Map #: Parcel #: �a.\\ Cd �' e ����� ��l�l-`���'6�� ( a� µe�- �� �i� 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 �� � s. r ��� _.� � ���� � 0 0 � -�—,� ?1T�.�T,�i o � � �!4 � �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 . `� 1�, �.� � / � \l � / I 1.� � ii. .s. �-. (� (Q.��y�'� 1� � �-m-as�,r„ ,�,r„ ��sn�.zn.�. ���.���a � ...- � � � � . . •. • . �J/�I� J�� ��. -• - `.-• �� 9: JG. J'��ti.�. Tag Map #�_Pa�cel # `��� Se�tion/Lot# . � �Z 6 —0� 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 �34 .� .�. __-- ��� -- � �, __ —.:..,�,� _ � ` _ . . .. - �rv ��-��r � - --� _ .....�� v � � io -- �. - � _ �g . so � —� _ ._____ _ __ . _� � �+ yr � �, _` .;'� • . •, --�r . „ � � � �G�1.�. I= ldo � ' S03' 35' 19"W 19.41' 11 ; ���� �� �[— � �� J � ����� � � ���� � 1L� �dZ Z' � �.���� � � ��5.� 11 J1. �'.' d�. ��� Aaplicani Locaiion: �� �]�ar� � f _ ��uc �0 � � 40F� �, � � �H � ,u �������� � � � ° ' o� a 0 � - . . �� �� o � r i� . . . 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 . - �� �' � � � h , 1 � 1'(��1�. IA - bd�� . . � ��+^�.c.� � - � �.t� �, - - . ;. ?C�-iC�, re�. 07/2�!'G^- � ����`3� T�s�� �NS�����0� ������.,95 A����� 98 a 1 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 . ��$'9�i' � Serial Disinbution ib-s- Easements Recard�d . � Pressure �8an�rol e' e erator ontract Low Pressure Pi � � Tri-�'artate A reemer�t Ap r. F'ipe 1lrtateriai and G�ad� - . . Vaives �' ' . �c�ma�sen� . . . �c:�d r��. 3113/C'1 : 3 � i+� » . .. . .�� � � •- �.: , ` � :;••��• �' ,t • .���'• �. • < f' '� • _ Y� . .. �;.:�� J t �y.:}yJi•�'�^ .�'` •r�.•.�+v �.... � ' •��K:'' "< '_^.v•-•V;^ �' <'"^ . t . .,.,. : •:•1.:>i'{.'n�.^..:,.:M »., �.�;;��:7������'�. M1���• •��rN•�� j �a- 'o'^�: �:: �','�r��N'Or!�a�«5$iiti 1 . aG • . , �.��;a:�.��:aa��.{ 31���+�7C"�31�; : ��, � ' . • �'�9� 3� �A� P�N �R � 9lL'�� �.Y��'T' .T���� _ - .��� � ��. 0 �t# . • � ^,�''�gT y�� • • .YT�� • • /'7,� •�y . . . � � �8 tlDH �9 R6AGa ���D�. Sll�JlVIdU�I � W�y rLLU� �,✓�'G i c� x � ;. �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