A40 417�e�.,���-;������,��
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Applicant:
�.�lh.`-��;��
x May� � � � �rc
SLUb6fJVl I � 11
' � �.-e�S�ctian' � t' �
�pra�e�em�.�'ermit
��r�i �alid �or � �"see �ea� I�% �par�ion
Type of Facility: � . . New � A.aai�o� . . ���� ���p�y U/P (( �
# of Occupants�t Q)C �# of Be ooms Pro �ted Dai3y Flow �D g.p,d. �
Proposed Wastewater ystem: S'� . � � Type:
Proposed Repair: ' � � Type: �
Permit Conditions: � �Q� 'S� �'C S'J�� � � ' . - .
Owner or Legal Represe
Antliorized State Agent:
Date:
Dats: Z�( �
The issuancs of this permit by the Health Departrneut in does not guaraates the issuanc� of other pez�rits. Tf is the respons�ility of the
agplicant/propezty owner to in sure that aIl Persnn County Planning and Zo�g and Bui7ding I�spe�tions requaemenis aze met �his
�pravemeat �r.rmit i� snbject ta revocatian if the site plan; �pl'at�'or� ti�e in.#ended use ciaanges. �e ��agovememt PerBsit is ��t �
a€%ct� by a ci�aa�ge in ov�ner'ship of the gsroperty. T�is permit was is�ued in c�ffipli�nca �vitPu btse provisaons of the North �arolina, .
Z�ws axd Rules tor Sewa�e ?'reubnenf and 19isuosal Svste�ns' (15A N�iAC 1�A .19�0). Neithe� �Pea�op �ounty_ nor°:taie.- "�
Envir�nmental �eaIth Sgecialist w�rrants th�t the s�ptic tank sy�exn m71 cantin�e to fnns�on sa#isf�ci�si�y in #iae futnre or�t&:nt.
the-water sup�ly wi11 reroain potable. �• .
� Auatiao�ation t� C�nstruc�t �asiev�ates� 5yste� (},$�q��A for �uiga$i�g �er�it) � •
*. SeE site plan c�d additional attachments %)• � Z �Ow � � � . -.
• dr t�
Pragosed Wastewater System: ��Afn� �2(ir Ty-pe�__��__ Wastewatez �low T_ �� �;.p.d. �
New � Re�air Expansion - � .� Soii LT�B: . 22 S g.p,dJ ft 2
Type of Facility: �I�' G�S _• � Basement _ Yes �C No
'�7�.5$�'�ater Sy�$�3�n Re�gig�'�3a�e�$s
T� Size: 5egtic '��n�t:' �C.=" gafl �P Ta�alc: gai �rease Tr�p: gai
I�r�i�fie�d: Toial �r-..�: ��D 0 S sq f� Total Length 1� ft '�an�a Trenc$a ��p�9a � Z��`� in
�r.emc,�a �'id#� � #� 14�nimanan Soifl �over: �o i� 1�im;m��; 'g're�ec3a �epaa�ic�n: �_ �#
Dista�abu�om: � �iisi�ibu#aon �oz Serial ��tribu�non P'ress�e ��old � � -
.�.
sn�cations: � —�✓� �l�A,�-;�--� �i-��i+� • /'%uS�- �it61V� C -�- D (i►��vP• � ..
/; ,i1�P 1r Q � S G.vv-e�./ _ . % '.�,_ a.. �..: �`n s �r.. �. �.... �,. T�—
State Agent: J,�
Permit Ex�iration Date:
The type of system permi�te� is Conven�ionai
P��-
(��r��r/�eg� �a�aa�As�ss#�.�ee:
Date:
�C Ac:,�tea Alternative. I a�c��t tile spe�cations of the
Date:
rCI� rev. llli0i4�._
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INOTE: AREA ShIOWN ON
THE REFERENCED
� PLAT LOT 3
� I S 1,7:. 47 AC .
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�N 17.41
'� ACRES
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NOTE: AREA SHOWN ON
THE REFERFNCED
P�AT LOT 4
IS 17.40 AC. `
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tJOTE: AREA SHOWN ON
THE REFFRENCED
P�AT L.OT 5
1S 17.48 AC.
�-.o _— N .`� N82'47'36"W 432.95
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�ATED BFARING o
' TAPICE BASED ON —� v; r ^,� �
?l.[NF DATA SHOWN � iD A C R E S d- �Q�
t REFERENCEU PI.AT J� o�`N'
� rinrE: � •• � BARRY S. BAITY
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CONCRETE
MONUMENT
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WELL PERIVIIT (New ��tepair�
Tax Ntap: �fl Parcel: ��
Subdivision: Lot: �i�'a�
Applicant's Name:
Mailing Address: _
Phone Numbers:
Location of Property: ✓p�� � i �� • "� '� Y'i `( �1 ��S �� ^�'
Permit Conditions:
1) See attached site plan for proposed we111ocation. "
2) All applicable State and County regulations governing construction and setbacks apply.�
3) Permits expire S years from the date of issue.
Other Conditions/Comments:
Permit issued by:
l�
fii_�i
Date• q Z� D
CERTiFICATE OF COMPLETION
New Well Inspection:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
` Concrete Slab:
We11�Driller:
Pump Installer:
Well Approved by:
Date Sample Collected:
Person County Environmenta] Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
License #:
License#:
Date:
Date Results Mailed:
Phone: 336-597-1790 Fax: 336-597-7808
8/ 1 /08