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The District,Health Department
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prange, Person. Caswell, Ch,a3ham. Lae Counties _
" F � '
Water Supply ;�r�d
iragRavE��rrs
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Location• - �� ` " y
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Contractor: `
W er Sup ly: Private �-� � blic
y�,,sa, t�' � 1.+�� � � � ; i�.�=-l�� ��,�0 � �"�
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�����ishwasher, Disposal,
Sewage Disposal Facilities: No. bedrooms
washing machi e, �� rf�ut�O�atic �appliances , s� �
Size of tank: �� � ' NitriScation line: ;
Other disposal facility: . "
Water supply and Sewage disposal':facilities location, installation and
protection must meet state and local re�ulations.
SeptiC tank should be pumped out�every 3 to 5 years and shall be maln-
t8ined by owner in such a manner as� not to create a Aub11C he3lth h3Z1Td.
Septic tank and nitrification line MUST BE INSPECTEB AND AP-
PROVEI3 BY A MEMBER OF THE DISTRICT HEAi.Tx nEPAR.TMErrT
F.RF.D AND PUT NTO USE ON OF THE IN5TALLATION IS COV-
Slgri �r i �'--x1�..` �R `---�'��"'r�x �p�
,,� Sanitari ,
Counter- ,� �'; . .�'_•_�� - d.
aigned�`"•�' .`-'-;�',o: ;-`�.�- ,;�
(C3'wner or his represen�ative)
/ ! �
Certificate of Completion „.. � ..�----
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�r
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Date Approved: , $ant�arian f U �—
(OVER)
Location of well and sewage disposal facilities sketched on back.
Apalication Date: �r� � v � �
Amount Paid: �
RecEiet �:
Tax Man #: ��1 I
Parca! #• J
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/
APPLlCATION FOR SERVICES �
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IF T!-iE IPIFOFtM�►TIOtV IN Ti-19E APPLICA'T10N FOR APd IMPROVEMEflIT PERIIAR IS II�CaRRECl' F�►LS1FaE�
C�iAhIGED, O0� THE SITE IS e4LTEi2ED. THE�f T�iE 1�ttPROVE3I�EAIT PE3iI�IIT AND AUTNORI�TiOid TO
COMSTi�UCT SHALL BECONiE INVALID. •
'f) Permit requesi�d 9ay: (Owner/agentlprospectiv own
Home Phone: �`�9' � 6q � O Address: .� � ' �
Business Rhone: � � ,. . ,� 7� � � .
2) Alame and addr�ss of curreni vwner:
.� s
3) Property Description: Lot size: 3���Township: � + Subdivision: Lot #
Directions to the p�o erty (lncluding d names and numbers): `7 — 9�
� rf
, a� a _ G�oZC
4) proposed Use and $truc#ur� Description:, answer each of the following gue�tions:
a) Proposed . Existing , Type of Structure: Width: � Depth: s
b) Number df Bedrooms: � �. Number of occupants or people to be served:
c) Basement Ye�_, No . Will there be plumbing in the basementT �
d) 6arbage Disposal:.Yes �� No _ -
5) 1A(ater Suppiy� Yype: Private t/ {new 'V or existin9� , Public� Comrnunity , Spring _
� Are any welis on adjoining property? Yes VNo _ If yes, please indicate approximate location on the
'site pian. � . �
6) Does your property cantain previo�asly identifled jur�sdic8ional wetlarads? Yes_ iVo `=
PLE�►SE !�O'TE THE FOLLOIfl►IMG:
9� PLAT OF THE PROPEi�TI( OR SITE PL4lV MIDST BE SUBMITTED WITH THIS APP�6C�►T1�N.
9 PROPEiZTY LINES AIdD CORNERS MUST BE CLEA6tLY MARKED. �,
➢ i'HE PR�POSED LOCATION OF ALL STRUCTURES MUST BE STA6CED OR FLAGG�D.
�'�HE SITE MU$T 8E t2EADIL�I ACCESSIBL� FOR AN EVALUATIOPI �Y THE HEALTH DE�AR7'iViEiVT
STAFF: �
I hereby make appEication to the Person County Health Department for a site evaluation for the on-siie sewage disposal
system for the above-described property. I agre� that the cantents of this application are true and represent the maximum
faciliiies to be plac�d on the property. I understand if the site is aitered or the intended use changes, the permit shall
became invalid. '
� ��jalv � �cC � ���— �) �1 � � 1
Owner or Legal Representative Date
PC;10, rev. 06127/02
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PLEASE SEE A�Tr��+ ��d..r4I�T F�,IIt �I.,� SI�+ LA3IOgJ7['
Tax Map ��l I Parcel # 5 Township:
Applicant: _ �,��nl-� �t �z�,rs
5ll�7�1V1910Il: LOt # •
Location: IS�T -� �3 � �n�rs wh��'e1� Rd � Coa� ,�o,�rs ��/hi�-�ie1c1,�'d
'�yp� of'VVater 5upplly: � Individual
Requireffients:
Site Approved By: �^
Grouting Appraved By: '
Well Log: � ✓ "
Pump Tag: �
Well Tag• � �
Air Vent: � �
Hose Bib: �
Casing Height: �
Concrete Slab: �
Well Driller:
Well Approved by:
***�See Attached Site Sketcih***�
Colnmunity Public
Liner:
'Installed by: _
Depth set: _
Grouted:
Date:
Wate� �ample:
Wells must be 10 feet from property lines. �
��Wells must be 100 feet from septic systems. ,�
Wells must be at least 25 feet from any building foundation.
� i� .�� ��� ►. t��� � ' t ..�
Date:.
PC�ID rev 01/27/04
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]E��a-�,.-,.,.-�.-�.���.�.IL I�33L�.�.]L�71�
SITE PLAN
Name ���L�:rS Taa Map #� � Parcel # J�
S �vision �- Secrion/� t#
'�nJt�s.B i_�l� j�
Authorized State Agent Date
System camponents rep�esent appmximate rnnrours oaly: The conua�ctormusttlag the system pdor to be 'gnni a,f, theinstallstioa m
lnsure rharpmpergrade is mainrained
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Scale: N �l N�
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PCHD, rev. 09/12/Ol
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Location:
Subdivision:
Grout Log �j �
� � Tax Map /rZ� Parcel # �
Lot #
. - WeII Constrac.tion
Distance From nraresi Property L'me (Miuimum 10 fcet) (�o �
Distance from Septic System (M'mimum b0 feet)
Total Depth: �� ft Yeld �` __-_ GPM - tatic Water I.eveL-
Water Beazing Z.one.s: Depth�_ f� � 3�__ ft ft ft
ft
Casing: �
Depih: From .�_ to �� Diam,et�: _,� in .
Z`S+pe: Galvanized Steel -
Weigh� Thiclmess: .� i�l Height above Gmound: in � /
Drive Shoe: v� Yes No Any problems encountered wh�e setting casing? _Yes _� No
If "yes" give reason: . .
Groni: �
. Nea� Sand/Cetnent Concrete GraveUCe�ent /
. -•. Aimular Space �Vidth • mches Water um Ann Space Yes �` No
Method of Grou� Pumped Pressure Poured � Depih �_ to �� Ft
Materials Use�L- � .
No. Bags Portland cemc�t � Weight a� 1 Bag Po�mds .
ff mndtme ( gravel, cat�n&�) — R�tio to -
ID plates: �Yes _ No 4 x 4 slab ✓Yes No
Liner: , - - -.,.
Depth: Dat� Installed:
Drilling Log
Grou� Installed by - �
Location Drawing
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I hereby certify tbat ii�e above� iafa�ation is coa+ect and t�at ti�is well was G�ns� in accardance wi� regulations set fa�
by the Person County Health Deparbmeat. , ' .
Si�gaatnre of Conirxd�or I
m# 3�fG ,��. —z��o7
�'amp Instaument
Pump Installation Contractor_ �/ �j/G �� State Regislration Number. 1P ��
�P �F� � fl $ Sfatic Water LeveL- 2S' ft
Pump Make & Modei- /�ie� S P�p Size and Rabn�- '1 L hp �_ gpm
I hereby certify tlmt this pwmp was installed and t�e wetl head completed acc�dmg to the Pexsan Couaty Well Rules in effect
an dus date and that a capy of this record�as been �ovided to-fi�e well owner. .
�P �II�' �'e-_�%ii.." l �,-� � , Date: ' 2�^+� � P(;HD rev 01I27/04