A41 13r
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The District Heolth Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
Permit VOtD after 3 Years Dat 3^ - �
Owner:
Location:
p, Contractor: %� � v �'1 �'+
�
V � Water Supplp: Private '' Public
��
Sewage Disposal Facilities: No. bedrooms Dishwasher� Dispos8l�
washing machine, other autom tic appliances `�
Size of tank: NitriBcation line: �d0 L� -� /
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HE H DEPARTMENT
STAFF BEFORE ANY POftTION OF THE I LATI COV-
ERED AND PUT INTO USE.
Date approved: Signe
Sani
Well:
Sewage Disposal:
By:.
Counter-
signe �� dlil
( wn or his representative)
Cerlificafe oi Completion
Date Approved: � J �'" �� By:
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
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������ "� ✓ / ` � ' 0 819
ERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map #_� �, Parcel # �3
Zoning Township �.�r� �i�%��� _
Owner/Contractor
Location/Address�
Subdivision N
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Lot#
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As Installed
SEWAGE SYSTEM SPECIFICATIONS
epair Lot Area �a�.- Size of Tank_„t�
FD ✓ Mobile Home Size of Pump Tank ��'
usiness # of Bedrooms� Nitrification Line�
Max Depth Trenches_
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or inte ded use changed. ,
Well and Septic Layout by '' �����- //1���-�—� �
Comments:
Date Installed by Approved by.
ell Permit
Site Appro
Well Head
Grouting t�
WELL
ni-Publi
Instal led
SPECIFICATIO GS
_ Required Slab
Air Vent
_ Required W 11 Log _
_ Well Tag
Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or
misleading statements provided to him in the application. Neither Person County nor the environmental health specialist wart�ants that the septic
tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0
Applir.ation Date: 9-���� Tax fVian #: �� I
�mount �aid: ___ j�?�l �D � 3
Rec�i � �/ 7 I I�-arrzl �:
��% � �-1��.:'��- J.�" ��.� ��
i 1 � - - - �C � �TZ�T�L'iY'
�sci�aa-o�-*� ---�-� .eaa��.I1 �E�3Lo�.1L��.
APPlJCA710N F�R SEiZVIC�S
IF TNE 1NFaRMAT10M IN TNE APPl:.1CATION FOR AN IAAPROVEMEAIT PERMIT IS 1NCORRE�' FALS1FiED
CHANGED �R THE SITE IS ALT'ERED THEAI "tHE IMPROVEMENT PERMR AND AUTHORIZ�1ZlON TO .
CONSTRUCT SHALL BECOAAE INVALlD. -
�'6
1) Permit requeste b:(Ownedagentlprospective owner): u�SR LJ �19 ��
'�( e iv
Hame Phone: � _Y—�il� � Address: ' L� ����.�r—
Business Phone: d C 1 i'9
2) Alame and �ddress of currer�t owne�
3) Property �escription: Lot size: Tawnshlp: Subdivision: Lot #
Direcfions to the property (lnduding road names�and numbers): �•
4) Proposed Use and Structure Description: answer eacl� of the follawing questions:
a) Proposed . Existing , Type of Shucture: Width: � Depth:
b) Number of Bedrooms: Number of occupants or peopie to be served: -
c) Basemen� Yes , No Will there be plumbing in the•basement?
d) 6arbage �isposal: Yes No _
5) Water Supply Type: Private �new _ or existing�� Pubiic . Cammunity� , Spring _ .
Are any wells on adjoining propecty? Yes_ Na _ tf yes, please indicate approximate locatiori on the
'site plan.
6) Does your property corrtain_previousiy identified �urisdictionai wetlands? Yes No_
PLEASE NOTE THE FOLLOWING:
➢ A Pf�T OF THE PROPEiZiY OR SiT� PIA�i AAUST BE SUBMITTE� WI'TH T6�lIS APPLICATION.
➢ PROPERTY UNES AND CORNERS MUST BE CLEARLY MARlQ'cD. �,
9 THE PROPOSED L�CATION OF ALL STRUCTURES MUST 8E STAdCED OR Fi.AGGEU.
9 THE SiTE MUST BE �tF�►DILY ACCESSIBI.E FflR AN EVALUA770N BY THE HE�1i.Ti-i DEPARTMEiVT
STAFF.
I hereby make application ta the Person County Health Department far a site avaluation for the on-site sewage disposal
system for the above-described property, ( agree that the contents of this appiicatian are true and represertt the maximum
faciii�es to be plac�d on the progerty. I understand ifi the site is altered or the irrtended use ct�anges, the permii shail
become irnralid.
�.��. ���� � -1 f= o �
Cwner o� Legal Representa�ve � Date
PCHD. rev. 06127/02
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WELL PERNIIT
P]LEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: �,_ Pazcel # I J Township
Applican� U,SS� � ( �Or-f,an
�a �n i �- P�-�s �� �
�Lot
� # 7 cXaD �t �• r'n� �z�
T e of r u �/ Individual Communitp Public
R• ffients: � ��' �.� C� L 7t,c. �-' fl L c,�EL L
Site Approved bp �� 9 J��D � a'
Grouting Appmved bp�.-s s G-�q-62
�v� �g �-�s �, -,�� -oz
Well Tag G-ss � q-�c , � z
.Air Vent "
Hose Bb -7-05
Concrete Sla.b �
�� LL �(� � IQ. � t�,�Gt.S
� �,�� �p �J ��[—
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as�
Well Driller. �u+�'o� �J c c� 1�P� u��� �
Well Approved Bp: Date: le -7-05
� '�°5ee Attached Site Sketch'� �
Wells must be 10 feet from property lines.
Welis must be 100 feet from sepric syst�ems.
Wells must be at least 25 feet from anp bu�ding foundation.
Other conditions• --
:'; '" PCE�, rev. 09/07/Ol
����+ )'� . ���� ��
' � ' � � �lJ, l� ��
]E.�vas�m� � o��m.11 7F�T�m]I�IEi
SITE. SSE.TC]H[ �
N e SS c. (� �Or`t� Tag lYlap #�-41 Paazcel #�.
Su 'o l� � i} � � Section/Lot�#
c� �� r��
Authorized State Agent � . � Date . �
System components r�epr�esent upproxi�ate�Qontours only. Z he cmt#act�or mus�, flag the system prior to�
begirsning the irlstallaiiors to insur�e thatpropergmde is maintaisied
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C � .
E' � I� ��`
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X
s�:
(�D �
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15-7 S
Z'GHD, rev 09/12/01
%i 3 � °r�e�
���. S� ���.� �� �� oD � ' _�G� I
`'' --- C� � I�T�T� �Y �(�or�p� a�o � 1 n ��c11�� 1.ti� � �L
��a�as��rn�caa_�aa��11 �'���.���n. L�XsllSl� LJUll�UI�I°J 1 J �% Q t7�
Well Log
Owner: Tax Map� Parcel # J�
Location: `7 ' �4 S��r-2
Subdivision: � Lot # �i�
Well Construction
Distance From nearest Property Line (Minimum 10 feet) ( 0'�
Distance from Septic System (Minimum 60 feet) (np�
Total Depth: a'i s ft Yield: 1 s G M Static Water Level: ft
Water Bearing Zones: Depth ' ft 1�ft �-�- ft s��� ft o'�20 C���
Casing:
Depth: From �_ to � � ft.'-(� Diameter: (Q �� in
Type: Galvanized Steel -✓
Weight: Thickness: . v1 Si� Height above Ground: �� in
Drive Shoe: Yes ✓ No Any problems encountered while setting casing? Yes �No
If "yes" give reason:
Grout:
Neat: Sand/Cement
Annular Space Width
Method of Grout: Pumped _
Materials Used:
✓ . Concrete GraveUCement
inches Water in Annular Space Yes .� No
Pressure Poured ✓ Depth to
No. Bags Portland cement � r 6 Weight of 1 Bag �i y Pounds
If mixture (sand, gravel, cuttings — Ratio Z to t
ID plates: ✓ Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log
d.ocation Drawing
From To Formation
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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 Depaitment.
Signature of Contractor �� �,�n•� � ID # p 7 Date �j �� 7��i �
' PCHD rev 01/16i02
�J �G�G�jli CAy7�a�� �jylsy.� �f�CGh L'G!�/iaa/ la �--Z'4J4//�'�
Application Date: ��- I�} -1 �-- � f���+5� ������
Amount Paid:
Receipt #: `l 41 � �S ( ' � � ����
� O a0 ' — .IE:�mv-aa•aa,•*,•*�+,��n.�C:,ai.l� IHL�e.s.11d,�n.
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Services
Permit (Site Evaluation)
>300.00 (if> 600 end)
0 Mobile Home Replacement or Building Addition
�1 SG.00 �if site visit requiredj
0 'Well �ermit (New/Replacement/Repair)
$3A0.00/$200.00/$75.00
for 5ervices
� 3��'—z/�—�'�e�
Tax Map: ��
Parcel#: /3
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
�75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: 7i�c..� � 7 G:., d, �'//:�,�,�-
Address: ii ;�s �?d 6�,.,�s �'2 a•✓ •
,ve....� o-,- �, N G Z �59�
2) Name and address of current owner (if different than applicant):
Name: --•--�a fsc // /-� � f��
Address: ? Z � � /,��-djc �*,:/!� /�du al
/��, ��/z �►'I: /!.s . �lC 275�/
_,___-------,.
i
Phone (ho`me): LSZ-.3 y 2- o zzz.
(work/cell): --..,___ .__ _ _ . __.__.__._._.---
Pl:or.e: �TG - 3 6 5f - Z i ZS
3) Property Description: Lot Size: Subdiv;sion: L�t #:
Address and/or directions to Property: F�-o �.�, ,�o,� �,,.Y,, ,�� �s7 s ri- 5,..,� /z z T.e
s h f� /�s+r ft�. � v� R d ,r�rb�,,, ,�� .4. �-/- �, /�-,; !c a... L.
❑ yes nC�l o- Does the site contain any jurisdictional wetland ?
❑ yes C�o Does the site contain any existing wastewater systems?
❑ yes � s any wastewater going to be generated on the site other than domestic sewage?
❑ yes � �o Is the site subject to approval by any other public agency?
❑ yes G7�fio Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
L�e nt�al
ew Single Family Residence Maximum number of bedrooms: _�
� Exgansion of Existing System If expansion: Cu�rznt r�u�ber of bedrooms:
❑ itepair t� :�4zlfun:,tioning System Will there be a basement? � yes t� no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential �/�
Type of business:
MzximL:r: number of employees:
Total Square footage of Building:
Maximum numb�r o: seats:
�) Water Supply: ❑ New well ❑ Existing VI/ell ❑ Comr:�unity Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If plying for `A�u orization to Construct', please indicate preferred system type(s):
�onventional �J Acce ted ❑ Innovative ❑ Alternative ❑ Other ❑ An
P y
1 cef t� that the informatio ovided above is complete and correct. I alsa understand that if the information provided is I
inaccurate, or if the s' rs subs quently altered, or the intendEd use changes, all permits and approvals shall be invalicl.
�'rtdli��� G ��1.�J �D.� �G � ZOf� '
Si a re (Own egal Representative*) Date
* Supporting documentation required. �'�Jf�' �� ��' �N
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form rnust accompany any application requiring a site evaluation.
(]0/1 11 Person Countv Environmental Nealth. 325 S. Mor�an St.. Suite (: RnXhr,r� Nr �7572 «z�_�o�_»om
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J.L����T����n.���i����.� ���.�LLL��
March 5, 2013
David & Cindy Elliott
1185 Roberts Road
Newport, NC 28570
RE: Site Evaluation Application Dated 12/14/2012
Dear Mr. & Mrs. Elliott:
nsuring a healthy environment
The Person County Environmental Health Department has a policy that states any
application, which has not been acted upon for 3 months becomes void, and any fees paid
are then forfeited. Our records indicate that an application was filed on 12/14/2012 for an
onsite wastewater (septic) permit. Our Department conducted a site evaluation on
12/18/2012. We hm�e not yet received a st�rveyed plat sho►ving the new cut out lot. No
other communication has been received from you concerning this property. If action is
not taken by March 18, 2013, the application will become void and all fees forfeited.
If yuu have any questions concerning your applications, please contact Derrick Smith of
the 1'erson County Enviroiunental Health Department at 336-597-1790.
Sincerely,
dQa.Q. Q. ..b.�..
Derrick A. Smith, LSS, REHSI
Environmental Health Specialist
Person County Health Department
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573