A41 14�gp!is�tioa �at�: � � � I 1
Amount Paid: J �(j , UO
Receipt #: 1 �S 3 � Z
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C� `'�� ) f ll 1LG�� �l �
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�' �a�aso�aaa�aa�mIl ���m���n
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
1) Applicant Ii
Name:
Address:
2) Name and addr�s,s of current owner i Jdiff�e�re�
Name: �Q��' _.l,cr.�
Address:
3) Property Description: Lot Size: .y0
Address and/or di ctions to Property: �
.� _ . � _ � �, � / <_��. �..
for Services
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
$75.00
�Repair of Existing Septic Sy�t
Application: No Charge/ C�A
� �� ��
� '
`��'��Phone (home)
_ (work/cell): ��
applicant):
ion:
Phone:
Tax Map: �1
Parcel#: --1�
150.i
�
�
0
#: �
yes o Does the site contain any jurisdictional wetlands?
�s � no Does the site contain any existing wastewater systems?
❑ yes � Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes 0-� Is the site subject to approval by any other public agency?
❑ yes � Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
�,,,�o,; ( (�e rµ, �--
�n .SO�Ul�1���
$300.00
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms: �/ Occupants:
❑� E�x ansion of Existing System If expansion: Current number of bedrooms:
f9'i�epair to Malfunctioning System Will there be a basement? ❑ yes C�-r�o With plumbing fixtures? ❑ yes C-Fno
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well l�-E'�sting Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative � Alternative � Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�������� � � lo �
Signature (Owner/ Legal Representative*) D e
�` Supporting documentation required.
• Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site e�aluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC�27573 (336-597-1790)
Ti�►v �L +2�Atr�
Tag Map: �� Parcel:�
Subdivision
Phase/Section/Lot #
����, ) � ���� ��
� � � ����
7:E�e�.�a-��� ����.�1 IF-���.Il�1�
Applicant:
Permit Valid for: Five Years
Type of Facility: �
Number of: Bedrooms / Occupants
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
Auth�rized State Ageni: �_
(X) Owner or Legal Representative:
Improvement Permit
Non-exgiring
New Addition W
/ Employees / Seats: _�P
Daily Flow: gallons/day
Type:
Type:
Date:
Date:
The issuance of this permit by the lth Department does not guazantee the issuance of other required permits. It is th;, responsibility of
the applicandproperly owner ±o ' ure that all Person County Planning and Zoning and Building Inspecdons requirements are met. This
Improvement Permit is sub' ct tu revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownershi f the property. This permit was issued in compliance with the provisions of the North Carolina °Laws
ani! Rules for Sewage Treatment and D�cnosal Svstems'(15A I�iCAC 18A .1900). Neitber Persoa County nor the Environmental
Health S�ecialist warrants that t�e septic system will continu� to function satisfacto: ily in thc future, or that the water su�pfy wii!
remain potabte.
�uthorization to Construct Wastewater Sys#em
See site plan and additional attachments (�.
r
Proposed Wastewater System: �/�nit%rs(��%ldn/..�.� _(*)Type �t�_ Design Flow ?_ gal./day
New Repair� EYp nsion _ Soil LTAiZ: gal./day/ftz
Type of Facility: Basement: _ Yes _ I`do
(") System Types IIIb, Ilibg,l V, csnd V, requireperiodic system inspections by the Person County Health Department.
��� ��,�p� Wastewater System Requirements
Tank Size: Septic Tank �DDO gal. Pump Tank gal. Grease i rap gal.
Drainfield: 'Total Area sq. ft. Total Lengtl� _ ft. Max. `french Depth in.
Trench Width ft. � Min.S�il Cover in. Min.T'rench Separation
Distribution: Distribution Box / Serial Distribution_ / Pressure Manifold �_
Specifications:
ft.
Authorized State Agent:
The system permitted is: Conventional /Accepted i Alternati�e / Innovative . I ac�ept the conditions
and specifications of this permit. p � /
(k) Owner or Legal Representative: ���j%-u� �� �f-C��'�� Date: �
�
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
�
���.ss ���.��.�
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I� �.�-n a- � �. �. � � � �. Il IE� � �. Il � 1!�
Applicant:
Location:
�,� � T�g iriap �� Parcel # �
�� � Subdivision
—� Phase/Section/Lot #
# of Bedrooms C(vc dw,.i
�uerat�on .Permit
System Type (Fram Table Va): �; Product : ` I `�'"' � �� �
�g)
Type V& VI Expiration Date: Type V& VI Renewal Date:
This sysiem has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all coaditions af the Improvement Permit and Construction
Authorization. �
rn � �'C/.
uthorized Agent)
�� Sc��w�a-.
(Licensed Contractor)
W�l�
V
� OIcQ W2 � (
��� 31 �
(Date)
��`��(
(Date)
. �
���r�
- �_l_.._ �.._ � .
��
Scale .
i-�l �! r-
Tax Map: Parcel #:
Septic Tank System Checklist �- ��t
(Type II 1� System Type. � � �k �
I�lotes:
� Nitrification Lines
Trench Width: � ft.
Trench Depth: in.
Total Length; ft.
1�li�nim�un �ua� ft.
f'rrade (< .25" n 10
Cover (6" miniin
Setbacks
'From wells
Property lines
Foundations/baseme
SurfaceWater
Other: '
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
1Votes;
Application JDate: i -2N -
��nu�ntP��: �15 •oo
�ceip�#: ( 3 3 �
_______
�� ��°� ��,
1}
�.`~�, �" I�I�
` � �� �
fo� ���ice�
CI gmp�uveaneat PertFai� (Site �v�ttat�oat) �, t . qF Construcl
a
�200.00/$300.00 if> b00 � d • '� �� �' �� .' = � � � .ee is d r'
:�: ,:'•.
t� Ndobii� �ome Rep�acemen��b� �ttiidnng 1�ddilaoaa . �' ' � �' .'� �'1 �'ermit I��
�2S0.00. ifsife visitrs ' d ' - '� � � ZS,00 �
i�We�l P�rmit (l�tew/Ft s�i :pair �. • � Itepair of
-- -$�OQ.001$200i:0 �7a� . • ' r12r . • • . - Anniieatio
Ivame::
•, �. --_ - t .
- . � . . :;•.
- �.�� _ . • . .:� .• -
.
. �
�� Ta� I�ag: �i �i �
��� . �����#: _.,�.—
��n�:��. I
AuiborFzatio�
lent on tha type of
on ,
Septic Systeut
1 �' . ' .
n � (home�: 33(0- 3�2 - a35�
. , .-- - ,cell): �3�-5�3-�(p3�
`-_'Rflt�.lr�o 0 2't5`7 . • .• � .' • ; , .
�) RT�a�ae aaad addff�s� uf ���en� ��er �(f�cflaf%rent #h� �p�lic��): � � � `' � •
l�Iar�}e: _ ' � - Phon
Address•
i .. .
�•
3) �ro�Oerty I)escr�piaoaa: Lat Size: -/.�J9 S�} b—divisiab: .
Address and/or dizections to �'roperty: (�!$ �/u.���� j�; �
. . �� . •
• O yes CI no I�oes the site.contain atiy,yuusdictional wetlands?
❑ yes � no Does tlte site contain any existing w�stEwaier systezns?.
❑ yes C! no •is any wastewater going to be gcnei�tedvn.the site other th�
CJ yes 0 no , Is the site subject to approval by an� oth�r puhlia agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
.(if `ye�' is checked, �ilease provide supporting documantaric
�) �����se� U�e aitd '.��pe a� �i�c�e�ur�: - .
��tesidential � � . '.
t7 New Singie Family Residencs Maximum number of bedrooms:
[7 Expansion ofExisting System If expansion: G�urent number ofbedroon
❑ Repair to Malfurtctioning System WiII there be a basement? � yes � no
�NOII�&�BSi{BeEl�itli "
Type o£business: Total Square f
Nlaximum number of employees: M�num nu�
5) ��ter S�aPPi�': I� New well Ci Existing i�iiell, ❑ Cammunity Well ❑�
Are there any existing welis, springs, or existing waterlines on this property?
PieAse note any Irnown ground water xestrictians or sources of contamination:
b) � a�pRYen� �o� 61��oa�a�i�n #o Con�iruct', plea�e i�dica$e �n��erred
Cl Canventiona3 0 Accepted CJ Innovaiive Ci AIternative � Oth�.T
..�
I cert� that the infonsiation provided above is cornplete and correct 1 aTso zan
inaccz at� tlie si e i,s subsequently altef-ec� or the intendeai use changes, all�se
oz�r�x�
Sf�a (Owner/ Legal Represeatative*) •
''` Supporting documentation required. - ;
a�er��� are �a�id �o� eithe� d0 anonth§ o� are aa€�-e�pi�ing wiae� a
o � eoenp�efiea� °�ot �e�aratio�a' �o�r,a rr�u§t accoanpan3t aray agrgI�ca
Lot �:
�
domestie sewage? �
?�
.y
Occupants:
lith plumbing fi3ctures? ❑ yes ❑ no
•.
tage of Building. '
er of seais•
►i�� w���r a sP����t ��
J yes � no
��r� �e(�}: .
Cl Any .
ciand tliat �the information proUided d
�s and approval� �liadl be invalid.
. � t __ �
, � � - i-2N -�S
Date
�p�nied iay an ag�Oroved plai.
� reqyairing a site evalua�io�►.
. _ _ — . --- -- --- — - - _ _ . �. _ . -------- --- _ ___ .----
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�= � � ���°�
lE�ra�n�r��an�am�ra��o.lL lE-'IC�afl�a
WELL PE�i;1V,QT
(New_ Repair�� ) Ct,�na��
Tax Map: � Parcel: �_
Subdivision:
Applicant's Name: ,eSsic.± C.ceie%{�,�
Mailing Address: _(�� IR Ku� 1 Ik;1l s Rd
�.ex�eve T I� 2151�{
Phone Num6ers:
Lot:
Location of Property: _ � e� �� N,�,��( ( M�(,� J
Permit Conditions:
1.J See attached site plan for proposed well location.
2.J All applicable State and County regulatio�rs governing corrstruction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not arante a potable water supply
OtherConditions/Comments: �rw�� -i-a rv<<fa(f I;nrr
Permitissued by � Date: l-ZS-lB
�ew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Iastaller:
Approved by:
Additional Com`nents:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Rnvl�nrn Nf �757�
Certificate of Completion �,/ I
- L'�Liner: �Q� V 1 Z9lvOf S
' � EHSJDate
Depth: � �
Grout: �S � , �,��
�
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
ttha +
W�LL CONSTRUCTION RECORD
This form cnn bc uscd for singic or multiplc �vcils
1. Ncll Contractor InformaGon:
��� � n �Fk��
Neil Canuacwr Nnme
=–�-�1 `� -�—
NC Wcll Contracror Ccrtification Numbcr
�
_ i,. ��� (d� : �s s ,1.��►G
Company Name '
2. We1l Constructton Permit tl:
Lisf all applrcaGle u�e/I pen»!1s (i.e. Couoq; Stafe, {'ariance, brJrction, elc.)
3. �'Vell Us¢ (check well use):
OAgricuiturn( OMunicipaUPubtic
aGeothermal (fieatin�/Cooling Supply) l�tesidential Wnter Snpply {single)
❑IndustriaUCommercial ❑Residential Woter Supply (shared)
Supply
OAquifer Rec6arge
OAquifer Storage and Recovery
❑Aqutfcr Tcst
�Experimental Technology
OGeothermal (Closed L.00p)
�Groundwater Remediatian
OSa►iniry Sarrier
�5tottmvater Drainage
�Subsidence Control
❑Tracer
❑Other (explain under.�21 Ti
4. Dnte �Vell(s) Completed: /"Z�i' �� �VeU ID#
S�Wcll Locutlons '
� � �'i i �'7 Q �'►'i'Lv. �
fiaciliry/OwnerName �� FacilitylD;'(ifapplicable)
l�j sZ i-fu ��/t �'11;1/ c�( �o�G : o l�IC.
Phys�r l Addn;ss, City, and Zip
�r�sa �
County I'arccl Identification \o. (PIN)
Sb. I.atltude and Longitude in dc� eesltt�inutes/seconds or decimal degrces:
(ifwell tieid, one inUtong is su4Ticientl
.�% rR.3�• �S�f�,y �1�� ���-�1�r�
- ��.
6. Is (are) the well(s):� �ermanent or ❑Temporury
7. Is this u rcpuir to an exfsiing �ti�etl: es ar pl�o
lf tlris ts n �rpalr,�i(1 oid i�ro�sn isr// cossmrction i� jarniarion aird e.rp(airr die nuurre oJ'1/ie
mEu�tr iuidcr It?! renrarls seclion or nir the Gack ojtlzJs forni.
8. A`umber of wells constructed: _ '
For n�uttiple 7r fectiar or �1on•ti�»tersupplv �re(!s Oi\'LY crith 11re snme cansnt�ction, t•ou cat
suhuiit oxe jo�7rt.
9. Total well de th below land surface: __ �{,�l � �
Far ntultlple �rells 1�ist a!( deplhs ifJiJfe�rnt (eranrple- 3 �y200' arr 1Q100� (�•
l0. Stadc wnter level below top of casing: _ �O (ft.)
Ijuvrerlevd is aboce wsing, usc "+••
11.13orchole dlumefer: (in.)
12. �Vcll construcfion metWod:
(i.e, auger, mmry, cable, dircct push, ctc.)
FOR �VATER SUPPLY 1�'ELLS ONLY:
13a. Y[eld (gpm) � S Alethod of test: �,�
13b. Disinfectton type: Amount: y
For Internnl Usc OIvLY: �
� � ' J '—J !
������_ C -� ��i�
� ofCertiRcd W tmctor Datc
8y signing this fonn, / hereb�� eert�� fhat Ihe �tiY!!(s1 �4ns (icere) consrrucled in accordance
xtitlt ISA NCAC 02C.0IQ0 or !SA NCAC 01C.0?00 {ietl Cautrr�ction Standards ard tha� n
copp ojthis reca•d has been prorided lo !he �tp/( ouvter.
23. Site diagram or nddiHonal �vell details:
You may use dte back of this page to provide additional �vell site details or tvell
construction details, You may also attach additional pages ifnecessary.
SUI3DiIT"I'AL TiVSTUCTIONS
24a. For All Wells: Submit this form �vithin 30 days of completion of weil
construction to thc foliowing: '
Df��tsion of �Yntcr Resources, Informntion Processing Unts,
1617 Mai! Servlce Cenier, Iialeigh, NC 27699-1619
Z4b. For Iniectton iVelis ONLY: In nddition to sending the form to tha address in
24a above, also submit a copy of this form �i7thin 30 days of completian of well
conscrucGon to the follo�ving:
D1visIon of Nnter Resources, iJnderground Injecdon Control Progrum,
1b36 h1ai1 Sen�ice Center, Raleigh, NC 27699-1636
24c. Eor �Vater Suppi� & Injection \Velis:
Also submit one copy of chis fonn within 30 days of completion of
n�ell construction to t6c county hcalth dcpartmcnt of thc county whcrc
constructed.
Form G�V-1 North Carolina Departntent of Envirorurnnt and Natural Resources — Division of 1Vater Resources Revised August 2013