A41 47An�lication Date: � �6-� 7
Amount Pald: �o�
Receipt #: l7�_
Tax Man #t:
Parcei �!:
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APPLICATION FOR SERVICES
.:
->:.. ,. ;:: ,:ServicesRequesteci'.. �
, ,..: _:. : ,:. : :. _:,
_
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improvements Permit (Recorded Lot) -$200.00 ❑ Well Permd (New/Repiacement) $2
I Improvements Pertnit- $150.00 0 Construciion Authorizatlon for Septic
(Mobile Hame ReplacemenUAddition) $150.00!$200.00
I RepairlReplace ExisUng System Permit � ❑ Pertnit Revision Fee -$75.00
IF THE IIVFORMATION IN THE APPLICATION FaR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFlED
CHAFVGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CO(VSTRUCT SHALL BECOME INVALID. .
1) Permit requested by:(Owner/agent/prospective ownerj: /rMo�y �'7-;.� � (7-�' f��'an1
Home Phone: 336--s<<Q-s��s Address: __ �55 � t�l Ho/tew 1�J:.
Business Phone: 336- 5�'f7- oz'otl� k'oxbo�� NG. 2��7�
2) Name and address of current owner. __ /��ra�i� -� /� .� 1�; i� (T�'I )c`uw�
��ss c�-�«�i �-�oi��n-..
,�:oxbnr . Nc a.�,�#--
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3) Properly Description: Lot size: 33. l�c Township: T�Mbp�laf=Z Subdivision: Lot # a�S% �
Directions to the property (Including road�jn�am�fes and numbers : So� �
� _ I,� ��%� STrQU Y�PS�G((/ ITGf N� �� ri/w�" 't`l�l r�4%Q' �
ur �;� �i ,n e a L� � p�. e.. �S o., �e �'�jNt- Ca r��ks)
pCIfS SikYr:f� c�d:tes' �1�se c'�Kl ,1� ►'ooc�waF 0,,� y-�re r�5tif-.
4) proposed Use and Structure Description: answer e�aach of the foliowing questio�:
a) Proposed � Existing , Type of Structure:��x� �ir��k � wc�z.( hcus.z Width: Depth:
b) Number of Bedrooms: _� Number of occ pants or people to be served:
c) Basement: Yes ✓, No Will the�e be plumbing in the basement? 1�
d) �arbage Disposal: Yes No ✓
5) Water Supply Type: Private ✓(new ✓ or existing�, Public . Community� , Spring _
Are any wells on adjoining property? Yes_ No _ If yes, piease indicate approximate location on the
�site plan. �
6) Does your property contain previously identified jurisdictional wetlands? Yes,_ No ✓
PLEASE PIOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. .
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED..
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE S,ITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEAIT
STAFF: �
I hereby make appiication to the Person County Heaith 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 placed on the property. I► erstand if the site is altered or the intended use changes, the permit shall
becom ' v id.. G�
�� ' � � 07
Owner or Legal Representative Date
PCHD, rev. 06l27/02
' ��,� � � � ���.���
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w _� ' ``/ �' �� Ji �
�����„-„ n-„-, «��.�,,71 I����.IL¢11�.
T�x Map '� �rc�e{ :
Su;bd!i�ri s,i�aia
Fh�s�e Sect+ian�Lot'' .
��zmi�t �Ja�id �ox� ��ve ��
Type of Facility: h
# of Oc�upants � ,r �uc # of Be�
Proposed Wastewater System: _
Proposed Repaar: (' €��,►�r�
Iaaprovement �'ermit
PTo �piration
Permit �Conditions: �',-j\l Z,�� 8��te ��c�.r�
Uwner or Legal Regresentative Signatur
Authorized State �Agen�k ���?c��n x o
New �OAdc�itian �ate� Sn�pplp �
Proje�ted Daiiy Flow 4� g.p.d.
� Type: J a
� Type: ��
Date:
The ieenancg of ttris pe�tit by. the Health DepartmBIlt ia does IIot guazazltes tlle issua�8 of othel pe�. It is the responsibiliiy of the �
aFPli��P�Y owner to in siue tha# all Person Couaty Pla�ing and ZaIIing and Bu�d�g Inspectians requ;ircments are meL This
Improvement Permit is snbjert to revocation if the site plan, plat or the inteuded use citanges. The Improvemeirt $ermit is not
affecterl by a ciiange in ownership af the properiy. This permit was issned in compliance.with the prnvisions of the North Carolina
`Laws and �iules for Sewa�e Tretttment and l)isnosal Svstems' (15A NC�,C 18A .1900). Neither Person �onnty nor t�e
Enviranffieatal geaith Specialist� warrants th,at thg septic tank system w�7I continue tn function satisfactonlp in tiie future or'that
the water supply wi11 remain�potable. � . . " .
A�thorization to Consirnct Wastewater SysEem (I2eqnirerl for Bn�ding Permuit)
* See site plan and additional attachments (��• .
Proposed Wastewater Sysfem: C1�lyeY��i �v� � Type � Wastewater Flow�$�:p.d.
New Lc , Repair FxQansion . Soil LTA.R: a oZ.7S g.p.dJ $ 2 �
Type of Fac�ity: �{ �{� �_'� IIi.e � ��, c� we1�,r1� Basement _ Yes _No - - ,
�Vasteevater Systemn Requirements �
'Tank Size: Se�tic'Tank: � gal Pnmp Tank: �;,,, �,al %rease TraPs -' gal
�rain�eld: 'Total Area: t�7�i5 sq ft -Total Length 1�� ft � lYla�mum Trench Depth %� in
Tremc�i tiVidt�t �,"� ft M'inimum Soi1 Cover. �D �� in lYTinimmm Trench Sepazation: / �t
�istribnfson: �istribu#ion �o� � Sesiai Distribntion
Speci£cations:
Anthorized State A.g�nt �, i
Permit Ex�iration
Pressure Manifold
Date:
-�
The type of system permitted is � Cunventionai Acc�gte3 Alternative. I acc�t the spe�ifications of the
P�� . r �'
i�w�nerli.�gal �aprese:utative: �� �G ` Date: � 02% 0 �
. PCID� rev.11I10lOS
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I��a.�na-os• T-�-�•.��a��.Il ]HC�.m.]t�l6n.
SITE PLAN
Name�l M� i II iQM Tax Map # N� Parcel #�
S div�ston Section/Lor#
�d �� c� a� �-�
Authorized State Agent Date �
Sysrem compaaents represent appmadmate rnotouts only. T3e contractormustflag the system prior m beginning the fnstabarlon tv
msure thatpmpergrade is marntaiaed.
.�
� Ma�h-�a�n at1 �backs � .
'� � ��.�.� � 1►-��z�� �� on e�,-bur
�+ `�u N�� � r1�1Q1\ s���m ;� we.-4 c���-honS
� (�r� C��ins c-�; � Mee-�; ►-� Mon�oa�rt��
�
-� � �ues-� io-,S C�-ae�- Env. �
-�- ��t � ��t�i�
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SC�Ie - I': � �
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PLEASE SEE A'�'�r��,�+ D P� F4ilt �+ LL SI� LA.YO�T'�'
Tax Map �� Parcel # � Township:
Applicant• �� (�,',\\�C�m
Subdivision: Lot # � �
Location: ��,1 � -�- CR5 �`�+ nl,. . �r�, -�- CR� �,� �'rn;,-,�k i �.,,.I,o�l�. 4�� �
�
Type of 3�a#er 5upply: � individual
�.tequirements:
Site Approved By: /�l I
Grouting Approved By: �
Well Lag:
Pump Tag: T �.J / o
Well Tag: �
Air Vent: �
HQae Bib:
Casing Height:
Concrete Sla.b: -
� !��
Co�nmunity Public
Liner.
'Installed by: _
Depth set: _
Grouted:
Date:
Wate� Sample:
Well Driller• � v O�S o r�.
Well Approved by: � �� Date:
****See Attached Site Sketch****
Wells must be 10 feet from property lines. .
Wells must be 100 feet from septic systezns.
Wells must be at least 25 feet from any building foundation.
Other canditions:
J v�d 3���
PC�ID rev 01/27/0�
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•�r„� � s ► + .
' � ���7���
I�.a�.. �.�-o aa.sa�.d �.� 11 IE�3t 4..+� fl��
U, , r�. ., ! D
I� � �.
c;�t�t)l -�t,; i...,tt• � � �
.
D:�' D��!'� -t
ch�m�r: � Wel� Log
� m C� ,-�� �n
I,acation: 5 o I S�.- � � N ,� h,. Ra��+,�,-` ��// ""--
---'�'i-yi - �i3TYClI�+ �\�� Q:� �
Subdivieiur.:
I.OL�_
?ax Map � Pa�el # .��.
r�mbx.rl�kP 2�. m on� S`I� Luw� P.o
�"�- r d v c� 2U � c.�S�- ��S-�
Distanct Fn�m nearsst Prc� �%cl! Courtt�ection
Pext}' I-iae (Mimimum ! 0 feetj _ I O
bistanae fzom �ep4c System (Mu�imum 60 fee�) (,�� ��`�""
Tot�I Lkpth: 4 5� fi Yicld: � t3PM Static Water I.CveI: ________ ft
Wacer Hearing Zorres: Dcpth �{{ ac�� �} ft �
� 11 go
Ci�t� Law� �.D
C'��: � 3
I�tp�h: Frarn --�— ,l_____ to �� I3iameter: lp ►
Type: G�lvaniz�d Sieel �" � �
�'aght: � Ul $ Tbickness: � I� Hcight �bovc Cmound: _ I�_ ia
T1�ive Shoe: _� Y�s � No Any proble�ms r,nc;ouaierrc� whilc settiug'casing? �Yes �io
l �' "yts►' give re�.4an:
Gro�t: -
.�ir.�t: SsitdlCanent Concrete GrnvcUCemcnt
Annuiar Spacc Width � inc��s Water ia Annular Spact Yes No
.'trirthai of Gtvui: Pum�sai ��� Pr�ssiu�e Pourr�,d Depth to � Fk
'.►�dxtrri�tls Uaed: �
?V�. $ags Portlaud cement Weight of 1 Bag ._.._� Pound�
It m.�.xture (s�nd, gravel, cuttings} — Ratia to
ID plaus: ____ Yes ____ No 4� 4 slab ,� Ye� ____ No
D�� �+$ L6cadon Dr�wiug
t�ereby certii'y th� th� aisove informarinn is eorrect aud that this well was canstruct� in accorclance xzth regulati
s�r forth by •he P�rson Couuty Heaith Degartmea�
Si��ture nf Cuntractor _____ ��(� IL � a o�� Dste �_(�o - C)
- PCHD rev lll/1
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i'HtS S�S ;'�cs'�1 i-��,5 ��:.� i�4�T�LL�7 It� GO[��Ll�4�l�� V�I i 3� �F��1�A�S...� . R�ORTH
�'�1ROLl�A GEs1{��L ST�, s ilTES, �U�.�� F�R S��ilACE T��tiTMEi�? ��iD DlSAOSAL,
.a,i�D •.�LL COIi{�["iiC3NS C�� � Tl-3E �IVi�R01����T PE�,�IIT .�n{D G�NSTRUCTIOi�
�illi'�iO�si�TiO . . .
• � � �o -Zq-og' �
Au rize� State Ag�nt Daie
1 nstalle�. B�r �, Date: � I e- 2q f pg � '
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��y�� ���� �������"��� �����,��5 a � ���� ]9 a 1� ,
: a� 1Vi�i� ��� ��rca! � Sys��:� Type (Tabl� Va) a
O���er;A�pljc�nt ' �a S�bdivisior�
,�ddresslLoc�fion 5��; Phas� Lnfi � .
�����.'��tn� ��i���9�'��� �o��ar�����a� �n� in��a �m�
State �ID/da�e - Z -- JS I�'Z�Q � renct� UVid� � 3 %. ✓ s �o- Z9 -
Capaci � 5- n a aal. � � T.res�c#� De �h in:
Tee and Fi1i�r - � � T.rer�c�t Lsr� �.
� �afffie � Tres�cti Ga�ade � �✓ �
Sea(�nt Tre�ct� S �cin �
� Ris�r (ifi applicable) � � Roc� De and Qua�`
�'an�C Outiet Sea! Daensl�t� dOa�� �#c.
Perr�nane� il�a�er Pressure Late�ls � � �
. ��s�e� iank � � H�I� S��cing � .
S$ate D/da#e � o e i�'
Ca�ac' al. � Pi �. S1�ve
Wa#e roof /Sealant � Tu�n-u slP.rote�#ors �
Rise� ��ui��' S�tb���
1lVater Ti ht � Frorn� �llielts � �
� �'�m� �rom Prape�ty iines � �S -
Cl�eck ValvelGate 4��Ive Struciuresl�ase�ne�is � � . �/
�� Anti-si on o e � etc, es ! ratna e V1(.2 s
Fiaa�slSwitches � • � �Sur�ac9 Waters
.Alarm visa�le and audibie Public V1�a#sr �a�p lies •
E3ecirica! Com onen�is • `�I.e�ficai Cuis >2 i�.
� Rate m .. tiJVater Lines , �. �
A �-or�e� Pum i�hode�
81ocR Ur�d�e� Pum �
Puerz�o R�moval �Ro e/C�ai
. �•D'as�Bbu�aon: S�#ea�
� Se�ial Disin�bution
Press�are il�annad
Ln�nr PressUre Pi e
Appr. Pi � A:�ate�iai ar�d G�
, .-�- -- ..
■
1
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O��r
s Re�arded
�c:�d �i. �I'��IC�!
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
� r- � �
Name of Owner or Tenant ��`' � �' � � � � � �
Address � n � � �-' � �'� `` � C�''�`f County � e �5 !�"'i
1 ,
�
Collected By � � �--��
-� �%��s
Date Collected � � �' �'�"� �`;� � Time Collected l �
Source: m�ell O Spring ❑ Other
� � ; �,
Locatio : ❑ House Tap ❑Well Tap [��ther �+.��i ` � � :,;;�j'� �•,r� j�;� � f`�
/ � �
Charge pCharge
�**���****�������:�**�����*�*�*�*��������****�**����,������********�*�*�����****
*��*:��*�*���������*��*��������*��*�����*�*��**������**���***��****�**��**�***�
Total Coliform
FecaVE. Coli
Present
❑
f1
Results
Reported By �� %L ,�^-
bactreport
Absent
G.,� I F-F�t- �PS ���s I�- I a 3���