A41 50Application Date: � � � �
Amount Paid: � DO
Receipt #: '7 t 3 3
� ��
�� S� ������T Tax Map:
� �•;�- '�' �� Parcel#:
������
� unwu u-cayu aarnK, �ra d rn Il II�Cc en.1�4:1ia
for Services
Services Re uested
Improvement Permit (Site Evaluation) Construction Authorization
$200.00/$300.00 if> 600 d Fee is de endent on the e of s stem ermitted
Mobile Home Replacement or Building Addition Permit Revision
$150.00 if site visit re uired $75.00
Well Permit (New/R epair) Repair of Existing Septic System
$300.00/$200. 0/$75.00 � t,.»-� �� b�a� Application: No Charge/ CA $150.00 or $300.00
Applicant In ormation:
Name: er�r� i-Fe✓ C Ol�l- Phone (home): g3�o'S�/ q-3°��
Address: u►^ , (work/cell):
2) Name and address of current owner (if different than applicant):
Name: Phone:
Address:
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
Lot #:
� yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no 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:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? � yes ❑ no
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. 1 also understand that if the information provided is
inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�� �s
Date
* 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 evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
���, sf ���.� ��
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IE �w,�,� � �,� m,� �, �, Il IHC � �,.Il �]�
-- - --- —
WELL PERMI'� �,�j �„� C �t N1,-2w'�'
(New _ Repair i►/ )
Tax Map: � Par el: �_�
Subdivision: N f'�- Lot: �/-�
Applicant's Name:
Mailing Address: ,
% G 27 7 _
Phone Numbers: - 7� 3 �331�'So�� GS�`i
Location of Property:
�7 „,_ �) �
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years, from the date of issue.
4.) Issuance of a permit does not guarantee a otabl water supp/ly
Ot er Conditions/Comments: �,t�t�� fYlu,�,� �� l'��i�� rrtt2�d %' ����b�S ��°�
;
Z � �P
� � �
Permit issued
QNew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date: ��
Certificate of Completion
OLiner:
EHS/Date
Depth:
Grout:
�bandonment:
Date: �—�3-15 ��
Method/Materials: �,` �
:�-�c r�,2u�.P i�1 C�i,r�4 ��i—)�u ti 1. � t� W C�t."f'
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
WELL ASAN]DONMENT RECORD
North Carolina Department of Environmcnt and Natural Resourc.es- Division of Water Quslity
WELL CONTRACTOR CERTIFiCATION # -
1. WELL COlVTRACTOR
Well Cnntta�xor (Individuah Neme "' '
Well Conitactor Company Numc • � -
STREEI' ADDRE55 _
City orTowo State Zip Code
Arc�code - Phone number
L WELL INFORMA7701Vs
SITE WELL ID # (if applicable�, � � �
I
STATE WELL PERMIT �F rf applicable)
COUNIY W�LL PER1Vl17' � (f aPPli�ble)� ~' � � ,
DWQ or UTAER PERMIT #(if applicable)
WSLL U5E (Crale applieebte nsek 1Vlonitoring u en'i""
Mnric�pfYPabGc YndastriaLC�mm�ci�l AtrKaltun�l
Reeovery ]aj�tion Irrigacion '
Othu (listuse)
3.'4VEIL iO�C'AT�I.ON•
COUN'I'Y -,��QUADRANGLHNAMH
NEARESTTOWN• _
k . r.,o _ Kl�: - ,
(SttaVRosd Name, Numba. Commimiry. Sddiviaon, LotNa. Parcal, Zip Code)
TOPOGRAPHIC / LAND � .
Slope Valley F1at Othcr
(Circle appropria0e scttingJ
MaY he in degcaes.
IATf1UDE _ ._._ mmuoes,aecae�,arina
LON(3Tfi]DB . . � �
I,atit►sdellongitude source: GPS , TopograPhic map
aocatio�t of well �mcu be skox�+ on a USGStopn arap and
attached to tlrirform ifnot uiing GPS)
4a. FACQ.iTY-TLe name af d�s businas whae tha wolt o locatad. Complata 4a �d4b.
(If a raidential well, tkiP 4� comPlete 46, wdl ownsr n�f'ammtioa on�yJ
FAC�.ITY ID �(�f applieable) '
NANID OF FACILTTY
+�1M; �:1 :_► � '
City or 7'owA State ; . Zip Code
4b. CON'I'ACT PFI2SONIWF.LL •
N� G� . a �— t� �,
sr�r nnn Ss �
'�� � l�C �-?S`7,�/
City or Towa Statc Zip C
� �`T - ���'� b.'��T--
Area cod� - Phoae numba
5. vVELL DETAILS• '
a. Total Depth:.�L_ fl. Diamctcr:�,_in.
b. wa�er Levd (selow Mcasurin$ poinc�:._(�_ n
Me�svciag point is � tt above land sarfaca
�. ��:;�1� � �, D�
' a. Casing Dcpth (if Imown): $. in.
b. Casin� Retnoved: $. iu.
7. DISINFEC370N• c � G �'�'�o�iC
(Atno�t af65°1c-75% celcium hypochlorite usg�
S, SEAI.IIVG MATERW.:
� Neet Cement Ssad Cemeni
Cemecet m. Certkut ib.
Watra gal. Water gaL
ton[te �
' s�z m. •
Type: Slety_ Pdlets_
Water ga1.
Ot�er
1�+pe xaateiial 'i/Id J-1 � �An�
pmoont "� � 7 �6 �t,-� •
9. �XPZ.AYN MSTEDA OF EMPLACEMENT OF MATRRIAL:
1 .r� �J tt� ,r
i
' 10. WELY. DIAGItAM: Draw a detaaed sketch of the weII on dk back of t6is
form showing total deQth. depth and diametu of scieens (if anY) *�B
m�e we11, bmdvel intuval. iatavals of cacmg Patfoiat�, and depiLs and
types of 51l mstr�sls eam.
�, �
� xx. D�.� �.,��� 3—i 3-� S �
i no �ssY c�u-r�r xxa.s�s w�u. wns es�rmar�n nJ Aocoxanrres
R+I1H ISA NCAC 2C, VJELL CONS'CRUCITON STANDARAS, AND THAT A COPY �F
18IS RfiCORD fiAS HEfiPI PROVIDED TO 1i� WELL OWNiIi.
SIGNATUi� OF (EKI7FIED WII.L CONIRACTOR DATE
_ '
� . � 3 - I.� -a v!
SI 11JRBOP ATS WSt�.OWP�BABANDONIIQGT'HEVYELL DAT$
(!Le Pzivate wdl ownacmtsl be m rodividuAl wbo �jy shaodoas hisfi� rseidential wdl
in�with lSANCAC 2C1Q113J
���--L�ti�-,L.vr '-i «►fi-a�-, 3-1 � � oiS
PA1 I�IAML PEBSdN Nll4G T9E N` £L :
Submit a copy to t6e owner and the orig[pal ta the Divistoa of Water Quallty wlthin 30 daya. Form OW-30
Attn: tnform9tion Manaeement,16�7 Mail Service Center -- ltaleigh, NC 27b99•1617, Phode No. (9l9) 733-7015 e�ct 568. Rev. 5/06
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Applicant:
Address/Lc
Tax Map: � Parcel•�
Subdivision �,►//-�
Phase/Section/Lot # '
Permit Valid for• Five Years
Type of Facility: ��i�c��e
Numner of: Bedrooms � /
Proposed Wastewater System:
Proposed Repair: �_
/ Improvement Permit
1/ Non-expiring
2 S ��e nG� New �Addition _
Occupants �' / Employees / Seats:
Permit Conditions: ]�Q;,�-�-�;,, ct I l S�.f�acKS
Water Supply: �e ��
Projected Daily Flow:�� gallons/day
Type: �
Type:�
Authorized State Agent• Date: /2-1� ��i
(X) Owner or Legal Repres tative: Date: 3- ��' — �S
The issuance of this permit by the HeaCth Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, ptat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina �Laws
a�rrl Rules for SewaQe Treatment and Disposal Svsiems'(15A 1�iCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply wili
remain potable.
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Propose Wastewater System: 25°To %(*)Type � Design Flow �_ gal./day
New � Repair Expansio _ Soil LTAR:J . 3c� gal./day/ftz
Type of Facility: �ri��� �s i h� _ � y t3_R, Basement: _ Yes _ No
(*) System Types IIIb, Illbg, IV, and V, require periodic system inspeetions by the Person County Nealth Department.
Wastewater System Requirements
Tank Size: Septic Tai�k Q� gal. Pump Tank gal. Grease Trap �""--�gal.
Drainfield: Total Area j. Z4U sq. ft. Total Length DD ft. Max. Trench Depth 3( _ in.
p,C,
Trench Width �_ ft. Min.Soil Cover �� in. Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution '�/ Pressure Manifold
Issue Date: J Z- //-/y
Permit Expiration Date: J2-/J- (q
The system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions
and specifications of this permit. /�n
(X) Owner or Legal Representative: i� r �'� f �:-X � Date: � ' � � - � �
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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Subc�ivi ' � ' � � ` �� Sectiofl t# � �
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ut3�o�ized State Ag�nt Date
S,ystem cnmp'o�ents re,�i�esent a�b'�inoximata�contours or�ly: The coniractor »�us�tjlag �the .syste�a prior ta
.__. ___._ .. begenning the snstallar�ion tv i�sur+e that propargriade ts muit�tained �
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1�.�.� �- � �,�. � � � �.11 IE 3I � � Il -�.1�
. ���L ]PERIVIIT (New"V 12epair�
'�az Map: ��_ Parcel• ��
Subdivision: Lot:
Applicant's Name: � r
Mailing Address: r
RDXI,�Y� .r�c �,5��
Phone Numbers: R1�1- ►��q -�,3h I �31Q-�b�( - 1�52�(
Lacation of Property:
� 0
�101
t�ermit �onditions:
I) Seg attached site plan for proposed well location.
2) All applicable State and County regzslations governing c�nstruction and setbacks apply.
3) Permits expire 5 years from the date of issue.
Other Conditions/Comments: Qi�n�a �p a l� S� ,�ar:�� -
.i
P��mit �ssued by:
�
I)ate: ; , L�
�ERT'�'�CA'1'� O� �Old�LE��►l�t �
New �ell� Inspection:
f S/Date
� dn�y (� � Location: Z - t�
� en � h� �� Grouting: Z--t{ _ ��
P � � � �'VVell Log:
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
��f0i� " � Well Ta �
h� '� Ove � g'
�,,,,,, �� Pump Tag: Weil Abandonment:
Air Vent: -2-�.� EHStDate
Hose Bib: Completed: _
Casing Height: Method/Material(s), _
Concrete Slab:
. ,
i�Vell Driller: .�oU, e� �G� r i�
Pump Installer:
tiVell A�proved b�:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
License #:
License#:
�ate:
,
Date Results Mailed: ''
Phone: 336-�97-1790 Fax: 336-597-7808
8/1/08
���.ss ���.���
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I���a����•-�-•� ��.��.IL lE--II��.IL�I�
Applicant
Location:
Tax Map � Parcel # _Q �b
Subdivision
Phase/Section/Lot # N /�
# of Bedrooms �i
System Type (From Table Va):
Type V& VI Expiration Date:
Operation Permit
Product (IIIg): E�
Type V& VI Renewal Date:
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
�
(Authorized Agent)
l
(Licensed Contra tor)
to` 3
� 2-�5
(Date)
�/-2-15
(Date)
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S�al
PCH , re . 12/14/12
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Line Length
� � ►
Z'
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i
S 7'
Total Do �
Tax Map: � Parcel #: ��
Septic Tank System Checklist (Type II-I� System Type: �
Se tic Tank InitiaVDate
State ID & Date: ' - 2 -� �
-13-
Capacity: Q�-
Tee and filter
Baffle
Vent ,/
Riser ,/
Outlet boot �/'
Perm. Marker
Distribution
D-box (levels set)
Serial ,/�3 _ 2
Pressure Manifold
LPP
Notes:
Nitrification Lines InitiaVDate
Trench Width: 3 ft. S�l - 2-lS
Trench De th: in. ' �/
Total Length: ft. �/
Minimum s acing: ft. o� c, �
Rock depth/ uality
Dams/ste downs � ,c�-
Grade (< .25" in 10') _/
Cover (6" minimum) ✓
Setbacks
From wells 5 -Z-i
Pro erty lines
Foundations/basements
SurfaceWater
Other:
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Capa 'ty:
Riser (6 in.)
NEMA 4X Bo
Model:
Piggy back lug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Manifold
Number of ta s:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
Application Date: �b=� � � �o
Amount Paid: ��' , _
Receipt #: _
�
Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
l�Zobile �Iome Replacement or Building �ddition
$150.00 (if site visit required)
VVell Permit (New/Rep�acemert/P.epairj
$300.00/$200.00/$75.00
i
�� S� ���� ��T Tax Map: �4 �
� � • � � �� Parcel#: � �
�� �^ ������
lI�,a,���� R-��m �.�:�,��,.11 IHI �: �,.11 a:ll�
cation for Services
Services Re uested
Construction Authorization
(Fee is dependent on the type of
Pzrmit Rev�sion
$75.00
Rep.;ir �f Existi�g Septic Systern
Application: No Charge/ CA $150.00 or $300.00
1) Applicant I f�rmation:
Name: � Y1 i� C� �p
Address: (� ( �,1 � � � ( �P � � �.
f'� aX�CL1�%(' o�i S7 �
2) Name and address of current owner (ii" different than applicant):
Name:
Address: __
3) Property Description: Lot Size: Sub�ivis:on:
Address and/or directions to Property:
Phone (home): �
(work/cell): - .5 �
�r 33�-�04-do5a�
Fhone:
Lot #:
❑ yes � no Does the site contain any jurisdictional wetlands?
0 yes Q'no Does the site contain any existing wastewater systems?
� yes 0 no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes �no Is the site subject to approval by any other public agency?
❑ yes fl no 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:
IZ K Zi7 S�'�e-d-
❑Res�dent�al
New Single Family Residence Maximum number of bedrooms: �/ Occupants: �
7�xpansion �f Existing System If expans:cr.: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? � yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Squzre f�otage o: Building:
Maximum number of seats:
5) Water Supply: 1�Iew well L�! Exisiing 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 prefert°ed systein fype(s):
❑ Conventional � Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understartd thut if the infvr•rnation �rovided is
inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
� P1Y� ---
Signatu e (Owner/ Lega f�Zepresentative*)
* Supporting documentation required.
.. . ..� I
1
Permits are valid for either 60 months or are non-expiring when accompanied by an approved piat.
A completed `Lot Preparation' f'orm must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Heaith, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
I � ''j '':.....': . .
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'�.� •.... ..JL.�i,JLV���{/�� �W/�I!JL�� �
Bui��ing Addi�ionsi iV.�abile Home Repiacements
Tax Map #: A�! ( Pazcel#: 5� Address:
Appr�vat Requested for: Mobile Home Replaceme�t
_,� Building Addition
Applicant Name: C-,� �,, ('�-�-Y-�
�ddress: 14131 1-��r 1� M�11� 'Rd
`�ox.b�-�rv Nc �����{
Phone �#'s: '�'� Q-�- 3� q �� - y-�r-1�351
Permit Located: s/ Yes No
Installation Date: �-( - Z -� 5
Design flow: y � (gpd)
�urrert i,antruct v,aih Certified �pzra�or an fiIe (if rer�uiredj: N j�
Water Supply: _,� Well Public or Community
`vVastewater system shows no visual evidence of failure on: •'7- a 6- a o l(c (date)
(Applicant's signature if site visit is not required) ��,,,,_ � i�Q;�n ,���,,.,`
�
• _-_ ► �. � .. • • t, '�� � u ►.
• *. �. �.� �.�■ .. � r •�.
Addition/Replac��ert Appr��ed
���� �i�- .
Enviranmental Health Specialist
�1�1��R
Date
Persan County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Ph�ne: 336-597-1790/ Fax: 335-597-7808 �•�tiv.�ersoncountv r.et
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