A23 119�
_ = P.erson Coun�y Heaith ��epartment, � �
;; � �Sewage S:ySte� Improvem`er�ts :Per-mit �
. ����� �
Date: ,;�' � �. Pe it Vo'd After S-Years . -� o,�f
�
Ov�mer. �t V .. ��Yv� td-/.!. . . _....S� �:�2�.
.., —� .... ..—r-. �
. .. ...._ .
Location/Directions: — ` -
, .._.._..._..._ ... . .
,_y� . . . . .
_ .. .
. .
f. �_,___ . .._
Sdbdivision Name: • � ''�' � Lot # _ f
..�,�,. ,. __.._._..._._. _
�:'. A c}�e . - :T of .
pply: Private: Public: _
s: ' � Gazbage Disposal
t � B�.sement I�'ixture;
[AWII�: -
�
��.,.�.,�,. ��: _.�. . , „ ., , : _ . :
�.:.. ' -:'
-REPAIl2:; °;. REE�7.AL :.ATION ,."� .
-----�_.__..._..._ ,---- �- -- � —
.. _ .� -��,r
�Size of Septic Tank ..:�:���. allons Size�.of Pump Tank: v'�
,- -. .....,
Nitrification Line: _ . 3 �0 / :�-... ,
. ..r�-�-�--- � ----
Depth,of Stone:. 1.2 inch.es ', �1 c'� _ _
Max Depth of Trenches: � _
�Altemative System: Conv. Pump � LPP Pump .
Remarks: : . <
Date Well Approved: Well-should.-tie 100 f�. fiom;any;sewer sy,stem
-:BY ,/.� .. Sanitaiian � � � _
.�Y ��t,r � Sarutarian '.
� . - � � TE�OF CO1VIP.LETION .
Contractor ' � � � f � � ��]]
����.���r�.�.�.��.�r�.������.����������� �
Sewage System location; installation, and protecdon must meet state and local �
regulations. Septic tank:s}�ould be pumped out every 3 to 5 years and shall be maintained �
by.:owner in such;manner as not to create a publia health hazard. Sepde tar►lc and`d
niuification line-must-be-in§pected and-approved_by..a..meinber. af. the.pezson.County �k
:.Health �epaztcnent before any poz�on uf the ir.stallation is covered and put into use. If
... _� � .
:�:the�site plans oi intendeti use.change this"pesinit is subjecC�to revocarion .
�(G:S. 130 A-335F),.. _ : .
=Locadon of sewage di�posal �wage system sketched on•back. -
_ . . �OVER). _ , . ...
��
� .�
��
��
v "
.� .�
.a �
�
N y
x �
�
� a
� �
:+ y
d �
� „
ai .�
x ro
w
O p
�
o �;.;
. �
K �
� y
.Cr' � N
y � O
,� � �
«
�.� �
. a''� o
•N � �
o .°,co
a
o �
� a
o � �
y
•�. L�•
�-
3
�
� a
0
�
��
.c ?�
«
a
H
z
a, �
a.
`° m ,�
� �
� . �,
�
a _.,
y a
Fy f�/1 Cl�
��e�D To �e ��//�� e�eForPP sv� �e��- P yO�S O r� �50 y�,��/ 1rfPeT��
j'�v/l�I� fjfl s �l.rrs,�t•ei� �1'IA��i�i'✓e -3.s6-�8f�3�y�
�� ,�5��✓ps.s �6-aa� � � � � -
3s� a 6-53�y �
l���S�'r� /�C'G��tB✓+-�
\; erson Coun Health De artment
`�� � Environmentai Health Section
��;,� APPLICATION FOR SERVICES
Lot) - $150.00
Improvements Permit - (Unrecorded Lot) - $1
Improvements Permit - $100.00
(Mobiie Home Replacement/Addition)
ConsUuction Authorization - 5100.00
Tax Maa #:
Parcel #:
X; _ �<�- -
,-_ . , . ._ -<.
'ermit (New/Repiacemer�t) - $125.00
ig System Inspection - $100.00
YReptace 6dsUng System Permft
�r Site Plan - a75.00
1) Pertnitrequested by: (Ownerlage�prospectiveowner): I��If�� �-P �%� ��-�Pip, s��
Home Phanec33��5�'5�33�t,5 � Addres's: �/�,�1 �l�i' i7' ��j'. ,�.(b��'O//QI P lvl •a�>y.
�
Business Phone: �3l-,-aa�-��1�� f�.�� <�, ������� 5�7, ,�1��Z�i�g�a✓�iv -�' �2�>✓.�
2) Name and address of current owner. ��D �P�� i�.�-Re4�i saa/
�
3) Property Description: �ot s�ze:
Directions to the property (I�cli
_ Township: ;�P�SDiIi ��.
road names and numbers): �
�
d�I�c�cT �0� 3 /� � °t "r �O•rv�
� �} �l�C/OSP� `% 0 — �•
� �-l''O T?� �i?t�ti��i� R.o- iRr' a�h�'u P.�iT�q� �h9�8�4 �- tu��v o.c��,(y��,�.ri`r,�
4) Proposed and Structure Description: answe� each of the following questions: 7r� �� e,�'r �-
a) Proposed� E�dsting�
b) Sticic Buil� Modular ❑, Single wde �, Double �de ❑ '
c) Number of Bedrooms: `,� d) Number of occupants or people to be served: ���-� �;�i
e) Basement: Yes �, No�if yes, # of basement fixtures:
� Garbage Disposal: Yes�, No � .
g) Dimensions of Proposed Structure: Wdth: Depth:
5) Water Supply Type: Private,�.(new 0 or existing ❑), Public ❑, Community 0, Spring ❑
Are any wells on adjoining property? Ye�No 0 If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
_Conventional _Modified Conventional _ Altemative _Innovative
Other (specify): jV � � �'�D/'iSe
CLEARLY STAKE ALL CORNERS AND LlNES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLlCAT10N
I hereby make application to the Person County Health 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 faalities to be
piaced on the property. I understand if the site is altered or the irrtended use changes, the permit shail become invalid. I understafid
that as applicant, i am responsible for identifying and marking property lines, comers and making the site accessible for the
personnei of the Person Courrty Health Department to condud their evaluations. I understand that I am responsibie for notifying the
Heaith e artment if my prope coatains any weUands as designated by the Army Corps of Engineers.
` �,�.�� �o� �
wner o Legal Representative Date
PCND, rev. 10112/99
�� �
�
G��
��l , �_..
�
��' �,
r�
1
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: Parcel #
Zoning Township
,�/y' � �,i-�/DV'YI,S1�1
Appifcant 7 / t � „ n . � _
LocaUon:
r�
� � ��� Sectton• v v Lo� �
Subdlvislon•
TVpe of Water SupplY:
Reauirements•
Well Permit
aln� .
�� ���er l�.
I s� Vw�-�
�Individual Community Public
Site Approved by ✓ -
Grouting Approved b .� g 00
Well Log / � 28` Ob
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller•
Well Approved By: Date:
**See Attached Site Sketch**
Wells must be 10 feet from property (ines. �� ��-1- ?J-
Wells must be 100 feet from septic systems.� ��/X,((�(G���j �X (S 5����� ����
Wells must be �at least 25 feet from any building
foundatiorf. ����� � �
Other conditions:
PCHD, rev. 11/29/99
Application #:
Tax Map #:
Parcel #:
Person County Health Department
Environmental Health Section
SITE SKETCH
�� pin.o��e �f�,�N�r�✓1 � � H��ta�� t�rbor
Applicant's Name Subdivision ection/Lot#
��
thorized State Age
�-I � -�l�
Date
Svstem components represent approzimate contours only. The contractor mustflag the system
to beQinnin� the installation to insure that proper grade is ma�ntainer�
u—� — �
Scale: Y10� '��Loe.��
l'
,
PCHD, rev. 10/12/99
'" '''4 Caswell County Environmentai Health
P.O. Drawer N• Yanccyviilc, NC 27379
(336) 694-9731
Well Completion Report
Name: Q
Address:
Location: �/, �. �
Distance From Nearest Properry Line ��
� Ft,
Distance From Nearest Source of Polution ,_ o o Ft.
Total Deptt� of Wcll �d Ft.
Casinc� Type: Steel
, ----
GPM —�
Water Bearinc� Zones Depth ��� Ft, Ft.
Casing Depth From U to�G�_ Ft.
Diameter � %
In.
Static Water Level
Galvanized Steel `� �
Thickness - ,�� ��,
Ft.
If Stee1, Does Owner Approve Ycs No
Drive Shoe ��- Yes ,__No Height of Casing Above Ground /�
In.
Problems in Setting Casinc� Yes �-�
_ No Explain _
Grout 7ype: Neat
-- �Sand/Cement Concrete Annular Space Width
�_ In.
Water in Annular Spacc Yes C�Na Method of Grout Pum
p Pressure `�-oured
No. Bags of Portland Cement Depth From d
to _�_ Ft.
Weic�l�t of 1 Bag � ��S_ p�aper Slab Constructed L� L-�----
ID Plate
DRILLiNG Lc�r,
I hereby certify that the above information is correct and
that this well was constructed in accordance with the Caswell
County Well Ordinance
� ��� k, �'���,,,,
Siqna rc f Contractor
-��
��� �
Ccrtiticalion + "'
��� �� ���a v
Dato
Inspoction Comploted By •
--�...._"" .,..,,__,,,_, p � to, .