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A23 125^ , Person County Health Department Well Permit � end of Date: S-�� 9zThis Permit Void After 3 Years � SR# 13� I Owner: �o � N � o I � �' �C�2v LocadoNDirections• Subdivision Name: Drilling Conuactor. Distance fro � �earest perty Line� Lot # Distance irom Souice of Pollupon � S � Total Dep • t Yield: /�� GPM Static Water Level �, Ft, Water Bearing Zones: Depth ,�_� FG 3�FG FG Casing: Depth: From _Q_ to FG Diameter: L� Inches 7'YPE: Stcel Galvanized Stecl �� If Stce:, does owner apgrove: jCes tio Weigh� ,�i— Thiclrness: Height Above Ground: �.� Inches Drivc Shoe: Yes ✓ No Were Problcros Encountered in Setting �he Casing? Yes No � If "yes" give reason: Grout: Type: Neat Sand/Cement `� Concrete Annular Space Width 3 Inches ✓ Water in Annular Space: Yes No Method: Pumped Pressure Poured v Dcpth: From �. to �_ Ft. Materials Used: No. Bags Portland Cement � Weight of 1 bag ��, lbs. � If mixturc (sand. gravel, cu:tings) - Ratio: � to _Z__ ID Plates: Ycs V No 4 x 4 slab Yes ✓ No I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDAIv'CE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. Date �� Datc Sanitarian's Si;nature Date Completed Sketch well location on reverse side. � - - , _. - �_.. ,. �'. ---• . , . ; � r Person County He�ith �epartment Sewage System Improvements Permit Date:��4� s Permit Void After3Years t C� ��d-�� Owner: ��b�N -� Oeios ��t1C1� SR# Localion/Dircctions: � �' LafD � Sutxiivision Namc: �Gr�✓ Lot #� Lot Sizc: • "U'��T of Dwelling: Watcr Supply: Privatc: Public: Community: Bedrooms: 3 Garbage Disposal -'� Basement Basement Fixtures ,�, INFORMA��IE BY � ` " {%i . Sallll�'lllall: owncr or rcprescniativc REPAIR: � REEVALUATION: ---------------------- -- Size of Sepuc Tank: �� g�llons Si � o Nitri�cauon Linc: � Depth of Stone: 12 inches Max Depch of Trenches: Altemative S stem: Conv,�j'm LPP Pum �t7 Remarks: y t'� ��.� �.�--� � P-�-�� l! tn,� Date Well Approved: � �' 93 Well should be 100 f� from any sewer system BY Sanitarian Date Se e s pro - 3 BY Sanitarian CERTIFICATE OF �OMPLETION z d 5 � f�- Contractor. _�T�,� t n��, i c --------------------------- � Sewage System location, installarion, and protection must meet state and local '� regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained � by owner in such manner as not to create a public health hazazd. Septic tank and`b nitrification line must be inspected and approved by a member of the Person Counry � Health Department before uny portion of the installation is covered and put into use. If the site plans or intended use change this permit is subject to revocation. (G.S. 130 A-335F) Loca�ion of sewage disposal sewage system sketched on back. �'�1 � t�� `�PG I-�E�VER��,.�-�- �� I Gt,.�c;�..�) . h ._----�_--- � 'f`� Si�- � 32 � • l�f'' ( __. _._..:.a___ ,� _.__.r�u� � r-� r� c.�._ �: �, Application Date: � 6 Ainount Paid: � SO .O U Receipt #: i $ 3 S � C re�Jl��{- �Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) �Niobile Home Replacement or Building Addition $150.00 (if site visit required) 0 Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 , ��,sf ��1� 7�+ ��111�L7��1�� l'r]tII�*IIII•�II7�an"R1�3T.�rtl1.Jl 1l 1L�O.SI.A '� �lication for Services Services Reauested Tax Map: � � 3 Parcel#: — I�- �%`��a�FU�� 0 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 $300.00 1) Applicant Information: Name: C. N . �, �°o c.s-(: Address: )42� tii. Ma,n s-r �o,�bPro K G 275 73 2) Name and address of current owner (if different than applicant): Name• _ ��j �c•c,kso� � Address: )00 �'.;ck e�nac� C:cc1.e Y�lo�r:5�;11e h1 G �%S(o0 Phone (home): SL'!2-15a13 (work/cell): _$�'j?-S%7S Phone: 3) Property Description: Lot Size: O, q Subdivision: er�'i �fp,��orLot #: 1 0 Address and/or directions to Property: Z1Z Lor: 1.n. O yes no Does the site contain any jurisdictional wetlands7 �es ❑}�o Does the site contain any existing wastewater systems? 0 yes L1 d��Is 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 Q'no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4)�' oposed Use and Type of Structure: [�'Residential -�____� �qfA a� ❑ New Single Family Residence Maximum u�inber of bedrooms: O 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 ❑1�1on-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 ❑ S_p��r�i g Are there any existing wells, springs, or existing waterlines on this property7 �'yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred syst m type(s): � O Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other /�1, ❑ Any I cert� that the information provided above is complete and correct. l also understand that if the information provided is in ur te, or if the sit is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. ' � (� 17 Signature (Owner egal Representative*) Dat * Supporting documentation required. � Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any application reqairing a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � ..' I . � � ,. f � �; < { . , :: . : • • � � � � �.J �� ..a • n.. _ n �]l71.�7�.•�C°�9CIl.]L71'D4(LIC1L�a�.Jl. �c��.Jl¢� Building Additions/ Mobile Home Replacemeats Tax Map #:�- 23 Pazcel#:�Z_� Address: �/� l.�d,�i `�1-�t/� Approval Requested for: Mobile Home Replacement _� Building Addition G� � Applicant Name: ��,Z� ��/�,.��G1�„�/ Address: Phane #'s: �g�-/.5'�i� .r'q7—�� . Permit Located: � Yes No Installation Date: ��,3 Design flow: .�aD (gpd) Current Contract with Certified Operator on file (if required): —_L� Water Supply: �/ Well Public or Community Wastewater system shows no visual evidence of failure on: 7.�/ i 7 (date) (Applicant's signature if site visit is not required) Addition/Replacem�nt Approved Envirorun tal Heal pecialist `r� ! Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcounty.net � � � i �. =��.,�� Person County . L' �c�.. - - .._d! � �.._ �`�. � .11dr_ J' ` � *rj ji 'Y,y,%'i� ti � iw j �' r S � � ,�1 4. . ' � � ; r r' ' � y � i a" ^�4 � a. S r�u a! ✓fu�xaiFi�' • +�:;� i � f �, _ ''t • } 'K 'i� i ' . 4�' �+";4 S ��. � ' . � � �/�`� _ • 6 . ,;�'y.��c..'. � .Y'I�''i74�r,��° �^ .'r,9 _ '.,�`'� r. .1' " 'YY�'i ' � ' . .� �� ar OIe' . �yy�� ' ,j� Ji ! � ;a� !Ay,� �� r . �i�5`�1H1Rc+v{ ,� . t�r r. '+ i ' t . 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M' : . 4 h 4Y . ,Ep'A"'`Yv .. 1 1'} , ' � i�' ,-�, � . �� ,,, a �.,.-r� ','.. - �"- .�.'�€+"-�'.;- �F,�`i7 �'�� i.. 1 .�.�w �c . k,�i �l � �,�.� •:+�'t�,; <.4Lt '� . .r - �'h�i~�}1 d�L � Y , �_�" •' �� v' 'S~ll��'^+yts M�5 _v�,Y��4 � f -.' �dt+.'�� , ��,� � �, � r""�a�F� tr �yyY '�fi . af 'R! . *.. , k&'oi1'.: �' v� . ' � L � t� ' F , ... r3 �� t.: � �'�. ub��''�� ,'�s�� . � r 'n � . �' rI �;.. ,� �^��er �" �M !n. y. Ny 1�.. .�k� .: h. . � � � } .y .... �, _ .}. , r'_ 1' � � � ,� � rk. . e �� .�ti Y' .. � � '�' �. �f .. : . r'# .� M� ; �.: � . ._ . ,W �.r �•1. +� ,,,,� -� �� 4�i� �: . � 1 � � � T'1 � �}�� R �y,�F 't 'M1 � ' �� ` yy��,, �. ; � y+ � .. I '�� p � v y �. ' a .'� �� n� ,� 3.. ��: ' , �.. . ,..�:� .. . .._.. , . _ _ , t .' July 6, 2017 TaxParcelPublishing 1:564 0 0.40475 U.0495 0.019 mi ; r r r-- ��'—�' �' ,' 0 0.0075 0.015 0.03 krn Esri, 3nc., Person County GIS For Refeience O�ly -Mways re(ertothe alpinal sou�ca. Person County is not responsble ta Itie use, rtisuse, or misinlerpret etion otthis IMorrroCbn. ��-,� s�� ._._._ . . � � � ��- � ��a. � � �.�,-„-„ � � �� IL ZE-1i � � Il ��. Tax Map #� Parcel # Z Existing Sewage System Report For: �.D'�e�fie Home Addidon Type: Home Phone# J? �� %— 21�3Z Original Permit Located: � Water Supply: AJ�� `�C� Septic System Designed For: VResidential Business Other # Bedrooms_� # Employees Other �� System Type: (11 � I�'ank Size: Nitrification Line:��,� � Date Installed: � q 3 Certified Operator Required: %vi� On-site wastewater disposal system shows no visual signs of malfunction ona Pemussion is granted to: R/Y�� D�D�/t Comments: � 1 Y � / V � N �l�}'i� n 10�� idL� ��'.X" �� I � � � � .� Environmental Health Specialis � Date. dZ- � � Ac, sa'w �\'-' . 'S� �3 'i4 � Ac, c-2 �� / C-1 QQ` / , � 1 / TRACT s . �.�9 AC. / � � C-29 \.�. �� y7•�� G-3 y �Q/ eF ,5� ' 5�-1- s9 -- �a� �'4. �p �,9 •, /c� � eti- se �E, 'j•E, �_30 •l 9% . C-31 R-''A' C-9 c-a �_e �� 0A�� 06 Ac. 9 Y.S�i f0 . C-5 r C_6 6� ; rz ��, i� � 3 z � 3 , � �2 ' U v � "g � � � A� � ^ � 9 ^ �' O � �a.s{ � � , �. �1-� � vw,�� ` y " C-10 � q' 55 ` �,� :S � i c-i i :� , n ,: . n � O ;P .o � z: . 1.62 AC. r�: ; � �s � : ia �� l.a6 Ac. �yxez� � , ' � 1'�C � -R' "f'o . ^! �� y� � � ..� � �w,) �nr . T , � ` d ^e �'r� �'ti - JI — c�wa.0 �' ,d • .'1� ,4J: �(1.�� b � � 16 ` �� a�ca• . I ( �� o. w., .� ��, � M wlr�wl l -fflt� i5 ' � ,..�.�. ��' � �] oc ..�•.n �, � V d 7rrT ��f �M. 14 +-\. r s�wK�s�! .,,.,� c..a.o �� , 420' CONTWR •. {2 � Fit\ _ ......-•, ��on� Foc� ;, � � 13 'GQ �` o� � .�,� T �-j•A �Q �i%i� �� AIr �� KfIC1tD KM� . � �� p MATkiEAtATlJ1L " „�e�.n�o. i. PUMT . �� '� �, �} � f�l �� . I `� - 4 �s� l p7-� 1 c� ,!°'�.� ;.� ;,=L ,='pr...:,, �� . ��' ��o- f .'�-ll=-", . `.' ..,- . � � Application• Date: f�3 6'�oZ . � Tax fYtap: #: �� AmountPaid: I d • � .. . - - .% . f a � �ec2iqt�: � ' ' �. . F'arc�3�� '�`---�.�' 7• �� . ��•�� . • � � �-�� . . . 1�sa�r^s�rc,a�_-s�a�sa�..1� 7� 3L��.7L'�16� . . � APPLlCAcTiON FaR� SER1R(CES • SHA1.,L BE�ME iNVALdD. � 1) Permit requested �/: (Ovvnerlage�ilpros�eclive owner}: �i P.c� ��J SA�SC /L— Home Phone: „�3� � 5��6 - Zo3Z Address: �� b2� �<✓c+�� G c�.u� Business Phorte: -�36 -�y9 -//S�f�— /_" bsa�vy�l/� �✓L; Z7 z 5� 9 2� Idame and addae.ss � cvcr�nt owner. �� •��N �o /%bl� /L.ofhO c �L�a �� .' Z� Z�f3 3) Property �'escri�iion: Lot size: • 96 Ac2ri'awnsivp: G�;�� Subdivisia�:1 Directions to the prcperty (]n�uding r+oad. names and numbers): cu nn� ��_ cb,.. /l4 �`r� 7a Gu.a�rv�,vv//Arvl 2o/�O .SR 4) � Lct�: / 0 � •� fi� � Gy,�� 7'u.2n� R;q /� sr�.z�� g r�ry� �,�a cF �0 2; t.�F. ' Proposed t9se ay� d S'tructure DescpipHon: answer ead� af th follawing questions: �,, � s) Proposed ✓, E�dsting _, TYPe of Structure: N�s }�orn� Width:-sSg Deptfi: y8 b) Number of Bedroams: 3 Number of ocr�pants or peopie ta be served: �_ , c) Basemen� Yes _, Na ✓ Will tfiere he plumbing in the basemer�Y? d) Garbage D�pasaL Yes _, Na ✓ Waber SuQph/ Type: Privafie ✓(nevv _ or exis#ing �, PubGc_, Communify _, Spring _ . Aro a�ry wells on adjOining property? Yes ✓ No _ tf yes� piease i�dirdte appro�dmate lccaticn on the site pian. 6) Does the property c��ain previowly identNied jurisctictionai w�iancds? Yes _ No � C�lE�SE NOYE Ti�E Ft�LLOWiNG: '� A PLA,T OF'i�iE PROPEitTY OR SiTE P�Pt 91dUSi BE StlBYrii'F� WITi�9 Tii1S a4PPl.1CAT60M: a PROPERTY L1NES AND CDRNEiZS MUST 8E CL�ARLY fiiARiCE�. � THE PROPOS� LOCATiON OF �1t..!_ STRUCTURES NUST BE STAK�� OR �i.4G�E�. • 9 THE Sl7E iIAUST BE READILY AC��.SiBLF ��R AN �ci/ALllATION BY THE HE�LTIi DE��AE�iT STAF'r. !� here� make app!'�cation bo the Person Caunty Heaith DepartrYtent foc a siie evaluation for the on-sifie se+nrage dis�osal sysbern for the abave-descnb properiy. 1 agree that the cartterrts of this aQpGcation are true and repr2�xr� the ma�num faciiiles to be plac�i on properiy. I undefstand ii the site is altefed or the intended use ct�ar�ges, the permii shall became invalid. or /-z9-o-L_ Date Pc:�o, re+r. �an7ro� :��i€s��ioa �a.Q: � 027 � Amount Paid: I 0 � Receipt #: l`t 3 02 I ec'�, �� f�Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition 0 Well Permit (New/Repiacem $300.00/$200.00/�75.00 �� ; �� h�� : �, �,..,: ► • � Parcel#: I a . �� ]Eaa�$a�o�*+�* ��.��.Il IH[�mIl�lln Services for Services ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision 0 Repair of Existing Septic System Application No Chazge/ CA $150.00 or $300.00 1) Applicant Inform tion• �+ �1a—��!/�� Name: jYl G�/ 7/ Phone (home): Address• (work/cell): � - , -� ^ Z 2) Name and re s of c}�rre t owner (if different than applicant): Name: t� Phone: �1�� '"� Address: / - ri D Q.. 3) Property Description: Lot Size: Address and/or directions to : � �+' : �a-» /UIc1'1-r� ❑ yes O yes ❑ yes l7-qes ❑ no CYno C�Yno ❑ no Does the site contain any existing wastewater systems? `T`��+%�" � Is any wastewater going to be generated on the site other than domestic sewageT Is the site subject to approval by any other public agency? _ Are there any easements or right of ways on this property? L�'�D (�� ,� (if `yes' is checked, please provide supporting documentatiori} . /�-� L-v ►- 4) Proposed Use and Type of Structure: : �� '� �� a.. �Residential (�x� w g, ❑ New Single Family Residence I��,'.��ximum number of bedrooms: / Occupants: S P 4-- ❑ Expansion of Existing System If expansion: Current number of bedrooms: O Repair to Malfuncdoning 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 �xisting Well ❑ Community Well ❑ Public Water � Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no Please note any knovm ground water restrictions or sources of contamination: �,6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative � Altemative 0 Other ❑ Any 1 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. ��- a lo ignature (Owner/ Legal Representative*) Date '� Supporting documentation required. o Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat. � A completed `LotPreparation' form must accompany any application requiring a site evaluation. — — -- -- — .�r (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N�27573 (336-�97-1790) �`•..:�:,�y^'�, w'"� �ue �,'` St0*m l[�ools ��''; �. �?o.. . - - ��",...a� _ ._,T •— . 3 :��, � Designer: Lea Frederick �{'.,-`•.'-` SWD #KM066-16 � r: �� 3�- 3��- 32� y Vue Custom Construction dba Vue Custom Pools 211 Southside Sqare, Greensboro NC 27406 GC License #73733 Office: 336.508.2794 Fax: 336.854.7909 wtiwr.vuecustompools.com �� Enviranm�ntal Heaith �. f�a?o��kn Street Suit� C �oro, NC 27573 3�i3�i� �� SCALE 1 "=60' Client Name: Bob & Peg Jackson Address: 212 Lori Lane City: Semora State/Province: NC Zip/Postal Code: 273d3 1) � !) � � ' , � \� , C �� \ l � �-. � � , ..� � � -� �- ,:� � � ► � Suilding Additions/ Mobile Home Replacements Tax Map #: .�2� Pazcel#:�� Address: Z/ �' � ` � � � �� Approval Requested for: Applicant Name: Address: Phane Mobile Home Replacement _ /� Building Addition ��. Permit Located: Yes No Installation Date: � Design flow: �� (gpd) Current Contract with Certified Operator on file (if required): �� Water Supply: ✓ Well Public or Community Wastewater system shows no visual evidence of failure on: �✓' �!� (date) (Applicant's signature if site visit is not required) Additiore/Replacem€nt Approved Environmenta Hz lth cialist Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net