A23 142- Person County Health
. . - Well Permit
Date:� /S �ZThis Permit Void After 3 Years
Owner• %�� 1�f' �`� � � �
Department �
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SR# ��_
Subdivision Name: J "<- Lot #�
Drilling Contracwr. r-a� � �r «��
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Polludon
Total Depth: FG Yield: GPM Static Watet L.evel FG
Water Bearing Zones: Depth FG Ft. FG Ft.
Casing: Depth: From to Ft Diameter: Inches
TYPE: Steel Galvanized Steel
If Steel, does owner approve: Yes No
We�ght; Thiclrness: Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grout: 'I�pe: Neat Sand/Cement Concrete
Annular Space Width Inches
Waur in Armular Space: Yes No ''�
' Method: Pumped Pressure Poured �e
Depth: From to FG �
Materials Used: No. Bags Pordand Cement Weight of 1 bag ,�
lbs. �
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes No
4 x 4 slab Yes No
De th
From To Formation Descri tion
ro
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I HEREBY CER'fIFY THAT THE ABOVE INFORMATION IS CORREGT AND THAT �
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET r;
FORTH BY THE PERSON COUNTY HEALTH DEPAR'TMENT. �
Sigr�a' o FCo �ra� Date
� �r r ' � 7/l.��L
tarian s Si ture Date Issued
Sanitarians Signature Date Complete3
Sketch well location on reverse side.
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.Person County Heaith Department
ewa�qe System Improvements Permit
This Percrjit Void After.3 Years ���:.��er, E7� �. �.���
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I:ocation/Directions: � �
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Subdivis�n Name: % '
Lot Size. •`7� - • 6 Type of Dwelling: _
: Water Supply: Private: �''"'� Public:
Semi Private: If not Private Tax Map# _
; Parcel # of Water Supply or Name of
; Supplier#
; Bedrooms: Garbage Disposal
Basement Basement Fix s
INFORMA'�1 �ER�'I8`IED BYr G'�.�,��
$aflitaI'18t1: f ,� ��j,yv�y�l ` osvner or representative � j�%' I
REPAIR: REEVALUATION; - � ro
------- —�----=--------------- �
Size of Sepdc Tank: r] gallons" �, ,� ,� / �
Nitrification Line: ` _'�f':k'�. �
' Depth of Stone: 12 inches
Max Depth of Trenches: � - � � � � �
OPERATIONAL PERMIT: yes no '
Remuks: !'� � --^ - - � �---- �., U 1Fi
------------�----�----- —
Date Well Approved: Well should be 100 ft. from any sewer system
BY �anitarian ':
Date �k+ ge ystei Approved: y- I,S= �t.2
BY • � Sanitarian ,,�
CERTIFICATE OF COMPLETION ; "� �
' Contractor. � �uv. �P�.J'�i ' �
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Sewage System locadon, installadon, and protection must-_meet state and local �
regulations. Septic tank should be pumped out every 3 to' S years and shall be
maintained by owner in such manner as not to create a`public health hazazd.
' Septic tank and nitrification line must be inspected and approved by a member of •
the Person County Health DeparUnent before any pordon of tfie installation is
. covered and putinto use. t,� `
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L.ocation of sewage disposal sewage system sketched on back. � .�
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Chemical
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Petroleum _ Pesticide _ Lead
1. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospective owner/agent:
Widch: 30�'a`� �f Da�ble �r0� �
Address: �re-3� ��`� _ Depth:_ _ �r-co�n abov
- 8. What type (if any, additions, expansions, or �o
- replacement is anticipated to the structure or facility .
� tiQ�-l�s
, atthis sewage disposal system is intended to serve.
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Home Phone #: � ��,��«��.��
usiness Phone #• � `%._9 -SJI 3 � �,
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. Name and address of,current owner:
�S�M �2 —
Description: Lot size: I, 3-2 �
, Tax Map#: A � �
Parcel#: l4 Z—
Township: C-�r•�i�tu,�.�-``�'ti^ -
. Directions to property: State Road #& Road
iames,�tc. POi �.i �t-e. D Ir'.
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�. Water supply type:
private � . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No j�.
If so, identify location:
..
10. Type of structurelfacility: Proposed: DExisting: Q
Type of dwelling:
House: ❑ Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 'g �e� r0°�s ����
Garbage Disposal? Yes ❑ No � '
Basement? Yes ❑ I�Io�7 If so, # of basement fixtures: ,
6. Number of occupants or people to be served: -
CLEARLY STAKE ALL CORNERS OF TJ3E PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURFS.
I hereby make application to the PerS0I1 COunty Health Depal'tment 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 be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand ttiat before an Improvements Permit can 1
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have nc
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
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Signcc� Owner or Authorized Agenl
?ermit Issued ❑
Permi[ Denied ❑
Plat Observed ❑
Signature Date �
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- - � S-SUITAIILE 'PSPROYLSIONALLYSURADI.E U-UNSIJITADLE •
K.r:COMMENDATIONS/COMMENTS: � �
SPI`E CLASSIFTCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fi11
areas, wells, water bodies, slope�pattems� C�C.) C:\AMIPROADOCS�APPSEC.STIFWANCEPC .
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Person County Healtli Department
Existing Sewage System Report For:
Mobile Home Replacement �
X Addition �
Requestee: ("� � Home i'hone#
�n e �. �s Le�.�.�n�'
Q.�i ll�\)'t- �0�' � Business# J g /3L�
��C' �l� � / V� Tax Map# �'�— ���
Location/Directions: ,���r1e��s/��l �' �• �/L �aK PotiTt
�r�. ► % �c� k n,o ve _ .Dr. L o + �- �e._�-�01
Original Permit Located ✓
Septic System Uesigned For:
itesidential _,�� Business _
# 8edrooms _� # Employees
_ Other (specify)
Other
Uate '1'nstalled `7r� �� _/ � Water supply ` J�
'Pype of System ��.I.YYII� ���1 V �i�l'��D��L�I ____
Nitrification Line 5��i�3 �
Tank Size
U ,� /�
Certified Operator Required ( Y
On site wasL-ewater disposal system showes no visually apparent
malfunction on �'oZ^� J���
Yermission is granted to: l��il �
According to the attached site plan..
Comments:
Environmen�al Heal�h Su .
0
1Z�3-��
DATE
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Building Additions/ Mobile Home Replacements
Tax Map #:�_ Parcel#: !�Z Address:
Approval Requested for: Mobile Home Replacement
✓ Building Addition GZ�-�,.�,-�o��
Applicant Name: p �-�„��J �i
Address: Z�S �.�.-,� n �,,�F � _ _
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Phone #'S• q � 9-„�?��.��f z�
Permit Located: ✓ Yes No
Installation Date: t ac� Z,�.
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: 6l (date)
(Applicant's signature if site visit is not required)
Addition/Replacement Approved
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Environxnental ea Specialist
i
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