A23 172� �c�bb ����G�-; 2 � . A 1399
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. PERSON COUNTY HEALTH DEPARTMENT
� WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Tax Map # Parcel #
Zoning Township `
Owner/Contractor ; ate ��—
Location/Address �Qi %l1 � ('-�-��'S !'Yl ;� I �
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Subdivision Name _ Lot#
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Date
I WELL SYSTEM SPECIFICATIONS � �
Individual Semi-Public Required Slab _
Public Replacement Air Vent
Site A roved Required Well Lo�
Well �ead Ap�iroved , Well `ag ��_
by Approved by.
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit The
environntental healttt specialist is not responsible for false or misleading infotmation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the properly or for statements in tivs repoR that may have resulted from false or misleading
statements provided to him in the application. Neither Petson County nor the environmental health specialist watrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pernut.sam O 1/95 rev.1.0
ORIGINAL
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Recei�rt
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Person Courtty Fi�alth Depi
325 S. Morgan Street
Roxboro, N.C. 2757v
Cqurier'�2•?3-15
B'-3 )-��
Date
T., w:,� y __._--. ___ _�._ _.__ __ _
Improvements Permit.(Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
Imp.Fovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Pecmi[ (Mobile Home Replace) _ Permi[ for New Well
Improvements Permit (Addition) _ Replace Existing Well
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1. Permit requested by:�`������ 5•
wner ros ective owner/ag t:
Address: ��'1 eil'1 _ �1l G� � � �
�C-
d �-��,v 7. Dimensions r Pso o�,sed S��ur�
Width: �� ��"
`l/ Depth: ,
�
ome Phone #: C�� —" v v � ��
usiness Phone �: �.� �
. I�Iame and address of,current owner: ���1�
Property Description: Lot size: �� 3
Tax Map#:
Parcel#: _
Township:,
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5. Directions to property: State
�Ia es,gtc.
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_ �' �mcN�. .i
6. Number of occupants or peo�
i� . What type (if any, additions, expansions, or
�,� eplacement is anticipated to the structure or facili[y
that this sewage disposal system is intended to serve?
Etoad # & Road
�G��eS��I,c,:(l
�/'-C,
le to be served: �--
9. Water su ly tSPe:
private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
10. Type of structure/facility: Proposed: �Existing: Q
Type of dwelling:
House: ❑ Mobile Home: C�'�usiness: ❑
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No �l
Basement? Yes ❑ Nofl If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUC'TURES. .
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 facilities to be placed on the propercy. I understand if the site is altered or the
intended use changes, [he permit shall become invalid. I understand that before an Improvements Permi[ can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the propecty to the Health Dept. within 60 DAYS after the date oE the evaluation of
the site by the Health Dept., t�pplication shall become void and all fees paid forfeited.
Owner or Authorized Agent
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WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
g 3035
.
Not for waste water system construction. No permit(s) for Construction Location or
, Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � 2� Parcel #
Zoning _ _ _ Township
Owner/Contractor
Location/Address
Subdivision Name
ui���- � vi��i
I••
SEWAGE SYSTEM SPECIFICATIONS
Repair �ot Area �� r �
SFD Mobile Home
Business # of Bedrooms�_
Permits may be voided if
Well and SenSac Lavout bv,
Size of Tank_��
Size of Pump ank �
Nitrification Line�
Max Depth Trenches
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Well Permit Paid G�' WELL S'YSTEM SPECIFICATIONS
Individual Semi-Public Required Slab �--
Public placement Air Vent �—
Site Approved_ � Required Well Lo�
Well Head Approved v I� Well Tag �`p��
Grouting Approved V.1 i S��f
omments:
Date
by
Approved
This report is based in part on information provided the ho"meowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleadi�g information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amiprolpermit.sam Ol/95 rev.l.l
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AUTHORIZATION FOR WASTEWATER SYSTE1�f CONSTRUCTION
(Void sixty (60) months frorri date of issuanc�)
DAI'E: "1 � Z � 11�IPROV�tifEti� PER.��IIT � -��L�
TA.Y �LaP T: Z� Pr�RCEL �: % %�Z
o��,-��,�o�-���5 ��5�,-�:��,-�: .�a�t � ft��'r��
LQC.�TION/�DDRESS:
SLBDItiZSION �i�:��:
LOT �:
SECTION OR BLOCK:
�L-THORIZATIOti FOR CONSTRL"CTION ISSL�D B�i':
AUfHORIZ�TION C
1. The Wastewater system construction and installation must meei all of the coaditions the
attac�ed site plan and specifications as set forth in Improvemenu Permit m .'Ihe
consr=uctioa and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or plac�-d 'uito use uatil inspecied and
approved by the Person Couuty Heahh Deparm�eui.
3. Any akeratioas in site or soil canditions (including structu� locations) or modification in nse,
desiga wastewater flow, or wastewater characteristics as specified in the associated
. im�rovement permit and application, may void this authorization and associa#ed permits.
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4. CQnditions:
ScheduIe 40 soIid pipe over dams Keep septic 100 feet from anv welL 10 feet from anY
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= Persoa Requestmg:
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PERSON COUWTY ENVTRONMENTAL HEALTH
�ELL LOG
Date: • "1 '
Owner: _
Location/Duections:
SR# � .
1 tl _ `� .
Subdivision Namc. ._ _ ____ _ ____ Lot f? �-�-
Drilling Contrac[or:�___—.. ____ -------- -- —
��'};I.i. (_:C)NSTRUCTION -- - � --------- - --�-
I�istance frem Nearest Pro��erty 1.�n::_ �0__ __ I�istar�ce fr:�iii Sotirce of
I'ollutio�t_.._.�(1t? _ ._---.. � _
I�ota1_ I�cI�E��: !�t. i i�:lc�: j0 G:'r��i St.itic V•'a�r:r� I.,evc�l_�--- i't.
. , -..a?��-- --- __ ---- ,s�
l'Jater I3earin, %ones: Ueptl�_ �9t2___-"��-- --- �=� i:� �.� -._..
Casin�: D�ptti: �=rom--,-- �- t`-' G I=t. Dia�neter: -----------� lticl�:e,
--- - - `-� -. - — ._�.�o—__
`1'YPL': Stcei----- _.- ------(;;�lv�viiz.ecl Steel ✓
1C Stccl, clocs owner apj�_ ov��: Ycs j�o -----�-----�---
WeiUht: Th�ck,less:-���_.HeighrAbove Ground: l �,�,
Drive S}toe: Yes_ i� No ---�—_ In.,h��
�'�ere Problems Encountere.ci in Sc[ting the Casing? Yes TIo .�
„ _
Z� "ycs glvc reason: - ----
Grout: Type: Neat _ SandJCc,nent / Concrcte �
A.nnular Spacc Widch Inches
Water in ,Annular Space: Yes Nfl
_. Method: Pumped - Pr:ssure Poured �- - �.
Depth: Fr�m=_ (' :0 2a Ft.
MateriaLs Used: No. Bags Portland Cement Weight of .1 bag�lbs.
Zf mixture (sand, gravel; cuttings) - Ratio: �o
ZD Plates: Yes �' No � :
� 4 x 4 slab Yes � No
I HEREBY CERTIFY THATTHE A.BOVE INFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
fiOR`I'H gY�THE PERSON COI,i�Ct'Y HEALTH DEPARTMENT.
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ignaturc of Contractor Da�c
ZO' d 5LZ6-86S-9£E 6ui- L L!--�0 L LaM a��.au..iEg �/ZZ = 60 66-ZO-�oN