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The District Health Department
CASWELL - CHATHANf - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
i Date ��+—?-��� �
Owner ��- �G��=��;C��
Loca�:�� �. ' !.3 22—
/� ` � �� c-�c�-t�
. �� l�� :
Contractor: �-�^^� -�-��
Water Supplp: Private � Public
Sewage Disposal Facililies: No. bedrooms �� Dishwasher, Disposal,
washing machine, other automatic appliances
Size of tank: ��y� NitriScation line: 0 x
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY POATION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:
Well:
Sewage
By:�
Cerlificata o! Completion
.
SignecL � �-Z-�"'
•Sanitarian
Counte �
aigne � "
ner or his representative)
Date Approved: $� 2 L- 90 gy;��GC�[' -��^�+"'
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
I�OTE: Make sketch of
supplies, etc. Note special
at later date. Note locatic
(1)
0
s�
size and shape, location of house, septic tanks, privies, water
t. Write in measurements in order that installations may be located
adjacent lots.
.� (2)
Person County Heaith Department �
Well Permit �
Date:
�� This Permit Void After 3 Years '�
Owner:,�''`-� ��*-j-���..� SR# %.3 2 Z
Locadon/Directions• � ' �,
Subdivision Name: Lot#
Drilling Contractor. y Il ,a S��
WELL CONSTRUCTION ►d
Distance fro Nearest Property Line �S�/U� Distance from Source of �'
Polludon / cr
Total Depth: % F4 Yield: �_GPM Static Wat r Level �[� FG �
Water Bearing nes: Depth 'ZQ_ F� FG � F� FG
Casing: Depth: From � to � FG Diameter: i Inches
TYPE: Steel � Galvanized Steel �/�—
If Steel, does owner apptove: Yes No
Weight: �_ Thicimess: Height Above Ground: � Inches
Drive Shce: Yes � No
Were Problems Encountered in Setting the Casing? Yes No �—
If "yes" give reason: �
Grout: Type: Neat •� Sand/Cement Concrete
Annulaz Space Width '� Inches
Water in Armular Space: Yes No `�
Method: Aunped • Pressure Poiaed �
Depth: From �_ co 2 Ft
Mat als Used: No. Bags Portlar►d Cement _� Weight of 1 bag
�� lbs.
If mizture (sand gravel, cuttings) - Ratio: •1— to��
ID Plates: Yes '� No ►d
4 z 4 slab Yes �— No �
I HEREBY CER'I'IFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPAR'TMENT.
Concractor Date
�i/..��D 2S..�t�,,,... � -�Z-��
Sanitarians Signature Date Issued
Sanitarian's Signature Date Complete3
Sketch well location on reverse side.
'� NOTE: Make sketch of installation showin lot size and sha location of house, se tic tanks,
g pe, p privies, water
� supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
,, at later date. Note location of water supplies on adjacent lots.
(1) (2)
Application Date: �- � % � Tax Map:
Amount Paid: Parcel #:
Receipt#: �
�-.�`�. S.� ��.�.� ���
� � �c � z�r���r����-
7L�� zcawu�c-.�ca zcaica.-na� �La. �.an.11 7E�C.c�.ca.11. ¢�lla.
. Application %r Services . � :
(Septic Svstems and Wellsl
Services
L Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
C Mobile Home R�eplacement or Building Addition
$150.00 (if site visit required) �
0 Well Permit (New/Replacement)
$225.00/$125.00
C Construction Authorization
(Fee is dependent on the type of sy;
❑ Permit Revision
, $75.00
Repair of Ezisting Septic �ystem
No Char�e
Important: If the information in the application for an Improvement Permit is incorrect, falsified, or the site is altered, then the
Improven�ent Permit and theAuthnrization tn Cnrtstruct shall becvme invalid �
/�$) Services Requested by: / n �/
Name: �� ' C� Ri c� � Phone #(home): �,3�vr7� � U�� 6
Address: �U . � (worl✓cell): �'� � '��cr �
s"� , /t� � . �
2)Na�ne and address of current ov�ner (if dif%re�t than applicant):
Name: :
Address:
3) Property nescription: Lot Size: Subdivision: Lot #: �O �
Address and/ordirections.to Property: ���,,i Ga ,L�,� � f � � �.�,} .
4) Proposed I7se a. T`ype of 5tructure: �
Residential Business/Type: � Other
Number of bedrooms � / Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No _�
Garbage disposal: Yes No � .
-5) Water Supply: . �
Private Well (Proposed Existing � .
Communiiy Well: Public Water System:
Are there on the adjoining properties? No Yes
(please show location on site plan)
Note: A comnleted a� lication must also include: �
9 A pladsite plan of the property that shows property dimensions and the size. and location of all
proposed structures.
➢ A signed cvpy of the `Lot Preparation' form ver�ing ihai the property is ready to be evaluated
I am submitting this application io request sea-vices %om the Perso� Co�nty I�ealth �epartment. The
information provided is accurate. g under�tand that if any site is altered or the intended use changes, all
permits �ha�l becoffie invalid. � / �
�iga�ature (Owner/Legal Representative): 4 `� Dat� : -//-
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
���1 ; ��i �'�S�l.1J'�� .
! �` � y � � -� � � �.b.. � � �
��1."5^�.��—n-��^n-acL�_�.�.� 1!L 1La�a8►.��
Applican�
Loca#ion: .
/ �1
�x {41a� ' �rc I � '
S Ulb [��IV I �1011
� � 1.5�>S�C��IOf1! , t ,+
�pra�e�en� �ermit
��rmit �alfld �mr � �`ive '� I�o �ar�aon � `
T e of Facility: � New x A,ddition � ��ter Saa � W'eV �
YP ' �P Y
# of Ocaupant�/uQ of Bedroo Projectezi Daily Flow � g.�,d,
Pmposeri Wastewater System: -QJCi S�h4 • .. � � Type:�
Proposed Repair: 'I�jpe: �
Permit Conditions:
�
�wnes or Lega1 Regresentativ e: : � Date:
Authorize3 Stat;e Ageat � . � Date: 2
The issuancx of this pem�it by ti�e Health Deparmae� in does not guarautea the ��cnanr� of othet p�. If is the respo�b�iity of the
aFPli�QP�Y ov�mer to in siae that aIl Person CouuLy P3anning and Zo�g and Bw7�ing Inspes:tions reqtmr�ments are me#. �'his
�anprovement i'srmit is snbject t� revocation if the si� pl�; �pl�tt'`rii�� the inteude� nse changes. i7ae Y�erovemeat Pernmit is no�
a�'ect� 3ig a ci�ange in owner'siup oi the propertp. T�is permit was issued in cmmglianc� wit.�► t,�ts provisaons of the l�otth Carolin�, .:
`Zaws ared Rules fOr Sewacge ?`re�nent and I�isposal Svstems' {1,5A NCAC 1�A .1900). Neither 7PErson �ouniy.: nor� `t}ie.'. '=
Environmentai �eaIth Sger.ialist warrants khat the septic +.ank systeai w�7! cnntinue to fnn�tion satisfac#orilp in the futnre�or:ttiaf.
th�water snp�ly wiII remaia potable. . .
• r��atlno�-i�atioa to Constrnct'94�aaste�� S3►sie�t (.�qn�e� %r �a�a�ling Pe�at� � �
*. See site plan �sd addit�ional attachments (__) • � � � --
Proposeci wastewater System: i 57'i �✓QN ;d�%t � Zj,-pe�ac Wastewater Flow 3���.p.d. .
. New k Repair k Ex�ansion ' ,- 3oii La�: ^ g.p.d! $ 2 �
� 'Type of Fac�7ity: �� �P � ' � Basement � Yes _ No
Q�C . = 2X� S ��'� � ��t��va�er ��t��n �i�e�e�� . � � - . ..
'�� Siae: Se�c'�T�nk:'� �vv ga��X} �nP Tan�C:
l�rai�e�d: Tatal A�: �. sc� i� Tatal Length ��, �
�r.emc�a �id� `QX ' �
d
�ist�ai�u#�on:
Spe�cations:
gal dsrease �rap: gai
1Via��a� Ts�enc$a D�pt9a p k� an
Soi� �over. 'PX i�a M'in'a�aeaai'9.i�enc3i Sep�a�io4a:.pJ�� �#
baation �o� � X� Serial �3i�trabntflon Pressuae I�ianafold .
State Agen#:
Peiznit E�iration
r '''
Date:
The type of system permiite� is � Conv 'onai � A ted Alternaiive. I a.���t the sperifications of the
P��-
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�u�oazed State Ageat Da e '
`�� �P��� xP��aPP� �� �1y T3e cnana�ormuar9ag r6e system paarm beb •�mg ffie ms�ndva ao
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App(icant:
Location:
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��x M�p � � arc �
Subdivision
Phase Sec�-t.ion ot #
# of Bedroom.
� � `� .: :� � ' �:.
1 = -
Syst�m Type (In Accordance With Tabie Va): �
THIS SYST�flli Fd.�S �EE1� IMSTALLED tf� COI�18'L1�.NCE ViIITH �►PPLlC�►BLE . NORTH
G'AROLINA GEfVERAL STATUTES, RU�ES �aR SEINAGE TREATMEi�T AND DISPOSAL,
AND • ALL COt�lDITiOiVS OF � TI-8E 9iViPROVEi�EI�T PERIVIIi 1�►i�lD COirlSTRUCTION
.�11lTHOFZ C)N. �
� r� � w`� � /? � . -
� uthorized State A errt � Date
. �- �
lnstalled By. �'tt° d� � Date: � %2 �/l�~%
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. � �
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PCHD, rev. 07/2Q/04
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����� ����'{ ���������� �'��'�"���� ���� �@ � i�'V
Tax lViaQ # Parce! � Sysitesr� Type (Table Va)
OweierlApplicant Subdivisio�
AddresslL�cafiaon Sec/Phas� Lof � '
State �(D/date
Capacifiy
Tee and Fiiter �
Baffle
Sealant
Riser (ifi applicabie)
�''ank Outlei Seai
Perman�nf IVlarker
Pump Tank
c+.,+e n�a.�+o _
/Sealant
Riser
Checic Valve/Gate Valve
�41arm (visable and audii
Electrical Componenis
Rate (gpm) . .
Approved Pump fi�ode!
Blocic Under Pum� �
Pump Removai Rope/C
. �Dis�ribu�ion:Sy��
Serial Distribution
Pressure Man ol
Low Pressure Pipe
A�pr. Pipe i�ateriai and
0
,
0
� 1�9'�9i16�'P�064 L9�I�+
Trencfi �dth � ft.�
� Trenct� De th in.
T,renci� Len ft.
Trencf� G�ade �
Trencf� S acin
� Rocic De �ti� and Quai'
Dams/S#e down� etc.
Pressure Laierals �
Hole Spacin
o e ize
Pipe. Sleeve
i
Requireci' Seiba��
F'rom� Welis '
From Propesty lines �
Surface Waters
Public 11Vater Su iies �
Verticai Cuts >2 ft �
Water Lines
Ve�iicle�Traffic � �
Adjar�nt S�/stems �
�Easemenfis/Ri ht of V1/a
O#�ea�
Easemet�ts Recorded
e e erator ontraci
Tri-Partate A reeene�t
�
Comenen� .
pc:�d rev. 3t13101
�