A23 61.�
The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERM�p No.
(�� Date - � ? � S 1
Owner: ` E j � �'
Location: �
�,�� �
Cnntractnr• . '��� � ✓v �(�
Water Supplp: Private �'�� Public c
- � f'L.� u..^�r
Sewage Disposal Faciliiies: No. bedrooms � Dishwasher, Disposal,
washing machine other automatic appliances
Size of tank: � � - Nitrification line: ���-� � s��
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 an3 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 HE LTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INST L�TIO IS COV-
ERED ANB PUT INTO USE. r,r t/r�,��j �
� � % �// -
Date approved: — Sig / ecj.� ��"��k:y� ��V��
-�-� Sanitarian
Well:
Sewage Disposal:
By:
i
, Cs�unter- `
signed
(Owner or his representative)
Certificale of Complelion I '
� ��., �;`%~ -
'--' 1 f �t-1 � � - �:_..i� '
Date Approved: �' — � BY:
Sanitarian
. (OVEft)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make • sketch of installation showing lot size and shape, location of house, septic tanks, 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. �� ��
(i) �r\ t u " �' . �2� �' � J � � 1.��
�°�
/
�' JI 1 I I I�'�� �,_ 1 I�°tit�:-'I ��
�4 � � � � I I' I IYI� \I :.
5 �2`"� �� ��3 � �,s
0
0
�
Application Datei • �' � /
Amonnt Paid: "i � .00
Receipt #: ql � �10 O
' �-� 1701 ,..,
``-.`"� 1.� �„ 1� �llu
��y ^ ���
:L:n��as-vaan�a��d.mll ;
for Sepvices
C7 Improvement Permit (Site Eva,��tation) . �4 , . ..C�Constn
$200.00/$300.00 i�> 600 � d • ' � '+ ` � : �'• ee is �
0 Mobile Hame Iteplacemen�;5r Building Addition ., [] riermit
,
. $I50.00.(if site visit reauired� _ . � . � �Z5.00
� Well Permft
Taz 1Vfap:
�� Parcel#:
Au4horization
ent on the tvne of
• 0 Repair of Etisting 6epHc System
i) Applicant Infqrmation: _ - - �
Name: ��yp__[�e�'► w(�� � Z[3�f =i1�G
�Address: �' ►
e� �e ��- 2'i��'Ty .
2) l�tame and address of current owner (if different than applicant):
Name: � � '
Address:
�,�emorn� C 2'i?L4� . .
3) Property Description: Lot Size:3 •4� 2 Subdivisioh:
Address and/or directions to Property:
or
Phone (home): ��a=,,,�2�
(wor �cell): ��.�'S.�B� - [cL,�,G
. �r .
Phone �
� Lot #:
❑ yes ❑ no I�oes the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing v�3st�water systems?.
❑ yes ❑ no Is any wastewater going to be generated'on.the site other tt
❑ yes � no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentar
4) Proposed Use and'�pe of Structure:
❑Residential . '.
❑ New Single FamiIy Residence Maximum number of bedrooms:
[] Expansion of Existing System If expansion: Culrent�number of bedroo
❑ Repair to Matfunctioning System Wilt there be a basement? � yes � no
CJI�,on-Res,.,,,� identiat .
Typa o€business: Total Square fc
Maximum number of employees: Ma�imum nu�
�'VV�ter Sngply: ❑ New well ❑ Existing Well ❑ Community Well ❑ F
Are there any existing wells, springs, or existing waterlines on ttris pmperty7
Please note any lrnown ground water restrictions or sources of contamination:
domestic sewage? �
��
Occupants•
�ith plumbing fixtures? Cl yes � no
tage of Building.
er of seats:
�lic Water D Spring��.
7 yes ❑ no
� If applying for ��uthorization to Construct', please indicate preferred system iype(s):
� Conventional � Accepted ❑ Innovative ❑ Altemative ❑ Oth� �-. 1.
-- 1='. � .
I cert� that fhe infonnation providerl above is complete and correc� I also
inaccurate, the site is subsequently altered, or the intended use changes, all
Signatnb� (Owner/ Legal Representative�)
�' Supporting documentation required.
fl Perffiigs are valid for either d0 months or are non-egpiring when
o A compteted `iot Preparatton' %rm must accompany any �pplic
❑ Any
stand that if the infonnation provided is
'ts atid approvals sliall be iirvalid.
� ��- 9-�?
Date
np�anied by an approved pla�
reqniring a site evaluation.
• — — — - --- -- ---- -- _ _ . 1 _ - -------- ---- --- ----•
`�
���.s.� ���.���
- � � ����
���a����.��.��.�. ���.���
WELL PERNIIT
(New_ RepairL/)
Tax Map: f� Parcel: �L
Subdivision:
Applicant's Name: � �,if,,nl
Mailing Address:
Phone Numbers:
Lot:
Location of Proper[y: '%q� �fl� �, �S �J'.T ,p�: r�1 ,�n.
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.J Permits expire S years from the date of issue. �
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by:
�tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent: -
Hose Bib:
Casing Height:
Concrete Slab:
Date: L a
Certificate of Completion �
9 . %�D /65 �I.iner:
�� L,���� • EHS/Da�e
� ZS��S - Depth: �
� � � Grout: ���
.�����y
DAbandonment:
Date:
Method/Nlaterials:
Well Driller: License #:
Pump Installer: License #:
Approved by: Date:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
�3 :�
jo:o�
W��LL CONSTRUCTION REGORD
This form ca» bo use4 far aingtc ot mutdpto wclls
2, Netl Cantra or InformaUou•
��',�#� LY.r���
�Vel! (.lontruw� Neme
y3T� �
NC Wcil ConvactorCcrtfIIcationNumUcr
-- �i�TLG"� ��.rl��s �G
Company Nnma
Z. Wcll Cbwtruction 2'ctwlt #�
Lls( atl applicaWe swl! pr�uilts rl.� Caurory; .Stale, 1'artanre, lufeafon, rtc )
3. Weit Uso (check �velt use):
❑Agciculturat
C]b4unicipal/Pubiic
❑Geothermai (Hcati�i�CooGng Suppiy) �iR'esidentinl WAter Supply (single)
QlndusttiaUCommercial ❑Residential Wnur Supply (st�ared)
SuPP�Y Well:
OAquifer Reehurgs ClGroundwater Remedialion
OAqutfer Sinrage aad Recovcry [3Saliniry Bertier �
t7Aquifer Tcst CiStorm�vater T?rainage
OExperimenwi Technology (75ubsideacc Cantrof
QGaothermai (Claseci I.00p) pTracet
d. Dat� �Vell(sj Compteted: '�� " Wet! IDl�
Sa. lVcil I.ocatian: �
�L)�i�b ,�lL6L� s .
Yacllity/U�vnerNnmo Facitity iD� (if u�licable)
��6 .�.y�►,�.�,.�uB�,� S�•�a�ey ,�c
Pitrsical Addr��ss, City, pud 7.ip
l�
, r� �--
�'�++��;Y Nacccl IAintification Nn. (PIP; )
5t�. i�atttude artd Longitude 1n degreeslminutes/seCands or declmal dt�,rees:
(if�t�elt Oeld, ono ioUtong is sat�icicnt �
,� 36 �3� ' �..� q.�Q3_.'! ��. � � ��.., 2� � ' � ��
b. Is (�re) tqe well{sjep �ermanenf or G�'I'emporarv
7. is tt�is a repair to an existlng waJH �5 ur t'3tio
lf+hts ts a re�nlr,/tll outl�rn»�n �ir•t! co-nsMrclipir inlornurHai rur�t e.cplai�r ttte r,ah�re oj'1he
rcfw/r mider N?! rentarkc sec!lott r.r n�i ihe ixlck a/ thls Ior�,�.
S. I�umbcr of �cc!!s constructed: �
l�w� a�itldp/e irJnrtlon nr n,mrtiroter• arrf�plv urtls UNL}' xltn IJrr snme csmmuction, yhu cnn
suhrnii nnr tnrrn.
/
Y. Tntal we11 depth 6elow land surface: _ �� � f�.�
I�br qNthlp(e �rr11c ((st al/ deplhs rjdl/(errnf /'e.tarnnte- 3(ri,100' nxd 1(n!l0/l�
' �. /
!p. Statie wuter ievel belnw toE� oi cusiug: _ ���5 �{t,�
/1N17if7'iRVf:ISUF1olL�l'aflllg, 1IJC'.i.•'
11. I3orehulc dlamcter: ,�,�� ��u,�
12. Well construction method: ��ii<<% �
(i.r, eug�r, rutary, cab(e, dlm:t �w�h, ete.) ��
Forintotpa! Usc ONGY: -
22. CerttFicanon: Q.'T`' ` "
���� _ . .__..._ _ __ �Y /5-�2'
aignaturcoft' iticd N' 1! Cunvactnr � ��t
!1p slgning thls jorm. I kere�i� rer!!fi' thar Ittc �tixl!(s1 Has �iverrl cun�rru<!ed f�i ucet+rdunre
Rilh l3i1 NCdC (1?('.(//�X1 �r l.f.q 1J(,',!(' OZC .01pri IYett (���ricfnittiw! Stitnr(unls auri Ih�tf n
copv �j lhts rernrd has bze�� pro��i�led fo !he �twJl mt�rrr.
23. Site d(agrAm ar ¢ddltt�mai we11 cketnils:
You muy ��sc thc bacK ot'this page tv provido additiona{ �vcli sitc detaiis or wctl
construction details. Ynu may also atteck additic�nai;�agcs if necessary.
SU$bII1"fAI, T]V5TtICTIONS
14u. FoC All We�is: Submit ihis fonn within 30 dn,ys nf complctinn of �vell
rnnstnactian to thc faiiv���inu; '
llh�tslui� uf \Vuter Itesuurces, l�iformation Processing U�1t,
1617 h7ai1 Servlce Center, Ratelqh, Nt: 27699-I617
ZQb, i�'or In ection 5Ve1� ONLX: In addition to sending the form to the address :
24n ubcn�e, also submit n cnpy of this form �vithin 30 daye of cnmplciion of �v
conxttuction to thc fullowing:
Diti�lston of �Vnter Resources, Undet�round lnJecNon Gontrol Progrnm,
TbR VVATER Si)P}'I,Y 11'F.t,LS O\I�Y: 1636 hiaii 5e►��Ice Center, Ruiei�h, NC 2769y,ifi36
13n. Yleid a m_� (J tiiethud oi tcst: __�� zaa For �Vatcr SuDP�Y & �n�ecHon Ne11s:
{e� � �.____..--- �r_ni? _
, � �p "-' Also submit one copy of chis form �ti�ithin 3U deysaFcomp}etinn of
i3b. Dislnfeeflan h'�o: Y,.,� �,__ Amounh �� �J�T «'CII COSISIIUC[1011 (� t}7C CAUI1ty heaith dcpurtment of dtC county tvhete
'� CDqShUCICd.
Fotm G�V-1 Nonh t arolinn C�cpanment of tnviroruncnt ansi NFtwal Raources— Ulvisbn of Wattr Rcsoun:es Revucd Augus� 2013