A24 107A�plication Date: �`�"�� Tax Ma #: ���1
Amount Paid:
RecEipt #: 17 � ParcEl #: � � 7
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APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFIED
CHAFVGE�D, OR THE SITE IS ALTERED, THEN THE IMPROVEiVIENT PERMIT AND AUiHORIZ4TION TO
CONSTRUCT SHALL BECOME INVALID. �
1) Permit requested by: (Owner/agent/prospective owner): ��� S�`S co� )� „�„� � L�� C Q(�o �
Home Phone: `�SS'�'aa I Address: �'�-o� �-rs�=c�d fi�� 17�"O�
Business Phone: 7�5-`��Sq �� (�, r^ rrL �7.3� �
2) Name and address of current owner: ��� l�l��(�
�
3) Property Description: Lot size: •�� Township: e- u N�� �
Directions to the property (Including road names and num�
�
ivision: �� ��"� Lot # s
4) Proposed Use aryci�Structure Description: answer each of the following questions: t �
a) Proposed � Existing _, Type of Structure: F��'��Yfv Sr,rrf Width: �� Depth: ,32
b) Number of Bedroo :�_ Number of occupants or people to be served: 2_
c) Basement: Yes �No Will there be plumbing in the basement?�_
d) �arbage Disposal: Yes �No _
5) Water Supply Type: Private (new _ or existing_ ,), Public , Community_, Spring _
Are any wells on adjoining property? Yes TNo _ If yes, please indicate approximate location on the
�site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. �
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
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 property. I understand if the site is altered or the intended use changes, the permit shall
become invalid. ,
/
or Legal Representative
� � �C�
Date
PCND, rev. 06127IO2
910 342 9222
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Application Date: � "_� � �
Amount Paid: o7a.5�'• �0 ��
Receipt#: :31014 �-
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�E=�aa-�v-ii�-.ra.i�a.�ra-n_.r.a n-n.'�.er.]L 7E"1L.c�.cRll.�.��a.
. Application fo� Se�iees
(Septic Svstems and Wells)
G Improvement Permit (3ite Evaluation)
$200.00/$300.OQ (if> 600 gpd)
C Mobiie Home Replacement or �uilding Addition
$150.00 (if site visit re uired) �
ell Permit (New/Yteplacement)
$225.00/$125.00
Tax Map: ���
Parcel #: I 0 7
Services ite uested
❑ Construction Authorization
(Fee is dependent on the type of sy;
❑ Permit Revision
�75.00
❑ Repair of Existing Septic System
No Char�e
Important: If the information in t/ie application for an Improvement Permit is it:correct, fulsified, or• the siie is altered, tlte�: t/:e
Improvement Permit and the Authorization to Cv�:struct sfial! becnme invalid
1) Services Requested by:
Name:
Address: c � -
� `P_��9 fl�.Z , i�L' c? 7 �� �
Phone # (home): ��t��o -� aa � � 3 �
(work/cell): ���f— ��/�'j�'j7'/
2)1�laene and address of current owner (if dif%rent than �pplicant):
Name: P���1 YYi��-17}/��j=�/L.17
Address: �,� �� ��G r
3) Property Description:
Lot Size: �/y �yc�Subdivision: ��:Ci7?�'"L�! Lot #:
�, � ,
iI Sld�'►,
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4) �'roposed �Tse �nd Type of Structure:
Residential � Business/Type: Other
Number of bedrooms � 5 / Number of people served (seats/employees):
Basement: Yes No �� (with plumliing: Yes No _�
Garbage disposal: Yes _�No .
5) Water Supply;
Private Well Proposed Existing _)
Community Well: Public Water System: ,
Are there on the adjoining properties? No
��
a�'l acfoi iY7ora�l �� ( �`� �f '� `S��°1�
Yes (please show location on site plan)
1Vote: A comp[eted application must also include:
➢ A plat/site plan of the property that shows property dinaensions and ilze size a�td docr�tion of all
proposed siructures.
➢ A signe�l cvpy of the `Lot Preparatinn' form ver�inb that the properiy is ready to be evaluatec�
I ayn subanittang this applicataon to request se�-vices fpom the Person Coumty �Iealth I)epa�tment. The
anfor�nation providecl is accurate. I under§iand that if any site is altered or th ' tended use changes, all
per�its shall beco�e invalid.
Signatur� (Owner/Legal Representative): � � �a$e : �
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-] 790)
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SITE SI�TCH ��
Name � Taz Map #��.Parcel #�_
Subdivisi _ � Section/Lot#_S
� 23—�A �
A thorized State Agent . � ' Date .
System cnmponen�ts ne�iresent ap�ima�imute�contours only: The conimct,or must, fYag ths system prior to
beginning the inrtaAataon to ir,�sure that pro�iergrr�ds rs mai�tairled
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"WHETSTONE°
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30' UTILITY EASEIAENT
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CONTOUR �
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Tax Map � parc� ## I07 ..
Applicanf:
Subdivision: ��
L�cation. , —
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Tovvnship:
Lot #
�yP� o��a�e� �upp�y: _ Individual _ Cornmunity Public
I�e��r�anen�:
Site Approved By: �S
Grauting Approved By " �
Well Log. �
Pump Tag: _
Well Tag: '
Air Vent: ' .
� Hose Bib: �
Gasing Height: �
Cancrete Slab: � � ' �
Well Driller- �j A r� f.-�-{",�.
Well Approved by:
*�**Se�.A�ac�aed �ite �k�#ch*�*�
Liner:
7nstalled by: _
Depth set: _
Grouted:
Date;
Watea� Sample:
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 fest from any buiiding foundation.
�ther canditions:
Date:,
PCT3D rev 01!27104
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CAROLINA POWER & LIGHT
HYCO LAKE
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Date:.�e .-�..�► �.. �8'
Owner: .��� o�.`n s
Location/Directions: �J���-s-��,.,. _
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�uli._'�v�sion N�u»c: ..__.___ . . �
Drilling Conrractor:.�' �� � �� - Lot #
..._... :
- . .._ _ _
--��n.. S_ ....j�.1L ( ( ._... . .�.. ._ ��c... � .
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Distance from Nearest Prol�cr�y I.,i����._',._ - c,� �. . :�E.��>�
Po]lution .. o � -� �---��- s ll�st:incc from Source of ' �`�
w ��:e
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Tocal.Dep.th.. Ft. �'icicl: � �M ;
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Water B�earing Lones: Dc, �}� .�� ,--��-�-- �'� S[atic Wa[er Leve1 �� ��'��i
Casing: DepUi: Froin �P _:� _ . _ �'► � _.� -�,.5' �= t. Ft.__ �F�::. `i
TYPE: �—_to---- ►� �' �,�: t. T�i amctcr: G � �t. � ;
. Steel ` Gt�lv:�nizcrcl S[ecl Ynches :
X.f Stec:l docs . _ L . ' .,`'�;
, owncr uppj-ov�•: 1 �,; N�
' � • Wei,ght:� r�JLIC�Ul�.'.SJ. /�// X .1 A�.'1 . �!'i
e Shoc: --f-_�`=-- �ht� bovc G :. :,,
Driv Xes _ Nc�----__... �o�d:-__� z__'Ynches��;��:� �
Werc Problcros El�countcrccl in Scltint; 111c Csisin�;'i ycs No ��
Zf 'ycs" give rc.�soii: ------ ._.___ "
Grout: .Type: Neat -- _..____...--�-______ :. ;�;;�
7 S:1 f1C��C�C1]1CI1� �•'•��;ia�a
ic1T.•S �—_ C o;;ro;
Annu pacc Wi�]�� — _— oricrete ' • . . : ,���
— � �L iciics �'�,�,:�,;
�!ater in .�uiula�- S�acc: Y�:ti_ _.__...'_� No . . . ':�
Method: '��.--- 'rc. ___.__ �_/
DC�. PUIt]ljx ti . _._ 1 •::tiurr.___..__.____,_ 1'uurc:cl__ <--�� .. .. • . ;'
P From ._ ,� , ,... ,
Mate --�-._- �u --... _�-c�__I�t. . , :�+;
rials UsecI: No. .�3a�s ,l'c�rcl�u�►d Ccmcnt_ ;�:'`�
t of .1 . . ,�,'.
7Fmvctuie (sancJ, gravc:l, CUL[IIIS'ti) - IZ�tio: .��. 1�Yeigh �ba��lbs�'�
'�D �11ieS. iCS l/ NO � � ` ._____ _ _�_ t0 , . •.�,°'�'�,�,f.�
� 4 4 slab Xe� ---rNa -----....---.... _ . .. ; • _ .,:�h
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Fram �o -----.. . _._ _._._ _._ —_ ------
Formation Descri tio
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Z HEREBX�CERTTFY T�iAT'1'IIE �A,Bp�� ��NFORMA�1�'10N IS .
T�S WELL WAS CONSTP.UCI'�D I� �,CCORll CORRECT A,ND,
FORTH �X�T�-I� PERSON c:'OU:N��I� [�(l;nj.,���-X ULP�C T�''`�TI-i REGULA'�IOI�
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��.:r :::� . -.�;.-_ � �= =.- r - �::�' ''�;" .
_�:::.. :=o:= :� � - : :t - : - � o�ouc�� � - 3 3 7 s
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Location: r� h e-is��„�s� lI c� �/.� �n R o D1�c 2 7'S'] �
Subdivisia�.: � h � f � �,,�u� Lot # �_
- WeII Coastrac�on .
Distance From nearesi Property Line (l!4linimum 10 feet) rd -
Distance from Septic Syst�n (M"m�unm 60 feet) -
Total l�epth: �6 o ft Yield: 2 f� GPM • Static V{Tazer i.eveL- Z� $ •� �
Water Bearing Zon� Dept� ���� ���i g $ . -
o �
�= - f . �
Depih: Fmm . c9 to�.ft. Diameter: 6 �� in . ._
Z�ype: Calvani�ed Sbeel P� . .
Weigi� Thiclmess: _/g �- Height above Gc+o�nd: . ld' in � ;
Driv+e Shoe: t�Yes No Au3r problems eacoimtere� wh�e se�ting casing? Yes �No
If `�5,, give reason: _ " —' - _
G�ui:
. Nea� Sand/Ce�t Concrete GraveUC.ement
. --. Annnl�az' Spaoe Width - mches Water m Armuiar Spac� Yes ' No '� �
Met�od of Gr� P�mped Pre.ss�u�e - Pouned Depih ' to Ft
Materiats IIsed: - -
No. Bags Pordend ce�ent ' Weig�t o� 1$ag � Pounds . _ .
If mad�ue (saad, gcavel, �) —Itatio bu - -
ID plat+e� _ Yes _ No 4 x 4 slab Yes No •
7:mer: " - - -� - -
�: Da�e TnstaIled: Grout lnstaIled by: .
DriDiag Log
I�acation Drawing
�'}- . '
t hereby certify that t�e above� iafa�atiou is comect an,d �at rhis well vvas c�oct�d in �ce �vifli regulatiia�s sex fa�
by t�e Persan CauntyHealth De�t. . .
S�gaatnre o#C�racbor (�.�L.�o�' .� �--c� � ID # � .� %� Datc . S` �/3--c'�B' _
._.___
PemP I�e�t " .
��nst�i�ation �'on�rac�r y���C,vP f/e 1�;e1/ .DeCi //,•�� state P� xumt�: ,��d �S<
�P �P� ft Static watea� Level: �s ft �
�ttmp Make Sc ModeL- e J��/C ,P f Pump Size an,d Rafm�. �s� hP � gpm
��Y �Y �� P�P was ins�tled an�d ti�e well I�ead co�l�ed ac�duig to ffie Person Co�nty Well Ruies ia effe�t
xi this date a� t�at a copy of this �+ecord has bee� p�+nvided tothe well owner. .
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlvIPROVEMENT PERMIT
B 1434
Nc�t for waste water system construEtion. No permit(s) for Construction Location or
� Relocation Activity shall be issued until Authorization for waste water system construction
. has been issued.
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Zoning Township G .�
Owner/Contractor �� e (�, /�i n/ �_ ., te Z--2 � 9 rf r
Location/Address
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Subdivision Nam
ev�d !o�'!ac✓c a�'.F .R
_ Lot# -�
Permits may be voided if site is altered
Well and Septic Layout by
Comments:
Date
Installed by
use
Approved by
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'ell Permit Paid WELL SYSTEM SPECIFICATIONS
dividual Semi-Public Required Slab �
iblic Replacement Air Vent ��
te Approved i� Required Well Log
ell Head Approved tf- Well Tag _,, /
-outinQ Annroved ,l'd - � `7—� �w, D• bir-, ,�_ � : D ,-
Comments:
Date
Installed by_
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This report is based in part on information provided the H'omeowner or lus/her
representative in the application submitted for this permi� The environmental
health specialist is not responsible for false or misleading 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 environmeatal 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:\amiprolpermi�sam O1/95 rev.l.l
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IF • IRON FOUND � / � � �
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MP o MATHEAIATICAI / �
POINT
UNLE55 SIGNED. SEALEO IwD DATEC, THIS IS A
PREItYiNARY VIAT, N0T FOR RECORDATION, SAlES
OR CONVEYANCES.__
HAAlLER—JENNINGS
6c ASSOCIATES, P.A •�•
PROFESSIONPL UND SURVEYORS
212 5 LAYAR STREET - PO BO% 1266
RO%80R0 NOIiTH CMOLINA 27573
(338) 599-8712
N0, DELTA RADIUS. ARC TAN C10. BRO. CHORD
C- 1 O]'I6'SS 797.63 19.l2 Y.92� 575•SO'SY•11 tY.E2
C- Y 07•!a'07 161.21 21.35 10.60 N67•21•S�•11 t�.]S
t- 7 OG'O1'�3• �l1.21 63.03 71.56 S57'O1'SO•E 63.00
SITE LOCATIONS
PEGGY E. McFARLAND
CUNNINGHA� TWP., PERSON COUNTY. N.C.
SEPTEMBER 2006, HAMLETT-JENNINGS d ASSOCIA
212 S. LAMAR STREET, ROXBORO, N.C.
NEAL C. HAMLETT L-2465
I 1 1 1 I I
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PLAT CAB _____. HANGER _____
FILEO IN PERSON COUNiY RECISTER OF DEE05 ON TNE
"" DAY OF ""�"'. 40� � ""' 0•CLOCK �_Y.
""_'"""'"""""""""_"'""""�____""
RECISTER Of DEEDS
NORTN CAROLIN.1 PERSON COUNTY '
�, .___HEA}_���tiM�f,TT�.._, �ERiIFT T1uT THIS
SLNVEY IS OF AN E%ISitNG PARCEL (OR PARCEL51
11ITNIN _.�E650tl__ COUNTY AS RECORDED IN OEED BOOK
�.7_L. VAGE AA.4. AND/OR PUT ____ ____. PAGE ___�.
All PROVISIONS OF NORTH CAROLINA GENERAL STATUTE
�7-70 AS AYENDED REGARDING 7HI5 SUftVEY MAVE BEEN
YET. ■IiNE55 YY FU111, MD SEAL THIS _ZS_ DAY OF
_�P_T�!�3_. to_44_.
-��-- G =-----=------ -- ----
PROFESSIWuI LAND SURVETOR
I. __NELJ._�JfANI.LLi__. CER7IfY THAT THIS
iLAT NAS �RANN UNDEN YY SUPERVISION FROY
AN ACTUAL SURVE7 YAGE IIAER YY StPEM/570N
fDEED DESCRIPTION RECOROED IN BOOK �1Z1_.
PACE _CS4_. EiC.1fOTHER); iMAi TIE BOINDARIES
NOi SURVEYED ARE LIEARLY INDICATED AS DRAIIH
fROY INFORMATION FOUND IN BOOK __L__. PAGE
__L__: THAT TNE RAT10 OF PREC(5(ON AS LAL-
CUUTEO IS 1:_JSLASlA.t__: �T TNIS MAT US
PREPARED IN ACCOROANCE IIIiN C.S. �7-JO AS
aer�n. rtr�ss w oawtru� stcruruic.
REGISTRATION NUYBER AND SEAL TNIS _iS_ DAY
oF StPJF.Nd�fl. A.o., io_C6_.
SURVEYOR /�Kl.-�S_4.._c�_-?wY_iS1
REGISiRAtION INIYBER "'"" L �Ie3 �"""'
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Building Additions/ Mobile Home Replacements
Tax Map #: '� � Parcel#: ,� �'
Approval Requested for: Mobile Home Replacement
_� Buildi.ng Addition
Applicant Name• , ��� ���,'12y1�'�`� �"`-1��5 � �^I–�
Address: �,,,,� �
Phone #'s:
1 �C �
Permit Located: K Yes No
Installation Date: `�S' i. �� Design flow: _�� (gpd)
� �:'-�'�AP.�.�t/1
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) �---
Comments: ��,i>,��f � � .�;�� —�(lilCr �/ � �✓r'� , >.�-
_ � � � _ � . i _ ,. _ , � o > �, �.-� .. _ , . o.r . i' �
Addition/12eplacem�nt Approved
Environmental Health pe. iali