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A24 132Application Date: � ��"Q� Amount Paid: � � .� . o O Receipt#: 4 0 cS�d 6 j �-#- �,�� � � JL' �1L4.� �� � ti= c� � ��T�I"� 1 �� o ������-.��-,,�.��,. �.�..n �.�.����. Application for Services fSentic Svstems and Welisl Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit re uired) ell Permit (New/Replacement) $225.00/$125.00 T� Map: � a � l3a Parcel #: ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision t��-�� r��+�'�� � �}�� .�or �y ❑ Repair of Existing Septic System No Charge Important: If the information in the application for mz Improvement Permit is incnrrect, falsified, or the site is altered, then the Imnrovement Permit and tl:e Authorization to Construct shall become invalid 5ervices Re ueste by: Name: ��Gt� ��yii� Address: (���1 1,1D 1 ?., IZides� _7�_ J�n-c.i,�e.r.� �rn,�. �1/L o?7�'7� - Phone # (home): �14-'7�. - l���s (work/cell): q i4- a�o - 3fto � �, 2)Name and address of current owner (if different than applicant): Name: �c9n�� a.�o.� ��Or�� ( �'h.e �C� �l� " Address: '7 �Q.� �v,�^ n� a� �a � 3) Property Description: Lot Size�:� �%► j�J � Subdivision: Address and/or directions to Property: ��}r„-►.e� 6�t�� 4) Psoposed iJse and Type of Structure: Residential Business/Type: Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No _(with plumbing: Yes _ No � Garbage disposal: Yes _ No _ Approximate size of building foundation: Length Width 5 ater Supply: / Private Well �Proposed �/ Existing _) Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show location on site plan) Note: A completed apvlication must also include: ➢ A plat/site plan o, f the property thai shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the properdy is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representative): �ate: -d 11/07 Person County Environmental Healzh, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) 0 `•�+`�':, .:1.;�,..... ���• �;.. .':� :: . .. ' . , ,;:;� ..�.� <....: y . v�•, . `• �� � • ;,. . . ..: : ':'. i:':. �:: . . . :,..: . ... .. ����.' �' ..'. . y.. :.:;.. �. ,.. �. ; ..,: . . . .: . . .. ... . .. .:,::. .. , , �^'�.,. �.::r� �:�::�:'`����� ��71;i}9'3Si71�.�,�,��-�,��.,',TM��.-.- '� :��'73�:�.::�:.;81:]I:�':;��ld:`'7.LL�.�•,�.1L��:�. � �Y +' 9�' JI../J� �%1�.6.L19'8Y 1 . 1C'L�.t't�i7� 1:�� �� 1i3µ...'��' .'J �u •riiq '1'�� Vi'i�' 1Lr.9_I ��.d.��3'U'tl.J Jt Tax NYap � Applicant: _ Subdivision: T �,..�+;,..,. Pazc�l # �� Township; a�� Lot # Z � � ' 0 � � - � - 1 . 1 i. �. '�ygD� of �a�er,5ea�g��y: ✓ Individual Communiiy Public �t���a�ae��: Site Approved By: _ � Liner: Grouting Appraved By: `1' 'd � �Installed by: , Well Log. � � Depth set: _ Pump Tag: � Grouted: Well Tag• � ' Date• Air Vent:, ' � Hose Bib: � Water Sample: Casing Heigh� ' Concrete Slab: � � ` � Well Driller: So�, Well Approved by; �'*���ee Attac�aed Sa�e SI��#ch�*�� Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Weils must be at least 25 feet from any buiiding foundation. Other canditions: �� �. W�{ ( Sl-�e C. wa.s use� Date: 0 7 PCHD rev 07!�7/0� � �+ . P�RSON COUNTY ENVIRONMENTAL H�ALTH . W,. f � W�LL LOG Date: . /fl � .2. -� � Owner: :—i :,,,,. S o v� �� � SR# l3 � v ��� Location/Directions: � � ��b��vision Nvnc: Drilling Contractor: Lot # WELI. CONSTRUCTIdN Distance from Nearest Properry L'ule /" f�(�„_s llistance from Source of � Pollution o d ,,�s Total_Dep.th: Ft. Yield: 1d GPM Static Water Level �� Ft. � Water Bearing Zones: Depth �Ft, f�� F���Ft. �t. Casing: Depth: From�Q_to�_Ft. Diameter: �� Inches TYP�: Steel � Galvanized Steel .� If Steel, does owner approve: Yes No � � Weight: �3 'I'hickness; , eight Above �round: / � Inches Drive Shoe: Yes �No S : Were Problems Encountercd in Setting the Casing? Yes No ! r .r It yes" give reason: Grout: Type: Neat Sand/Cement � � Concrete � � Annular. Space Width 3 Inchcs Water in Annular Space: Yes No �— Method: Pumped Pressure Poureci ..�— . Depch: Fr�m �—to a�o r t. . Materials Used: No. Bags Portland Cement__� Weight of .1 bag�lbs. If mixture (sand, gravel, cuttings) - Ratio: �— to 1 �ID Pl t - Y � � � � � a es. es v No 4 x 4 slab Yes � No I HEREBY CERTIFY THAT THE ABOVE INFORMr�'I'ION IS CORRECT AND THAT T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS �SET FORTH �3Y�THE PERSOI�t COUNTX HEALTH DEPARTMENT: �c%�/ �' . Signature of Contractor Datc �`��.s:.� If��.I�.��� ��� �o�� v �' �C �'�✓�' �7' �` �'' � !f � C��S tl71 IF.a�..�►-�ia-o�rasm�►eax�.oIl IE�Io�e.Il��a. [D� (�Q� _ �'� ts� Q -�....�....� +awner: _ �LJ� ���1�. U Vyell Log Location: ------- strbdivieiur. �(�� n[ n - ---�------ - Lot * r� M� /�2�p� � l3� ______. Wel1 Conetneciiaa Distance Frc�m n�arest Pruperty Line (Muiimwai 10 feet) 0�Fj� Disi�ncc fram �apiic Systetn (Minimum 60 feet) ,� 0� �" �O� �p�: �,� ft Yicld: _,� j Q�____ GPM Static Water I,�vcl: ___L.5 ` g Water Hr.a�riag Zone�: Depth �_ ft ft fi ft C`aala$e � C� / I?ept�: From �"! to �� ft. Diameta :��� in Typa: G�lvaaixod Stezi ✓ Waght: _�, .�� 'I�icl�uass• � "` • �.L� Height �bvve Cm�und: � in Drive Shae: _� Yes N� Any probtetns rx�c,ounterod whilc setting inr.as g? �Yes No � �' "y�S" give re�.9un• Grout. iVr.�t: SaudlC�snent Can� GraveUCea��at � Armu.lar Spuc Width ,.,,__ inches Water ia Aanul�t' Space r Yes �✓_ No '�it�htx�i of Crouf: Pwnp�,i ,�_. Press� _ Pow�ed .�/ Dtpth _ to _�_ F� '�ktr�s U�ed: No. Bags� Portland cr,ment Wcigbt of 1 B8g ,_,_, Pounds► if mixture �sa�d, grav�l, cuttings} - Ratio to ID plaus: � Yes ____ No 4 x 4 slab ,� Yr�s � No ��� � � Location Drawin� I hereby c�tir'y th�.t the above informAtion ia correct and that this well was canstructed in accorciance w�ith reguiations sc:t fdrth by *he P4�son County Health Departmrant. 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"� � � � � � �� e � � ;''d � � ` �_ . . , PERS�TvT COUNTY HEALTH DEPARTMENT ' , WELL SEWAGE SITE, LOCATION IlV�ROVEMENT PERIVIIT Tax Map #_ Parcel # %3� Zoning Township ` Owner/Contractor '� ,,.,� ��h� v�'..�,� ��5� �_L�n �.� � Da e_ � / (� q �..._ Location/Address ,. _ A 0356 Subdivision Name 5.�.# Lot# � r7 As Installed .�yout � 1 • n ' �. � h/l�C �� �' ���� � ; � � �j �Y� �_ � �/, �;� , � 2 ,r �,�/� �-t-� c.� SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area� °I �tc��,S' Size of Tank � � SFD Mobile Home Size of Pump Tank� Business # of Bedrooms�_ Nitrification Line � Max Depth Trenches Pernut Void after 60 months. Permit �Void if not in compliance with zoning regulatiuns. Permits may be voided if site is alt e� o in n d use changed. Well and Septic Layout by Comments: -T_/ _ _ ,, Date�d� � I o�. : � -�.� Installed by 'S w 1�,.,� � Approved by Site Approved Well Head Approved, Grouting Approved_ Comments: WELL SYSTEM SPECIFICATIONS Semi-Public Required Slab teplacerr�, t Air Vent �/ Required Well Lo� � Well Tag /o �y�_ yv �J �� ,M� �D U j'`tf �i.�'e ✓1 /D �„� rJ �� Date - Installed by� (i(,;4'1:� Approved by l�nL��/�-,ar�;� . Tlvs report is based in part on information provided the homeowner or his/her representative in the application submitted for ihis pertrut 'I'he environmental health specialist is not responsible for false or misleading information contained in the application. The environmental h,,alth specialist is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tanic system will continue to function satisfactorily in the future or that the water supply will remain potable. c:lamipro�permit.sam Ol/95 rev.1.0 ORIGINAL PERSON COUNTY HEALTH DEPARTMENT SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT g �6 tl �Z 9� 2� !3� Date of In pection System Insta lation Date Tax Map Parcel # Address Instructions: Check yes or no for appropriate items and explain in space provided for rerrarks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and surface water diverted ? Septic tank needs p�u9�ping ? Inches of solids: N Septic tank filter cleaned ? Y� / ❑ / ❑� EFFLUENT DOSING SYSTEM: Required pumps present & functional ? High water alann operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids ? �� Inches of solids(pump/dose tank):_� Elapsed time readings ? 4 Counter readings ? rt 9 Drawdown rate: ^� � � ❑ / ❑ /�/ � ■ �� REMARKS �p�i2 �R y ,� ,/(D`1 " Qc CCPs'Si �� / � � ■ DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ Evidence of effluent ponding in trenches ?❑ Surface water effectively diverted ? � Diversions/swales properly maintained ? ❑ Vegetative cover maintained ? Protected from traffic/unauthorized uses ? Distribution devices in good condition ?� Field free of settled or low areas ? �!] / / / / / / / / � � ■ ■ ■ ■ ■ PRESSURE DISTRIBUTION SYSTEM: Tumups/cleanouts/valves/taps intact & accessible ? ❑ � ❑ h l4 Pressure head properly adjusted ? ❑ /❑ n� Q COMPLIANCE: Compliant '� Non-compliant ❑ Needs Maintenance ❑ ADDITIONAL COMMENTS: ������L'�!! • � • �� ` � c,�� �r a �a,-,L, ��r� a�'�e ���►o�a�-� Ct`Ci"P SS% fi�l� . � �,-, r�t S 1��:� f G:i'�c'r- � C(ry4n �.,c:� . o�J.Qv��r i� C,h/�-c'lkr 5���f ►-�— LtQ -�i vl. a�-�-'�-�- �� �� ��,s1��n •