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Person County Heaith Department
Sewage Sys em Improvements Permit
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Date�%'�U" " This Permit Void ter Years �'{�
Owncr: .v � �� SR# -�Z �
I,ocalion/Directions:
SubdivisionName: Ct ��' �/v Lot#��_
Lot Size: Type of Dwelling: .
Water Supply: Privatc: �� Public: Community: -
Bedrooms: Garbage Disposal
Basement Basement Fixtures
INFORMA �N �ER D B
Salli[3ti811: �QG� ow or repres civ
REpAIR: .—REEVALLiATIO_ `
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Size of Septic Tank:' �' V '
Nitrifica[ion Line: '�` �
Depth of Stone: 12 inches
Max Depth of Trenches: - _ _
Altemative System: Conv. Pump
$1Z0
LPP
PL�LS----U—________ ______._y� -_. -
Date Well Approved: Well should be 100 ft� from any sewer system
BY Sanitarian Scsv� T,�•�s f L'''r�p
Date Sewage System Approved: /Z -/7-%/ :Ns+�/� �''/�� � �-b
BY� � �r.� r;< Sanitarian
FICATE OF COMF'LETION
Contractor T.'�n�v -�:,..:s
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Sewage System location, installation, and protection must meet state and local �
regulations. Sepdc tanlc should be pumped out every 3 to 5 years and shali be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and'�d
nitrif'ication line must be inspected and approved by a member of the Person Counry �
Health Department before any portion of tiie installation is covezed and put into use. If
the site plans or intended use change this permit is sub' ct to�ev�tion.
(G.S 130 A-335F) � `� "� fw,,�
d,�-�s� ��� M�, ��� .-�, �� �-r�� ��� ��•�.
I.ocation of sewage disposal sewage system sketched on back. `� v�'s�� `� '��j%lP /"t
�""D ✓i /D - a �-Cj l �l • � VER) � Sr�t;�i c �"/,/ � �'c`/
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Pexson County Health Department
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- Well Permit �
Date: ��-�D �l � is Permit Void After 3 Years b�f
Owner:
a� �l ����-�e � SR# t 3�2 �
Location/Directions:
Subdivision Name: ` Lot #��
Drilling Contractor: U
WELL CONSTRUCI'ION - 'd
Distance from Nearest Propercy Line /��u.s Distance from Source of �'
Pollution 1d �d � /u. K �
Total Depth:��FG Yield: _,�� GPIv,( Static Water Level �Ft. �
Water Bearing Zones: Depth � FG `� 0 FG FG FG
Casing: Depth: From � to �� FG Diameter: (o ' Inches
TYPE: Steel Galvanized Steel '-� �
If Steel, d� _owner approve: Yes No
WeighG �_ Thiclrness: �GSCHeight Above Ground: � Inches
Drive Shce: Yes � No
Were Problems Encountered in Setting the Casing? Yes No �—
If "yes" give reason:
GrouG Type: Neat Sand/Cement �" Concrete
Annular Space Width .'� Inches
Water in Annular Space: Yes No �"
Method: Pumped Pressuze Poured �
Depth: Fmm � to �� FG
Materials Used: No. Bags Portland Cement � Weight of 1 bag
� lbs.
If m'ixture (sand. gravel, cuttings) - Ratio: � to 1__
ID Plates: Yes � No
4 x 4 slab Yes No
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I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
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Si C tra or Date
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anitarian s�gn re Date Issued
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Sanitarians Sig ture Date Completed
Sketch well location on reverse side.
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NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
�upplies, 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��1 ts.
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Application Date: � � 9 "� 7
Amount Paid:
Recaipt �: � � � 3 `i
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Person Cotmty Errvit�rnel�l HAedh
325 S. Morgan Str�t
. Su�te C
Roxboro, NC 27573
Tax Maa #: � � "�
Parc�! #: � 3 �i'
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APPLlCAT10N FOR SERVICES
IF THE IN1FOiZMATiOfd ifd TF6E APPL9C.4TiON FOR ,�A1 lMP4�OV�MEi�T PE1�fVIIT IS IMCaRRfE�T. ��1LSIFdE�,
C�I�►NGE�. OR TF;E SR'E IS ALTEiiED. Ti-BE3� T�iE 1nAPROVEMEIUT P�EFtIlflIT AND AUT�IORIZ/�'PiOfd TO
COPJSTiiUCT SFlALL BIECOAAE INVALID. �
'!) F'ermii recques4ed by: (Owner/agent/prospeciive owner): M1�k�� �ro�
Home Phone: 3�V- �`�`�- ��Z'� Address: d� S'�vNtiye�ao� (,N
Business Phone:�3�- S�h- z�z► SSM.� NC Z'►3�t3
l 2) iVame and addr�sss of c�rrent owner. h�l�u�vt4c. troeMs�
�G S`N1.i4yBRuok (�►�
�4i�o,�� Nc Z't343 .
� Praperty Descr�ption: Lot size: •�Z ��Township: 5"^°a'�
Directions to the property (Including road names and numbers): _
N n/I�c�,au'� rh��w t2� � �,rk
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Subdivision: U�Ic P��Nr�' �ot # 39
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P'e�posed Use and Struc�tur� escription:.answer eact� of the following questions:
a) Proposed . Existing , Type of Strucfure: ��� { Aoa�°�' Width: Depth: �
b) Number of Bedrooms: _�� �. Number of occupants or people to be served: y_� �X��N�.
c) Basement: Ye�� No �' Will there be plumbing in the basement? �
d) �arbage Disposal:. Yes •� . No ! -
1fi(a*„er �upply. TY�s�: Prn.�ate ✓(new _ or existIng�, Pu�!dc_, Com:r.�n:fy_, Spring _,
� Are any welis on adjoining property? Yes_ No _ If yes, please ind'icate approximate location on the
'site pian. � . . �
/6j Does your property cantain ginevio�+sty identi�ed jurisdic#ional wetlarads7 Yes ✓ No
PLEASE 9�OT'E THE FOLLOWIfdG:
C� a� K��a Ihti+- �
9 A PLA7' O� THE PROF'E�2N OR S1TE PL.AN MllS'i BIE SUBMf�'TED WITH YHIS �P1L9C�T1�N.
➢ PROPERTY L1NES AfdD CORNERS MUST BE CLEA►RLY MARf�D. �,
➢ THE PRC?P�SED LOCAT10iV OF ALL STRUCTURES MUST BE STA6CED OR FLAGGiED.
��HE Sil'E MUST SE READILY O�CCESSiBI.� F�R AN EVALUp►TION �Y TiiE HEALTH DE��►RT�iEiVi'
STAF�: �
l hereby make appEication to the Person County Health Department for a site evaluation for the on-siie sewage disposal
system for the above-described property. 1 agres that the cantents of this application are true and represent the maximum
faciiities to be plac�d on the property. I understand if the siie is a(tered or the intended use changes, the permit shall
become invalid. '
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Owner or Legal Representative � Date
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�"�smt.�.�'�7n.�'++� uC�.'�f.� �C,tB..�1.�iC�.
�aaa��ag Adc�itio�/ �obile ���� Replac�ffi�e�t�
Tax Map #: A z�i Pazce�i#: /3`� _ � .
A�proval Requested for. Mobile Home Replacement
Building Addition � '
Applican� Name: �
Address: • ' b
. .S¢w►arn' C 27343
Phon� #'s�:
✓
Pemnit Located: �'Yes No
Installaxion Date: /z-/z —9 / Desiga $oar.. � (gpd)
Cuaent Contract �vith Certif esi r on $1� (if requirecn:
Water Supply: Well � Public or Communiiy
Wastewater system shows no visuai evidence of failure on: (date)
�'. �APPlicant's signature if site visit is not require�
" � Add'a#io�e�aiac�n�nt A�provesi
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Enviromne � Heaith Spe�ialist � Date
� 11/i5105
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SITE SI�ETCH
Tag Map #_f��.Pa:�cel # /3'�
Sectian/Lot# 34
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