A24 48Person or firm doing installation: v i r� � v � � � qr�
Address �{�i. � � �
�i �T�"�
No. of persons to be serve� Bedrooms 1�2 3, 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine ��� �
Recommended• Septic ta ! 1
,� / �
Nitrification line: f ��'�,t �%� �-�
Above recommendation based on information received and observed
soil condition. Sentic tank and nitrification line mus2 be inspected and
approved by a member of !he Disfrici Health Departmen! staff before
any portion of the installation is covered.
Date Approved: �p "� �� 7�
By:
Countersigned
Signed
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
(Over)
'�� c,a�F° _�.,., �r V�l. �,� '
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later �
t �ate. � i _.
SUGGESTED INSTALLATIO (Da�� ) FINAL INSTAI.LATION (Date ) l���
(Road or Street) ' (Road or Street) "
.'
'-� _J. , I I� ' -ID�a ,� _� R .I _-I-- 1-- v1�-
.
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�8f24/20a5 1a:1� 33b59778�2 PERSON C�UNTY ENVIRO PAGE ��'
�.' -
A iication Date: ��� �J j ax Ma� �: /��� �7
Amount Ratd: , d
ec�; t�: 3 4 Parc�l =:
�� ����� ,��- �.l.�►.1.1� 1� �� O�Gy y
��G� � �� ���LT1���[ � \� a �
��a—r-sx—�.�a��-'--- ��cE.m.IL ���c.m.l+�il�. � � ��
; � a�' �e�.�
AP_PLlCAT10N_�'flR_$Ef3Y1��S � p
IF TH� FQ M TTON IN THE APPLiCAiION FOR AN IMPjZOVEMFaNT PE�,M1T 1S INCORRECT. FALSIFiEfl,
CHAPIGED. �R THE SITE iS ALT�R��, TH�N TH� iM1�RUVEM�NT PER1�IT A�[D AU'i'W�RI�A►'rION_TO
�QI�S _ UCT SHALL BFCOME INVALiD. �
7� Permit reqaested b:(Q�meda e rospecthie ov,me Jat�N �� • L�l � 1�
Home Phane: G 1-�1- i Address_ C O 3
Business Phone: • • Zy C.
Ce1 � '"�
�) Naime �and addr�s af currsnt owna� G H� T' a�d 1�1 �� ORRts
Yz wric� ni
vu .
3} Praperty Description: Lot size: ` 56� Tawnship: �t1N / i�Ubdivision: �.�. FYA! Lot #�
Direc#ions #o the properiy (tnduding road names and numbers): SEE ATT�i LNF iR�ct�eNs
4} proposed Use and Structure DescriptioR; answer ah af the fotlowing questions:
a) Proposed ✓� Exisfing Type o# S#�uc#ure: �ey�E wdtn; 6� Oepth; $�
bj Nurtxber of Badrooms: � Numbe� af oca,pan#s or people to be �erved: �
c) Basem�esrt: Yes� No _ Wiil_t�iere t�s plumbtng in the b�asement? YES
d) Gartiaae DisQasz : Yes . No ... C�
�) 1Nater Spppiy Ty�; Private �{new � ar existi , Pubtic, ,. Community� , Spring _
;Are any wells an a joining proRerty7 Y�No � ff yes, pleas� indlcate approximate iocation on the
sfts plan.
6j Does you� property contain previotRsty id�tifled jurisdictlonai wetiands? Yes_ No„�,
PLEASE NOTE THE FOI.LOWING:
�� Avrr�P �
AN�y .
V'
➢ l�l PLAi OF THE PROPERTY QR SITE FLAN MUST BE $UBM1Ti'ED WI'iH TH1S APPLtCAT10N,
➢ PROPERTY UNES AND CCiRNERS AAUST 8E CI,�ARLY MARI�D.
5' TN� PROPOSED LDCATI�N OF AL.L, STRUCTURES MUST BE S7AiCED OR FLAG6ED.
➢ THE SRE MUST BE �A,�ILY A�CESSIBLE FQR AN E1/AL,UAII�DN BY TH� li��AL.7H �EPAR'i'f�lEiV'�
STAFF.
I heraby make apptication to
system for the a6ovs� "b
facilities bc� be p1aC8d/��e
become•invalid: /% /,
County Health Department far a site eva{uabon for the an-site sewege disposal
� I agree that the contents af this applirtion are hue and �epres+ont the maximum
1 undetstand if the stte is atter�d or the intended use changes, the permit si�sU
�ega! R�presentative
� / o �.
ate
PCHD, �e+r. OGlz7J02
AUG-24-2005 WED 02:1�M ID:ARCLIGHT PAGE:2
►�
e � �
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✓ ,t' ; ,
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s 1
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`•.,,,�:>.,�1 ' �` if��" ' nsuruig a healthy;environment
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--�4 �.�a�����n���.� ���.���n September 16, 2005
Re: Application for Improvement Permits for John Lynch at O.T. Evans S/D Lot 17
Health Department file: Tax Map # A 24 Parcel # 48
Dear Mr. Lynch:
The Person County Health Deparhnent, Environmental Health Division on 9-15-
2005, evaluated the above-referenced property at the site designated on the plat/site plan
that accompanied your improvement permit application. According to your application
the site is to serve a four bedroom residence with a design wastewater flow of 480 gallons
per day. The evaluation was done in accordance with the laws and rules governing
wastewater systems in North Carolina General Statute 130A-333 including related
statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative Code,
Rule. 1900 and related rules.
Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina
Administrative Code, Rules .1940 through .1948, the evaluation indicated that the site is
UNSUITABLE for a ground absorption sewage system. Therefore, your request for an
improvement permit is DENIED. The site is unsuitable based on the following:
_ Unsuitable soil topography and/or landscape position (Rule .1940)
X Unsuitable soil characteristics (structure or clay mineralogy) (Rule .1941)
X Unsuitable soil wetness condition (Rule .1942)
X Unsuitable soil depth (Rule .1943)
Presence of restrictive horizon (Rule .1944)
_ Insufficient space for septic system and repair area (Rule .1945)
Unsuitable for meeting required setbacks (Rule .1950)
_ Other (Rule .1946)
These severe soil or site limitations could cause premature system failure, leading to
the discharge of untreated sewage on the ground surface, into surface waters, directly to
ground water or inside your structure.
The site evaluation included consideration of possible site modifications, and
modified, innovative or alternative systems. However, the Health Department has
determined that none of the above options will overcome the severe conditions on this site.
A possible option might be a system designed to dispose of sewage to another area of
suitable soil or off-site to additional property. �:
For the reasons set out above, the property is currently classified UNSUITABLE;
and no improvement permit shall be issued for a four bedroom on this site in accordance
with Rule .1948(c). This property does still have a valid two bedroom permit with an
existing septic system that appears to be functioning properly which could serve a two
bedroom residence. phone 336.597.1790
fax 336_597.7808
20-B Court Street, Roxboro, NC 27573
e y
� ! Y 1
However, the site classified as UNSUITABLE may be classified as
PROVISIONALLY SUITABLE if written documentation is provided that meets the
requirements of Rule .1948(d). A copy of this rule is enclosed. You may hire a consultant
to assist you if you wish to try to develop a plan under which your site could be reclassified
as PROVISIONALLY SUITABLE.
You have a right to an informal review of this decision. You may request an
informal review by the soil scientist or environmental health supervisor at the local health
department. You may also request an informal review by the N.C. Department of
Environment and Natural Resources regional soil specialist. A request for informal review
must be made in writing to the local health department.
You also have a right to a formal appeal of this decision. To pursue a formal appeal,
you must file a petition for a contested case hearing with the Office of Administrative
Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form,
you may write the Office of Administrative Hearings or call the office at (919) 733-0926 or
from the OAH web site at www.oah.state.nc.us/form.htm . The petition for a contested case
hearing must be filed in accordance with the provision of North Carolina General Statutes
130A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C. General
Statute 130A-335 (g) provides that your hearing would be held in the county where your
property is located.
Please note: If you wish to pursue a formal appeal, you must file the petition form
with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS
LETTER The date of this letter is September 16, 2005. Meeting the 30 day deadline is
critical to your right to a formal appeal. Beginning a formal appeal within 30 days will not
interfere with any informal review that you might request. Do not wait for the outcome of
any informal review if you wish to file a formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative
Hearings, you are required by law (N.C.. General Statute 150B-23) to send a copy of your
petition to the North Carolina Department of Environment and Natural Resources. Send the
copy to: Office of General Counsel, N.C. Department of Environment and Natural
Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy
of the petition to your local health department. Sending a copy of your petition to the local
health department will NOT satisfy the legal requirement in N.C. General Statute 150B-23
that you send a copy to the Office of General Counsel, NCDENR.
You may call or write the local health department if you need any additional information or
assistance.
Encl.: Rule .1948d
Si cerely,
� `-�
Adam C. Sarver, RS
Environmental Health Specialist
;
Apaiication Date: ti �'"9 "� �
Amount Paid: I��
RecEiot #: � 7:�T
Tax Ma #: � �`�
ParcEi #: `f'�
�`���� 9� ���� ��
' -ti- � � ZLT1��'I� �
�aava.a-���a--^-^ �eaa��.71 ?E�mm71.�7Ea.
APPLICATION FOR SERVICES
COMSTRUCT SHALL BECOME INVALID. �
1 Permit re uested by: (Owner/agent/prospective owner): �-�f � � D������� T-�
) A
Home Phone:- Address:
Business Phone: 9- � �
2) Name and address of current owner. Pil�k rs
► G�,
3) Property Description: Lot size: T.ownship: .� ubdivision: � L�v�`-'Lot ##�7
Directions to the property (Including road names and numbers :
4) proposed Use,an�d'Structure Description: answer each of the foilowing questions:
a) Proposed � Existing Type of Structure: Width: Depth:
b) Number of Bedrooms: '�/�lumber of ocxupants or people to be served:
c) Basement: Yes , No !�V�II there be plumbing in the basement?
d) �arbage Disposal: Yes . No _
5) Water Supply Type: Private �ew _ or existing�, Public_, Communiiy , Spring _
Are any wells on adjaining properky? Yes _ espt��as�cate-a ' ate location on the
� site� plan.
6) Does your property cantain
PLEASE NOTE THE FOLLOWING:
_ �
identified jurisdictional wetlands? Yes No/
' - i S ^; i�. /�� i� � �
.oG�-2 G� > � �
_ y���'O% �,z ��v/c
9 A PLAT OF THE PROPElZTY OR S1TE ST BE SUBMITTED WITH THIS�APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEA, "�,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAICED OR �LAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION B`l TOiE HEALTH DEPARTME�IT
STAFF. �
I hereby make application to the Person
system for the above-described property
facilities to be placed e py� erty I
become invalid. /�i��//
or Legal
th Department fo� a site evaluation for the on-site sewage disposal
the contents of this application are true and represent the maximum
if the site is altered or the intended use changes, the permit shall
� ���
Date
PCHD, rev. 06127/02
AnplicatPon Date: � � � �
Amount Paid: I_O Q
RecQipt �: _� 3 c� � <t n
Tax Man #• � � �'
ParcE! #: �T �
•���� �� ���� ��
- _..._ � � �.T� ���
� aa.�r�a.a-ama�a.�-�-� �a:a.��a.Il. �ita�a.7l�lla
APPLlCATION FOR SERVICES
YJ�
�eQ
�(��
IF THE IiNFORnflAT10fV ild THE AP4�L&C.a1Ti0iV FOFt APJ IA�PR04/ENiEi�T PE�II�IT IS INCaRRECT F�+►LS9�iED
CH�►NGED OR THE SITE IS ALTEitED. THE�I T�IE IMPROVE3lAENT PERRAIT AND AUTHOFt1�►i10Bd 'TO ,
COh1STRUCT SHALL BECOAtiE INVALID. •
1) Permi4 requesied by: (OwnerlagenUpr�specttve owner): � s� °�- �G1 T- f�c,9 ��'�"� �'�" -�
Home Phone: 3�-`a.aLo - �[' �`l � Address• 3 � J
Business Rhone: /1/C •
2) DVam� and addr�ss of current owrner. �- �-a va—
� 4� 3 �`- l � M6 oc �
s� S3
t l,__ � �
3) Property Descr��
Directions to the
4)
5)
���G� ��� � �e �
�a-
'?g
Prflpmsed OJse a �rdecture Descriptfon:.answer eact� of the following queStions:
a) Proposed Existing Type of Structura: Width: Depth: �,
b} Number df Bedrooms: �� �. Number of occupants or people to be served: �
c) Basement Ye�_, No � Will there be plumbing in the basement?
d) 6arbage Disposal:.Yes � � , No _ • �
ifiiater �upply. Type: Private r/ (new _ or existin Publ'�c� Community_, Spring _
� Are any ells o� adjoining property? Yesg�o � if yes, please indicate approxima#e location on the .
• 'site pian��c,� eQ � 6-�r 1 o-f- .
6) Doe� your pr��aerty can4ain previ�u�ly icdentifi�d jurasdi�onal wetlands? Yes_ No_
�
PLEs4SE NOTE THE FOLLOINIPIG:
➢� Pl.l�i O� THE PROPEiZN OR SITE PL.Aid MUST BE SU�MiI'TED WITH i1-lIS APPLIC�►TIOPI.
9 PROPER'tY LINES AND CORNERS MUST BE CLEE�►►RLY MIARKED. -, �
➢ TFiE�PR�6?OSED LOCATION OF ALL STRUCTURES MUST BE ST�►�CED OR PI-A►GGED.
�� YHE SITE IUiUST BE READIL�I �►CCESSI�LE �OR AN EVALUATION BY TNE iiEALTH DE�ARi'A!(E�IT
STAFF: '
i hereby make application to the Person County Health Department for a siie evaluation for the on-siie sewage disposal
sysiem for the above-described property. I agres that the cantents of this appiication are true and represent the maximum
facilities to be piac�d on the property. t understand ifi the site is altered or the intended use changes, the permit shall
become invalid. i . . �
or
��cs�%
Date
PCyD, rev. U6127/�2
:: IE��.�:3l��
Driller I�D » / �
C o m��� n;yr N�� m e►� �'
D•at�e Drifleci � " /
C'�rnnt T .na
Owner:
Location:
Subdivision;
-----�----- �.
Lot # • -
• WeII Constrac.fion
Distance From neare� Property L'me (Minimwn 10 feet) � D t
Distance from Septic Systein (M'mimum 60 feet) � D'(i
Total l3epth: �DD ft Ytel - Z-- GPM • Statia Water I.eveL- �$
Water Bearing Zones: Depth ��' ft ft ft ft
Casing: - � If . �
Depth: From � to � ft. Diam,et�er: �(`� in .
'I`ype: Galwaniz�d Steel , -
Weigh� Tluclmess: � j$� Height above Graund: .� Z" in � ; �/�
Drive Shce: � No . Any problems encozmtet�ed wh�e setting casing? Yes " No
If `�es" give reason: . . .
G�ont: / � .
� Neat Sand/Cement ✓ Concrete GraveUCem,ent /
. -•. Annular Space Width • mches Water in Annul�r Space Yes ,�` No •-
Method of Grou� Pum�d Pressure Potmed �/ Depth �_ to _?� Ft
Materials IIsed: - -
No. Bags Portland cement ' Weight o� 1 Bag � Po�ds . _
If mix#�tte (sa�, gravel, cuttings) — Ratio to -�
ID plazes: _/ Yes No 4 x 4 slab �Yes _ No
I:mer.
- -<,.
Date �nstalled:
Drilling Log
Grou� Installed by: �
Location Drawing
l�om To Rormaf�ion � h•
S .1 -\ �� 1 .
L� - k � (�e �� ��''� �� ��,�
Z�b or� {7 - " �� ,,�•�
/ �� -
' � C Orlt:or� /'e.� �
s
C
I hereby certify that the above� infarmation is cosect and that this well was Gons� in acc�dance wi$i rcgulations set forth.
by the Person Counfiy Heal#h Deparhnent : .
SYg�xtnre of Cuntrnctor _
G"
ID#3��r ��. $��-��
Pump Instatiment
' � l ���/
Pump Installation Contractor_ lr�L � (/vK�- Siate Registratian N�unber: ��i'"�l
� �/�� �
�mp Make & ModeL- ftr%_�t� W/-ater Level: —'S � Size and Ratin� _l�hP � gpm
�,�, � Je�. r�
I hereby certify that this pump was installed and tt�e well head completed accard�g to the Peison Coimiy Well Rules in effect
on this date and that a copy of ti�is record has been pa�ovided to-�e well owner. ,
p,,�.�, �+,,�,,,,�,,�, V
s ..,.`p illS�' uCt "`g�"`..aa C ���' `/�Lil� .� �C' �� �L� I�.�/ Q �%�
'�'VELL ABANDONMENT 1tECO�tD
Nocth Carofina Departmcn[ of Fnvirenment and Natur'al Rcsources- Dieision of �'�'aier Quakity
�i'ELLC4NTR4CTORCERTIFIC�IT��N# 33 �C�
7. �\'ELL COI�'TRACTOR:
_ �Q��1 �_ .�— -��c1_�_�- �.
Wcl� Contr.�ctor (Individuai) Namc
� �
���'� e�-r� - L� e �L �-�-�-f • �
1i'e1I Contractor Company Namc
Si'[LEGT ADDRESS � L' E � 1Jy �
_��,� l��_��—_ ��s'?�
City or Towm Stalc Zio CoJc
�
�:,�3��- Sg� —d�_
Arca codc - Phonc number
2,1ti'ELL IPlFO[LtiiATIOV: �
SITE WELL ill # (ifapp���b1�
STATE WELL PER1�lIT � (if applicab4:L ��
COUNTI WELL PER1ti11T f: (if applicable)�/� -
pWQ or OTIiER PERMIT # (ifapplicable) �
tiYELL USE (Circle appliqble use): ��ionitoriag �sidential
MuoicipaVPublic InduslriaUCommercia[ Ag�cultural
Recover}� Injection Irrigation
Qthcr (list use) u, -- -
5. WELI, D1:TAIIS:
' f'l. Diamctcr. r�:� in.
a. Total Dcpth:��
b. Water Lc�'el (Below A�lcasuring Point): ,L�'+� �_��•
Mcasuring point is _� � F�• abo��c land surfacc.
6. G�SINC: Lcnglh Uiamctcr
a. Casing i�epUi !if known)- —, -- ft. _ _ in.
p r�. ��,.
b. Cas'ing Removcd: _ --- � -
7. DISINFECTIO�I: � ��
(Amount of 65%-75% calc ium hypechlori 1e uscd)
8. SEALIlVC �iA1'ERIAt:
3. WELL LOCATlO�I:
COUI�?Y v � QUADTtAIJGLL• NAME , -
13EARE5I' 70VJN= �d 7
_�/t i 1/'G- / �,L% � � f -
(StrceURoad Namc, Numbcr, Cammunity, Subdivision, Lot No., Parcel, Zip Catc) 9.
TOPOGRAPHICJLA�,� SETTINCs:
Slope Valley (�a� Ridge Other —
(Circle appropriate seuing}
May bc in degcas,
LATiTUDE _ — muwtcs, secoods, a� in a
� dccimal format
LONGRVDE � __
Latitudc/longitudc source: GPS Topographic map
(Localion of tirel! must 6e sl�oti•m on a USGS topo map and
attoched :o thuforrt ijnar using GPS;}
4a. PACILI"CY-Thc name of Sic buciness w''iere the wcll is locaud. ComPtete 4a and4b.
(If a resid:nlial �.zil, skip 4a; complete 4b. weli awncr iniornutian ady)
F:ICILITY ID t1(if appiieable)
NAr•lE OF FACILITY
ST�6'I' ADDR�SS _
City or Town State Zip Code
Neat Ccment
Ccment � lb.
Water J_ ��L' Bal.
Bcntanitc
aen[onite lb.
Type: Slurcy_ Pellets�
Wa�er � Sa�-
Other
iype ma�crial �^
Amount
Sand Cemen[
Cecnent �b•
Water fi��•
E�1N 1�1��OD O' . F+� +�CE�� 1V- 7 Ol"� '11AT�RrAL: — J
p 6� �SCs�{ �-J� �� �
10. NELL DSAGRAh1: Draw a dccailed sketch of Nic well on the back of this
form shoc��ng [otal depth, dep�h and diatt�eter of scneens (if any) remaining
in thc wetl, gravcl intcrval, intervals of casing ne�forations, and depths and
cyp:.s of C�ll materials uscd.
I1. DATE �V�T:L AB.MIDOhED �'gC/L � v� �
I DQ liCRtBY CERTIFY THAT 7'HIS w'�.LL tiVAS ABANDOYED IN .'�CCORDANCE
W3'f[l 15A NCAC 2C, «'EL� CDNS'IRUGTION STANDARDS, AND TI-41T A COP3�' Ot
'RiIS ittCORD [iAS BEL�1 PROV(DED TO T7{fi WELLO�L'NSR
^ - - /'� � ���� ''�-�
SIG(RA"I71RE UF' CERTISIED W ELL COA TRACTOR
DATE
4b. CONTACI' PERSONlWELL OWNER:
9 � SIGNAI'CREOFPRIVATEWELLOW'NERABA!vDONII`IGTHE��'ELL DATE
�TAi�tC • h�_b,�L'� � �% � (7'hc private �vell ow•nec must be an iudividu•rl w1w �rsonallr� abarxluos liis`.�er r�ideatiai well
STREEi ADDRESS /" l�� '� — in accordancc with 7 SA NC�.0 2C A l l3.)
-����=� `! �.
1C. � c>
p)tI[� tED I�AAtE OF PERSOPI ARANDONIPiG THE WELL
Ciry or Town Scate Zip Codc
Ac� ea code - Phone number �
Form G�V-=�0
Submit a cop}' to the oKncr and the original to thc Division of Watcr Quality witl�in 30 days. Rev. S�Ob
Atln: InTormntion Management, 161711ai1 Scrvice Ccntcr - Raleieh, NC 27699-1617, Plionc No. (919) 733-7015 ext 568.- --- -
6'd 9LZ6-869-9££ e�;euae8 •� y}iey{ dZZ��O 80 90 ��W
�� �
�, a �
�~ y � � � l��°��`
�x :d�i.�.��.�.���.�i����i.� ..LL. .1L. .�ra�.�llr�
�uilcling Aciditions/ l0�obile �oane Replaceanents
Tax Map #:�� Parcel#: g
Approval Requested for: � Mobile Home Replacement
- Building Addition �
Applicant Name: 'L�en ylj � Eu 1 r'<5
Address: "
Phone #'s:
Permit Located: � Yes No
Installation Date: --�0 Design flow: Z.�a (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: V Well Public or Coxnmunity
Wastewatex system shows no visual evidence of failure on: �a -� Z' D% (date)
(Applicant's signattue if site visit is not required)
Comments:
Addition/It�pl ceiri�nt Approved
3 -Zs-oS�
Enviro ental Health Specialist Date
`� 11/15/OS
�
-rr-----__.,.....,...,, 2J"s-�7�10
Amount Paid: G
Receipt#:
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_ ��-- �C � � ��C`�
J E:.r.:tZ.O� ]t ]t: .C:D ]tT.:It]iYT. �['s ]i'31.'Q:..LIt..Il IF^3L �_--.ati Il. ��L-.:la.
Application for Services
(Septic Systems and Wellsl
L Improvement Permit (Site Evaluation)
�200.00/�300.00 (if> 600 � d)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required) /J
❑ Well Permit (New/Replacement)
$225.00/$12�.00
� aX Map: ZY
Parcel #:
Ser�ices Re uested
� Construction Authorization
(Fee is de endent on the e of s:
❑ Permit Revision
G �75.00
� Repair of Existing Septic System
� No Charee
Important: If tlze information in tl:e applicatiott for an Improvement Permit is i�zcorrect, falsified, vr tlte site is altered, t{ien the
Improvemenl Permit and the,4utl:orization to Construct sliall become invalid.
1) Services Requested by:
Name: �� p�� i5 ��ul j SS Phone #(home}:
Address: (work/cell): _
2)Name and address of current owner (if differ�nt than applicant):
Name:
Address: � �
3) Property Description: Lot Size; Subdivision: Lot #:
Address and/or directions to Property: '— a C.a d —� L
d�e,���,ee,5 N��ll ��1- �(� ov� St,��p ►>,�� =� � �►� Shore re Dr 7
La t�o �te,. ���- ,.�mh�1 "
4) Proposed Use 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) Water Supply:
Private Well (Proposed Existing _) �
Comnnunity Well: Public Water System:
Are there welis on the adjoining properties? No Yes (please show location on site plan)
Note: A comnleted anvdication �nust also include•
➢ A plat/site plan of the property that slzows prope�ty dimensions and ihs saze and lmcation of all
proposed structures.
> A signed copy of tlae `Lot Prepaa�ation', f'orm verz�}ying ihat the property is ready to be evaluatec�
I am submitting this agptication to request services from the Person County Health �.lepartment. The information
provided is accurate. I underst�nd tbat if auy site is altered or the intended use changes, all permits shail become
invalid.
Signature (Owner/Legal Representative): � ��te; 2 � g
11!07 Person County Environmental Heaith; 325 S. Morgan St., Suite C, RoxUoro, NC 27573 (336-597-1790)
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SiTE PLAN
Name �/ l�ll�K dIM Tas Map �k,� Parcd #�
S Secrioa/I,or# •
� G —12-0�
scate Agcat Dax
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iasaie rharpmpagsadeJama�craiaerL ,
,
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Tax Map f�_ Parcel #� .. Tbwnship:
Applicanf: �n�,,./ _ � Lov� 4- n �/� � .
Subdivision: ! r �+ �
T�e of �atea-,5uppgy: � Individual _ Cammuni Public
tY
gteqnirements:
Site Approved By: /V1 �
Grauting ApProved By: /0 6 7
Well Log. � �
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Pump Tag: � �
Well Tag: - '
Air Vent: ` .
Hose Bib: � �
Caeing Heigh� �
Cancrete Slab: � � � ` � �
`Nell D1111er: ���n � �'-�-�
Well Appraved by:
****Sce At�ac�aed �ite Ske#ch�***
Liner:
7nstalled by: _
Depth set: _
Grouted:
Date:
Water Sample:
Wells must be 10 feet from property lines. �
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:,
PCHD rev 01.�27J0�
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