A24 55���: sf .���.� ��
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WELL PERMIT
(New_ Repair ✓)
Tax Map: � Parcel: �
Subdivision: � � Lot: �
Applicant's Name: _11�11��__, ��11��2� f�LG
Mailing Address: (oc�
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Phone Numbers: �'j�� – �i�v�� .� —=�� !.�/.� �
Location of Property: ��� i��`��',���.
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Permit Conditions:
1.) S'ee anached site plan for proposed well location.
2.) AP applicuble ���te and County regulativns governing consiruction and setbacks apply.
3.) 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: - � Date:
�Iew `Ve11:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Cert��i�ate o# Com�le�io�
�I.iner:
EHS/Date
Depth: �'
Grout: ✓ J � t
4's- (�S- SP
i�Ja�[.r Lt)r �.J�
Adriiteonal Com.ments:
Date Sample Coilected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results 1�lailed:
Phone:336-557-1790 Fax:336-597-7808
ilj2oj13
Application Date: g �b
Amount Paid: 7 . Ov
Receipt #: 17�2 9 74
CYe� `�- � � � - I G� AAl
❑ Improvement Permit (Site Evaluation)
�200.00/�300_00 (if> 600 end)
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- - — - ---- _ ----
f01��n �c��1
cation for Services __
5ervices
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required) _
�Well Permit
A1AA I�A/N�
Taz Map: ,�,_
Parcel#: �_.
❑ Construction Authorization
(Fee is devendent on the type of
❑ Permit Revision
❑ Repair of Eaisting Septic System
Annlication: No Char�e/ CA $150.00 or
1) Applicant Information: . _
Name: � �j^G Phone (home): 3 `
Address: ' ' ' (work/cell): ����,� �e.��9
2) Name and ad ress of curre t owipe if different than applicant):
Name: 1 Phone:
Address:
7
3) Property Description: Lot Size: .''1?5 Subdivision: Lot #:
Address and/or directions to Property:
� yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage?
❑ 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 documentation) .
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? C7 yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: 0 New well 0 Existing Well ❑ Community Well ❑ Public Water � Spring
Are there any existing wells, springs, or eacisting waterlines on this properiy? ❑ yes ❑ no
Please note any imown ground water restricrions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, th site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
�
Si ature (O r/ Legal Representative*) Date
* upporting documentarion required.
• Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat.
. A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
�� " The Dis�r�ct IH�alfh Deper�wn�en�
�:
�,,; : Orange, Persan, Caswell, Chatham, Lee Counties
� S. � .
,�`� � � �' SEPTIC "I"ANK -PERl�e11T'
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r. IL SL Date� �
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Name of owner: �
� � -
� � � Name of contractor: _� �+�- � �
Q � �- �
� , � Addre d Direct�; ns i' �� � ���s -� �
o �� �-� � �� N�� � � � ►�
Person or firm doing insialZation: � 1�.��i.�li� ll +�. �
Address �"�� � �'< !'�'� �E'Z��—f�--�=F .
.
No. of persons to be serve� Bedrooms 1,�3, 4.
Additional appliances Lo be used: Disposal, dishrnrasher, _washin�;
—�-
machine _
�-------. �
Recommended• 5eptic tank—L.Le' �� ; .
1�.��.�" _J .
. ,
Nitrification line: -�s1�,L1.�1�-• � l'��'����-�—=1—�'� �/.
� �'.i"Or'�(C�G
Above recommendation based on information received and observed�
soil condition. Septic tank and nitrification line must be insp�cfed mnd •
approved by a member of the D3�trict Health. Departruenf st� before
any portion of the installation i,s .covered. '
Date Approved: ,�... �p .�7
uigne� �
Sanitarian '
By• " . • .
O. David Garvin, M.D., M.P.H.
District Aealth Officer
Countersigned
' (Over)
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WELL PERMIT
i •
i•Caswell-Chatham-Lee-Person Counties
! DATE ISSUfiD: /' 'B JDATE DRILLED: COU �1� StrY�
i OWNER:_'� ' 7� D STfj�E • • 3.�
I ADDRESS: � � � �n �@��(ed � � �I�I,�, YEAR
DRILLING C NTRAC OR: 1�i(i��+.�-
+ - NAM.E ADDRESS
� • - WELL CONSTRUCTION
Distance�_fror Nearast :�operty iine Distance from Source oY
Po l lut io�' "-
Total,-�e�th: Ft. Yield:�_GPM Static Water L vel: FY.
Water Bearing Zones: D�h:�t• Ft/ �t. Ft.
' Casing::;' Depth: From�Lto Ft. Dia�Seter• Inches
TYPEc Steel Galvanize3 Stee1 V
If Steel, does owner appro�+' Yes No
Weight: Thickness: `� Height Above Ground: Inches
' Drive Shoe: Yes: No:
Were Problems Encountered in Sett�.ng the Casing? Yes_ No_
If. "yes" give reason: /
' Grout: Type: Dleat Sand/ ei�F:nt: Concrete �
Annular Space Width ��Inches
__.Water in Annular Space: Yes No
Method: Pumped ssure Poured �
Depth: From to Ft.
Materials Used: D:c. Bags Partland Cenent Weignt of
1 bag lbs: • - ' '--
If mixture {san3�rarel, cuttinga) - Ratio: to
ID Plates: Yes��N o Chlorination: Ye� No
4 x 4 slab Yes (/ No
r . r.
De th
From . 'to Formatio Descri tion
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT A D�"THAT THIS
WSLL WAS !'ONSTRUCTED IN ACCORDANCL FII E TIG Sc.T ORTH BY
CP.SWELL-CHP.TH:1M.-:,EE-P�P.SOi1 DIST. H.^.P ` _ /
Signa ure of Contractor Date
FOR HEALTH DEPA ME US N
�.P.EASOCI FOP. NO INSPSCTION: `��
' �
5 al-S�ah's Signgture • /Dat
Sketcn well location on reverse si e. Use established re£erence
points.