A24A 14�'h� t'}ys�ri�� 'Nea�'�I� �3epartmen��
Oranga. Person. Caswell. Chatham. Zee Catsnitea
SE�'T�C TAt�t{ PER.�tT
DB�c_..s.L=-� " ? �-�
� ) _ � }
Name af owrrer: ��r�'�"�' x „f"`•'�_t�'�"j
' Nume ot contractar: •
�Address and Dicentions +�''-T-,- rz��4�,r.. �,(�fpr a�
�RI� �l�r..�t' .��,��J��� a� r�-
I'eraon or itrm datng tnst�►llation: _���r�--�-''�-f1tr;,?
, hddmes ,
No. af persons to be served Bedsooms 1, 2�,'}„ 4.
Add[iionnl a�spllnnces to be used: D13pa9G1, diehwasher, wnshing
machine
Itecommanded: Sepkic ta
IVSt[�StCAfLOR line: �"� /'� �� / --- �
hhave tecommendation based on in[ormntion received nnd abserved
&oit c�ndltlon�. Septie tank anci nitri(leation line musi be ins�peeied and
npp=avad bg u memhex oi thn Districi Fieaith Dogaztment gtaif befare
n�tiy Qoction oP the installation is coveced,
Date Approved: �'�" ��-
SI[�ic[�
Snnitur'cctrs
� gy; t�
� Q. �avid Gnrvin, M.D., M.P•I�i•
� Dtstr2ct IIcatth atiicer
�
a
m
N
ce
0
N
ti
a
riC
�
CouniuYaignnci .�
(QYCC�
�I
.�`'"-7.
'�.
'.R iy
�. O
� �
tl �'a,�
� �' � �
a ��
r ��
� � !'f'
H
; o 'a s''
vx m Q
R„ � M,
yb
„ ro y
a ���
�o
� a
� a
m �.
� �
H aQ.+
v � �
a o
T�r±`�i ts
J P� Ffs
� o �
H
a ro
y �i
� � p
a �+, n
;1� �
P�
O�y � �
�� o •
� N �,
n � '.
~ � N
a' `
`D w
i F• �
n H
' n C
• a. ro
� '�
� �, R
� N
�« �
� �
J
8
t�ppIics.�itm Date• � I
A�:�vf�tPaid: � _ zUD, O _._._�..�
�U
Re�igt #�: t G7 �G j _._______._
� #°��� � Au
(Siie
Mob3,ie
or
x
��� �f ������
+Ct��.7I�'7C'�'
ir,...n�oYua�a.�l �calf,�c
S�.xvic.e.a
far Services
Caa�raction Anth.orfiatlon
(r'oc iQ �c an tha t�
permtt Revisian
p.l
z'az Map: �.�
Pa.nxl�i: �
pair of Ezlstin� Septic sy�b�m
Applicatian: No C1sar�el CA �S15Q00 ar $340.Ot1
. „ w�� , � ��:,��
:�„ � :. .: `
...., i a:
> ,: � .�
�+ ' f y
r.. a'• 4' '. V .� 1•. � 1 � 1' ' 1 t: 1 :/ t i r: 1
` ! ...♦
:i/i,' ! ' i�.?� a /} . . i. .
. , . f � .�:!) .. • � r� �.�,�
. -
,.. :.. �. .• ..,;,.,.� ,��. + -
3� prupertp Uesrriptioa: T.�ot Siz� �,�i � Subdivisian:
.ar3amx H,�•il�� a�rccti,nnsta I'i�+�Y �_.�.'..M'_t
Phane (lwma}: � E!' �'3G SlO�'
(woric%e11): � Y3� e7Y
ill�lli�i. �r •�
#:
P,�n CS �ta!°cu�
❑ ygg 0� Doe� it�c �iin wu�s any juaa3i�asmat wcuaaas=
[.}y� Q no lloes iiss sita � s�Y �s�'�'� ��Y C���''�Af�. S�?s�
Q yc� C�i l's saY �� �� ���� oa tl�a sitc othcr thau d�tic s�aSC�
�,�es [�a Is chc sita snb,�ec= u, appa�� �Y �Y o� F�lic astncY�'
❑ yes C�nmo Are thcre auy essemeuts vr right of ways ou this pmperty"'t
{`xf `ye.s' is chccked, pl.ease Fm'�� ��PP� dtxcua�.emtxtiaai
4} Pro sed Use and'Y�pe ot' Str�tctur� J���1,�'t:'L'%�!if%� lnJ'L'�GC�
� af bctirooms _I.Oc��
t7 N�,S;rgic:Ersvu7Y,R�i���...�_ . 1�+Suximtu�amim}xr
O Ezpansion of P� SYg� I� aup�ioa: Cuucnt aumba' nf bedroams:
[7 Rcpsir to MaLfuucrianowg SYsxm w�l ffi�re ba a basem�? r7 Yes O no with piumbing $xtnres? O yes Q no
Q�Te.n R�enl�t T� �q�e £ap'ts�e o€Bc�.ildin�
Typo of bnaircess: Ma:immr► m�nher of ae�ta-
nfa�cm+un uwmbor of oa�ic+Y'�e=
zS � .al.�'
�-O 'E- P l"'^� l� ,�c� fi'�;'
ti�
�j W�r Snppty' il %Tnw tivett C'1 R�cidins Weil C! C4m�itV WG� � Publtc Watc� Q S��
nr eai�ti watcrin¢es csn t}�is �ra�'1 �� �� r+'.�'K�'`loW,1t�
.Ar. t�cre say existxn8 `uejts= sPrmEa� '� ai chr�t�tiAn: _ t�+Sentt,ud�Sl/'f -
Plesn.m no:h ama* 1cIIo�Vsi �'oae.ter �ts'aictions tat' satn+cas ........_ _._ __...
b� ���YOt'AIILWIFct�aa{r�������'i����fl�u�-./�Qiyi,tQtlSIItiv�C Q�;Ya' v+lo�V'4Ft?JtY'M'+��a7+ Q1�4y
� Yt•'A.l�l}T3i� Q AlA.GjJLt3i� Q �tl.'V�6
Ievrr�.l,fy ahut si�u I��n.ulf�.rr. f.r asxd�...iC.Yb,a�w�e iLs rontFticaD ttrs.�•vnrvwat laabar aw.l.,r.�tutea/.Cxwt iffX� i+�i�•=+�•+f.e+r�p�n�s�rie%ea r♦
inaccurat� the site fs steb�sequently alterert. or the intended use chang�s, alY�tr cmd appravats shul? be irrvalicl.
�/,..?�?.�� ���-----
� ,_,
IIi'e (,Vw�Y I.cSai R�7?r���') Deto
* goppoztiag documemtatianizquizCcl.
. Permits are valid for efther 6ti mouths or sre non-e�irin� wheu scx�ompanied by an apparoved plat
. A co�anplered �Zat Prapmwt�ron' fortm m�vt arr»m�s�y enp' $gpiic�tion Y�uiYiti$ a SYt� eYttltuiion.
(IWl:+} 1•ersosa C.otsGt'V8�1c*IrutsxTz�r»l Hawil.i�� 92:5 Si. Maiisaiva �L. �uatt S:'. Yt.�.L{�'b.TTC_:; '7S?t ('S'S�S-49T 7?�}ii)
���.sf ���.���
�--�- � � ����
�ua�n�roaa�am�rad�.�. g'��e����a
WELL PERNIIT
(New ✓ Repair_)
Tax Map: �,q Parcel: �
Subdivision: ��/r��� r ��,��� Lot: �
Applicant's Name: �j,��� ��jN�
Mailing Address: Z ��1��� � y� � .
��Du��S 'rU.�U� � f�, 11i�i�` �7Z/�
Phone Numbers: ��� —��/— �j� � �
Location of Property:
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction 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: /l/f/,Y>�/.�i�1 � ;�P�'r�s'�'1iGf � �f�'�1L
r�' Z: �L��
, Permit issued by: Date: /
�1ew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Certificate of Completion
QLiner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
ConnectGIS Feature Report
�!i �� IGIS
l �,vee, H�:sri���.
133�
: r.
r' ��h
,' r �
-� 7���v��ra
'v`i�Gi-�-
�?�A
�E�'T'iG
` `-���`'�- Tc M
Person County Ernironmen#ai Health
325 S More n Str ..t i�
$lll�8 Ci
Roxboro, NC 27573
� � 7� T ' ��J «2G✓�i k} C _
-��� G� a��
C'�� ti T �,-` �-�
L� +a�-��i7- �7�it�
�
�
$2 �
Page 1 of 1
Person
Printed April 18, 2016
See Below for Disdaimer
��- :.��. i
1631
, ._
,.::: -
` ' _
� 'ii"`' - _
i ;r
'•�_' �: i :. ";r `r
- ` ��-� Total Len�th: 325.93 Feet
� � ,
A (}
��=='-'_�_.���_� � 3562.�i 5 Sq. Feet
CJ�.0 V Yt��eS
`� ' �`—� Of �a. h��1�85�
�' F. " -
' � ' - - ____ i, : �30 Feet
OTICe: Recently, we have had several users report browser compatibility issues when tryiny ro access our GIS website. Typically, the problem stems from users wno F
�wntiy upgraded to the Windows 8 operating system or a new version of Internet Explorer. We were aole to resolve this issue by directing users to the Internet Expl�
ompatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US/internet-explorer/products/ie 9/features/compatibility �
this does not solve the problem feel free to contact us at the number Iisted on our main page. Weicome to the Person County GIS Website. ConnectGlS has b
repared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system
otified that the aforementioned public information sources should be consulted for verifcation of the information in this system. Person County, Mobile 311, Connec
ssume no leqal responsibility for the information in this system. Grid is based on the NC state plane coordinate system, 1983 NAD.
l�ttp://gis.perso��countv.net/CcrnectGIS_v6!DownloadFile.asl�x?i=_a�s_i11ap5e5t�8799?e89... 4!18/2016
-��