A24A 23v
Additional appliances to be used: Disposal, dishwasher, washing
machine �Q �
�
Recommended• Septic ta /
Nitrification line: � `� ` � I �� �' V / � ►�� — � � � �
Above recommendation based on information received and observed
soil condition. Sentic tank and nitrification line must be inspecied and
approved bp a member of fhe Distric3 Health Departmeni staff before
any portion of the installation is covered.
Date Approved: � — � � � �j �
Countersigned
Signe�
5anitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
(Over)
NOTE: Make sketch� of installation sh ing location of house, s ic tanks,
adjacent property, etc. Write ' measurements in order th stallatio
date. �
SUGGESTED INSTALLATION (Date ) FINAL INST ION (Date_
(Road or Stre (Road or
����s�v�■
������r.���
� ��
. - .
�
s, water supplies on
y be located at later
_ )
�_ � � � �
��.
A�plication Uat�: 9� ��-d� i ax �a�o �: �'2� �
Amount Paid� ___� tf o2.3
R�c�iut #: � 3 � ParcEi �:
� � ��3
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�.� M� L � �'�
'� .�PP�ICATIOM FOR SEi�VIC�S
CONSTRUCT SHAL.L SE�OME IfVVALiD.
'�) Permit requ�t�c! by: (Oevner/a ent/prospective �w�
Home Phone: �.� ���9-7/� Address:
Business Phone:���/-�Sb - 9d'.�i3
�) N�e and acddress of curre�t owrner: So9�n �
� y. .�/�cI �'ll' �:�I�rF�'
� ,�<a�,��s,�
�) Property Descraptoon: Lot size:� Township: Sub ivision: �y%fili-5
Directions to the prop� (Including road names and nurmb� ): ,�biy1 , o� b_
�%� �
/ / �°e� �� �
��
/�� .����'�J�
i'
Lot #
� , . � ��� �` ti7 c*-�
- �J L" //Y �U�f� � � - � t�/ Ul�' i` L" �j-`II� /� ��i� .
4) Proposec9 Use and �rei.acture D�scription: answer e t� o'the f�owing estions: �. �
.a �
a) Proposed _, Existing lG�ype of Structure: � .� -- f"o"�'e Width: � Depth: o�
b) Number of Bedrooms: �- Number of occup ts or peap to be served: -�
c) Basement: Yes , No _ ill there piumbing in the basement?1�
d) �arbage Disposal: Yes , No '
5) �ilater Supply Type: Private ✓{new _ or existing , Public_, Community_, Spring _
Are any wells on adjoining property? Yes�_ If yes, please indicate approximate location on the
'site plan.
fi) Does your propeety �ontain g�rev6ou§iy identafced juresdictional wet9ands? Yes_ No�,�
P��4SE 4�OTE YHE FOLl.�IAlIIdG:
9�► PL.�►T OF T�BE �ROPE�'�Y OR SiTE F'LAM NiUST �BE SU�Ni1�TE� NVITi-6 T'i-�1S �►PPL�C��IO�f.
➢ PROP�RTY LlP1ES .�1PlD �OR9�lERS �US"�' BE CLEAR4.Y MARK�D. �
9 T9-lE PROPOS�D L�C�►T10M OF ALL STRUCTURES fifiUST 8E ST�►KEi3 OR FLAGG��.
9 T4�E S17'� iViUST �E 3�DILY ACCESSIE3L� �OR AR� EVALUA�I�h�! �Y iiE 9��►LTF9 fl�EPARTiiIiE�T
STAF�.
I hereby make applicatio� to the Person County Health Department for a site evaluation for the on-site sewage disposal
system bove-described property. 1 agree that the contents of this appiication are true and represent the ma:cimum
fa ' ies to bee�laced on the property. I understand if the site is aliered or the intended use ct�anges, the permit shall
or t,.�gal Representative
9=/ - ��
Date
PC}-ID, re�. 06/27/�2
•�1��J�� LL Li.G[ I V✓ V�
� /� ??}}'' �\ 4 �^�
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IE ����,*„ ,.,..,, ,B��.Il IE7i�.�.Il�
SI'Y�. S��'I'C�.
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.. . /. .
i_: � f�L
,. -
' � � . - � ' � - �
° sy� �o�� ���t �p�o
begirening the issstaAation to insure
Scale: � V l 0 vl �
'T� lblap #��Pascel # o� �
Seciion/Lot#
a�-�
Date .
zte�tontvurs only. The cantrd
propergnrsde is maintained :
Cu �'
\ d Sa� /
1•�
', flag the system j�rior to
�l 5� %�
�w '"�' ��Q s�
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pCI�, =ev. 09/]2/01
Mar,27 2014 7:58RM Martin L Vernon, CPR 8468350 p.l
n
ApplicatioaDate: �7 ��,.�� � ����� TaxMap: 1��'7' �
AmouaEPaid: 0, O ,,_.. .► � Parcel#: �"
Recelpt#: _�t.�yo6_, �:����� , _
rec�` � �►sa..i�•o»-�*oan�.a.� :1E3�a,�..l�a. �
C c ar�� Applicatlon for Services
❑
❑r
❑ Canatrttction Authorixatio
�,Faa is dcpendeat on tbe typ�
o rermu Re�€elon
$75.00
0 Repa lr of Exlsting Septic E
Applicatian: No Charge/
� 1} Appiicaut Informatian:
� �SII1D: �alr-�lYl �- `�►Z.�e�� YeC' /'j0/l�
� Addross:
� 3
� 2) Name sad addreas aP tur t owaer ilf difPerent thaa applkantj:
ivame• s A �e_ '
� Address:
$150,00 or$300.OQ
Phone (horne);_� _�__�_ _�' � g —
(worklceln: �! ( et —'2�1� �� �
Fhone:
�C.
3) Property D�scr3ptiau: I.ot Size: '.�6 Subdivision: ��S �Jo u Lot #: ��
Addross andfar diroations to Progerty: 1 1 3 t'Y� r'�
,�5� r�r�t� c _
0 yes �o Doss the art� canta�n auiy� jurisd�ctlanal wetIands7
63'yes ❑ no Does t�e site contein aay existutg wastawater systems?
❑ yos C�o. ts er►y wastewater g�ing m be generated an the site ather t�an damesiio saws�e7
❑ yes �[s the si#e subj eci to agprova� by any oi�ar pubtie ngency?
� Y� i�io Are there aay easements or right of wsys ou ihis prapertyl
(if `yes' is c�,sctoed, �lease pravida supporting dncumentatian)
4} . oaed Use and Type of Straabare:
[
� New Sing�e Family Residence Maximum pumber of bodtnoms: ^� �
O Expansion of Bxisting Systern if expaasion; G�trent numbar of bedrooms;
O Repair to Mat�nctioning Syste� Will there be e bascmern7 CJ yes l,1na-- With plumbtug #ixtuc�es? ❑ yes ❑ ao
0 OII-AE
Typa of businass: � Tote1 Squara foaiaga of Huilding:
Maximum Qum�er of empl�yees: Msximum numbor of seats:
5� WaterSapply.: ❑ New weJl [9'�'sdng Well � Community We11 ❑ Public Watsr !] Sprin_g_
Are there any existing weils, s{rrings: oi axiatmg wat�,rliaes on tius property? C�1.y� Q ao
�) if app�ying for °Autb�orization to Construct', Ple9se indicate pre�erred systern tJ'Ae%}:
Q CflnventionaI � Acceptad � Innavative O Alternative 0 Other p ppy
I cert�f jr rhat the rnformation provided above fs complete rmd carrect.l also ttr�derstaxd that f the irrfnrmarinn provided is
inac , or� if the srte ' s�bsequently altered, or the fRtetrded use cltunges,� peermita and appravals sharlt be invalid
Si ture owner/ Le a! � Z7 �
g� ( g Representative*) Date
* Supporting documentaiion requlrtd. '
• Permit� are valId [ar eiitther 6U ra+�nt6s ar are non-expiring whan accompaat� by an agpro�ed plat�
� A completed 'Lo1 Prepuratfon' form muat accomp�ny any applicattaa reqvir�g a sf�e evalaatrian.
{10/! 1) Person Co�nty Environmental Hea�t�a, 325 S. Morgan St., Suite C, Roxbaro, N� 2757� (336-597-1790)
:
,
� ` � �� � ,��,.,�► � �` ` r � •,�;
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�,��.:�.-�ti���_��.�.,��z�.C.�.�l '.I����.�.11 �:�
�a���d��a� t�����m��/ IY.��bfl�� ���� ���fl����a��n��
Tax Iv1ap #: Aa'�A Parcel#: o�_ Address: 11'3 MA�S w�Y
Approval Requested ior: Mobile Home Fceplacement
X Building Addition
Applicant Name: Mttttnrl �- E-u�t3�si�1 V�t�
Address: 84 48 C Ass� Co►>¢r
RA��b� ,.�,c. anbr3
Phone #'s: 919 - �S� fi - `[a� 0 9 �9 - � �v - �f �.�5
Permit Located: X Yes Tlo
Installation Daie: 9 a4 9b Design flow: 02�1 (gpd)
Cunent Contract with Certified Operator on file (if required): 1J � .
Water �upply: � Well Public �r Community
Wastewater system shows no visual evidence ef failure on: 4IaI ti� (date)
(Applicant's signature if site visit is not required)
Comments: APP�ov� 'SO
�
4�ar.� Q't 5�C A c,�.w A�� o� �'Ct�t�. oF ��� ��was�o
s'muc�.�Vp.� Ac�� A�PPw�v�. t�e 1�1cXtt�s� �.a C14�R�ow�.5 �►t,v�w�tJ ..
��r1������l���H����a��a� ��p���r��1
�.�..� Q ..�..�
Envirorunental Health Sneciaiist
ya�
Dat
Person Cot�n�� Environment3i :� eaith; 3�5 S. yiorgan �t., Suite C, RoYboro, NC 2 i�73
Fhcne: ��6-�97-??9C/ra<:: ���-�9�-i�0� � t���:v�jr.�ersoncoun�t�,.i,e:
��� ?,� ���� �1.1��
� ������
�iaa�nsosa��aa�m� IF��O.mu��in
SITE PLAN
I Name ��a`1' 6�"4PKS�11 V�qt� Tax Map #� A Pazcel # a
i Su}�diviss'o,� ��, �v-o Secrion/Lot o`l3
� ��� ,J� A 1
i Authorized State Ageat Date
�
System componeats tepresent approximate contours otrly. The coaCaaormnstJlag t6e system priot to begianing the iasrall�tion to
, insuretlratp�pergradeismaintained.
I _
�a2 .'� f#
�
1983
'Z.?`� •�
2�20
C'
�r �^�w�"�"^�.,�� �
� .�L�� '°°,�.i
� v'
� � P �+v
�1
� a'�"�16
72T1
za8s �,
,�o
;�
F .y
�
8i.3 i:
105
�
w��`
s�y�u'r`''
��C.� 1.-A1'4�,
1 : 50 Feet �
,:
r:. ��
! ��''�' `� A 001053 1
� ���
PERSON CO TY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOC.ATION IlVIPROVEMENT PERMIT
Tax Map # /}2y �- Parcel # �
7.nninu _ ToWrisllip
Owner/Contractor
Locatic�n/Address
ision Name
r�yout
� S� ��,,,�,—
��'l � �'� � � V�
�
-�Y �.�.-�" �- h-��" .
w � ����
�`S
.
� �,,,� � �,�,��.;.� S �`
�
a S � �� '
� . - !��/�
� ,
—
� ,� .
� , -,
.•
. ►. '�i'��1�
� � � � �ii�i��
--,•-- • ., -,-, �- - � ...,r...r.,,-r. ...T.,,� .. .
Ji.'vVt�u�, a i� i�ivY �r��,ss ii,r� i iv1�Ta �. ,
Lot Area Size of Tank �� I�j r� (�f _!
Mobile Home Size of Pump Tank
siness #ofBedrooms � NitrificationLine , ��O �3 Y �.,iv
Permit Void after 60 months. Permit
Permits may be voided if site is alt e
Well and Septic Layout by
Comments:
Date
Site
Comments:
Inst�lled by.
Approved
Max Depth Trenches ��' �t v. � �
if not in compliance with zoning regulations. ���
use
Approved by.
WELL SYSTEM SPECIFICATIONS
emi-Public Re ' ed Slab
:placemen Vent
Required Well
Well Tag �
Date Installed by Approved by
This report is based in part on information provided the homeowner or his/her rcpresentative in the application suhmitted for this pemut The
environmentai health specialist is not responsib(e for false or misleading info�rnation contained in the applicatioii. The environmerrtal heakh specialist
is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleadin.;
statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tank s}^2em will
continue to function satisfactoiily in the fuhue or that the water supply will remain potable.� c:�amipro�permitsam Ol/95 re �.l .0
�� � ���� ��
�'��, . ,_ J , :
�—: �.
: �:�_����
ZE �� a �- � �.� � � � �:Il . IE� � �.IL�3L-�: .
WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map o?�'( P cel # ��l' � �p:
Applicant: 5 vPS'�
Subdivision: Lot #
Location: ._ _
�e��,r„ ••�. � � J• ---,
Type of Water Supply: � Individual _ Community Public
Requirements:
Site Approved By:
Grouting App�6ve
Well Log: �
Pump Tag:
Well Tag:
Air Vent:
Hose Bib:
Casing Height: _
Concrete Slab:
mer:
d By: � 'ti � Installed by:
Depth set: _
Grouted:
Date:
Well Driller: �J aK 5
Well Approved by:
****See Attached Site Sketch****
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:
✓-� i r�• �
Date:
PCHD rev O1/27/04
�--��,� -S.� ` ���.� �� o� oD � � a
... ,�l �T �i M�
�.� ' �.r� �,.J 1V� Jl �L. �U�u�1W ��l��o� �� ,�r•��'�SG-L`t L
�aa.arna-ca�s►�raaa�rn.��.e�.g IF3C�mm.Ild7Ea � � ���a-1 �d ,�
}� �- y m o �--
Grout Log
Owner: _� � S �n V �si" rn� n.� Tax Map�,4 Pazcel #_�
Location: ryt a, • R-
Subdivision: ' Lot #
•' Well Constrnction
Distance Frorn nearest Property L'me (Minimum 10 feet) '"'�
Distance from Septi�5ystem (Minimum 60 feet) �
Totel Depth: � IS ft Yield:1� GPM Statie Water Level: �.� . ft
Warer Bearing Zones: Depth „�,��fi � ft� ft ft
Casing:
Depth: From �_ to _,�_a-��i, Diametcr: 6%.� in
Type: Gaivanized Sieel �
Weight: _,/�� Thiclmess: �8� Height above Ground: �,y in
Drive Shoe: �ri'�es No Any problcros encounttred whiie setting casing3 iYes No
' if "yts" give rcason: —
Gront:
Neat: SandlCement � Concrete GraveUCement
. Annular Space Width �_ inches Water in Annulsr Spac� Ycs �-AFo
Merhod of Crrour. Pumped Pressure �ured Dcpth _� ta � Ft.
Materisls Used:
No. Bags Portlscxd cement Wei�ht of 1 Bag � Pounds
If mixture (sand gravel, cuttings) - Ratio _� to (
ID plates.•V Ycs _ No 4 x 4 slab '�Yes No
Ltner: " � �
Depth: Datt Installcd;
Drillfng Log
To Formstdon
Grout• Installed by:
Loutiun Drawtng
I hereby certify that the above information is carrect and that this well was eonstructed in accordar.ce with regulations set forth
by the Person Cotmty Health Departmeni. �
Si�twe of Contractor
Pamp Installrnent
3 a nAt@ � a-� o�
Fumn Installation Contractor: State Registration Number:
Purnp Depth: ft Static Water Levei: $
Pump Makc & Model: Pumg Size and Rating: hP SPm
I hereby certify t�at this puanp was installed and the well head completed according to the Person County �'Vell Rules in effect
on this date and that a copy of this record has been prvvided to the wcll owner,
R�n�nTnalellarC......,t,�eo e:uawuo� �u o• uos�a ��
l;l YOBiL6S9CC 4=. H t I 3 J d �1V CI�OI 400L�Bb%IO