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A25 154c ti .� r � m � 3 � �� .� .� a � x � 0 � '� � � -� -� a � �. N a-� � � y o � � � b o ° � ? w � � r. „ w y � � N Fi � b.�� c � � � c a a, '�+ � c •N 3 :� .: � o � � -• � a 00 0 � ew • •O :+ I � X i � a � o � : w � � d � ^�ny y H O � . � y . a a; . "z' a � � d . O a zH � Per.son County Health-Department � Sewage System Improvements'Permit � Date:��fiis Pe i Void 5 Y s�/�C �$R# �� ; Owner. -I • ip �+n � Location/Direcaons: �.� . I.ot # Lot Size: �4 ' T�Y�� I.��ell' . ��"i Water Supply: Private: —��'�lic• . mmunity: Bedrooms: Gazbage Disposal�g - Basement Basement �xtures � � INFORMA D B $ailif8Ii8i1: ow er or rep:esenta ' REPAIl2: ... REEVALUATION: Size of Septic Tank• gallons Size of Pump Tank: Nitrification Line: � '� 'V e Depth of Stone: 12 inches , Max Depth of Trenches: Altemative System: �Conv Pump PP Remazks• � � , , . � - . .. .. _..�—��-_-�.____.___��..__________ Date Well Approved: Well should be 100 f� from any sewer system BY Sanitarian • Date S e A ved: • � BY Sanitarian .--� TIFTCATE OF COMPLETION Contractor. —,• `� � � Sewage System location, installation, and protection` must meet stste and local � regulations. Septic tank should be pumped out eyery 3 to S. yeazs and shall be maintained � by owner in such manner as not to create a public health haiaid. Septic tank and'd nitrif'ication line must be inspected and approved�.by,�:a member:of the Person Counry � Health Deparnnent before any portion of the installatiqn.is covereil`and put into use. If the site plans or intended use change this peimit is subject:to revocation (G.S. 130 A-335F) . � . I.ocation of sewage disposal sewage system ske[ched on .back. (OV R) � �r� v � n �� , � ` � t` Person County Health Department � Well Permit � Date:' -� U 's Permit Void ter 3 Years '� Owner: � SR# , Locadon/D' ons: Subdivision Name: Lot # Drilling Contcactor. F-��..;—�1 % � WELL CONSTRUCI'ION � Distance from Nearest Property Line � u- S Distance from Source of Pollution Q � �. Total Depth: ?5 Ft Yield: .��GPM Static Water Level Ft � Water Bearing Zones: Dept1� QO_ F� � Ft. _%� Ft. �F� Casing: Depth: From _�_ to �_ FG Diameter: G__% Inches T'YPE: Steel � Galvanized Steel ` If Steel, does owner approve: Yes No WeighC �_ Thiclmess: Height Above Ground: � Inches Drive Shoe: Yes V No Were Problems Encoimtered in Setting the Casing? Yes No �' If "yes" give reason: � Grout Type: Neat � Sand/Cement Concrete Annulaz Space Width F3 Inches Watet in Amwlar Space: Yes No v Method: Pumped Pressure Poured v Depth: Fram �_ to FG,f Materials Used: No. Bags Portlan Cement 7 Weight of 1 bag _ j� lbs. T I f mix t u re (san d, � a v e l, c u t t i n g s) - R a t i o: � to �_ ID Plates: Yes No � 4 x 4 slab Yes +-�— No q I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECI' AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTh�NT. ' /A .Y.Cil�le� 1.U��( C,.f>y ��/ /� /� i Signature of Con�actor Date . Sani 'ans Sign re Da Issued Sanitarians Signature Date Completed Sketch well location on reverse side. Application Date: � d" a S� � � Tax Map: A a s, Jr� Amount Paid: Parcel #: Receipt#: �� ' -,- CC � �� Q-�" �:�-vnv-xaata�,•�*�• �c,�rn�..s�.11 �Ta�, w.11�.7�a �, " Application for Services (Septic Systems and Wells) Services Re uested � mprovement Permit (Site Evaluation) � Construction Authorization " $200.00/$300.00 if> 600 d) (Fee is de endent on the e of system ermitted) �Mobite Home Replacement or Building Addition ❑ Permit Revision .�}�5�$�evisit re uired $75.00 ❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Services Requested ,6,,1': S�j��p�g5 Name: JoL � 1�.�. t�b �v� � � Phone #(home): a Address: (work/cell): 50 � - 0 �, Is_ � 2)Name and address of current owner (if different than applicant): Name: ��d V o I.�� 2� 4� R e s c.u� ��n� _ Address: � a,q I� ac.o r C� -�'_ef�o (� � �ox(3oS2o,, n1C �'7S-l� 3) Property Description: Lot Size: o$ � Subdivision: Addressand/ordirectionstoProperty: C��ro Vd�. F�� Does the property have previously identified jurisdictional wetlands: Yes No Lot � 4) Proposed Use and Type of Structure: h�,�� -�Re-�-��, Residential Business/Type: Other � {�0 R.� Number of bedrooms , or Number of people served (seats/employees): Basement: Yes No �_ (with plumbing: Yes No _, Garbage disposal: Yes No �_ 5) Water Supply: Private Well � (Proposed Existing _� Community Well: Public Water System: . Are there wells on the adjoining properties? No _ Yes (please show location on site plan) Note• A comvleted application must a[so include: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that the properiy is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. Signature (Owner/Legal Representat' � � . Date : �b��-,/ 08/11 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) -'''--_ i ,_,, � ,_,,` � �''--_ i ___��'�-, i ��_`_`_J t � �� ' -� , � � : � � .�� ,. b 1 , � �� ,� � � �l.J ��J 1`�� 1�' T.1� �� 1�:�.�-�.��<��.�.;��.�.�.�1 !'�C�:.�,I1��. � �u�n��a� ��a��aa�! I`Vg��n�flce �II��a� fl��n��n�� Tax Map #: A 7 � Approval I�equested for: Applicant Address: Phone #'s: Parcel#: t 5� 1VTobile Home Replacement � Building Adclition Permit Located: V Yes Installation i�ate: � - ( � � 0 No ? Desi� flow: _ Current Contract with Certified Operator on file (if required): �Vater Supply: �/ Well Public or Community �) (bpd) Wastewater system shows no visual evidence of failure on: � l- Z-( � (date) (Applicant's signature if site visit is not required) � Comments: A��n�go��pYa�� a°�a�� /1 �3-ll Enviro ental Health Specialist Date 1 ? / 15/OS :��,�� - . �� ]��m�A��,ll ]HI�.�fl�. . SITE ��TCH .: . Name � d�) �a�.,.� ( I Tag Ma # S� Patcel 5 Subdivisi . P �— #-L-�- . Section/Lot# ---�--- ��. - _ /f - � �// � utho�ized State .Agent � � Date s'9�� mpo�sts s�resent u, pproximate �contours only: The contractor musf, fTag the , ystem�rior � beginning the installa�tian to insure that j�ropergrade rs muintai�red _ � • -- - _.__ ___ _--,_ . -- ------�--------- — , - - -- ___ --- , _____. \` �` -___________ - � • _______-- �� tl \ \ ��"_—_ �m+l \ p \ � ` � W�y6 \,\ ��r � \`` �y y � \ \` \ VZ \ � \ Vg \` \ \ �'8 Fn N,afdklOM "'-_�_.��_��_�__� 7A'L6l o� ayz �p P � m;{ N fa !� � a g mp�m NOO �g� 9�� J�jZ O Q }i{ U _ � N D C �-'�Z DN�2 NN�� D�D O�Z� Z�Z�DN�. r�cn- c�mR,� 2=�DN �a �X�� o�g i�N� Z .�. �- �'��? �� m � m � � � rn Z � n � � � 0 � � � � � z � rn m �