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A25 210�1pg_ipdo Da • �� v . , ��Z � � ' • �� � �� � Perso� Couirtv Hesith Deaartment Environmerrt�i Heaftt� Sectlan . -. - � �;� x jax Maa �: � � �� �: � `�� Psrn►i# requested by: Ovm�/a eettprospecHve owne�: ���8� f�•f�Y Home Pho�� G- 4-33 �G . q,� � s� rrl. �//'H' B�ttt�s Ptlone' o � ��,-., crn a, � ni C, ,�.� 3�/3 Z� Name and addrass of cun ant owner: �c�t--�, •�� r� y � � �G �Ic •c ��,, i .�d k � c„-Y-u-n A � �v - c- z � 3 Y� � 3� Property Deacriptlon: Lot sfax � Tow�mhia � L,.. N. Ns/1 �r� Ofre�ons to the ProP�Y,��9 road names and ntunbers� ��A�.� A N �) Pcoposad Use and Shvc�ue Descrtptian: anawer eact� af the fonowing que.stbns: � �P� 4 6datlng � / b) Stk�c Bu�t Q Madular �. Single .� e a DouDle Wfde � � Nwnber af 8edroomx 1�� dI Number of occ�aNs� ar peapla to 1� setvod; e) Baaeme� Yea Q No �yes.� of ent fixauax �� Gerbage 8isposa� Yes Q No � 9I Qtmensbns. af pro� sa�,rs: wi�h: .�,.�, �:�4.. �'Fa1�M Use.. � Watsr 3uPPhl �fPe. Pdvate Q'�i�aw �eai.s�n0 �I� Pt�c 4 Cort�rtun�Y 0. Sp�9 0. Ace any w� on a�oinin9 ProPer�? Yes 6�lVo � tf yea, IacaUon / f1 �i�0 8j Please lndtr.ate Deai'ad Syat�m Type: (syst�a can be nnlosd In ard� of Ycia' �) �Ca�veMlonal Idodifled Convstttional _ Al�w �nnova�ive OUur (s�dlyj: �S � ��s � ����� ��� CLEAiiLY STAKE ALL CORNER3 AND UNES OF THE PROP9tTY. STAKE THE CORNF�S OF ALL PR�POSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPLiCATiON I hetaby rtieke app�oa to thn Pecaon Cou�y liealth Depactrne� ior a a�e avabuaUon ibr tfie a�aite �qe dispo�l aya�m fo tlte above-d�x�ed property. t ag[ee tltat the coNenbt of this � a[e truo and top�+�t tho ma�dmum �es to 6� ptaced on the propesty. 1 u�de�tattd if the siEo is aitersd or the �ded u�s c�at�psa. the petmit � becane invaqd. I undetstan tt�at as ap� I am cesporo�le. for identliying and nmrtdn9 P��hl �, come�s and rt�aking the aibe auxeaabte foc th pessonnd of the Petsott Cauniy Hea�h Departrttent to candud ttteir avakmtloc� I tat�nd ihat 1 am re�ons�e ��9 � Hea�h Depactment lf mY ProP�hl � �Y � � d� hY � �11 �� � �teacs. l �L! o - % ZJ�' nr Leaal e n�e �\\ , � V R _ f��� ��q .. . � . . � N ' ' f ,I � .. '�T ,. . .. � � •, • • ' . . � � 'd. ��```� :.:�4i�"�.�i°'"! , . � r-. .,-.ij.. a'„�,-s.•, r' . .- . . ! ,,.':✓'�• . , •.�>.�I.��.�r � y,.... ,�": , � , ' �� ��1� ." :ti.r.. di�.�=. IOd b�d � � 'MOOdf \� i� .,+�•[��3 . . , r�� � �. _ •.:i;. .;a.,.. .. . . � �� . f � ��.:. �. �; -.. . _ � = L ..' "!� ; • �' • ': . . L. � `� ' 7 ..;5.�� , . . . . -'`�� ' i " .. • . . .. .. . . . .. . , . ' . ' .. � + �.4. . i. ' . • , . . . . . Y . . ' . . ,. 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' . . • i�.lf f-iT•14•q-[ ���0 �.\ � � � .... . . , . �I r'=. � �-lt.N.p•� I .'a• PLEASE SEE ATT 7ax Map #: 2oning Applica Locatlo Subdivision: D PLAN FOR Parcel # 1 / Townsh(P / '�•� ��'� � I�l�:il' ±l �,L� _ LA SecUon: Lot: CP � � �a�c�� Improvement Permit A buildinq permit cannot be issued with oniv an Improvement Permit New✓ Repair _ Addition _ Type of Structure��j. Water Supply��l �%j� ,�o /1 p # of Occupa�t # of Bedrooms Other �S�ed w�� �x��^ `l "/ Basement? �Basement Fixtures� fn� � � Q(/� ��� �J Vw Projected Daily Flow: � g.p.d. Permit Valid For. [8'Five Years ❑ No Expiration � I a) �(� ({�: GDVII�°��i�fcD�C�i ProposedWastewaterSystemTyp :���a�������� �� Q��) l `^ � �I`" ' {'wv���J Pump Required? Yes � o . �,� i �. _ Permit Conditions: -, - Owner or Legal Representative Signature: • Date: - ' Zd"-� Authorized State Agent: • Date: - � ` The issuance of this permit by the Heafth Department in no way guarantees the issuance of other permits. The peRnit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. This siEe is subject to revocation if the site plan, plat, or the intended use changes. The tmprovement Permit shall not be affected by a change in ownership of the site. This permit is subJect to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Type of Wastewater System !;0((�l/(a Facility Type: Basement? 0 Yes o Wastewater Svstem Reauirements , Septic Tank Size: J��� 9allons Maximum Trench Depth: � inches Aggregate Depth:� in. iter Svstem (Required for 1�fastewater Flow: � g.p.d. �vv� New Repair DExpansion ❑� Basement Fixtures? O Yes Gl.nlo Pump Tank Size: 1�i1� gallons Total Trench Length: �_ feet IV at �Y� Soil Cover: � inches Trench Separation: � Feet on Center Other: V�`7 V � � Permit Expiration Date: �- �J� '� Authorized StateAgent:i. ����( � ��1dJ�.�= te: 6 ���V The type of system permitted ❑ does Q does not differ from the type specified on the application. I accept the specifications of this pertnit. Owner/Legal Representative Signature: -�-� �a�� � z�Y PCHD, rev! 10/12/99 PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax MaP #: � �� Parcel # �/ / Zonfng 7ownship (/l/`�� 1 l V 1 � YA�' V� � �{' ApPlicanx ����"�` . Location: �/� / U/ � C'%�V ►c(. 1 ✓ �/\ � ,r�l !� � 1 d �� j/ 1 / s Y �" � Subdivislon: Section• Lot• Wel( Permit Tvae of Water Suppiv: ✓Individual Community Pub(ic Reauirements• Site Approved by ✓ Grouting App oved by ' Well Log Well Tag Air Vent Hose Bib � Concrete Slab Wetl Driller: rv+�P � Well Approved By: Date: **See Attached Site Sketch** Welis must be 10 feet from property lines. Wells must be 100 feet from septic systems. Welis must be at least 25 fe t from any building foundation. ���� �oas-�'es t � � �o �� �,�s . Other conditions: PCHD, rev. 11/29/99 Person County Health Department /� Environmental Health Sec/t''on Tax Map #: fl � Parcel #: �f� Zoning: Subdivision: Township: G(,�.VI1�) ll��%�� Section: Lot: • . . . � %/./. � 1 /:. . . . �. II � I / 1. .. �/` � � Operation Permit System Type (In Accordance With Table Va): �Q, THIS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLICABLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION AUTHORIZATION. .�/II/.' ; • %1/ �i1 / � li . . -. - •.- �_ - Tax Map #: �"%� Parcel #: �� PCHD, rev. 10/12/99 Person County Health Department Environmental Health Section Zoning: Township: Subdivision: Section: Lot: Appiicant: � Location: 2 t�C�l • Operatiora Permit 1. LOCATION AND SEPARATION DISTANCES / A) System meets .1950 setback requirements ✓ B) Distance from system to any wells 7/DD � C) Distance from septic tank to foundation I 2� D) Distance from system to property lines �/D � 2. SEPTIC TANK A) Visually inspect the exterior walts and top of the tank ✓ B) Visually inspect the interior walls, baffle, tee; filter; riser, lids, air vent, bottom, and water tight outlet ✓ C) Date of tank manufacture - D) Tank serial number 5- '�{-Z E) Liquid capacity of tank 1,� DDD gallons 3. SUPPLY LINE TO TRENCHES A) Grade ' (1/8 inch per foot minimum) B) Material supply line ' constructed from �''�%�D P��. C) Diameter �� ,, D) Length �� � E) Distance from tank to drainfield/distribution device �_ 4. DISTRIBUTION DEVICE(S) A) Type B) !s Device water tight J�' � C) Distance from the distribution device(s) to the trenches �� D) Is the device on a level foundation E} Does the device pertorm according to its design specifications F) Record the inlet and outlet elevations 5. NITRIFICATION FIELD A) Trench depth inches � B) Trench width inches � C) Distance between trenches ZGl � 01/1 �f��/1 � D) Number of trenches � E) Length(s) of trenches ' ,lit )l F) Aggregate depth _1� inches G) Aggregate material and size H) Record septic tank outlet elevation � � I) Trench grade _ (< 1/4" per ') J) Step downs a. Minimum of 2' of undisturbed earth �_ b. Proper rise aver step down ✓ c. Solid pipe used ✓ d. Elevations of step downs Se �(Record elevations and show on as built) ��`�See "�s built" pla n attached sheet. ,# PCHD, rev. 10/12/99 Application Date: � �6��� . Amount Paid: 1,�0� � Receipt#: � 6 �a 4 � . � --}}- � ���_ � �� ���� 3� 4 ��..����.��.�,,.��.��.�,.�� �L.�.��.s:�� Application for Services (Septic Svstems and Wellsl Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 d) obile Home Replacement or Building Addition $150.00 (if site visit re uired) ❑ Well Permit (New/Replacement) ' $225.00/$125.00 T� Map: /� � � � Parcel #: � 7 � �0.r� _ � n a C o� � I ► N a,�n . � e �ore � °^^ ` � o v.'� S-� U.� e V _ n0 A) � ❑ Construction Authorization (Fee is dependent on the type of sy; ❑ Permit Revision $75.00 ❑ Repair of Ezisting Septic System No Charee Important: If the information in tlze application for an Improvement Permit is incorrect, falsified, or the site is altered, then tlie Improvement Permit and the Authorization to Conshuct shall become invalid. :) Services uested by: 1 Name: � 1 Y1 Phone # ome):3�10 �9� -51003 Address: IK� e d (work/ ell . c( I�-} �'�-1 ��Ss�cj 1 �, e rr,t-� ro. . IvC �-l"���1-� 2) Name and address of curr nt wner (if different than applicant): S�- �� Name: L�-� 0. O� �O%i��/ 1-�.y , �,\/ �� Address: � %' 3) Property Description: Address and/or direction Lot Size:o�ao� � Subdivision: Lot #: 4) Proposed se and Type of Structure: Residential usmess/Type: JV�O� �� 0.1� 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�l� Width 1� '� ) Water Suppty: Private Well� (Proposed Existing � Community Well: Public Water System: Are there wells on the adjoining properties? No Yes (please show locarion on site plan) Note: A comnleted application must also include: ➢ A plat/site plan of the property that shows ppoperty dimensions and the size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that tlte property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. Signature (Owner/Legal Representa.tive): Date: G - � � � 11/07 Person County Environmental Healxh, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (33F-597-1790) " - - - - �; : _ __ -, � - . _ ..�---_�_. _ -- — -- - _ �.-. ,�^""`�. . ti.��_ _ `� .� i `J - y. i � � '__._'_"_' _ . r+. � � i �l .� ' :• � _. _.'. � �'� j , __ ' { - �:_s" � �. � '. ! j �. di ' � � `� -__ �, ; ��, -- --M,.,.. -- -- -- _ _ �='- - �.,-�� �- __ - -__����� �� ,n ' , � .. . ��� r , f �p�,, n' �c r ` �'�n�4 � ,J# �J �, ',_ i ni 7 � ' n iVi�rj'? L�" �," �iO�,G'1 � -�. -- - _ - __ �,_ --„-� "``� ;=a.' �--_ �:LM.��.`i - s y — .�, �.. —•'�-. ,vJ$,1 Q2,� q� �u'?�'� %. GRAY LIF= ESTATE TM#• Ac5-47 RECN: 1615� PIN#� 9988-02-c9,-2001 D.B. 578-267 P.G 1-16 � J ri� f�! (��� � � � � � J � :✓" S7 % �g 38'41 9�� -�tF -. - _. . � �.i__. :Tr;". H. H'INT.^�.I '.?- �c..-?i 'Y� �� }`J -_�.., ;�8c-U�-G;-��.Ji � __.J� �:�-. . 9 � . . - - -- � ----- ...... v :. _._.. i , _ - --_-: i P,idD�E1,/ C. h+'JNDAY. :�i ;� i7TH_RS TMn� A35-55�3 RECN+ 165 PIN#s 9988-02-88-2391 D.B, z61-886 ^rlriT ,?D�Tit+ N:"� �il�d n °erscr. �ount� - 'h�' ___ �C�f 7f �_ �� -- ---_ '�'c;cc': _ �mcnca . �crrac,, ;?ecrst CONTR❑L � C�RNER i �i�:E ''.��t�� � :�d` ; _'d�': H � ' �9.e5 _ � � ��a.22 � :s� '�OAi� ' �? � Ia4.53 ' �; �.49 ' �� i 47.331 92.581 � 29.58 � tqoal _i(1'. o�C9i ���,�� ���; '9� �Ci 26'.lE ��1'S I , . . .. . � � . . '. _.'��I _' .i`7 � State of p�o,-�h - ' _=o.JS: Co ��. � ., ._ _a � ,2 231 unty of Pzr�o^ ,ai �.�-+i : I, ! �i�•.�. _�s. _ii . —'�-'-`�._ -- �- - � J _ - � - � � i which this cer;i= �_ . . _ � �. - _ �` �_�_i statutcrv �A,...:__ ' = . :: .... , _ _ _ . _ . - � , =^ � �� � � � a � �o� �? � � � � �1 � � 3. �� .3��7H�3.�7"a.�'��3.,'m'nr-n cC��5.11 ��+�..A� ���g �.���ti��f ��b�� �o�e ��i�����t� � � ,� ah'��,,�°� ,,,�a� o��,.,y Tax 1r�a.g'�#:_��, I'aa'c�i#: /� %'`i �' +� �/�.01'�.�`��� Ps -. � � / • !�`) .�li � 1�'�. A�pivvai Requeste3 for. V I1�obi% I3ome �la�me�rt � Building .t�dditwn � . j . _. J � ' A�plican� 1�Ta�1e: �,�P r� U I.�ra d S�ie t' � A�ress: • ' � 2.7A �V1 c('Y h o.e� lv1 i�� R�I. . � � ' �h�21�:#'Sr:� ��ife—'J'1R"' i�Qf�� � 3 . P�ID.'i� �.00B�: V �E.4 . �O . . installatio�. Date: ' � - - D�gri $oev:. � (gPci) Cu�at Cantrae# � Certif�esi Operator om i�� (if r�:s�ited): . . . '��41'�tez Supply: V�Tell � Fublic o� Comm�y i�I�ste�vafiex system sllows no visuai evidens� of fa�i� on: (� ^� 3- d� (ciat�) ��. (A�Piic�n.t's sign� if site vsszt is not rec�e� � " Se�. S�� e�C ' � � ���t������ ��at :��r�v�� � - � � �� v�' �. Envao � � Heali3i Sp � Date � l lll�/�5 15 . . � � :��y7�J� ��ld���� � ' �� � � �.J 1� � �1. ll��w�iu-�,�„ ,�,,.,, ���.11. 7HI��.]L� - SI'I'E S�'I`C�-I .� Name �� J vv� f.� ra � S��r Tag Map #�Pa�cel #�% Sub ' � . � Section/Lot# -�..� - 2 3 `�� � utho�ized State Agent . - Date . S.ystesaa cmm�mnen�s r+e�resen� ia, p�ia�ximute�contosars ora�: ?'da� c�s�f�c�ear �s� j�� t3�ee s�s�es��ir�or t� be�anrsing t3ae isas�iallataon io s�asaaae t3s�tp�o�iergr�� i,s stsc�iretass� � �(,i �ft � � WCI� � � � � � 76. 2p3 acres ��- �� �� d � �, o. � �° ' N � �- � �� � -� ; � . ,�,; � � s.��, .�. � _1 _��y.� � � �%'�(,� 1 � ' 4 a.� y. ` /� N � �1�'i%Y.i '�" ��y,ac.���.'� - � 1 1 �" �Li''. 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L.,,S -. ---._____._.---- Pollution , v d w �ius. llas�.il,�� Crom Source o,f ' Totall�ep.t.h: -- s �'t. �'ic:]cl: � � _ C;��M .�t�l�ic Water L,evel � (� Water Bearing :Lones: veptli ._.� `t�,.� �'t. _ . . 'Ft. Casing: Deptli: � R .____..___�'I•�_._ F[. �[. , Froi a� t c, --____ � ___ __ ..__I��i. . TXPE: Steel . ------ ._... llia�iic�c�-: ` � Ynches XF Stccl, doc:s owncr a��pcov�: C� �,�.'n��`'cl S[ccl__ L_–. , . . ' Weig}it:_�_ '�'t�ic --.... Nc� . . .k�icss: --' llrive Shoc: _� ✓^.Nc�--�:I-1c'ght A�vc Ground: S Xcs_ .. ` che � Werc Yroblems E�icountcrccl in .�e:ttini; tlic C:,si.n,�? Xcs IC "ycs" �;ive i•ct�o�i: ----__.._. o �— . Grou t: Typc: Neat ------------._ ._...__.... _.__--._� _'__� 5 •, � 1/C . ::„:. .. 1C c,nlcl�l --- . A.nnular: Spacc Wi�]��_ 3 — - ----___Coricrete ' ' ' ��''�° �: T� tcllcs ";�' Watcr in A.nniil.u- Spr�c�: ���.., . _ ----- � Mc[1iod: No � _ . . . .--- -- 'w,� �x:cl�_ _ _ l r��':;.. --... _� , Dcpcli: From .._._ ��u���: . _.__-- �'uurc�cl--- � . .. � � , .,. Mate . �--�_.._... <<� _ 2_C� __I�t. . . . z-ials Uscd: No.13al;s ,('c�rtL•uid Cc�i�cnt � � .If mz;.turc (sZnd, �;r;ivc�], cut.tiri� . --._..� Wc��;1it ot'.l ba � � , `:'�) - R��t�c�: �._`�._,lbs:., ID � l:itc ✓ ----._-�-- to `.:•�?; � s: �'cs-_�_..._ _. _ Nc.� . . ` � �� �;lab Ycs___ �'`�: Nc, - .._ :. .. .... __. ___. __ _��I�.II.I.INC� l..�X�__ I'c,��rnaticm llcscri ,�.. .: --- - — -�---���.� .. ------..�o._'�-�� .%� ro r...r r�--�o - � _--__ ��� � 7 --.- . Z �EREBY CE�ZTIF�r T�-I�1�..1.[-YL n.I3()V � —. T�S WELL WAS CONS`1'RUCI•L() �� �� 1NrORM,�•1•,[ON:[S CORRECT ., ion ��RT�-I �3 Y�T�-I � PERSON c"'n(�.N�'Y [�11 �/11: TO� L�.NC'E WITI-I � .. .. I1! :`I'M CN"!'. . � REGULATZONS� ;' . _ _ . ��C��— .��_ � � _ .5i�;n;,turc c�f f�on�,,��:tor ---- . Datc �.,c"'--�- - .. _ � PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG � +9 Date: - G -c�'� ' Owner: � �r Zcf.� � SR# ` � � Location/Directions: � ��'` 7 � Subdivision Name: Lot # Drilling Contractor: c�.�e--�( � 2,�:Q�.� �,�c WELL CONSTRUCTION Distance from Nearest Properry Line I v Distance from Source of Pollution ( G a Total.Dep.th: � C�`t� Ft. Yield: � GPM Static Water Level a?.5'" Ft. Water Bearing Zones: Depth,�_F[. F[. Ft� Ft. Casing: Depth: From 6 to�ZFt. Diameter: Inches TYPE: Steel - Galvanized Steel If Stee�, does owner approve: Yes No Weighc: Thickness:� � Height�Above Ground: /�/ Inches Drive Shoe: Yes ✓ No . Were Problems Encoun[ered in Setting the Casing? Yes No � If "yes" gir•e reason: Grout: Type: Neat Sand/Cement �/ Concrete Annular Space Width Inches Water in Annular Space: Yes No - -. Method: Fumped - Pr:ssure � Poured � . _ . - Depth: Fr�m O to � O Ft. Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs. If mixtuie (sand, gravel; cuttings) - Ratio: to ' ID Plates: Yes � No � � 4 x 4 slab Yes � No � I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERSON C^vui1TY HEALTH DEPARTMENT. ta������G"1r-/L%�:�w�iv i • � ��-- � ' • • �i � �