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A25 25�Application Da�e: r� ��$ � Tax Map: � Amount Paid: �� • Parcel #: 6�� Receipt#: C� � ���� `-_.��.� ��IE�..� ��� - -�- � � ���-� 1L.. ���-�L u Ka �3 ,t,,.-„ «-� � � �,. ii �a r �.-.� � �: �n Application for Services (Septic Systems and Wells) 1) Services Requ ste by: / s Name: �'L► ✓% y� t� ��/j Phone #(home): .7 ��� � d 3 Address: ��3 cG�-�y ,'l ���� (work/cel]): CiT f� � r� � '� 2)Name and address of current owner 'f different than applicant): �/� � ,2 Name: �gi�1-P 4 S S���v� Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: 4) Proposed Use and Type of Structure: Residential Business/Type: Other Number of bedrooms / 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 Lot #: (please show location on site plan) Note: A completed application must also include: ➢ A plat/site plan of the properry that slzows property dimensions and tlte size and location of all proposed structures. ➢ A signed copy of the `Lot Preparation' form verifying that tlte property 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. � I_� _ �� Signature (Owner/Legal Representative). i Date :� C 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ���.�� ��1P.���T -- � � ���� ��.���� � ���.� �z�.�:��� SITE PLAN Name �'P' V ln �9 �G �a Pl' Tax Map #.�-S Parcei # aS ubdivisio Secrion/Lot# o� ��f � � C� :�uchozized State Agent Date Sysrem cnmponeats represent approadmate canmuts oaly. The conrr�crotmustl7ag rhe system pdor tn bPa nninan rhetns�atioa m iusure r6atpmpergrade Is mararained ._' �/'a�c�SP� �P�� ,$'�`fP Mcr!`�pd w, �,n�� �?.,c� �1 VP "t'`�Qgs� �- W�► I M �s�- b e a-S -� e i" -� �o �.. c7`^� bv ila��� -�o�., d4��d-: �,S � � e i �� r� M cr� 7 �S'��o�i L 5�,�,� � —_.. �� �f C`� ' j�lv'� C�n 7 �/'°L� Q /``i� � ��•,� . —�t !S w �P � �, � i4�S Ts/U (� W ��L� �'`� !�P c o� M p., c� p� -t- o cr�cr., �v� SC� LE : �v�S _" ��1� � uPSi'��' S G�l� �nU t rd��-r��t���. �}Qa I �-�-, �P�.���-, ���t � �$ 33�- S�?-/7`�'� . E?�i S�i.�9' � � � 0 � ����� �.� ���� �� �..� ' --._ � � � � Jl � 7�.��.� m �.n.-�.���.ffi.11 1I� � �.Il �1�. � rP pI4 c. P-�., p^�` ��� ���21VIi�' (1`aTesv��epair� Tas il�Iap: �_� Parcei• � S Subdivision: �,ot: Applicant's Name: M e 1 v i� � 9�- c.C., 1Vlailing Address: �, g 3 fo M�� Pe S��� Q� i'hone Numbers: S9�1- �Sd3 n of Property: S 7�% M� C�G,Qes M ; 1J e-� �a,. a �'ermit C'onditions: • 1) See attached site plan for proposed well location. Z) All applicable State and County regulations governing construction and setbacks apply. 3) Permits expire � years from fhe date of issue. Other Conditions/C'omments: �� P S'; �- p s p{P�cLi , � -t ; ,S /'e Go,�, ,,,,�„ �,�',� -i-o Q %a., Jv-, e X,-s`�=�ti � �-JP / / Pea�nit �ssued by: ►"> ' l��te: � C� ��� ���'�'�'�Cr�TE t�F C�1�I1�'�'�011T I�ew Well Inspe�tion: E S/Dat/e Location: ✓' � � lzl �$/ Grouting: Well Log: Weii Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well �riller: Pump Installer: �ell Approved by: Date Sample Collected: Person County Environmental Health 325 S..Morgan St., Suite C Roxboro, NC ?7573 Liner �nspection: EHS/Date Instalier: Depth: Grout: We91 Abandonmeat: EHS/Date Completed: Method/Material(s): _ �acense #: License#: I)ate: Date Results Ylailed: '� Phone: 336-597-1790 Fax: 336-597-7308 siiios ' �. �r � �/ ,�,`�.'�:5:�"� :��1�'�1�:��;�. �� ..:. :::.. �...:_.. :o� �D.�7`��''�''�.'` �`i�ra�ri►a�mse�,x;^si���:.r�.$:� IE^3L•�.w��,+E�a Uo �1111c�' Il� � .`_��i.r� fl , ,.... ���.� .�5 ��� /v i (1 �I' ... �� �• • //�1I�!!!!:�?-�. . . , . ; . _ • . . i� � _T . � Wef! Coyutr�u�dioa Diatance Femm �taxe�t Propetty Line (Minimuai' 10 feot) '�' Di�ca �om Sr,p�c Sys�om (Miaimum 60 f�et)✓ 1'ocal Deptb: ,�,� ft Yield: _ 1"�_ GPM Steric WMtar Level: n Water BaariuQ Zonea: Deptti � R� ft ft ft ' Cas�n�s , nepth: �'rrnm�� to 8. Dlarricb�x: ` in Typc: C3nlvaaized Steu1 �—� � �Veig1�� ,,,_T„ Thio3mess: Kai�hht tbove {irouud: _T in Drive. Shoe: _�Ye� N'o Any probleam eacwmta�pd wtlila ee�it�g casin�? Ye� _,,,_ No lf "yes" �ive nasoa• Grott:' Nes� Sand/Ccm�t ✓ Conozate Cwavel/Camoat Atmulir Space Width _�` �nchea W m AnauLu �ca Ye� ✓Na Matb�d of Orcu� Pumpod __,_ , Presuae �o�d Dep� to FL M�tteri�l� Ured: • Na. Ba� Portlaad cement Woight oY 1 Bas �_ Pouade If mixture ( g�xvel, cuttin�) - R�ttio ,�t� i ID platw: �aa �, No � x� �Lb �_ No Y1roa�: � Depth: Data ]tutslled: �,_ Grou� lnstallad by: ��� � � Lucation D.rswWg � � ��X �m�.� �,.�.: r�.,.-f•- . I tlwrcby oatity thst the above infarm�tion ia oorrect and that this well wae eo�ucxed in accordenca witl� regulations �ot, fott t by the Pea�on Countir Hea1t!► �e�e_ . f 51�aawrs c� Cotttr�ctox � �a 2amp Y�tRllmat Date _„��, f�i�,� P�,a�p It�tallatioa� Coa�ctor; �tate Ragiitrstioa Nutnbcr• Pump Depth: & StatIc W�tarLavel� ft Puazp Mxlca & Model: Ptrmp Siu e�d Reting: hP ._.._ �p� t hertby oertiFy that thiA pump w�u in�tallai arid tha well liead oompletod eccordin� to tht Pcrsou C�unty Wcll Ruies In offect on tlifs date attd tiuu e capy of tlus incord hae been �xevided io the woll owner. Punap InstAller Slgnature � D�: FC�iD rcv 4127/04 iQ aLiN�7 rIf1T w�i�f � : ����nn � w.. �.� � ' _ _ _ . ' _