A25 25�Application Da�e: r� ��$ � Tax Map: �
Amount Paid: �� • Parcel #: 6��
Receipt#: C� � ����
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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)
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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�� ,$'�`fP Mcr!`�pd w,
�,n�� �?.,c� �1 VP "t'`�Qgs�
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_" ��1� � uPSi'��' S G�l� �nU t rd��-r��t���.
�}Qa I �-�-, �P�.���-, ���t �
�$ 33�- S�?-/7`�'� .
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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
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�'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
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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
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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_
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51�aawrs c� Cotttr�ctox
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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
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