A25 33�
The District Health Department
Orange, Person, Caswell, Chatham, Lee Counties
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT N .
s Date_4�.? 1 �, - ' i ( .
Owner: ' :� -� �� -
� . a �
Location:
,i � , ,
� . . y,:. •. � . :,
'p, Contractor:
�n
� Water Supply: Private Public
� ,.
�.,,. ,,
Sewag�.p�sposal Facilities: ATo.- edrooi�s�-'� Dishwasher, Disposal,
r-' `
t.vkashing mac��%other automatic appliances
Size of tank: � " ' •r ' - - �' Nitrification line: f � "��r % � �- " _
• • � -��-
Other disposal facility: _�t-'�� ��! �• ��- �� `;� ^ r""':�� %� '�`+�" ,
`1..�,,.., „ ,
�� i'vL�'a.1�3�)�i, ia,.:;t.iti�+-.,'
Water supply and sewage d.isposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
PROVED BY A MEMBER, OF THE DISTRI T HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE. �. J
� / f ,�!/ � -_ s
' , ,f 1,._
Date approved: Signed ��r- �/ � %- - �
,, , � �---��•� _
Well: ` Sanitarian �
,
. A
Sewage DisposaL• 1 : ,' • , ' �,
Counter i ; , i �1.�' .- � , ,
signed -` : ,:f _-
By' (Owner or his representative) � ""
. 'i
Certificate of Completion ��� '�
/+ ,.1, ��. �~�,'� .
Date Approved: �c"" �• �-''By: - ., � ��
� `"' `-'T�� 5anit�ria�' .
(OVER) ��
Location of well and sewage disposal facilities sketched on back.
� ' �
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. No e location qf water supplies on adjacent lots.
(1J ��9 O ._ 1 ,P�I _ _ ' .,, i "��/ ��% �2� ��v�n 1! .n� A� _ _ � _ _ /,
�
�
The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPRO S PERMIT N .
� Date '
Owner: �
Locat'on: '�
G� e �-.�-� tL Y/
a
Contr tor: �� `��/`3�°
Water Supplp: Priv�te Public
Sewage Disposal Facilities: No. bedrooms � Dishwasher, Disposal,
washing machine, other sutom ic appliances �
Size of tank: Nitriflcation line:
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be maln-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INS LLATION IS COV-
ERED AND PUT INTO USE.
Date approved: '��;�.�� Sig
Well: � � Sanitarian •
Sewage Disposal• ` Counter - '
"/ 3 C Qlgn
B3'� { (O ner or his representa ' e)
, tmtt VOID aff�r 3 Years
CestiScata ad Complelion `
Date Approved: ��By:
ni ari
<OVEFt)
Location of well and sewage disposal facilities sketched on bacic.
' NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
� supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
�
E �
WELL PERHZT
Casvell-Chatham-Lee-Person Countiea
DATE ZSS� _�DA� DRZLLEQ:����/ COUNTY: �
OWNER: ���r�� �i L) ROAD/ST�R�FjT:i /
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution�
Total Depth: L.G.VFt. Yie1d:�GP!! Static iiatez Level: Ft.
Hater Bnaring 2ones: Dep�h:� Ft. FjA�/ Ft.
Casings Depth: From��to Ft. Di�iieter: �nChes
TYPE: Steel Galvanlzed Steel Y
Zf Steel, dou cvner app Yea No
ileight: • Thicknessz� Neiqht l►Dove Ground: Inehes
Drive Shx : Yess No:
Were Problems Eneountered u� 5ettiaq t�e CasingT Yes_ N_
If 'yea' give reason: . /
Groui: Types Neat Sand/Cement: Concrete
Aanular Space width Incbes
iiater in Annular Spaces Yes , No �
Methodz Pua�ed ure Poured
Depth: FYoa to �`_ Ft.
Materials Lted: No_ Bags Portlaad Ceaent iieight of
1 bag lbs.
Zf auxture lsand ¢ravel. cutiings) - Ratio: to
ZD Plates: Yes �/ No ChlOriAations Yas No
4 x 4 slab Yes� No
. ZsiUii:i�
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I HERESY CERTIFY ZiiAS THE 1180VE INFORtSA?IOH ZS CORRECT SH112 SHZS
:dELb WAS CONSTRUCTED ZN ACCORDANCE it5 FORSH H7
CAS�TELL-CHATfil1lS-LEE-PERSON DZST.
. Sagnature of Con::a DaLe
• ' FOR HEALTH DEPARTTSENT USE ONLY •
REASON £OE NO IKSpECTIONs
� Saaitarian's Sigaature Date
Sketch vell locatioa on reverse side. Use established refeseace
points. .
r
Apoiication Date: $ � �� 2^ Tax �Iiaa #•
�a-� r .
Amount �aid• �
Recaiat #• Parca! #• 3 3
�� ' ���,�� �I��..��� �0.��
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APP�ICATION Ft3R SEitVIC�S
IF �1-lE INFORMATIOM IN 'THE APP�:�CAT10N F�R AN IMPRO�IEiV1EPlT PERMIT IS iNCORRECT. FALSIFiED,
. CHANGED OR THE SiTE IS ALT�RED THE➢V Ti-1E IABPliOVE�IIENT PERMIT APID AUTHORIZATIDId TO �
CONSTRUCT SHALL BECOIIAE IM/ALlD.
1) Parmit requested by: Owne�la errt/prospec�ive owner): U� � t� OQ�1
Home Phone: � : �, �� -$ I G � Address: o'Z NtC � /�l < < �
Business Phone: - QO � �Mo }�n. . �7 �
g�� Oak 1
2) iVame and aldclress rnent owner.
�
3) Property �escription: Lot size: �a'+ Townshlp: �"'N �� Subdivision: Lot #
Directions to the prope�ly ()ncluding road names and numbers): •
4) Proposed Use and Structure Description: answer each of the foilowing questions:
a) Proposed . Existing , Type of Structure: �dth: Depth:
b) Number of Bedrooms: Number of occupants or people to be served: �
c) Basement Yes , No Will there be plumbing in the�basement?
d) C�arbage Disposal: Yes No _ .
5) Water Supply Type: Prnrate new _ or existing___), Public . Cammunity� , Spring
Are any welis on adjoining property? Yes_ No _ if yes, please indicate approximate location on the
� site plan.
6) Does your property contain_previousty ident�fi'ied jurisdictional wetlands? Yes_ No
PLEASE (VOTE THE FOLLOWING:
9 A PLAT OF THE PROPER7Y OR SITE Pl�iV NIUST BE SUBMITTED WITH THIS APPLICA'�'ION.
➢ PROPERTY LlNES �ND CORNERS MUST BE CLEARLY MAR6QcD. �,
9 THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
9 THE SITE MUST �E RE�►DILY ACCESSIBLE F�R API EVALUATION BY THE f�F�LT�-t DEPARTMEAlT
STAFF.
I hereby make application to the Person County Health Department for a site e�aluation for the on-site sewage disposal
system for the above-described property. I agres that the contents of this application are true and represent the maximum
faciiities to be placed on the property. I understand if the site is altered or the intended use ct�anges, the permii shall
become invalid.
O�/✓��/L '/G
Cwner or
AP'ii�[ g /� �
O V�
Date
PCFiD, rev. 06/27/02
������� ���� ��
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IE���-�,�,,,.-�,� ���.I1 7L���.a¢I�
WELL PERMIT
PI.EASE SEE ATTACHED PY.AN FOR WELL SITE LAYOUT
Tax Map #: o s Pazcel # b�� Township C���a1�-
Applican� �Q��; ��a�
Subdivision: Section: - Lot
��no�: � a � $� rn��+� �. • � � � -
Tvne of Water Suvulv� ✓ Individual Communitp Public
Requirements•
Site Approved �-� �'s � aq-� �
Grout�ng Ap oved bp �' "l`�Z
Well Log .
Well Tag;
Air vent �
Hose B�
Concrete Slab
_,�
,
��� ' 1 � , . l
Well Approved By: Date:
'�See Attached Site Sketch'�
Wells must be 10 feet from property lines. �
ells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other
t�
n
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Q?c �s t��q � �X \
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PC�ID, rev. 09/07/01
S�
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Name �Qn��e ����� . Tag Ma.p # oa5 .Parcel # U33
���� a�$-� n�-Fc,•.� t�;\� Za � Section/Lot#
, $ -a9-v�
Authorized te Agent � Date ��
Syste co represent approximate �contours only. ?'he contractor must, fTag the system rior
begin the i ' n to insure thatpropergrade is mazntained �— 2�b?
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PGHD, rev. 09/12/Ol
Bar�e*te Well Drilling Inc 336 598 9275 07114105 06:09P P.001
�.,� (� � D� P�QC�P �d � Ot �� i O
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T�.����.Q.������.�:�.11. � �33L�.�.A�]kz� D&�0 DG�� �
„�_ ,/ Grout Log
Owner: ,� G�ti 'CI'�- �� ��c�G Tax IV1ap/�aZ.� Parcel # ��� • .
Location: Cy •
Subdivision• �.ot #� �� � J .
��f •
, • Well Cons�ruction �
l�istancc From ncarest Property Line (Minimum 10 fr.ct) l�
Distance from Septic System (Nfinimum 6d feet) ! 4�
Total Aeptt�: j�U ft Yield: � CxPM • Statia Water Level: ,�.� ft
Wabcr Bearixtg 7Anes: Depth �#� � ft ft ft
Casin�:
Depth: From . d to � ft. Diameter: CP in
Z�+pe: Galvanized Stee] f
- Weigh� Thicl�ess: !8� Height above Grocmd: � in
Drive Shoe: �es �To Any problems encountered whiae setting casing? Ycs �iVo
Tf "yes" give rcason'
Gruut: '
Neat: Sand/Cement Concrete C'rraweUCcmcnt �
�. A�nnular Spaae Width ___.. .___. inehes Watcr in Annular Space Yes No �
Method of Crrou� Pumpcd Pressure Potiu�cd _�- Depth G to o�, U Ft
I1�ate�ials Uced:
No. Bags Portland cement ' Weight of 1 Bag ��ounds
If mixture (san� gra�el, cuttings) — Ratio to
: ID plates: es � Na 4 x 4 slab �s _ No
Z,iner:
� Depth: Date Installed: Groufi: Installed by: _
Drilling Y.og Location Drawin�
�xom Ta k'ormatiox� '
�- �o
� � � e�s �� j l
. ��
, a�
� lxex'eby certify tl�t the above infarn�stion is correct and ihat this well wa5 cottstrucled 'm accordancc with regulatioris set forth
by tYt� Persot'► County Health Department. '
Si�naturc of Co a 7� �' iD #d y�� Aate �- ��" ��
` " Puuap Installtuent
Pump Installation Contr�ctor: ��-��5tate Registration Number: [���
Purnp Depth; ft 5'c W ter Leve1: �c� �� ft
I�ump MakC & Madel: • Pump Si•rx and Rating: � a-- hP �_ gPm
i hereby certify that this pump w�s inst�lled and thc we11 head completed accarding to the Person Caunty Well Rules in eff'ect
on tY�is date and that a copy of thi d has been to the well owner. .
�"umv Insta�ler i�n�tw'e . _... .. _ Date: r" r�/`� � PCHA rev O I/Z7/04
�� S� ���.� �� �� oo � 230� . . .
� '` * �`'� �C � �T1�'II� � � , � a� �►� I<►N �I�.�
��-���-��.,,�-„ ����.� �z��.a�� D�o Dr�O(lod � -
Owner: �G l
Location: �
Subdivision:
��
Well Log
Tax Map �� Z.5 P arcel # d 33
Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from e tic System (M' um 60 feet)
Total Depth: � ft Yield: � GPM Static Water Level: ft
Water Bearing Zones: Depth ft► 05 $ ft ft
Casing: /� /�
Depth: From Q to lp� ft. Diameter: (5�,�� in
Type: Galvanized Steel t�—p
Weight: Thickness: . � p8 Height above Ground: in
Drive Shoe: Yes No A.ny problems encountered while setti.ng casing? Yes
If "yes" g-ive reason:
No
Grout:
�1eat: SandlCement ✓ Concrete GraveUCement
Annular S ace Width inches Water in A.nnular S ace Y s No
Method of Grout: Pumped Pressure Poured ✓ p Depth � to Z� Ft.
Nlaterials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: V Yes _ No 4 x 4 slab ✓ Yes _ No
Drilling Log
Location Drawing
From To Formation
�_
I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person Coun Health Departme t.
Signature of Contractor ID # 23 � o Date — � �Z
PCHD rev O 1/ 16/02
Sep-03-02 08:14A
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Tax Map #: Ao�s Farcd # o33 _ Township C ���a.-�-
Applican� r�,� ��-�-� ----- - ---
Subdivi�ioni ' � Secriou• Lo�
Location: � � 7 4'� 1'1'��CdhII,.} ri.1:�j �
... • :'- ►..� .. •. .�•. ,. • .
.
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P.Ol
Sitc tlppr+o�aed by C'� � - �q�-a �
Grauting Approved bp
'Well Log . �ac.a. C�k �t..a��- �C? � ��'
W�11 Ta{�
Air Vent , .
Hase Bib �� �`5` �� '�'Q'`'� ��` -
Canczet�e Slab �
� �
'C�Gell Dtyll�r. n Q.x �s �,� `'J� 1
'�Vell Ap��oved By:_,_, �3te•
'+'+'See Attached Site $ketch*�'
�WeIls must be 10 fcct from pmperty lines. �"J.
Well.s muat be 100 feet frvm septic spstems. "�"r
Wells mu�t be at least � feet &om �ny building fo�nd�ior�.
Ot�er
PCF�, tev. 09/07/Ol
5ep-03-02 08:14A
P.02
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SSETCH
Nazne ��n�+;¢ Tax Ma # O�s p .
p �....,�, atccl # U 33 ,
S�iaa ���-� n-�c��...,,_. r�,,�� Zr. Section/Lot##
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Autho ed ' te Agez�t � Date
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b�s tlu in,r o� t+o iba7sria t�r.st�btnfie�-gr,�dd ::s rnairita,�ed z7b�
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