A25 98Person County Health Department �
V`�lell Permit ��� �
Date: I I- �"� 's Permit Void AfSPr 3 Years �� '�
Owner: U c � SR# �
I.ocation/Directions:
�
Subdivision Name: ` �C
Drilling Contractor: �
WELL CONSTRUCi'ION ►�
Distance from Nearest Property Line Distance from Source of �'
Pollution�q� �
Total Depth:l L.(�FG Yeld: �_GPM Static Water L,evel Ft. �
Water Bearing Zones: D� � F� Ft. f�FG
Casing: Depth: From to FL Diameter IO�+[ Inches
TYPE: Steel Galvanized Steel .�
If Steel, does owner approve: No -
WeighC Thiclmess: Height Above Ground: Inches
Drive Shce: Yes No
Probl E ter d' Settin the Casin � Yes No
Were ems ncoun e m g g.
If "yes" give reason: - � d
Grout: Type: Neat d/Cement Concrete ;4
Annular Space Width � Inches
Water in Annular Space: Yes No ,/
Method: Pumped Press e Poured'
Depth: From � to FG
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
ff mixture (sand gravel, cuttings) - Ralio: to
ID Plates: Yes � No
4 x 4 slab Yes �— No
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN CCORDANCE W1TH REGULATIONS SET
FORTH BY THE PERSON COUNTY EP NT.
�Y I��ZQIQ�
�� Date
� / I�r/
Date Issued
Sanitarians Signature Date Completed
Sketch weil location on reverse side.
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. Note location of water supplies on adjacent lots.
(1) �2� .,_ .
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Application Date: 6 �� � � � ���+5 (' ���� �� Tax Map: �' � �
Amount Paid: � �,,; �� � � ���� Parcel#: �
Receipt #:
lE�:�ma*an-�,.*,.,.,�m�.�,�,.11 'IHI�,�,.Ila�.
tion for Services
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 �
❑ Mobile Home Replacement o Buiiding Addition
$ I50.00 (if site visit requir
0 Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
� Construction Authorization
(Fee is dependent on the type of system permitted)
� Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: ����.,c.,.i� �s�-iw,�cv� C�.d.,� �v �
Address: �{S� �,�ai� p�
Tr„c�� �(TL 2,7s'�
2) Name and address of rrent owner (if different than applicant):
Name: k �
Address:
Phone (home):
(work/cell): 51� uS) �!(�'�1 %
Phone: q�g—�g�-9", %1?
3) Property Descriptioa: Lot Siae: Subdivision: Lot #:
Address and/or directions to Property: Lt LJ,,,� 1�irt 5�-, �� A+w Gwb �►�+. !�k Ce�.,,,�..�i
C� ..�l.v�tiy h-rns ��rr'� /'�L t�J'G�Vi�J i�t� Ff/, Q�' a� %�knL�c., FO� .
❑ yes no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?
O yes � no Is any wastewater gaing to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedraoms:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
� Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes 0 no
❑lvon-Residential c� e e k
Type of business: Total Square footage of Building:
Maximum number of employees: Maximum number of seats:
5) Water Supply: ❑ New well I$I Existing Wel( ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative O Alternative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccuYate, or if the site is subsequently altered, or the intended use changes, all perrnits and approvals shall be invalid.
-- - — —= — -- � le ) % — —
Signature (Owner/ Legal Representative*) Date
* Supporting documentation required.
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
/1(1/11� porenn �nnntvRn�nrnnmonta� uao�+� '27� Q�/Tnrrt9n e1' Q711iP:� �nv�+n.-n T�T(ti7'/C7Z /']ZG G(1'1 1'lfln\
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�- � � �..� I 1—I �- .:� I � I �
Building Additions/ Mobile �ome Replacements
Tax Map #:�-25 Parcel#: L%� Address:
Approval Requested for:
Applicant
Address:
Phone #'s
Mobile Home Replacement , �
�/ Building Addition ��G�G � � ��
Pennit Located: ✓ Yes No
Installation Date: — ' �/ Design flow:
Current Contract with Certified Operator on file (if required): !1,_�
Water Supply: ✓ Well Public or Community
(gpd)
Wastewater system shows no visual evidence of failuxe on: � (d te)
(Applicant's signature if site visit is not required) /��jT <�
• � - � , ' . . �. � �i
,�
Addition/Replacement Approved
---- �— — -- -- — -- _ �O/� /�c1
Environmental H alt pecialist Date
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.�ersoncountv.net
ConnectGIS Feature Report
Page 1 of 1
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VOTICE: Recently, we h,�ve h�id su�eial ���seis ie��ort biowser compatibility Issues �ahen trying to access our GIS website. Typically, the problem stems from users who ha�
ecently upgraded to the Windows 8 operating rystem or a new version of Intemet Explorer. We were able to resolve this issue by directing users to the Intemet Explor
�ompatibility View tool. This link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US/intemet explorer/products/ie-9/features/compatibllity vie
f this does not solve the problem feel free to contatt us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGIS has beE
�repared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system a
iotified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectG
�ssume no leqal responsibility for the information in this system Grid is based on the NC state plane mordinate system, 1983 NAD.
http://gis.personcounty.net/ConnectGIS_v6/DownloadFile.aslix?i=_ags_map012aa8cb49d4... 6/6/2014