A26 11Person County Health Department �
Well Permit �
Date: �� ��� y3Tws Permit Void After 3 Years
Owner: �, � � v� + � SR# ���
Locadon/Direcdons:
Subdivision Name: ' C #
Drilling Contracwr.
WELL CONSTRUCi'ION
Distance from Nearest Property Line Distance from Source of
Polludon
Tatal Depth: Ft Yeld: �2 GPM Static Water Level Ft.
Water Bearing Zones: Dep� � Ft. F� �;Ft.
Casing: Depth: From to FG Diameter: h� Y Inches
T'YPE: Steel Galvanized Steel `�^�—
If Steel, does owner approve: jY�_ No
Weight: Thiclrness: ti Ov Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grou� Type: Neat emen Concrete
Annular Space Width __�_ Inches
Water in Armular Space: Yes No
Method: Pumped Poured ✓
Depth From —�- � Ft
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixnue (sand, gravel, cuttings) - Ratio: co
ID Plates: Yes `� No
4 z 4 slab Yes � No �
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I HEREBY CER'I�Y THAT THE ABOVE INFORMATION IS CORRECT AND THAT `"
'THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH REGULATIONS SET �•
FORTH BY THE PERSON COUNTY EP �
It Zq
Sign of on Date
fl i�
anitarians Signa re Dau Issued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
Application Date: � � � -CS 7 �
�mourit Paid:
Receipt#: �
���_ � ���� ��
"� --- c� � ��.TS�"IC �
IE=�.�.'�c-n.-.v-iin: a:av.a.�ra-n..ai+:�La.ifL.ui.71. IE":JT..e�.zca.1�.R::1l�n.
. Application for Services
(Sentic Svstems and Wellsl
Services
L Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
C Mobile Home Replacement or Building Addition
$150.00 (if site visit required) �
C Well Permit (New/Replacement)
$225.00/$125.00
TaY Map: �
Parcel #: I I
❑ Construction Authorization
(Fee is dependent on the type of sy;
❑ Permit Revision
� $75.00
Repair of Existing Septic System
No Charge
e
a�� �e�e�
e � a nti
Important: If the information in t/ie application fnr an Improvement Pern:it u incorrect, falsified, or the site is altered, t/:en tlie
Improvenient Permit and the Authorization to Construct shal[ become invalid
1) Services Re ested by: , �
Name: � � Phone # (home): 5 �7' `3- � g4�
Address: � �� (worlJcell): �_ Cl �- p 2 Qj �
, �,.,,���,�� �
B)Name and address of current owner (if different than applicant): ��—"7 �/� ��"h
Name: 4
Address: '�-n2�a� lQ �' � ,, � � o
� ���
3) PropertyDescription: LotSize: bO�pSubdivision:
Address and/or directions.to Property:
4) Proposed Use a Type of Structure:
Residential Business/Type: Other
Number of bedrooms � / Number of people served (seats/employees):
Basement: Yes��a No �(with plumbing: Yes No _�
Garbage dispos�l: Yes No v�
5) Water Supply: .
Private Well �Proposed Existing _)
Community Well: Public Water System:
Are there on the adjoining properties? No �----�-- Yes
Lot #:
(please show location on site plan)
Note: A comp[eted application must also include:
➢ A pladsite plan of the property that shows property dimensions and t/:e size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the 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 Representative): � ,���� Date : � - % - o %
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applican�
P�rmit �al'ad �or �✓ �'ave �e
Type of Facility: i v
�prove�ent ��rmit
_ I�Tn �piralaon
New Addition � �ater S�app�y G� ,
Projected Daily Flow �,{� g.p.d. -J Gue��
� Type:
. Type;
TaK Ma� ; � �rcel �
Suibd�ivision
P�h a:5 e��S ect�i�a�n: La��t �
# of Occupants �� # of Bedrooms
Proposed Wastewater System:
ProPosed Re�air: �
Permi# Conditions:
Owner or Legai Representa.tive Signa�ure: � � �:
Authorized State Ageni' • . Date: . . .
The issuance of this pexmit liy the Health Depar�e� in does not guatantee the ;�����a of other per�rits. It is the responsi3�iity of #he .
aPPli�P�Y owner ta in sure that all Peisson Countq P3anning and Zomng and Bu�ding Inspections requirements are met �1his
Improvement Permit is snbject to revocation if the site plan;�plai?`oi�'the intended use changes. iiie Ympravement Permit is not
a$ected by a ci�ange 9n ownership oi the property. Tlus permit was issued in compliance wi#h the provisions af the Nor-th Carolina, .:
`Laws and Rules for Sewa�e Treabnent arid Disnosal Svstems' {�.SA NCA,C 18A .1900). Neither PBrson �ounty�;�tor°"tlie-'''� �
Environmental iHealth Specialist warranis tha# the septic tank $ystem w�71 continue to fnnction satisfactorily in the futnre'or�#liaf.
the-water suppiy wiIl remain potable. � •
� Authoriz�tion to Construct �ast�v�ter S9stem (�ecluia'ed for Bn�ding Perffiit) �
* See site plan and additional attachmentr (_). � � . -.
Proposed Wastewa#er Syst • H�� � ' .' , ,I,y,Pe _� Wastewater Flow Z�Q g.p.d. .
New Repair �paasi .- Soil LT • Z g.p.d1 ft 2
Type of Fact7ity: �� �p� , pr;� o � � Basement _ Yes _ o .
. ���te�va��r Syst�� ��remen�ts �
T�nk Size: 5eptic'�ank:' ��S���al Pnmp Tat �-ik=�---��a% Grease Trap: --�—�••��
n
Iarai,afieid: Total Area: sq i� Total Lengtlt ��' �' ' 1V�affimuffi Trench I)ep� 12 an
• *� o.c.
Trenc� WidtL ✓ fft �atm Soil Cover. �_ in 11Tiniffiu�i Trencil� Separation: �#t
IDists ii�ntiton:
Specifications:
�istn`bution �oz ✓Serial �Disi�'bntion I'ressare I�ianifold
� ., � .
Permit Expiration ate:
The type of system permitte3 is Conventional Ac��ted Alternative. I a���t the spe�ifications of the
Peimi,t- > >
��l���►1 �8a�aa-�s�ntataae: Date: � �/�-� -
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