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� (L e �.e` 'C" APPLICATION FOR SERVICES
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5ervices Requested:
_ Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
Permit (Unrecorded Lot)
Permit (Mobile Home Replace)
Permit (Addition)
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
1. Permit requested by: r-- I7. Dimensions or Proposed Structure:
�wner/prospective owner/agent:_ Width:
Phone #:
:ss Phone #:
�Tame and �idress of current owner:
�
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
9. Water su ty�pe:
private public ❑ community ❑ spring ❑
aa Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
. Lot size: �► R 3� c✓CS'
. Tax Map#: � oC (o L� �
Parcel#: 1 �2. � ,� i �+�'�e'
Township: O I� �� e 1� � 1 l
. Directions to property: State Road #& Road
etc��� �` I 33
Number of occupants or people to be served:
10. Type of structure/facility: Proposed: �Existing: ❑
Type of dw�el,l�in
House: Ld'Mobile Home: ❑ Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �-
Garbage Disposal? Yes ❑ No C�
Basement? Yes ❑ No �so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PersOn County Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property t the He lth Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this ap ' ation s�a� become yoid/�nd all fees paid forfeited.
.. !1 / ►
Owner or Authorized Agent
Permit Issued C9�
Permit Det�ted,�❑,., /
Plat Observed L4�
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Signature Date �'`'2'0 y� � f *
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�ncmxs-sr�eEvnLVAnox nxer5t ' nt�2 :'€: n�na :: ,u�a� .<'
:
1. SLOPE (�) S ��) $ $ g
P O_, `" /� PS . PS PS
� � U U U .
2. SOII. TE}CTIJRE (12-361N.) S S S
(SANDY. LOAMY, CLAYEY, NOTE 2:I CLAY) P �� PS PS PS
U U U
�. SOIL, S7RUCTURE (12-36IN.) S S S
(CLAYEY SOILS) P �� PS PS PS
U U U
3. SOIL DEPIH (IN.) S S S
S � b�l PS PS PS
U U U U
5, RES7RICiiVE HORIZONS (IN.) S S S S
(AIPERVfOUSSTRATA,ROCK) PS � PS PS PS
U �� U U U
6. SOIL DRAINAG&GROUNOWATER S S S S
(EXTERNALR W7ERNAL) PS ��� PS PS PS
U � U U U
7. SOIL PERAIEABILITY S � S S S
(PERCOLOATION RA'I"E) PS ` PS PS PS
U U U U
8. AVAILABLE SPACE S S S S
PS PS . PS PS
�� U U U
9. SI7ECLASSIFiCAT10N(SEEBELOW)
SOIL SERIES
SSUITABLE PS-PROVISIONALLYSUITABLE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:WMIPRO�DOCSIAPPSEC.SMF[NANCE.PC
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PERSON COUNTY�HEALTH DEPARTMENT
WELL A�D SEWAGE SITE, LOCATION IMPROVEMENT PERMIT —�
Tax Map # .� �i Parcel # /.�D
Zoning Township D� Y� ��i //
Owner/Contractor j N�-� L.�C ,.��� �p Date g-?[.,.=��
Location/Address �'� I nl � � 2 U � � �T��� �}��-ti�-."�k'�
'-�'.-�w'``--� S.R.# l 3 �
A -��--> >R--� , -���—T—
Subdivision
�
Lot#
�\ As Installed
C�Cr
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i�QQ,„
�3���, 5 i
, ` 3� �
� /Z ��v J;�'
SEWAGE SYSTEM SPECIFICATIONS
Lot Area .d{• `i_SG� r'r� �ize of Tank_
Mobile Home Size of Pump 7
# of Bedrooms�_ Nitri�cation Li
Max Depth Tre
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//
073�
hS
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or ' nde us cha ed. ,�Z ,(� o�' �� ��
Well and Septic Layout by
_ p ner
ell Permit Paid
�talle ob�
4��--
WELL SYSTEM SPECIFICATIONS
Individual_�Semi-Public Required Slab ✓
Public Replacement Air Vent �
Site Approved Required Well Lc
Well Head Approved �% � ���a Well Tag
Grouting Approved -.2 -9
Comments:
by
IL
Date �t�� �'�� � Installed by �Q�/�'lf�l S Approved by�
This report is based in part on information provided the homeowner or his/her representative in the applicanon submitted for this permit. The
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or
misleading statements provided to him in the applicaeon. Neither Person County nor the environmental health specialist warrants that the septic
tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam OU95 rev.1.0
�
Date:_.�- Z�-��
Owner: �.�-�._L�
Location/Directions: _
��L�'�vision N�unc:
Drilling Con[ractor:
� �' .
I'L'RSON CO 7'Y �NVIRONM�NTAL III:ALT[I
�
[JI,LL LOG
. .
SR#
LU L #
WEL,L CONSTRUCi'IdN
- � Distance from Ncarest Propc:rry Line �� �s llistancc from Source of �
Pollution���,,�s �
Total Der.th: d�-- Fc. Yicld: GPM Static Water Level Ft.
Water Bearing Zones: Depth • �) ,. Ft. 9S' Ft, Ft. �t.
Casing: Depth: From____Q_to�Ft. Diameter: �� Inches
TYPE: Stccl Galvanizcd Sceel .�
If Steel, does owncr approve: Ycs No
Weight:�_ Thickncss: , eighr Abovc Ground: /� Inches
Drive Shoe: Xes �� No I:
Were I'roblems Encountcrcd in Scttins the Casing? Ycs No !
r n
It yes" give reason:
. Grout: Typc: Neat Sanci/Ccrnent � Concrete � �
Annular. Space Width 3 Inchcs
Watcr in Annular Spacc: Ycs No �-
. Mettlod: Pwnpcd Pressure �oLrc.d .f— �
Dcpth: Fr�m �ito -Za rt.
e
Materials Used: No. Bags Portland Cement�_ Weight of .1 ba�_lbs.
If mixture (sand, gravel, cuttinas) - Ratio: �--. to )
� �ID Plates: Yes_ c.� No � � .�: � -
� 4 x 4 slab Yes �� No
____ DRILLING LOG �
Fram
To
�
Formation Description
�
I HEREBY CERTIFY THA'i' THE ABOVE INFORM�TION IS CORRECT AND THAT ��`':
THIS WELL WAS CONSTZUCTEll 1N ACCORDANCE WITH REGULATIONS �SET
FORTH �3Y�THE PERSON : OUNTX HEALTH DEPARTMENT.
�'��_ �� � . ,�, �-�- 9�
Si�;naturc of C'ontractor Datc
Application Date: � � '��s
Amount Paid: � .S'0 .Od
Receipt#: �} � � ,2 3
���, � ���..� ��
�� - --�- � � ���-� -�-
.�E'!..':rn.��in: a:a.n-n..ix-n�n..a:�.na.�:.rs..IL ?�r¢�.ala,.11.Q::.��-ia.
Application for Services �
(Sentic Svstems and Wellsl
Services
L Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 d)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required) �
C Well Permit (New/Replacement)
$225.00/$125.00
Tax Map: 02 �
Parcel #: I � Q
equested
❑ Construction Authorization
(Fee is dependent on the type of sys
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
No Char�e
Important: If tl:e information in the application for an Improvement Permit is incntrect, falsifted, or the site is altered, tlten t/te
Improvement Pe�mit and t/:e Authorization to Construct shall become invalid.
1) Services�juested b •
Name: {��� i,�, d Phone # o e):
Address: t S C� (work/c��'1��5 I=q d ���.? �
2
2)Name an address o current owner (if different than applicant):
Name: � 1.����li'
Address: � Y �
NC 2 7
33�e-s�R� �9q2
3) Property Description: Lot Size: 2•�� a��bdivision: t�i �i�' �2� Lot #: �
Address and/or directions. to Property: �
4) Proposed Use and Type of Structure: �.� ��� �O ��
Residential �_ Business/Type: Other �
Number of bedrooms / Number of people served (seats/employees): � o� � x 4 4,
Basement: Yes No (with plumbing: Yes No _�
Garbage disposal: Yes No
5) Water Supply: -
Private Well �_ (Proposed Existing _X )
Community Well: Public Water System:
Are there on the adjoinina properties? No Yes �_ (please show location on site plan)
Note: A completed annlication must also include:
➢ A plat/site plan of the property that shows property dimensions and tlze size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifying that t{te 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 understan that if any site is altered o the intended use changes, all
permits shall become invalid.
� ,p
Signature (Owner/Legal Representative): � Date : O D �
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
40 0 2o ao
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BAR GRAPHI lnch = 40 ft.
LEGEND
NF • NAIL FOUND
NS o NAIL SET
IF • IRON FOUND
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Appmv� �equ�st�d for.
Paa��#: / 20
��ba�� Hoa�e I�e�lacs�
✓ Bualcii�g .Adc�a.ti�n (�t000 �
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Installa�a�n Date: ] - �� -�l(� Desa�i ��w:. � (gPc�
C�t C��tra,�t vvith �ss�ti�esi ()p��r oa� fifl� (if res�aaire�: � .
�l'�t�r �a�ly: _��Te�. � Fiibli� o� C�Ynm�i.i�
i�7'�wat� syste� sh��vs n� visa� evid�ce of faal� on: �` 7—O R� (date)
��. {�p3ic�t's si�e if site vaslt is not x�s�sa�d}
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Subdivisi ` . � S�ctiofl/Lot# 7i
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tho�ized State Agent . � Date .
S�IS�B9D3 Cmtripm9JBfE� NB�YBSBi1Y'L��J�9'Y9�CZ8➢�f�'CO�Y#�SdYS OYII�: �'he co���r »s�t, f8as� t3ie s�rstervs�t� r t�
be,ginnirag tdse iaastalla�aors to irasaare tds�tps��liergr�e is �scairetass�ed
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