A26 134Per§on �ounty Health
,��v���.e
Department
Permit
Permit # � � �� ��
SR# 133 �
i�',�e� Qa� les
System Improvements
Subdivision Name: � �' ��mm ' d � Lot #�_
Lot Size: ype of elli g:
Water Supply: Private: Public: Community:
Bedrooms: 3 Gazbage Disposal
Basement Basement ' es
INFORMATION CERTIFIED BY � `
Environmental Health Specialist: � q `� �u"e
REPAIR: REEVALUATION:
-------------------------
Size of Septic Tank: � 00 � gallons Size of Pump Tank:
Nitrification Line: %f�� 3 �
Depth of Swne: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
----------------------f—f=
Date Well Approved:
BY
Date S va e S
BY
Well should be 100 f� from any sewer system
Environmental Health Specialist
�
�
v _�-t, t iriLt� i� t�r ��mr� i iviv ,�
Contractor. �� � a� � � �
------------------------- �
b
Sewage System location, installation, and protection must meet state and local �
regulations. Sepdc tank should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nicrification line must be inspected and approved by a member of the Person County �
Health Department before any portion of the installation is covered and put into use. If �
the site plans or intended use change this permit is subject to revocation �
(G.S.130 A-335F) �
L.ocation of sewage disposal sewage system sketched on back. �-t!
—�+
(OVER)
� NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
.
� su�glies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at l,�tgr date. Note location of water supplies on adjacent lots.
�
. m���� ar�x�.E�
���,, �erson•County Health Department
, Well Permit
Date: �'�'` is�ermit Void After 5 Years
Owner. F �.� �oo�s' SR# �33�
Location/DuecUons:
Subdivision Name: �J; m I Pa.t vP �,� r..� Lot # /�" _
Drilling Contractor: 11Ca��_�fiA �1�! �
WELL CONSTRUCI'ION
Distance from Nearest Property Line Distance fmm Source of
Pollution i�'
Total Dep� FG Yieid: v GPM Static Water Level Ft
Water Bearing Zones: Dep�F FG Ft Ft.
Casing: Depth: From to� Diameter: Inches
TYPE: Steel Galvanized Steel✓
If Steel, does owner approve�iNo
WeighG Thickness: 1 Height Above Ground: Inches
Drive Shoe: Yes No "i
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat S ement Concrete
Annular Space Width 7� Inches
Water in Annular Space: Yes No
Method: Pum d Pr ur Poured �
Depth: From � �to Ft
Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs.
If mixture (sand, gr�l, cuttings) - Ratio: to
ID Plates: Yes No
4 x 4 slab Yes�—No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCfED IN ACCORDANCE W1TH REGULATIONS SET
FORTH BY THE PERSON COUNTY HE�D IPART NT. I' � I��
. �
� iI/z�l ��t z
Date Issued
Sanitarian's Signature Da Completed
Sketch well location on reverse side.
y
{i
NiO�'E: Make sketch of insfallation showing lot size and shape, location of house, septic tanks, privies, water
sup;nlies, etc. Note special problems existing on lot. Write in measurements in order that installations may be
locat�d at later date. Note location of wat n adjacent lots.
_ , y _. .
���
� �� o0
� (����lYCS \ � : .,•
,N" �'''�
�
� � � I - � /
�-
}�Permit requested by: .
�wner/pro,s. �eccive owner/agenC �� � � c� ��
Address: ��L�.��� �'�� �c�id�r'�� � �'
�
�
w
U
�
a
ome Phone #: ��- �`14�
usiness Phone #: ��'�' 1� �
2. Name and address of cuRenc owner:
W
�
z
7. Dimensions�or Proposed Structure:
W idth: �-�
r�o.,►t,• l•90
PropertyDescrip[ion: Lotsize: 1-u� °��eS .
Tax Map#: �- �O
Parcel#: � 3 -
Township: ����— - -
Directions to property: State Road #& Road
ames,�tc.
G
8. Wha[ 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 supply t}'pe:
private�.public❑ community❑ spring❑
Are any wells on adjoining proper[y?Yes`� No �
IIf so, identify location:
of structurelfacility: Proposed: �Existing: Q
Type of dwelling:
House:C� Mobile Home: C►�Business: ❑
Type of business: '
Number of Employees:_____ •
Number of bedrooms: .3 –
IGarbage Disposal? Yes ❑ No (�
IBasement? Yes ❑ No�If so, # of basement fixtures:
6 Number of occupancs or people to be served• ��_� `
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PersOn COUrtty Health Department for a site evaluatica fon ahe �rue lte
sewage disposal system for the above described property. I agree that the con[ents of th�s appli
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 Petmit can b�
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 to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
� \ �.���
Signc� Owner or Authorized Agenl
�
Permi� Issued ❑ Signature Date ,
Permit Denied ❑
Plat Observed ❑
�
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet a�eas, �11
areas, wells, water bodies, slope pat[erns, etc.� C:V��IIPRO�OOCSV�PPSEC.S�t FW�NCEPC
02f25l1997 09:30 5971799 PLAt•ItJIN6 AND ZOMING
� r l l� [.1
�
• /VI � c� 66 dS/ �a �; t,�1� ��-
� j�., �� -�
�,��
Dac�� � ,��cr-a,�.c-
� r�s-� _
, r- f2. o r-�-
�.!$ e' � t- c.Y 1 �
� �4., G- f�
� �� �
I dU1C-
p ( e .r�-�3�. �
d_'�• �,( �L` R 5 r, � �'
04 n/ � T� C!�' �� c�
�� diSr p�
--� + S
�; �'� PlR�✓
� �� �� uis'c.
�� � r
f,� ��,,�C «.s�
U
� � o �-�
���
�
�
.
0
�
PAGE 03
B 1433
PERSON COUNTY HEALTH DEPARTMEN'T
WELL AND SEWAGE SITE, LOCATION IlVII'ROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
, has been issued.
Tax Map # , � a2 �o Parcel # /�� �
Zoning Township '
Owner/Contractor ,- r i ' G✓ i Date 2- 2/- �i' `7
Location/Address ! �fo '� n '� f��'
' s.x.# 33 �
Subdivision Name Lot#
�C��� ��e EWAGE SYSTEM SPECIFICATIONS
M epair Lot Area /, �(v GtCref Size of Tank � �;��� /o�s
� SFD Mobile Home � Size of Pump Tank iv-� +a
usiness # of Bedrooms�_ Nitrification Line '' ��0 'X3
Max Depth Trenches
��.1 � � S� re- f� 2"' '''-e ls ja� �S ,�e� •,. `�G�``7
v Permits may e voided if site is altered intended use changed. �"�` �
� Well and Septic Layout by � v��
a+ Comments: __
�
�
Installed by
el! Permit Paid C� WELL �STEM SPE�I�'ICATIONS
jividual Semi-Pu c ReQuired Slab /
Approved
Comments:
Air Vent
ell Log
by
Date // Installed by �' f Sr/lv-� (�� Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permi� The environmental
� health specialist is not responsible for false or misleading information
contained in the applicahon. 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
H him in the application. 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:lamipro\permit.sam O1/95 rev.l.l
Application Date: � � �
Amount Paid: 1 Q,6
Receipt#: � a3 q�''7 C.I��-a� I3
��`� f � ���..� ��
�� - " -�- � � ���n�
.JL_.r :C']l.'�sr ]i ]C�aC:D LT.:Ii3T..K�.:! ]CT.YC:.CR..�. .I�C K7.'tILll.-Q:. ��
Application for Services
(Sentic Svstems and Wells)
C Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 d)
� Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
T� Map: � � �
Parcel #: ��
Services Re uested
❑ Construction Authorization
(Fee is denendent on the tvne of
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
No Char�e
Important: If the information in tlie application for an Improvement Permit is incorrect, falsifed, or the site is altered, then tl:e
Improvement Permit and tl:e Authorization to Construct shall become invalid
�) Services Rec�ue ted by:
Name: .%� S� �(r'C�-%�i
/
Address: 3 a�`� I,�/�`..1.- SO/� �j v,
Phone # (home): �� �1'- � `!� l %
(work/cell):
2)Name and address of current owner (if different than applicant):
Name: �-G�u �
Address:
3) Property Description: Lot Size:
Add d/ d' t' t P
Lot #:
ress an OT ITOC IOriS o roperty. �„ �. V.1 .ar � r vni� �.�� v� ��� w � r.. ..� �
� � i
�
4) Proposed Use and Type of Structure:
Residential _� Business/Type: �'- l� /� �- Other
Number of bedrooms � / Number of people served (seats/employees):
Basement: Yes No _(with plumbing: Yes _ No � Garbage disposal: Yes _ No _
Approximate size of building foundation: Length_� Width �(
3S Water Supply:
Private Well (Proposed Existing �
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
(please show location on site plan)
Note: A completed apnlication must also include:
➢ A pladsite plan of the property that shows property dimensions and the 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): ` / � �� �� �Vti'3 �� " Date: � � 6
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
.r
��
) ���
� , � �
*.��� � b d �
� � � �.+�. '3 ��
�]�II.�7"ID.B:'�778':i3.'�"�^s tC3'��JL .1� JY.C��
���� ����ti��/ 1����e ���e ��i�s����t�
. T� � #:�_ ���: 3 � �
A�Pmvai Re�ueste3 for. �Ma�Ce Home Repia�amea�t
. � Bnild�g �dtiition
� �aiv,es l�Jo`se� � ew�k�
A�plicant Name:
� Adc�ress: • ' 3 3 6 Nlor oa u 11 � a�tn `� .
� � R�boro,� IfC 2.757� _
' �h�ne #'�: -�4$�-��99-7 = �O �I-- 79�
Peanit �LQeate3: ��'Yes . Na .
Installa�aion Date: 3- - D�gn $a�v:. (n D(gP�
t
;.
�
Cu�nt Cantra�t v�ith Certif.esi Op�rator og� �ii� {if res�ired): . .
�l'ater Supply: �we�I � Fublic o� C��nm�ani#.y 13
. � . � . � LI'`� ,
�Tastewate�r system shows na -visuai evidenc� of fa-�u� on: 2� t �' d$ (c�at�)
��. � (A�g�iic�n.t's sign� if site visit is nat zequired}
Conlment5: Ma„��'ai'n ��� �iNt�n � �row� Gi�� DA�-�s � S�oii�c.
Environfnen�cai H tb. �e�
� in�i�s � C� .
n
0
r '
� 2-1t-o8 �
ist � Date
iJ�� (o t � t 3
11
•���J�� �.a �.���� .
.�' ,/� ,/� �j''�'�4
' '`f �J �q/ � V �y lYT
�71a�Y]L'm"'n �emm ��'�'..�.JL ��OS.LLlCJI3
Nai71e /'IQrS�n WDAd.S
Subdivi ' n
Autho�ized State Agent
SITE S�TCH
Ta,g Map # Z(� � P�cel # /3ll
Section/Lot#
_ � Z-�/-o� �
Date .
System cvm�o�ents rre�resent ap�iroximute�contours only.' The contractor must, fTag the system�irior to
beginning the installation ta insure thatpropergr�acde as maintuaned
5; � t� �.��,
�
�
�� .
�, ConC�d �.�-p � —.-- �p�ibri �U�(ta Nl - � � � � 11�
1