A26 185APR-13-2011 10:O11W FRO�- T-003 P.DO1/001 F-5TT
Application llate: �`� 3"� � QD �-� �~' �i'ax Map: l� Z Cp
� A�nount Paid: 0 d, O 6 �� b• Parcel #: J�S
�teceipc#: 5 0 � 1 G l
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Application for Services {Sepac Systems and Wells) ��
1) Services Requested 6y:
Name• TI-IEMI�TC�+�i
Add�rss: Pv ���4 �
a rv m�_ .u:: d27 S7 '�
Phone # (home): C 3 3Cr ) ���i'���
(work/celn:
2)Nsme and address of current owner (if different t6an applicant):
Name: Je r+� Le t mCx�rt '�' J �cd�=1�h rr. , r3r�t}-
Addtess: _ _
3) property bescription: Lot Size: 1�_ Subdivision: /�oT Lot #: �
Address andlor directions to Property: L or z ►�►� o rzTOW r�u��� ►� n-n
'p �er3 a�za iJG a 7 S-7�L
4) Propostd Use and Type of Strocture:
Residential ✓ BusinesslI'ype: ��'
Number of bedrooms ��lNumber af people served (seats/employees): �.
Basement: Yes No �_ (wich plumbing: Yes No _)
Gazbage disposal: Yes No _�_
S) Water Sapply:
Private Well CL (Proposed '� Exisang _�
Community Well: Public Water System:
Are there welis on the adjoining properties? No Yes (picase show location on site plan)
Note: A comn[eted annlication must also include:
➢ A p/al/site plan of the property that shows property dunensionr and the size and localinn of aU
proposed structures
D A signed copy aJthe `Lot P�eparation' form verijyi�g that the prope�ty is ready to be evaluated.
I am submitting this application to request services from the Per.�on Coanty Health DepartmenG i understaud tbat
if t6e information provided is incorrect or ii the site is snbsequcntly altemi, or if the inttaded ase changes, all
permits und approvals shall beeome invalid.
Signature (Owner/Legal Representative)t Date s '7 - �.3" ��
10/08 Person County Environmental Hcalth, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applican
Location:
T�x M�� � - Farcel # �
Subci'ivision
Ph�se Sect�ion Lot #
Permit Valid for �/
Type of Facility: �
# of Occupants n»x
Proposed Wastewater
Proposed Repair: �
Permit Conditions:
Five Y
# of
Improvement Permit
No Expiration
t� P, New �Addition
s �_ ,� Projected Daily Flow '
Water Supply �/ � �
g.p.d.
Type: 1�-L
Type:
Owner or Legal Representat�r Si atur�: � . � � Date: %� - �S — ��
Authorized State Agent: � wr�\ � Date: L/ - 2/-%/
The issuance of this pernut by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Rules for SewaQe Treatment and Disposal Svstems' (15A NCAC 18A .1900). 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.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_�.
Proposec�Wastewater System: Cc.' l�Z � ��q ��Je�'ype _�'!� Wastewater Flow �D g.p.d.
New � Repair Ex ansion Soil LT AIt� � 3 g.p.d./ ft 2
Type of Facility: './ Z� 2 Basement _ Yes No
Wastewater System Requirements
Tank Size: Septic Tank: %(�D(�gal Pump Tank: --gal Grease Trap: gal
Drainfield: Total Area: � sq ft Total Length � ft Maximum Trench Depth �Dinc
Trench Width � t Minimum Soil Cover: �_ in Minimum Trench Separation: � ft
Distribution: �Distribution Box �►/ �Serial Distribution Pressure Manifold
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Authorized State Agent: -! � _
Permit Expiration
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Date: �- Z�-11
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The type of system permitted is Conventional `-' Accepted Alternative. I accept the speci�cations of the
permit.
Owner/Legal Representative: � Date: � � / s " ��
PCHD rev. 11/10/OS
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Sta.te Agent
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Tax 1Vlap #�� Paicel # � 8's
• � Section/Lot# 2
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Sysfiem components repr�ese�rt appruximate�contours only. The � ntractor must', fTag fhe system prior'to'
begarning the nts�tallaiion to insure tha�t�impergmde is main .' d �� . .
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Applicant
Location:
Tax Map � Parcel # � �S
Subdivision
Phase/Section/Lot #
# of Bedrooms 6�
Operation Permit
System Type (From Table Va): Product (IIIg): !�' �
TLis system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
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( thorized Agent)
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(Licensed Contractor)
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(Date)
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Taac Map: � Parcel #: (�
Septic Tank System Checklist (Type II-I�
Notes•
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System Type: �
Pump System Checklist
Contracted Certified Operator (Type IV +Systems):
Notes•
NOTIFIED BUILDING INSPECTIONS:
(Revised 12/09 BH)
Copy of OP e-mail Date:
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I� .�� a n- � � a�. � � � �. ll IHL � �.11 � I.I�.
V'V�I.,i, I'EI2M�T (New ✓ �2epair�
Taz Map: Parcel: ��5
Subdivision:
Lot: �
Applicant's Name: � e �-{�G�
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Mailing Address:
Phone Numbers: 3�(�- ,�q -gD�f �
Location of �operty: � � �I --7 (� �, n �,� ►�LA_ I � i� � Z �
T-
�ermit Conditions:
Ij See attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply.�
3) Permits expire 5 years from the date of issue.
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Other Conditions/Comments: �� �r; h�-?'q ( h !� �' S�1' �C�S �
,
Permit issued by:
I�ate: �-2/-��
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� C�R'I'�I'�CATE OF CO1d�LE'i`IOI�1
New VVell Inspection:
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
E S/Date
-�z-�l
Liner Inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: �lt,fnP��/ License #:
Pump Installer: License#:
Well Approved by: Iiate: - G
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date Results Mailed: "
Phone: 336-597-1790 Fax: 336-597-7808
S/1/08
RESIDENTIAL wELL coNSTRucTioN uEcoun
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ✓ 7 6I '�
1. WELL CONTRACTOR:
a � �
Well ConVactor (Individual Name
Bamette Well Drillina Inc
Well Contrector Company Name
611 Barnette Tinaen Rd
Street Address
Roxboro NC 27574
City or Town State Zip Code
3c 36 � 599-0015
Area code Phone number
2. WELL INFORMATION: ^ 1 `
WELL CONSTRUCTION PERMIT# T�.X M� J h�d
OTHERASSOCIATEDPERMIT#(ifapplicab�e) R/�l ii5
SITE WELL ID #("rf applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply p�
DATE DRILLED � �l—%�
TIME COMPIETED Z0� AM ❑ PM �
4. WELL LOCATION:
cirr: �oxb9/fl couNnr ��
INO/��/1 Q�.!(�A.v+ ��i GO� +Z
(Street Name, Numbers, Community, Subdivision, lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAN SETTING: (check appropriate box)
❑Slope ❑Valley lat Ridge ❑Other
LATITUDE 36 °�� d0 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE ��_° U 2' R 2/ " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: �S Qfopographic map
(location of.well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER �� ��C�
Owner N��/�!�
ow<�l�M �?ai �� 2
Stree Address
��50�� /G. �. a�s?y
City or Town State Zip Code
3c �� Sr9 �'�Y`�
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:_� 4v ��'
b. DOES WELL REPLACE EXISTING WELLT YES ❑ NO L�
c. WATER LEVEL Below Top of Casing: 2� FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS �. FT. Above Land Surface"
"Top of casing terminated aUor below tand surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): � METHOD OF TEST BIOWtI ZOfTI
f. DISINFECTION: Type HTH Amount '� Z
g. WATER 20NES (depth):
Top� Bottom Z� Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
T. CASING: Depth Dlameter Weight Material
: Top�i _ Bottom� 6 Ft. 6%! ,,�i�u _ ��_
� Top � r_ Bottom�_ Ft.� � I vY �SL�
. Top Bottom Ft.
8. GROUT: Depth Material Method
Top rJ Bottom � Ft. Sand/Cemenl Poured
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft, in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
; 10. SAND/GRAVEL PACK:
Depth Size
: Top Bottom Ft.
: Top Bottom Ft.
, Top Bottom Ft.
11. DRILLING LOG
Top Bottom
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/
/
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12. REMARKS:
Material
Fo^ ation Description
S•
t� A�_
�a .t S'�► �t
�' /yNG[C
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
?-!� 6
SIGN� OF C FIED WELL CONTRACTOR DATE
% y�� C��� �
PRINT�NAME OF PE SON CONST CTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :(919) 807-6300 Rev. 2/09
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�Phone:3 b - � 9 -w v �'� , Addtes� ✓ �
ess Phon� �1 ��3 S' & 6'7 I � s1F I
2) Name and ad�ss oi current owner: ���'P�211 /i%ovP�' d t1�c./�: �-orL: T�
3) Proparty Qescrdptlo n: Lct siz� t. O S T�p; o L'�
Directiotia tio the crooertv tlndud'um rnadrtarr�es aru! numhersl:
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4) Propossd l�s and �re Descr�pflon: answec rh ottha powing questions .
a) ProPosed F% F�tn9 TYPe of Shuc�u+� • tn.l - ' lAAdtK.�, pe�
b) Number o! Bedraom� ��� Number of occuparrta or peopb b� servec�
c) BasemenC Yes'�'No �WN th�e ba ptumbing tn the }/�� • ..
d) � �� Yes � Nu !' ,+f5'9t�' h�1 !-�/- b Z .
Sj 1Nabr SuPNY �IP� Priva�e ✓r�ew�or ead�n9 .�, Pubiic_, CarturxtNi�l ,, S�n9 _ .
Are•any � on adjoinin9 P��1? Yes _ Na _ lf yes, pfeaae i�be appt�oodrtmia loc�iori art �e s�e �.
6j Does tha pr+op�rty c�ntain pr�sviactsiy ider�ftod jur�d �atlaods� Yes _ No �
PLEA9E NOTE TNE FOLLOWING•
'� A Pl.AT OF Ti� PROP�i�C OR SiT.E PLJW YUST BE 3U8YITTEfl NIITEi THIS APPLCATtON:
%�OP�_R7Y LWE3 AND CORl�ZS YUST BE CS.�!►RLY YARl�.
➢ THE Pl�DP03� LOCAT10N OF ALL 8TRUCTURES fWST HE STA1� OR AAGGE�. �.
➢ THE SiTE �tt13T BE READILY A�IBLE FOR �1A1 EYAI.UATION BY THE HEALTH D�l1Ri'I�t' �TAF�. ..,�
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Ta�x M�E� '� • P�rc�el # •
Suhcl'ivision
IPh��se Sect�ion Lot # �
Applicant: Q.. r �00 I"�t-
Location: �Yt n r-to� pu,l li'�cm ` Q ol. Znd lo� on 2
Improvement Permit
Permit Valid for � Five Years _ No Egpiration
Type of Facility: � i nq ( c. Fa m i( y� i I I i n New _ Addition Water Supply ri 1au.-Ee w c( I
# of Occupants (.Q Max # of Bedrooms � Projected Daily Flow � g.p.d.
Proposed Wastewater System: G�aU ���Y �nOVa�i �� ��`Jo rcdc�c.��o�) Type: .��a.
Proposed Repair: �ru� i t�! Znnevt�r"�t C�,SYo �.c-duc��a^) Type: ?�I �
Owner or Legal Represe
Authorized State Agent:
Date:
Date: � a0—Q�
The issuance of this permit by th� Health Department in does not guarantee the issuance of other peimits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inapections requirements are met. This
Improvement Permit is subject to revocation if the slte plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. Thls permit was issued in compliance with the provisions of the North Carolina Zaws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900).
Authorization to Construct Wastewater System (Required for Building Permit)
* See�site plan and additional attachments (�.
Propose Wastewater System: � raJ ity Tj� /tOVa.�i �c. Type f��, Wastewater Flow ��g.p.d.
New � Repair Expansion _ Soil LTAR: � .p.d./ ft 2
Type of Facility: 5 i nRt t Fam; I Y Ow c f �� n q, Basement _ Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: � � OO�gal Pump Tank: �1 � gal Grease Trap: N 1 A ga��� (
Drainfield: Total Area: � sq ft Totnl Length 3� ft Maximum Trench Depth �� ����'
'n b�toM
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: I ft
Distribution:
Specifications:
Distribution Box � Serial Distribution Pressure Manifold
,f Trcn�h d� a��, �'s ��
nr �c� r`n S f [ �iOrl .
0
Authorized State Agent: �
Permit Exnira on Date: n-
t rcd, C�nfra�fo� S�+oul� rnc�� �NS
'The type of system permitted is Conventional V Innovative
the permit.
— "'-�-�--^--i�.�a�� Renresentative:
Date: � �'��
Alternative. I accept the specifications of
Date:
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Name �' c rrY (Ylo�rc ,
Su i
Authorized State Agent
Taa 1VIa.p #�� Parcel # � 85
Section/Lot#� 2
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� Date �
sy� ��o� ��� �pro����u� �y. T�
beginning the instaAa�ion to insure that�iropergrade is maintc
�C �c,�1 1$� 1
LP
F�arn c�.nt�� o F
pv c.n c�c,�d P� W�r [.� n�
Scale:
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rtructor must, flag the system prior to
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PCi-3D, rev. 09/12/01
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veyor's
�ove.
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Date
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�tness my hand and seal this day of ,
19
My commission axpires .
50 25 0 SO 100 150
SCALE IN FEET
Notary Public
,� Ernest B,Wood,Jr, , PLS-z648
��,, 6�s�, 252 N.Lar�ar St,,Roxboro,N,C, 27573
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