A26 189Apalication Date: b �' � � �
Amount Paid: OG. U ,
Receipt#: �2.? � D,F n � �-�/
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Improvements Permit (
Improvements Permit -
Person Countv Health Department
Environmental Health Section
APPUCATION FOR SERVICES
,� ,:: S��riiGes �equssted;�; ;��
► - 5150.00 ❑ WeU Pertnit (Ne+
Lot) - 5150.00 O, ExisUng System
(MobUe Home ReplacemenUAddWon)
Tax Mao #:
Parcel #:
on - 5700.00
,aL
System Permit
�
1) Pertnit reque�e d by Owner/agent/prospective owner): -:/�1 LFE . � 1,,/�J d;� /y) . f�; �
Home Phone:�.��- - '7�� Address: � � (,�� ,< <J
Business Phone: . -�?� J uR % ,_� 2?Sc( I
2) Name and address of curront owner. ���1 �� /d �� v✓��
3) Property Description: Lot size: �+01� Township: C7L; ✓� �ct� (..� lvW,✓s 1j; �.- Lr,S,'/
Directions to the property (Incfuding road names and numbers): _ L��49/; �/cr X6c�p
0
4) Proposed Use �a d Structure Description: answer each of the following questions:
a) Proposed�[f, 'sting ❑
b) Stick Built,0;�odular 0, Sin le Wde 0, Double Wide ❑
cj Number of Bedrooms:,� d) Number of occupants or people to be served:
e) Basement: Ye�No � If yes, # of basement fixtures: 0 •
fl. Garbage Disposal: Ye�No�'.,Q-Y.��..� 8'.-'7.-� � .
g) Dimensions of Proposed tructure: wd �Q , DePth: O
5) Water Supply Type: Private �(new � or existing 0), Public O, Community 0, Spring �
Are any weils on adjoining property? Yes ❑ No O If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
_Conventtonal „_Modified Conventional _ Altemative _Innovative
Other (specify)•
ry�� •�
.
� c�n/ ��W t/ S J
S � (o �..� oL;'ro�' !�: �
��Z � /�� hi
CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY.
' STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPUCATION
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 aitered or the intended use changes, the permit shall become invalid. I understand
that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessibie for the
personnel of the Person Courity Health Department to condud their evaluations. I understand that I am responsible for notifying the
eal D partment if property contains any wetlands as designated by the Army Corps of Engineers.
Owner or Legal Representative �!v 6� l
. Date
PCHD, rev. 10/1?J99
Application Date: �'��'� U Tax Map: o� �
Amount Paid: �Uv. U U Parcel #: I� �l
Receipt#: q p �� � ��� � � a
Ov - ��fd ��"
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� i � �` I 1�_':. �ra.�a�ii u aa n-n srnn �c-, �cz� �E:.en 71 1C :�L x-,.tn. IL �:li�a !j /•) � 1 � �'
�'Y ���
C� �� Application for Services (Septic Systems and Wells)
- Services Re uested
fi7Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if > 600 d Fee is de endent on the e of s stem ermitted)
❑ Mobile Home Replacement or Building Addition L Permit Re��ision
$150.00 (if site visit re uired) $75.00
C.' Well Permit (New/Replacement/Repair) U Repair of Existing Septic System
$300.00/$200.00/$75.00 No Charee
1) Services R� ested by: ,`
Name: ;—�^ep��r,�Y1 HQcv�.eG i
Address:
NL r►5'�
Phone # (home): 3�-5c1'1-55��
(work/cell):
2)Name and address of current owner (if different than applicant):
Name: ��;�-lr� (?�r; �-
Address: uv� t�
� \%�-��._. , IJC_
3) Property Description: Lot Size: (•(�$ Subdivision:
Address and/or directions to Property: �-►W Y 5'1 [�J -�i E
C�.�.� ✓' �1 ��l L N t 11 � 11 .�n r�.\ 1_ r�- n n 1 v �
4) Proposed Use and Type of Structure:
Residential �� Business/Type: Other
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No _)
Garbage disposal: Yes No �
5) 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 comnleted application must also include:
➢ A platlsite p[an of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifyirrg that the proaerty is ready to be evaluated.
I am submitting this application to request services from the Person County Healfh Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all .
mits and approvals shall become invalid. �"
nature (Owner/Legal Representative): �' Date : �' � �� �� �
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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T�x M�p � P��rcel # :
Subcl'ivi�sion
Ph��se_ Sect�ion Lot #
Improvement Permit
Permit Valid for �Five Years No Expiration � j�f
Type of Facility: ',� '.� New V Addition Water Supply Ic�e ��
# of Occupants �v # of B drooms � Pro ected ai low g.p.d.
Proposed Wastewater System: �� C.Z r� t�► � Typ •
Proposed Repair: � Type:
Permit Conditions: � � n n� Ce�ba�.uS
�
Owner or Legal ]
Authorized State
Date: � �� 8 �� b
Date: $--�7—�d
The issuance of this permit by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspecrions requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Rules for Sewa�e Treatment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that
the water supply will remain potable.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_J.
Proposed tewater System:� Q�q;� ��e� a r� J,crn�r�YPe�� . Wastewater Flow 3��5 g.p.d.
New _�,��Repair Expansion► Soil LT1�R. .� 5 g.p.d./ ft 2
Type of.Facility: �;�/�-�e �es��n �e Basement _ Ye�
Wastewater System Requirements
Tank Size: Septic Tank: i oao gal Pump Tank: gal Grease Trap: ' gal
Drainfield: Total Area: 3(� sq ft Total Length _ f D$p ft Maximum Trench Depth �� in
Trench Width � ft Minimum Soil Cover: �_ in Minimum Trench Separation: �_ ft
Distribution: � Distribution Box Serial Distribution Pressure Manifold
The type of system permitted is Conventional '� Accepted Alternative. I accept the specifications of the
permit. .
Owner/Legal Representative: te: ( �— g' � �
PCHD rev. 11/10/OS
:.��—,� �� 1�1�1t�.��l�
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� SITE S�.ETCH .
Name �`r-�p c� om I-�v���S Taz Map #�Parcel # 1g�
Sub ' _ � Section/Lot#
� 8`'/7- /U �
Authori2ed State Agent . � Date .
System cvmponents rre�resent crpproacimate�contours only: The cont�rrctor must jTag the systemprior to
begin�ing the installation to insure that propergrade rs maintained
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Applicant:
Location:
(' 2.
l��
�ation I'ermit
Tax Map ���Parcel # � �
Subdivision
Phase/Sectoin/Lot # �_
# of Sedrooms i
�e Cs�
This 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.
System TYp e: (In Accordance with Table Va): ��� Product: C�� �e.+�
Initial: V� Repair: Expansion:
__...---.. ..___._.._ __..- ------ -- -- -
_ .. � ��- - � -
REHS/REHSI
l�i�r �rs I��.e�4
Licensed Conhactor �(���� C� ,
�J�t'
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Date
�r /z v
Date
C���+ �"b° �
Scale 0 "l'�
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Tax Map: �2� Parcel #• ��
Septic Tank System Checklist (Type II-VI)
Se tic Tank I itiaUDate
State ID & Date: �,- �-(- (c� ✓
1
Capacity: S a � �
Tee and filter
Baffle
Vent
Riser
Outlet boot
Perm. Marker
Distribution
- - --
- -- -- _ _ _..
-_ _ _ _
-_- ox_ e_v_e_s set._ ..._ .. __--_- --
Serial
Pressure Manifold
LPP
Notes:
. � � �4►4, �,�
System Type.
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Capacity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back plug
Hard wired
Alann functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure Manifold
Number of taps:
Size and sch:
Contracted Certified Operator (if applicable):
Notes:
Tank Com onents InitiaUDate
Pum model:
Block (4")
Nylon retrieval rope
Float tree and attachments
On/Off float swing: in.
Ala�m float (6" separation)
Anti-siphon hole
Check valve
Tllreaded union
Gate valve
Conduit sealed
Outlet sealed
Approved and secured riser
Su ly Line
Size and material: in. sch.
Length: • ft.
�
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. �VE�L 1'ERMIT (New�pair�
Taz Map: (e Parcel:
Subdivision:
Applicant's Name: I'Y �dO►� �PS
Mailing Address:
Phone Numbers:
of
Lot:
h
Permit Conditions:
1} Se� attached site plan for proposed well docation.
2) All appdicable State and County �egulations governing const�uction and setbacks apply.�
3) Permits expire S years, fYom the date of issue.
Other Conditions/Comments: , ,�__ , , �
.%
P��mit issued by:
I)ate: �', � � �/d
C]ERTIFiCATE OF CO1d�LE'I'IO1�T
New Well Inspection:
EHS/Date
Location:
Grouting: t t-IS f 0
Well Log: `
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Liner inspection:
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
Well Driller: i�Q�Me,�Z License #:
Pump Installer: License#:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date:
Date Results Mailed: ' �
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depardnent of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 t� C� �
1: WELL CON'�AC^OR: n/���
c�� ( �
Well ConVa t�dr (fn ividual) Name
Bamette Weli Drillina Inc.
Well Contrector Company Name
611 Barnette TinQen Rd
Street Address
Roxboro NC 27574
City or Town State Zip Code
3c 36 � 599-0015
Area Code Phone number
2. WEU. INFORMATION:
WELL CONSTRUCTION PERMIT#���,Q ��{
OTHERASSOCIATEDPERMIT#(ifapplicaWe)��,, / �f' �j�
SITE WELL ID #(it applicaWe)
g. WATER ZONES (depth):
. Top �� Bottom�� Top Bottom
� Top Bottom Top Bottom
: Top Bottom Top Bottom
T. CASING: Depth Diameter
: Top � Bottom 6 3 Ft. 6� I Y
� Top Bottom Ft.
. Top Bottom Ft.
Thickness/
Welght Material
S`�R--zl ��Z .
8. GROUT: Depth Material Method
Top U sottom Za Ft. Sand/Cement Poured
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Siot Size Material
3. WELL USE (Check Applicable Box): Residential Water Supply � Top Bottom Ft. in. in.
DATE DRILLED �� � Z— t� Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED 3 b c� AM ❑ PM �
4. WELL LOCATION:
CITY: �A�clo�/'-D COUNTY 1`� 0 S� "�
�
� .1�� � f�i�lGs L��
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SEITING: (check appropriate box)
pSlope ❑Valley lat ❑Ridge ❑Other
LATITUDE 36 ' ' DMS OR 3X.xXXXXXXXX DD
LONGITUDE 75 ' " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: �PS QTopographic map
(loca6on of.well must be shown an a USGS topo map andaftached to
this fonn if not using GPS)
5. WELL OWN/E-,R /�
/— /GPMvk / h� M t 5
Owner Na e
!-�w�� �� �
Street Address /�(
A�YtJ]a✓b / � • �' o� 7� % �
City or Town State Zip Code
�33�, �4?- �'s3r
Area code Phone number
6. WELL DETAILS: �(�
a. TOTAL DEPTH: 3� d T'�'�
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO �
c. WATER LEVEL Below Top of Casing: 2� FT.
(Use "+` ff Above Top of Casi� g)
d. TOP OF CASING IS � FT. Above Land Surtace'
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): ` METHOD OF TEST BIOWII ZOtll
f. OISINFECTION: ry� HTH amount 1/2 Cuq
10. SANDlGRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bgt�om
o / y
���
, �l Ti O
/
/
/
/
/
1
�
. 12. REMARKS:
Fo ation Description
��P�� � l
��
�LC
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.
_ -(Z�-(�
G TUR F CERTIFIED WELL CONTRACTOR DATE
� � n � /A � � �l `1� '1
PRINTED NAME OF P RSON CONSTR 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/O9