A26 79r
The District I�ealth Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
'PROVEMENTS PERMIT No. •
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Owner: � �(/1.�� e-1 � � ,S` ✓r� e�
Location: ^ ��
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Contractor:
Wa2er Supplp: ivate � Public
Sewage Disposal Facilities: No. bedrooms '� Dishwasher, Disposal,
g',y� hing machin other autyomatic appliances
�Size of tank: �T s? r y�1 Nitrification line: G��'�� ,�� `
��
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an3 shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE,..INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRIGT�HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THEi INSTA�,LATI QN IS CO y�-
ERED AND PUT INTO USE. ; � I 1 i/� 1 1
Date approved: _
Well:
Sewage Disposal:
By:
Counter-
signed
(Owner or his representative) •
Certificate of Comple2ion
Date Approved: �� 1 g� By. ` _
nitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. WrSte in measurements in order that installations may be located
at later d e. Note locatio of � r supplies on adjacent lots.
(1)�,.2�'� � �� , W"�. �2� 5,�. �?crs
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Application Date: � a�51p�7 � '� Tax Map: �
Amount Paid: / � � Parcel #: _�_
Receipt#: /D3a�9
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TE�:�,.�z�.�,�.,�,�.�,�..,,.-�..�..�.IL 7E-�3L.�.�.:Ii.a�:lh..
. A�pli���ioa� for �er�ic�s
(Septic Svstems and V1/ellsl
�e�ic�s
L Improvement �'ermit (Site Evaluation) "
$200.00/$300.00 (if > 600 d)
Mobile�Home Replacement or �uilaling Addition
$150.00 (if site visit required) �
❑ Well 1'er�it (lYew/iteplace�nent) .
$225.00/$125.00
G Construction ?.uthorization
(Fee is dependent on the type of sy�
❑ Permit itevision
$75.00
❑ I�epair of �xisting Septic System
No Char�e
Important: ,�f Phe in,for�nation in tlie applicatiai for rr�e Isnpvovement I'ermit is incvrrecs, fr�isified, ow the site is altered, Pl:en the
Irnprovement Permit nnd the AuPhorization tn Cn�sstruci shall 5ecome invalid
Sea�vir.�s iSeqa�est�d by�: (
Name: � I � � ��C�`� �
Address: r� n . - � ' � ,
� � 4 ? `'7 °
Phone # (home): � - �2.g
(worlJcell : 3�6-- Sq�- �2 C
2)l�a�ne �nd a�dress of ceaa-�rea�i oawnea� (ef d'a�e�eeat tE�an applecae�t):
Name:
Address:
3) Y'�a�pea•#y �escrapt�on: Lot Size: �� 5ubdivision:
Address and/or directions. to Property: j�� ( �',�-�-�� pu
Lot
4� P�op�sed �Jse anal Type of Streactaer�: ; /
Residential Business/Type: Other � Q.V`cx �< S� Op
N u m b e r o f b e d r o o m s / N u m b e r o f p e o p l e s e rv e d ( s e a t s/ e m p l o y e e s):
1-� Basement: Yes No (with plumbing: Yes No �� )
Garbage disposal: Yes No �
� � 5) �atea- Saapply: �
Private Well � (Proposed �xisting �
Comrriunity Well: Pablic Water System: '
Are there on the adjoining properties? No Yes _
(please show location on site plan)
I�oie: A cv�n�letesl ran�ldcatio� �aust also incdude:
9 A plat/site plan nf iB�e property ihaP shaws propeY�y �lanaeatsions and tlae �ize. and locaiio�a o, f's�ll
propo�ed structuwes. �;
9�4 signeri copy o,�'the `Lnt �.�e�caraiion'�o��rt "ves��i�b thag the prvperiy r,s �eaady to be evraluadera!
� a�a sub�itti�� tlaa� a�pincatio� to reque�i seH-v�ces ��oan the �ers�n Cmuniy �eal#!a �epaa t�ent. T'lae
�farBnataon provYded 'as �ec�ara$e. X undepstan� that �� a�ay si�e �s ��tered or the �n$�aaded use charn�es, a�l
perffiits ��all beco�e iaavalid'. � °
�� � � � �
S��s���u� e (Owner/Legal Representative): �`�ct� � �� � � ���,� e j,
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-�97-1790)''"
C��'���`r�
Application Date: �J 20�(p ��� S� ������
Amount Paid: . .r. ,,.� • ��- � � ����
Receipt #: '�
1�', snwn n•aa an. ¢aa c� ua din ll 1H[ K� r.n. � tt�a
Aoolication for Services
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
0 Mobile Home Replacement or Building Addition
, $150.00 (if site visit required)
Wetl Permit (New/ acement/Repair)
$300.00/$200.0 75.0
Tax Map: �� a
Parcel#: �
uested
❑ Construction Authorization
(Fee is dependent on the type of system permittec
❑ Permit Revision
$75.00
O Repair of Existing Septic System
Anplication: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: 0. e. � E � �fV`
Address: �0 V` 01� c►.l ( t ,
� C 2
2) Name and address of current owner (if different than applicant):
Name:
Address: '"`�e 4 S ov�
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property: T,�
Phone (home): ��j � S-1 Q '�gzg
(work/cell): ?> 3 (� ��('z (2O6
Phone:
Lot #:
❑,�/yes no Does the site contain any jurisdictional wetlands?
4q yes ❑ no Does the site contain any existing wastewater systems?
� yes �j�o Is any wastewater going to be generated on the site other than domestic sewage?
� yes G�d o Is the site subject to approval by any other public agency?
❑ yes Gd no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
�,Expansion of Existing System If expansion: Current number of bedrooms:
�a'Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well SLJ Existing Well ❑ Community Well � Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
Please note any known ground water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted � Innovative ❑ Alternative ❑ Other ❑ Any
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate t e sit is subsequently alt red, or the intended use changes, all permits and approvals shall be invalid.
� ' - ��
ignature (Owner/ Legal Represent ive*) Date
* Supporting documentation required.
Permits are valid for either 60 months or are non-expiring �vhen accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
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IE ��a u- � �,� �,� �.�.Il IE3C � �. Il �l�
WELL PE�T / �
(New _ Repair ) L. �'�'Q �
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Tax Map: Z�E' Parcel: �
Subdivision:
Applicant's Name: Q'� � ( �
Mailing Address: 0 r �., �,�r-,
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Phone Numbers:
Lot:
LocationofProperty: .� j���70r� L'�l�%a�"� {�'
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by:
Certificate of Completion
�New Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments: l� / � ��s � �s
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date: '��
�L�,iner: �
�EHS�ate
Depth: '
Grout: --� -( �
QAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
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Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
il/26/13
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��c�� �dd�tio�/ ��bi1� �o�e �����a�a�
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P�i#:
� Mob�e Home Replaceme�t
�� Building Additian�G q ra �� �
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Permrt I.ocate.d: � -'Yes . No -
Installation Date: A-IS' gl Desiga �ova:. �( �(,gPc�
Cuu�ent Contract yvith Certi�ezl Operator on fil� {ii reqiurern: �
Wat�r 5upply: �/ � Weil � Public or Community
Wastewater system shows no visual evidence af fa�ure on: 1Z'/D � 47 (date}
��. t�PlicaIIt's signature if site visit is not required)
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' � ���itio�e fl����at ��rover�
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� Envsro entai.� Heal Spe�ialist � Date
� 11/15/05
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SI'I'E SY�TC�-I �
Name �� 'n Taz Map # ��e . Pas:cel #,�_
Sub ' . � Secrion/Lot#
� /2-1�-07 �
. .Authorized State Agent . - Date .
System cnmjionents r�e�iresent a�broximate�contours only: The contmctor must, fTag the system prior to ;
begirming the i�xstaAation to i�,�sure that propergnade is �naintairled
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