A26 9Application Date: lo�a5��1
Amount Paid: Iv'�"-p.�
Recei t#• � l�
p . �
Tax Map: ��_
Parcel #: �i
�.� qt�1�4 ��`'-��� � ���.���
-�- c� c� �.� � �
�'..aca�s i�v-ocqaaTM�*-^��ca�.,+�.11 I�i<c�.w.Tldl�a
Application for Services (Septic Systems and Wells)
Services Re uested �
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 if > 600 gpd) (Fee is de endent on the e of s stem ermitted)
Mobile Home Replacement o �t�on ❑ Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
� �v eed s y s-{-�� �-�-d.Kk. o�o. � ima.rke �
1) Services Requested by: "
Name: �2V��2 ���k' Phone #(home): 33 � 23 � 0 S o$
Address: P 0 � o>c ll � 3 (work/cell): 3 3 6 S 64 a 9'� �j
g,ak(ooc-n� N G �75'i 3
2) Name and ddress of cu rent owner (if ifferent than ap licant):
Name: �f�Y1 CQC� �.l hi '�� �.�`�"�a��'5-�- ��
3) Property Description: Lot Size:
Address and/or directions to Property: �
Does the property have previously identifed j
Subdivision:
.0 S �1
wetlands: Yes No �L
Lot #:
4) Proposed Use and Type of Structure: �
Residential Business/Type: Other pt G r1i G S�j1�4-4C�( I p�a��
Number of bedrooms , or 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 plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the Zot Preparation' form verifying that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid.
Signature (Owner/Legal Representative): Date : ��• 2 S• � �
08/11 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
ConnectGIS Feature Report
Page 1 of 1
k ConnectGlS has been prepared for the inventory of real property found within this jurisdiction, and is compiled from recorded deeds,
plats, and other public records and data. Users of this system are hereby notified that the aforementioned public primary information
sources should be consulted for verification of the information contained in this system. Person County, Withers & Ravenel,
ConnectGlS and other mapping companies assume no legal responsibility for the information contained in this system. Grid is based on
the North Carolina state plane coordinate system, 1983 North American Datum.
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Tax Map #:�� Parcel#: "I
Approval Requested for: 1Ylobile Home Replacement
� Building Adciition
Applicant Name: (1 c�
Address: �
Phone #'s: ;�(� -Z3�l-Ur(��_ 3�(�- Sb� - 0930
Pernut Located: Yes V No
Instaliation i�ate: ? Design flow: ? (gpd)
Current Contract with Cer#ified Operator on file (if required):
Water Supply: V Well Public or Community
Wastewater system shows no visual evidence of failure on: 1 D- 3 l-�� (date)
(Applicant's signature if sit� visit is not required)
COrilrrient3: �jnrnJ� -i7�f niC_N1
A��fln�g����pYa���aa���a� 1����°od�s�
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10-3�-11
Envir nmental Health Specialist Datz
11/15/OS
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,�,�la ��
ty Rermlt nqu�stsd by: {Ownerla�rntlpraspeclive own�rj: �.,�s� '�CJe� � l',_,_o�Co�d� ��`i� ���C..l(u�,
Hame Phon�: �gS�-c°)aya � Address: ' �
8usinese phon�: _5�9 -�i��. . .
2� Namo and addr�a ot.cumant owaer, o�rcJ� i�� �°�P�a l�'l -�-�-� � cc � 1�� c,
.. _�Qx6ato,_,. �o?�%ar?r1`i .
3� Prop�rty D�scrlptlan: Lat siz�e: Tawnship: �' '� Suhdhrislon: IU(� Lot �
Qlrectlons ta tha pc�nPerty (I�cluding road names and numbe�rs): •
�
�) Pr�pc�aod Use and 5tavct�rn Daacription: anawer each of tha f`olfow��g que��ong:
a) Proposed . Exlsting ,� Type af Struucftue: � Wldth: ' Dept}�: � .
b} Numbe� of �sdrooms: . Nutnb$r of oc�u�ants o� peopls•to be serve�:
c) Basemert� Yes . Na � Wii! there be plumbing in the basement?
a) c�beQe D�: Yes ._., No _ .
�j Wa�n- Suppiy't�: Private (new or exlsftng� ub!!c Community.r,�, Sprin6 .�
, ' ��welEs an adjalnln8 F�P�Yt Yea No �%J�piease indicate �PPnoximats iacation on the
�} �� Y� �P�i *�� P�vlousty idsrttlHsd juri�dictlanaf woiiaru�s? Yes_, Ho �
PLF.;�i3E NOT'E �E �OLt.�VYMit3: ' � _
3� �c PLAT � THE PRi.1RERT1f GR 81i� PLAN !�tl8'(' 8E SUBMCTl"ED W!'TH TH13 �►ppUCA170N.
�' PROPERTY LWE3 AND CORNFRS MU3T 8E CLEARLY MARltEp, ..
➢� THE PROPQBEQ LQCATION �F ALL STRUCTURE31YilJST �E. gXAi�p OR fiLAGGED.
A�7iE 9�TE MUBT BE READILYACCEB$181.E FOi�qN EypL,UAl70N HY'!"HE HEI1l.TH�DEPARTM�NT
9TAFF.
I hereby make
system fac �
facii'�ies F6s,
on C�rrtY Heslth �epartment f�r a slts eva{ua��n far the arr-sife ssL+r�ge dlspns�l
-ty. I agre at the contents'ofi this a�plicaticn are true and rspresertt irhe max;mum
. i und nd if the sitfl is aiterecf or ttie intended usa rt�anges, tti� permlt snaU
//���
Oste
i Lx t ,y�.� T "� �' (w�P(7�sA?i. f �,J�] hft�' y1+3.7.�'} ) i i J;,� � � �� ' :;s�N`.KY
�' ��. `��.�� t(;°s�'M� �i4 �.��t� � Q • �' . `,iu�$�Gi1�^'� �"�Y� w`�E s'..Sr .r .:.. .. .... . .5
. :.: � Y�� �s�..,r�``" .�. ; � � � . . w' x r;». . . �... .
'�mprovements PermiG (Established/Recorded Lot) _ Reinspection of Ex�sting System (Loan Closing)
Imp�ovements Pecmit (Unrecorded Lot)
improvements Permit (Mobile Home Replace)
vements Pecmit (Addition)
Repair/Replace extst�ng Sept►c System
Permit for New Well
�,_. Replace Existing Well
1, permit requested by: . ' 7. Dimensions or Propo�ed Structure: I
owner/prospective owne a en �e� �1� ve r('o ns4- Width: �
ddress:—����- � �� ' _ Depth: `�
I �' _ 4� � � . Cl � .s�t3
- 8. What type (if an} ;�addit[bns, expansions, or
� replacement is anticipated to the stnicture or facility
.-a that this sewage disposal system is intended.to serve?
� ome Phone #: �Qq"a 53 (',[aS�' S —
� usiness Phone #: _ _—
a
Name and addreSs of cument owner: 9. Water su ly t}�pe:
�n�_or � ;._ �a� j.J� ��-hncl i5�- (' � rc privat public❑ community ❑ spring❑
�'jp '� c oY d.i��hur _� Are any wells on adjoining property?Yes ❑ No [�
' ,�,� h.,,�a nf C' .�'"l S 73 If so, identify location:
�
. Property Description: Lot size:
Tax Map#:
Parcel#: _
�Township:
, Directions to property: State Road #& Road
!ames;�tc.
: � � , ,. c n n 1 "� : . ,. ... 1 o.aC'� �•.r,-�-f
10. Type of structureJfacility: Proposed�Existing: Q
Type of dwelling:
House: ❑ Mobile Home: Q Business: ��r�
Type of business:
Number of Employees: �
Number of bedrooms:
Garbage Disposal? Xes ❑ No Q
Basement? Yes� NoC7 If so, # of basemen[ fixtures:
6 Number of occupants or people to be served: � '
CLEARLY STAKE ALL CORI�IERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PerSOri COUI1ty He2tlth DepaCtmerit foc a site evaluation for the on-site
sewage disposal system for the above described propecty. I agree that lhe contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if the sife is attered or the
intended use changes, the peRr►it shall become invalid. I understand that before an Improvements Pecmic can bf
issued, I must present a survey plat of the property to the Health Dept. I underscand that in the event I have not
delivered a survey plat of lhe property to the Health Dept. within 60 DAYS after the date of the evaluacion of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
permit Issued ❑
Permit Denied ❑
Plat Observed ❑
i. s�o�cA�•
Signature � Date
soa �crv� u2•M �a
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Person County Health Department
Existing Sewage System Report For: Mobile Home Replacement
� Addition
Requestee: J�`'� �t�� �n5 .�+�Y1 Home i'hone# �99'"�3�%
� � .� � 1,]OX �{ l � Business#
�O�C�Z�.� N� �J%�j%3 'Pax l�ap# 111-tD�" 1
Location/Directions: �{�5`� nJ "{p �1�.��Y1 l�Q�. �
L��-� �n Ce�nC�� C i�c.�- i2G� • --
Original -Permit Located
5eptic System Uesigned For: -
ttesidetttial _ Business Other ( speciFy ) ��, �_r (..�
# 13edrooms # Employees Other � c�� ni�%�.�
llate lnstalled Water supply (��/�-%�
'Pype of System LJe-�i�1��(��i�1`�Y�R.i _
Nitrification Line
Tank Size
Certified Operator Required N�J'�
On site wasL-ewater disposal system sliowes no visually apparent
malfunction on �I $ �9 ri
Yermission is granted to: �� t'1(y.�(�« �i'l.�,C.(_C.��
According to the attached site plan.. -
C o m m e n t s: 1 V'2-u.� �(.l 5'F-e-M _ C1J � � � b��'Y1S'4��_ (.J� �.e _`b I_
m ��S
Environmental Health Sy�G. i/ `
� DATE
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT 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 # � 2 �p Parcel # �
Zoning Township ` Cc.
Owner/Contractor (� �nec,rd � l� <<_ r('_h. Da --�I
Location/Address� J��i� nt T[� o n('r�� C'. I� c.�r .� P� r� r1-J'k'n e.
� : ati�- s.x.#
ision Name _ Lot#,
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank �`�J Q'� �Q .
SFD - Mobile Home Size of Pump Tank I� ��
Business # of Bedrooms Nitrification Line (fl `�S �+'
��r� Max Depth Trenches a�i''
Permits may be voided if
Well and Septic Layout by_
Comments: �- � � _
altered or inte,�ded use changed.
Date � ° /3 /91 Installed b ' Approved
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
Well�"ead
Grouting �
Comments:
N
;� Date
Semi
Installed by
Required Slab
�jd# Veri� „
Well
Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application 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 co�ditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
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 tbe water supply will remain potable.
c:\amipro�permit.sam O1/95 rev.l.l
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�� ^-� � � � � � �
�na��i.�r-��rnn�n-n-n��ntE�si.Il ���.zn.IltE�a
Owner: �
Location:
Subdivision:
�
Drii'Ier ID # � i
Com��ny N�me �� '
D�t�e Dri!I'leci • �
Lot #
Tax Map,�. Parcel # �� q
Well Construction
Distance From nearest Property Line (Minimum 10 feet) � U
Distance from S_ e tic System (Minimur�r 60 feet) r�t�
Total Depth: �� �_ ft Yield: �_ GPM Stat� Water Level: o�� ft
Water Bearing Zones: Depth /�� ft�,�?.S ft � ft ft
Casingc
Depth: From � to �_ ft. Diameter: �_ in
Type: Galvanized Steel /�
Weight: Thickness: �88 Height above Ground: 1y in
Drive Shoe: �Yes No Any problems encountered w�iile setting casing? _Yes /�10
If "yes" give reason:
Grout:
Neat: Sand/Cement Concrete Gravel/Cement �
� Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped. Pressure Poured _1 Depth _�_ to �O Ft.
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds �
If mixture (sand, gravei, cuttings) - Ratio to
ID plates: � Yes _ No 4 x 4 slab � Yes _ No
Drilling Log Location Drawing
From To Formation
U
0
0
n
� 1
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I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person C t�' -t n. _
Signature of Co tractor C.�� ID # s��v Date /l ` 7��
PCHD rev 09/30/02
���.�� ���..���
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w�� ���
��� s�� ���� �� ��� w��, sr� ��o�
�� �� #: f�C� ��� # � �D��
���� Concord �'x,.�'s-� C�u��G,
Su�c�ivasio�: N 1� S�ct'aon: Y.o�
�'�� �i Water 5����:
��c�ig�.cean�an�.
Iridividual Com�unity Public.
Site Approved bp � �' `'�
Grout�ng Aplxoved bp -
Well Log �c�i-1 � � 7L73
Well Ta.g,;
Air verit
Hose Bib
Concrete Slab
�;� - i t ;i - � /�
W�..�pa�ved. ��: D�.�:
�See 1ltrac3ie� Satc S�tcfi'�
Wells must be 10 £est from propertp lines.
Wells must l�e 100 feet from septic systems. �
Wells must be at least 25 feet from anp biulding foundation.
Other conditions: 1' �QCG I,.� � t� �.S 5�,� �n , f��� W �l� lC�� F�Orn Sc.p�b��-�
l.� ��n k, 0 ld- ta� ( �
j� ��, d�o! x C� `�Sla.b x g i ��t,�.s {��cK�
PC��, rev. 09/07/Ol
. ���� J J� ���� ��. V '
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1Eaa.�a�r�,�,• +� �aa�.rn.Il IE3[ �alltEll-a
siz� sxExcx .
nc��d t S-� %urc-� �Tax Map #�a� Pa.�cel #�—
ub vis' n N I Section/Lot#
o �1��_
co Authorized Sta.te Agent Date
� Systefn comportents r�epresent a�'iproximate contours only. The contmctor mustflag the systemprior to
� beginning the instatlation to insure thatpropergrade is maintained
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