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A27 125ount I eceipt H O , paid i �6. °° �� .IAD �I�.2 C% fc--- a�,�� i � _ �.g a ...n... -^r�. �-3-9 � Date vements Perrai� (Estabiished/Recorded Lot) �_ Reinsoeccion or �xis[ing System (Loan Closing) ImGrovements Permic (Unrecorded Lot) Improveme�ts Permit (Mobile Home Replace) Improvements Permit (Addition) _ Bacteria ReoaidReplace existing Septic System _ Per,�ni[ foc New Well _ Replace Existin� Well _ ChemicaI ._ PetroIeum I Desticide � ._ Lead . Perr;�it ;eques;ed by: . wne:/praspeccive o ne:,' ,ddress: �� n �( / 7. Dimensions or Proposed Stn:cture: nt: c. � d Width: 34 � / Depth: 5� ; c:a � Home Phone r: ¢ usiness P�one �: -'S�1Q-1�'f0 a N . Pro 8. Vvhat type (if aay, additions, expansions, or re�lacement is antici�ated to the structure or faciiity that this se�va;e dis�asai system is incended co serve? d addres o�_c:.�rcent owner: 9. j%v ater supoly ty�pe: , ' D private �( . public ❑ community ❑ spring ❑ Are any �ells on a�joining property?Yes ❑ No � If so, identify locacion: DescriDtion: Lo[ size: 1 � � Tax Map; : 1�. � / Parcel�: �� Townshio• � ✓.� - .� � � �— � Directions to property: ames,�t�7 � / , ` 1 ' /U l, S State Road # & Road d,2 10. Type of structure/facility: Proposed: �Existing: C Tyge of dwelling: House:� Mobile Home: Q Business: ❑ T of busil�ess: YFe Number of Employees: Number of bedrooms: ______�,. j Garbage Disposal? Yes ❑ No I� �,Basement? Yes ❑ NoII If so, � of basement fixtures �6 Number of occupancs or people to be served• � CLEARLY STA� ALL CORNERS OF THE PROPERTY AI�ID THE CORI�IERS OF ALL PROPOSED STRUCTURES• I hereby make apptication to the PerSOn COunty Health Depar�ment for a site evaluation for the on-sit�: sewage dispvsal syscem for the above described propec[y. I agree that the con�encs of this application are true and represent the maximum faciiities to be placed on the propeRy. I understand if the site is� altered or the intended use changes, the permit shaIi become invalid. I understand that before an Improvements Permit can b issued, I must pcesenc a survey plat oE the propercy to the Health Dept. I undetstand that in the even[ I have not deIivered a survey plat of [he pco rty tv the Heatth Dept. wichin 60 DAYS after the date oE the evaluatien of the site by the Health Depc., tEy��plication shail become v�id and all fees paid forfeited. Signec� Owner or Authorized Agent 00 'UOi Pa zi L\ � � � , 6/ R_9 : 7 • p 6L bbf= b' � �G . 5t, 610/! = � 11 I f� ' — _!�� ~ �,. g[-ZZ'9` h� `�'" a Z� i -�--- IJ' ��" ,,, n: � . _,;- - � _� a L8=7 OLF-t� ; o p�: p 'l r ; ;� _ `� , v � � A : ,�. � � �� , � � •E� ry at' rr '.. _ . �. •� . ., ' •. ' . 1 . .� . / _ . w ' .�. � • • • �!. ' "�y , 668G/ ) : '- ' . � 96�fZL`=H .. �. � � � .,/Y,�JI.s/C� . . - -� I ., . '.. . � � � .. . C"�`, \ ' .` - , �. i . . V � sa �yz = � �'. �` 96'F�[L•d Z �� , Fl.9.rc�0av i492 2�Z � o+- j � i- .\ / � f � '__..-..' ��.5.�� .�.� _: � �� - c� �O ��I`' � ��rn.�n.ic-�irn��rn�.rn.Jl �L��.IltE71a � �r�' �`� � Owner: ,� Location: Subdivision: r Dr��aorr a� � _� a � � — a�o _�u� n � ° S ►�� ,�:�� . D� Dr�O(lod � _ s, z. VVell Log Tax Map �� p�cel # �� Lot # /`S _ —�--_— Well Construction Distance From nearest Property Line (Minimum 10 feet) �/ Distance from Septic System (Minimum 60 feet) �-- Tota1 Depth: fJv ft Yield: ,� GpM Static Water Level: _ g Water Bearing Zones: Depth b' a— ft 6� ft ft ft Casing: Depth: From _ D to �_ ft. Diameter: � � Type: Galvanized Steel ✓ Weight: �_'��ess: J�� Height above Ground: . Drive Shoe: ✓yeS No � roblems encountered while settin� �in If `�es" give reason: y p � �' —Y� �0 Grout: Neat: Sand/Ceme�nt -� Concrete GraveUCement A.nnular Space Width •S inches Water in Annular Space yeS c�o Method of Grout: Pumped Pressure ✓Poured Depth p� to�o _ Ft. Materials Used: No. Bags Portland cement Weight of 1 Bag � po�ds If mixture (sand, gravel, cuttings) — Ratio � to��_ ID plates• ,�I'es _ No 4 x 4 slab r/`Yes No Drillin� Lo� T _--�---- ,. . hereby certify that the above information is correct and that this well was constructed in accordance with regulations �orth by the Person County Health Department. of Contractor ])ate _ �- - S ,- o � PCHD rev Ol/16/02 Application Date: � --} 1�� Amount Paid: �j�jjL Receipt #: 7 (� �l � • �.,,��, 3.� �� `1.J�1 V Taz Map: /'T o�, 7 ��3�J .r:,' �� Parcel#: � ��s��¢�ll ��ffiIl�h� tion for Services Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 if> 600 d Mobile Home Replacement or Building Addition $150.00 (if site visit required) 0 Well Permit (New/Replacement/Repair) $3 00.00/$200.00/$75.00 ❑ Construction Authorization (Fee is dependent on the type of system permitted) ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant In rmation: Name: ��, `YrL•�-c.� Address: � '�� S �' ,^ � � �� !J � „-�� -C.�- � c 2) Name and address of current owner (if different than applicant): Name:�,(tri� � �V►zi�1��t �ri��i►�� ,� Address: ' G 'L'i S'1�{ 3) Property Description: Lot Size: �. � �j Subdivision: Address and/or directions to Property: li,;,^,� �✓.� Phone (home): �� L-� ci �- f,'o / P (work/cell): '� 3 6 - � a � � i e � / Phone: #: � � 0 yes � no Does the site contain any jurisdictional wetlands? � yes ❑ no Does the site contain any existing wastewater systems? ❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency? ❑ yes ❑ 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: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well ❑ E�cisting 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: � ��a�� r0.� � � X � ;6 ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any 1 certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Legal Representative*) * Supporting documentation required. Date • Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �'onnectGlS Feature Report Page 1 of 1 , ... .. �,�.��- . _----"-'_� `"-` � -�,-�'m' � ,,, J�� , _y= � � Person Printed September 13, 2016 See Below for Disclaimer .. . � �. � . .� ��J�;,i; , . . .... . , , . . ` . , . .,v�,_ . :, ... ' .. J _ � . - . . . . . � '_ -- _. . . --- . . _ -�-�- _ J _�_ a�,_: ' g —�—= —'�— �� -- �� —y� � _ _ '--�- �' � � �j ��'> �� ... . . ... .. . .. . .., � . .. A � .. ., ,. .� � � . £ �. _': .. ��:�� .. � � .. . . f . �� .. . ... . , . . . � . �`." � .. ..., � . � —�` "' ' � � Y � I 5 i�'I I � � � "� ' �`�` ' �➢ �� . .� � �� 4� ' � ,. .. � � � g�.'�.� �. �-�if � 5- � 'v � @� � �`��f �� , ; av+ � F � �ga��. �� ' %` � � � ��"� � � c.i � �`�� ,�� . �� _: � � � � an= �^ . ,. . �� , � � �� .r s�- '�� .k:. t :� � � � . �� R � �` � �� % _ �, �' F \ � � � � ��. � 4 . . �ntd F' "'� & 1' �� '.� .i� � �'� � � �ap ' � � i � bY R f � 0. II � x � a�� A :A�S�.� ��sR. ��" �:� '�.��' �� •� �� '. �' � i �� ,� ��...�. � � �� §;�. „� . , i P� � 3 r �°ffi'�`�* �2. �..�- I �:� '" �m �....._..,m� '� . , ,� '�I � �.. .. .. � '� g —� PI a . . � �y , � . � . . . . `� •�..� �&. �� y m � ry$" . , 7 i �a� � �. 1 , � ; � � � �� ..•.� t .� �� -; � i� .; �� A � . rt . � _ t ��. . _ : � :E i. ' i �,r � _ � �� ,�F � a _ . .� . � � ; � � � ��.� � �. �.. � �� . � r � � �`�, ` � . �J �� F � Ct ^ �� " , ar �.', �a ' ,� . �. �. ,. ... . � � s;r : ' a : � � _ ; , .��,� : . �� .: . ; �� :�, t, . JOTICE: Recently, we have had several users report biowser compatibility issues v:hen trylny to access our GIS veebsite. Typically, the problem stems from users who hav� ecently upgraded to the Windows S operating system or a new version of Internet Explorer. We were able to resolve this issue by directing users to the Internet Explore :ompatibility View tool. 7his link is to Microsoft's "How To" for the tool: http://windows.microsoft.com/en-US/intemet-explorer/products/ie-9/features/compatibility-vie� f this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGlS has beei �repared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system ar� iotified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectGl'. 3ssume no leoal resoonsibilitv for the information in this system. Grid is based on the NC state plane coordinate system, 1983 NAD. http://gis.personcounty.net/ConnectGIS_v6/DownloadFile.ashx?i=_ags_map65436e7b4c6f... 9/ 13/2016 � � � J l � i � . `►,� ► � � ._; �� na.�nm�na.n�rn��n.��.�. ��.��n. Building Additions/ Mobile Home Replacements . � • � ' - � . � �I / ." /i. �.+ �.�i. " ;�i,, s.:.�_ s i r Approval Requested for: Mobile Home Replacement ✓ Building Addition 7G-��c � ` L�� Applicant Name: �,iC �`� Q�l�7�,Rs¢ �a� _��c/a�'.2 Address: Phone #'s: Permit Located: ✓ Yes No Installation Date: pD Design flow: �(gpd) Current Contract with Certified Operator on file (if required): 1�� Water Supply: ✓ Well Public or Community Wastewater system shows no visual evidence of failure on: e�� /l1n (date) (Applicant's signature if site visit is not required) • l� fi ../� 1 �:. / i %�l� Addition/Replacement Approved Environmenta H alth ecialist �_— Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net �onnectGIS Feature Report . �4l � � �'a. i �►er' � �7 wtia H��sri*+c �' _ 1,;5 �u '"'1, �i_�'., �,i;a � SS y�, �17 ��_•_ ;.5 � t„ � Z . � �r� ��_ _ _ — - �1 t:r�i r:1ti y �ti �' ��,� G �sr� 15�t1 Page 1 of 1 ,+Ly ' �—/� � Person Printed September 16, 2016 See Below for Disclaimer 15a�a _ � � sFt, ? �•, ��,� �t, t3 :'!: 1 ft :i,T x; +; �—' �� ? i` �, �� 4: �---�^ � ----,�.'� .�.anE �� , 1 � � �� -� 1 � . �` `— �,�°� �:� { Person County Environmen#al Health `� �-:�� '��, 325 S. Morgan Streeet � 1�`; SU�B �' Total Length_ 231.67 Fsst � 1�; ROXbOr�o� i��i %J�73 33� �s63.57 Sq. Feet or.06 �+,cres �T��. `� � a��`'�� arSq.Miles , . � �°��'' � 1 :50 Feet. OTICE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who hav� �cently upgraded to the Windows 8 operating system or a new version of Internet Explorer. We were able to resolve this issue by directing users to the Internet Explore ompatibility View tool. This link is to Microsoft's "How To" for the tool: httpJ/windows.microsoft.com/en-USlnternet-explorer/productsre-9/features/compatibility-vie� this does not solve the problem feel free to contact us at the number listed on our main page. Wekome to the Person County GIS Website. ConnectGlS has beei repared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system ar otified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, ConnectGI ssume no leqal responsibility for the information in this system. Grid is based on the NC state plane coordinate system, 1983 NAD. , http://gis.personcounty.nedConnectGIS v6/DownloadFile.ashx?i=_ags_mapbb157bc8a9b... 9/16/2016 L : ,: . , • �� / � J•J.�r �� V � • ' � , . � � � •. �'��j•��.j� . "�" �.�-a$ o,.�,.,.�Qa.�.a.i� ��ca�v-wica _ � ._ ._.. ......... , �, p,�M�;,#: �� . Parcei #: �� . Zoning: Townshlp: �� ` �( . 31�bd(vision• � Ya �� :�_: ��: . Section• Lot• �� Applicant . � � e i � ��-a�" Location: � � � . "� �hu'� 1 � � ,T��' � � ��r� �peration Permit � System Type (In Accordance With Table Va): `l.w�b THIS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLICABLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEINAGE TREATMENT AND DISPOSAL, AND CONDITIONS OF THE IMPROVEiIAENT P�j�,MIT A� CONSTRUCTION AUT�I qN. - � �J� � � � /l-3� 5� � _ Authorized State Agent-- � � � Date . . �lls � .i;%=„y;s � . . .- . :;; . .�,� '� �� °._ N `�� a «s. � �pt� � .� i11.-�. . �:-.:� �- �; (..� �P �`� � �S � .: M � ��,� S � f'/�(� � r� 6�, � ��-a�� T � �vU° �� rt—a�- o � � � ��oo 5��, 3a� � +> "J � � � W � a � i: i1i 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 # {� �� Parcel # � 2 S Zoning Township O i; J e��( � Owner/Contractor J.�,C.� w; n�-I-eCcGQ Date 2- 2b � 9 9 Location/Address � r1 N`r K M��Gz�C�0. LQ. o r� � e-Dc^n� S.R.# Subdivision Name L t{nm0. � � �t �j ��-( � l� Lot# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area 1.�Z ,�{ Size of Tank �'`� �� SFD L Mobile Home Size of Pump Tank �� O Business # of Bedrooms 3 Nitrification Line �� `�3 � Max Depth Trenches o�'-}'" Permits may be voided if site Well and Septic Layout by Comments: ��,ok� � c Installed by or �5 - i -� ,�i�{�� changed. Approved by -0 Z_ 'ell Permit Paid L� WE�L SYSTEM SPECIFICATIONS dividual ✓�emi-Public Required Slab ' '3'� � �blic placement Air Vent � 3'�% te Approved Required Well Log ell Head Approved Well Tag ,� 4 3'8� �outing Arrroved 2'1��b2 �aS�- b �J� ,/� �} �3'Da Comments: Date PIL � r ��;(, � �.. s; -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 conditio�s 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 the water supply will remain potable. c:lamipro\permit.sam O1/95 rev.l.l N . � ►