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A27 134/ � � ,� �e�Nson County Health D pa�nt � � �eti�ag�.�ystem Improvements Permit Date: •• �� • This Permit Void After 5 Years Permit # Owner• �� v� �� v� S ar SR# Location/Directions: SubdivisionName: 1��11�'.rd CJ'PD.Y ��r/�s Lot#�_ Lot Size: �• do � G+'� s Type of Dwelling: Water,Supply: Private: —.�,� Public: Community: Bedrooms: Garbage Disposal Basement s ` Basement Fi INFORMA ION RTIFIED BY Environmental Health Specialist: owner r sentative REPAIR: REEVALUATION: Size of Septic Tank: allons Size of Pump Tank: % � Nitrification Line: � � /'�� ' t , �6�,�,� + Depth of Stone: 12 inches Max Depth of Trenches: /o � � � Altemative System: Conv. Pump _�� LPP Pump o� Remarks: _I �� - Date Well Approved: BY Date Sewage System Appmved: �i +�ics Well should be 100 f� from any sewer system Environmental Health Specialist BY Environmental Health Specialist CERTIFTCATE OF COMPLETION Contractor: -------------------------- Sewage System location, installation, and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained by owner in such manner as not to create a public health hazazd. Septic tank and nixification line must be inspected and approved by a member of ihe. Person County Health Depaztrnent before any portion of the installation is covered and put " to use. If the site plans or intended use chan e�ie-osrmit is subiect to revocati�n, _ � (G.S. 130 A-335F) ��„ _ n _ � � � Location of sewage disposal sewage system sketched on back. ��,�,(l� (OVER) � �2., �_ � x � � b .� NO�!'E: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special pro%lems existing on lot. Write in measurements in order that installations may be located ai later date. Note locatirtfi o� water supplies on adjacent lots. � . (1)� .- (2) �� . �� ■ ��5 �� .�■��. ��. ��■�� ■■��■��.�■��■�� ■■��■ .��■■■■�� .�■�■■�� ■��■■■■■■■. �� .��.� ��■�� ■�■. ��■ ■��n�■ ■��a��■��■��■ . .. Site �tion Application ~ Fee, 'ol�ected YES 'V . � �`- � � APPLICATION FOR IPiPROVEMENTS PERHIT NO Date: �-7�n� �, �/%7" 1. Permit requested by: Address: Home Phone �� : owneriT�rus�aective ownerc agent: 2. Name and address of current owrier: Business Ynone �f: 0 3. Property Description: Lot size: �-% r�/�2�P�/ 4. Tax map 4�: -�� owriship: /(,J/I � / / / /� - Subdivision Name: _ Lot �i: S. Directions to property: State Ro 1�� & Road Names, etc. ,_., . , _ I .. � �l.. .. /il;.,�/.� .�9 iJ�l7 ..► 6. Permit requested for: New Installation: � Repair: Additional Renovation re-using present system: 7. Number of occupants or people to be served: o� 8. Dimensions of Proposed Structure: Width: Depth: 9. What type (if any) additions, expansions, or replacement is anticipated to the struc- ture or facility that this sewage disposal system is intended to serve? 10. Water supply private? V public? community? spring? Other source? (Specify): Are there any wells on adjoining property? D If so, identify location: 11, 12. Type of structure or facility': /Proposed: � Existing: Type of dwelling: House: /✓ Mobile Home: Business: Type of business: Number of Employees: Number of bedrooms: � Garbage Disposal? Yes No ii Basement? Yes 'ps. No If so, number of basement fixtures: ? � Clearly stake all. corners of the property and the corners of all proposed structures. z co I hereby make application to the Person County Health Department for a site evaluation or existing system 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 altered or the intended use changes, the permit shall become invalid. Permits are valid for 60 months from date of issue. Permission is hereby granted to enter the property for the evaluation. G.S. 130A- 5(F) . � � S ed Owner or Authorize� Agent � H w � � w m r 0 � m �o � n �� r• � � Permit Issued Permit Denied Plat Observed U � '""" .�; � , �,�.�,,,��y�. �, `, � . .: �-,� ►��,`,`, •,/�� : .. �t' �'/� t!1'�`��'� % � I[�l!�l/�� `1 �l�i��l'!,, L , ��•J� �► •� ,� C��.� :��,.► � / _ r 'I �;� "` , . Yc�� , l �` � � I � � �� f n � � �� a�'�3' I�ACTORS - SITE_EVALUATION ____ AREA 1 AREA 2 t�REA 3 AREA 4 1. SLOPE (�) 2. SGIL TEXTURE (i2-36 in.) (SandS, loamy, clayey, Note 2:1 clay) 3. SOIL STRUCTURE (12-36 in. (Clayey soils) 4- SOIL DEPTH (in.) .5. RESTRICTIVE HORIZONS (in. (Impervious Strata� rock) 0 : SOIL DRAIrIAGE/GROUNDWATER (�cternal � Internal) SOIL PERMEABILITY (Percolation Ratc) OTHER (specify) S PS U S PS U S PS U $ PS U S PS U S PS U S P S , a� � U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U S PS U $ PS U S PS U S PS U S PS U S PS U 9. SITE CLASSIFICATION � � (See below) . SOIL SERIES S- Suitable PS - Provisionally Suitable U- Unsuitable RECOt�4�NDATZONS /COMMFSITS : S PS �T S PS U S PS U $ PS U S PS U S PS U S PS U S PS U S:�_TE CLASSIFICATZON DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, Wet areas, fill areas, Wells. Water bodies, slope patterns, etc.) A 1710 PERSON COUNTY HEAL`TH DEPARTMENT WEL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # �� Parcel # I 3 Zoning Township D I�� e � Owner/Contractor pn Date - G�c�''J" � Location/Address o Sc�r, • " „ S.R.# Subdivision Name i�Cyv�O� .�e ��GL�O Lot# L.� SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area Size of Tank SFD Mobile Home Size of Pump Tank Business # of Bedrooms Nitrification Line Max Depth Trenches Permit Void after 60 months. Permits may be voided if si Well and Septic Layout b Comments: Date Installed by ;ermit Void if not in compliance with zoning regulations. altered or intended use changed. � Approved by. -- � -L} WELL SYSTEM SPECIFICATIONS Individual_�,�Semi-Public Required Slab Public Replacement Air Vent Site Approved Required Well Lo� Well Head Approved Well Tag Grouting Approved Comments: Date Installed by Approved by. This report is based in part on information provided the homeowner or hisJher representative in the apptication submitted for this pemiit. The environmental health specialist is not responsible for false or misleading informadon contained in the application The environmental health specialist is also not responsible for concealed conditions on the propeity or for statements in this report that may have resulted from false or misleading statements provided to him in the application Neither Pecson Courrty nor the environmental health specialist wazrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain poiable. c:�amipro�pecmit.sam Ol/95 rev.1.0 ORIGINAL � , ` , . � • . ` t J PROP�S�D �LO�`PLAN � � • ; • � t , . � � ' . � ' i�' �c3 b�rt �r� ,� � . � � i ; � �N :� , ; �.I�; � 4 S � = ~� � Z 3-.--� i , �.. ; , � '7 _ � i�3' , " _ . � , � � � 1 ' _ . �3`9_2�! ; , . . , 1 ' � ,; . 1 ` f � : , � . _ # � , , ,� j , , , . , , , . , . . , , . , .{., S 19_ 16' YO�D 896-�6• . • . ; , , ; , . -t-b.I.;A� . M1 , j. , , �Km . /h � / ' I � . G�G �1 . � . 30_65' - - � -''-- N O � �--'---__ �3�-�g''---c��l 300► s.� 130� �O�_______-.- R/� - ' - - DRAWN 7/13/98 � - - - - - - RCJ � 442_65' TOTAL 30.65' J�-00 03:39P A�Hcation pats; l � "rd �'l � Amount Paid: � Od Recelot it. 30 Person County Health Deoartment Envfron eMa1 He !th Se on A�PUCATtQN FOR SERVICES Imp�men� Permft (Re�ed Lp!) - i16 0 Improvementb Permk - (Unrecaroed �on . � (Mobils t+ome Rep�eOamenUACdfdon) Con8truWon AtdlwrlrailOn - S1�.U0 System inapecdon - ii( iePlece E�stlnp Syatem P_O1 Tax Mao #: P�rcel #: —_ - 5125.0p 1? Pennit requeated by: (Owne�/agenUprospaCtive owner�: K Q � c� �� (' _. ��dY 1 S w Home Phone �pS� f Address: a�. � Bustness Phone: — 3 71 1 Z � f Z) Nsme and addrose of current ovmer. � 1 d C. �' �oY� S�. J p� yls� 7� .1-� J-+�r v�d o vt 2oa� �� tiic �-��_3 3) 4) Property Dsscriptlon: l.� e�e:�•�rtTown�hip: �-►U t= H l� Directions l01ha property Induding r�pad nemes and numbera : L5ri_ i k��T F/26 y.q _, j2U X�'ja v� �, v� „ �� L � -T- , ' a ti tr �c`ln� Propoaed Use and SWcturo Oescriptlon: answer each of the folbwing queations_ e) Proposed� Existing 0 bj SGdc Built �, MOdular J�Singl6 Wide C7, Double wde r7 cj Number Of 8edrooma: �� d) Number of Occupants or pepple to be served: e) easament: Yes �, No�(t yes; �! of basement fixtureS; � Garbage Diaposal: Yes 0. No� / g) Dlmensiona of Aroposed Str�Scture: Vlridth: �� p@p�; �� '' J ��w, ScS�� 3) Water Supply Type: Private�(new't�or exis8ng 0), Public D, Community u, Spring � � Ar8 a y wells bn adjoi�ing propeRy? Yes 1j� No CI If yes, IocaGon, j�-� �C�� G�V S t S a u� /` 6) Pleaae Indicate pealred System Type: {aystema can be ranked In order of your pre eren eC )k� 5' N e J W el� l s � � S� h �� O h, � YOv�-� 4.. e��-- �-�- Gq�ventional �Nod;fted Conventtonal � Altemathre �Innovatfve 11 ev� L.o-�. Other (speclfy); CLEAR�Y 3TAKE ALL CORNERS ANb LINES OF THE PROP�RTY. STAKE THE CORNEi2S OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY Pl.AT' OR 31TE pUW TO TF119 APPUCATION I hereby make applic&tlon to the Per3on County Heglth Department for a gite eveluation for the on-site sewage digposal system for the above-described propenyr, i agree that the contents of lhis appUCation are true and represent the maximum fBCiGties to be placed on the proparty. I understand if the sile is altered ar the intended use Changes, the permit shBJl become invalld, I understand (hat a9 applicsnt, I am reaponsibte for identifying and marking property linea, comers and maki�g the site aocessiWe tor Me person�el of the person County Heaith Departrner�t to condud their evaluationa. I unders��d that f am responsible for notifying the Hea partment if my property con an weUands as desi nated b the A Co Y 9 Y �Y rps of Engineers. Owner or a� R resentat;ve Z�' 2 Od � P oate PCHD. rev. +a�uea Y ✓ . �^w y � .. �-av �� ?�p, l $ ..._��n-,,,` . , p�.•s '�..w«uTM^- � 9 � x. � � . � � ..^s`-7�s'^ � � � � V � � ��n.�a��n�nn��n.��.� ��.��n. Ronald & Doris Johnson 990 Robertson Road Roxboro, NC 27574 nsuring a healthy environment October 4, 2013 Re: Application for improvement permit for property at 990 Robertson Road; Health Department file: Tax Map A27, Parcel # 134 Dear Mr. & Mrs. Johnson: The Person County Health Department, Environmental Health Division, on October 3, 2013 evaluated the soils at your current residence that accompanied your improvement permit application. According to your application the site is to serve an additional three bedroom residence with a design wastewater flow of 360 gallons per day. The evaluation was done in accordance with the laws and rules governing wastewater systems in North Carolina General Statute 130A-333 including related statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rule. 1900 and related rules. Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940 through .1948, the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system. Therefore, your request for an improvement permit is DENIED. The site is unsuitable based on the following: Unsuitable soil topography and/or landscape position (Rule .1940) X Unsuitable soil characteristics (structure or clay mineralogy) (Rule .1941) X Unsuitable soil wetness condition (Rule .1942) _ Unsuitable soil depth (Rule .1943) Presence of restrictive horizon (Rule .1944) X Insufficient space for septic system and repair area (Rule .1945) _ Unsuitable for meeting required setbacks (Rule .1950) _ Other (Rule .1946) These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated sewage on the ground surface, into surface waters, directly to ground water or inside your structure. The site evaluation included consideration of possible site modifications, and modified, innovative or alternative systems. However, the Health Department has determined that none of the above options will overcome the severe conditions on this site. For the reasons set out above, the property is currently classified UNSUITABLE, and no additional improvement permit shall be issued for this site in accordance with Rule .1948(c). However, the site classified as UNSUITABLE may be reclassified as PROVIS�R��'S97.1790 SUITABLE if written documentation is provided that meets the requirements �� e$97.7808 325 South Morgan Street, Suite C, Roxboro, NC 27573 .1948(d). A copy of this rule is enclosed. You may hire a consultant to assist you if you wish to try tq develop a plan under which your site could be reclassified as PROVISIpNALLY SUITABLE. You have a right to an information review of this decision. You may request an informal review by the soil scientist or environmental health supervisor at the local health department. You may also request an information review by the N.C. Department of Health & Human Services regional soil scientist. A request for informal review must be made in writing to the local health department. You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form, you may write the Office of Administrative Hearings or call the office at (919) 431-3000 or from the OAH web site at http://www.ncoah.com/forms.html . The petition for a contested case hearing must be filed in accordance with the provision of North Carolina General Statutes 130A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C. General Statute 130A-335 (g) provides that your hearing would be held in the county where your property is located. Please note: If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER The date of this letter is October 4, 2013. Meeting the 30 day deadline is critical to your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeal. If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by law (N.C. General Statute 150B-23) to serve a copy of your petition on the Office of General Counsel, N.C. Department of Health and Human Services, 2001 Mail Service Center, Raleigh, N.C. 27699- 2001. Do NOT serve the petition on your local health department. Sending a copy of your petition to the local health department will NOT satisfy the legal requirement in N.C. General Statute 150B-23 that you send a copy to the Office of General Counsel, N.C. Department of Health and Human Services. You may call or write the local health department if you need any additional information or assistance. � Sincerely, �J�.1�, a. �:�, Derrick A. Smith, LSS, REHSI Environmental Health Specialist Encl.: Rule .1948d ConnectGIS Feature Report �� ,�—�r..rr-.,�-;--�-�M� �^ `/EF. I'::�I'IC� �.lE �1 ' �. . . � � — � ' �� - `� q,�� - s�`��: � � � �� _: i �, ` � -� � � �.i � '. �: _ _' a�� `� wos Page 1 of 1 Person Printed October 03, 2013 See Below for Disclaimer � � � ,�,��;_ � � �: � � �� ,,�,,.,. <. , ., _. � f, � k�', ` '�" �1� �=�'� , �4'� �1"v '�� . _'�, � `ti _ �L - ... �� 1 �:�t , �� '� I � i� �� ' s,`�.�� , : _ � �-_ — �� .,��_ .,�;�" - • �� ;'� , r ��_ r _ ��' : M ` . ��fi ., � r�� ' �b �,A�, �� . ' ', � �� ' ��, �� r � �; � �y" .y � . . . . �� 1✓' j{�� `F T_ 3 � - i�_' �. J(j 8 T �• [� � L�'x i��, ..�-._ _,. .. t iri -. - . _ _ : tW1 .+�. � �� I ., c o ft _ Ri�BEF,TSCdJ, , . . _ , _ ,� . . ,_. `� . �� . ,. � � z : .:-. .. _ ._ . _ ... :,. . .._. ,... . ,... 4."� ...�.��. �,_ . _. — .a �,. . _u�.�+. �,. , .: _. �; 1 z==;�, i�, 1 tt ! Y 1, r, � 1� f; , ��` ; � '� �� - . _ � + �. r ; .�� '� � 5 �r '-`� �'�. j � '1 \ N - _ �j � �,+ �� : f• : b � �� 1 __ 6375 � - 6882 � j; � ,�326h � � : .+ f � - � - it4 � �T ` � ��e, �' . ` ~ y� : I �� (` _ ..-� ` . ��L � I . . �� - • '�' � 00 Feet � � _ '�_, ,,�t�• .i i �4 �' � � ' — - -- - NOTICE� Recently, we have had severai users report browse� �o��patibtldy issues when trying to access ou� G:� webste Typ:ca�!y !i ,: :otem stems from users who have recently upgraded to the Windows 8 cperating system or a new version of Intemet Explorer We w2re able to resolve this issue by directing users to the Inteme Explorer Compatibility View tool. This link is to Microsoft's "How To" for the tool http //windows microsoft.com/en-US/internet-explorer/products/ie-9/features/compatibility- iew if 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 beer prepared for the inventory ot real property found within Person County, and is compiled from recorded deeds, plats, and other public records Users of GIS system are notified that the aforementioned public information sources should be consulted for verification of the information in this system Person Courty, Mobile 311, ConnectGlS ssume no le al res onsibilit for the information in this s stem, Grid is based on the NC state lane coordinate s stem, 1983 NAD. � L,�.� �;. �� c �." �� ;,� tL,. � �1 Z,�}, ► Z) .�,� b� ,�.�� g� �z� w�l�'� �� '" �-'� �a`1 so', 3� 2b ` 1,a>�tZ" "� �" w� �-L1 LCY" �S"1 LIFf'� http://gis.personcounty.net/ConnectGI S_v6/DownloadFile.ashx?i=_ags_mapaef1�6a03cd1 £.. 10/3/2013 Application Date: � 6' l' � 3 `�� (� �� Tax Map• A�� Amount Paid: �00 .UO r,. ," �!�- � � ��,�� Parcel#: . i1 Re�eipt #: � !.� t.� q 4 � � �IE":.�rnwn.n-aDv.n.v.�rn�.an.tiaaIl lE-`i��.a�.)ld:;Ir. � �Q1 1 —4-Q � l � �N I 74 Analication for Services M.oP� �� Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) ❑ Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 Services Re uested ❑ Construction Authorization (Fee is de endent on the e of ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: G 33 G��3 �.g6% Name: � ,' � D r�5 �v � �1S �l Phone (home): Address: �l' �16 Qfl h �� (work/cell): — aXboro� � 2) Name and address of current owner (if different than applicant): Name: Phone: Address: 3) Property Description: Lot Size: �—� Subdivision: Lot #: �� ) Address an or directions to Property: 15 g =� o1�►n t� i r S i-op ld /%�i J �+ � r7s an d � � /r''` � '� �d �J7'� ❑ ye o Does the site contain any jurisdictional wetlands? ❑ yes �ryd Does the site contain any existing wastewater systems? ❑ yes �� Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes �� Is the site subject to approval by any other public agency? ❑ yes CC]"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: � ❑ Expansion of Existing System If expansion: Current number of be�dr� oms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes Gd'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: L✓J New well ❑ Existing Well O Community Well ❑ Public Water ❑ Spring � Are there any existing wells, springs, or existing waterlines on this property? ❑ yes Lgno 6)_ If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all pernlits and approvals shall be invalid. , � �� / 2a [3 ignature ( er/ Legal epr ntative*) Date * Supporting �cumentation required. Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT Tax Map #: _ Lk oZ I Parcel � �� Zonin9 Township - - �� . \i � � , � I . Apptica�L� ni�i S � ��/�..�� f�h/1CC�✓1 .. LocaUon: '`�J� �I T(�.� i t��-, �1'� � n5l�er� �cP TI L�D �'e.r��. l t � '�o b er� �o � �o �- Q� ,�o nol or� . �� , Subdlvislon• SecUo�: Lot improvement Permit A buildinq permit cannot be issued with onlv an Improvement Permit New V Repair Addition Type of Strudure 5��, Water Supp(y ��Q�C.. � # of Occupants a #�of Bedrooms 3 Other Basement? �f Q Basement Fuctures?�� Projected Daily Flow: � g.p.d. Pertnit Valid For. ive Years ❑ No Expiration Proposed Wastewater System Type: �i i n-�.�L^�r�.�l�I��(�( T"v 7TC' Pump Required? �Yes No�— Proposed Repair :_�'g� �� D T� � Permit Conditions: Owner or Legal Representative Signature: Date: Authorized State Agent: Date: �� t The issuance of this permit b e Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for chedcing with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if the site plan, plat, o� the intended use changes. The Improvement Permit shall not be affected by a change in ownership of the site. This pertnit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Authorization To Construct Wastewater Svstem (Required for Buildinq Permitl Type of Wastewater System� Wastewater Flow: 6l�q.p.d. Facility Type: � New Repair DExpansion ❑ Basement? O Yes O-t4o Basement Fbctures? O Yes �-tdc— Wastewater Svstem Requirements " Septic Tank Size: � gallons Pump Tank Size: �� gallons Total Trench Length: �� feet Maximum Trench Depth: �� inches Aggregate Depth: � Zin. Maximum Soil Cover. � inches Trench Separation: ,� Feet on Center � � � Other.��'�d�.2� �X-�tilA-(��-n_1�Q �,(�U�t� �j X�. �� yI�QQ� ► Permit Expiratio Date: � �'� }� Authorized State Agen : Date: The type of system pennitted ❑ does 0-d es not diffe� from the type specified on the application. I accept the specifications of this peRnit OwnedLegal Representative Signature: Date: PCHD, rev.11/18/99 z O � x 37. /; 370.62' Tota.l 339.22' POND � : HOU3$ 14' R�au p,rea Garage 314.08' Proposed Plot Plan For: Ronald & Doris Johnson Drawn: 7/5/2000 Scale: 1" = 100" 6S� ._... _ _ _ mes _.._,. _ �� 689.76� � _ . . SR I 306 60' �W (Robertson Road) �, J • 6.28 ACRES Part of Tract C 205.08' 1.72 ACRES Part of Tract C PC 9 P 27-2 423.06' Total 37.13� �—.._.._.._. — 144.03� 30.06� 442.65' Tot ''� �� ' ►. • �� ZE��.�� .¢.�.71 IEZL��.]l� Applican� 1�ober��o� �� . i ��x iv1-�,� : . P�:rc�El = S�u l�.ci:i �� i��i o ii �P�h:ase �ec�tiora Lot r ��erat�oii: Permii System Type (In Accordance With Table Va): . � � THIS .SYSTEM HAS BE�N IN�TALLED � IN COMPLJAPICE WITH APPLICABLE NORTH � CAROLINA GENER�IL STATUTES, RULES .FOF� .SEWAG��:TREATMENT AN� �DISPOSAL, - AND ALL CONDITI�NS OF THE IMPROVEMENT � PERMIT . AND CONSTRUCTiON AUTHO . Tl .. � ' � ' ' � � , . . . . , . .... . -•' "/I�•i•/.V �� .. . .. .. � � Au#horize S te �A nfi � � � . � � � � ' � • Date • - = � � � . � . . . , . . .. . . .�ys�a.�. . . � . �m1� a ,�� Instailed By:� �1 WIVVL(� �GW IS Date: �'��- �a-r,� ��- �•a-oy � �� . �. . . � . � � � ��' .- . ; : � . . � . � _ -��,�� _ �i. . . . . . _ . . r�-�� _ .. . �. . . � � � � I �I .:. .. . ... . . _ ..._ :. __-:�_: .: - -� ... . . . .. � ��,. �v . . � � . . � .. . . . . � _..� cP. .�� PCHD, rev. 07l29/02 � � � PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Nlap #: �-�� P�,� 13�i Zoning Townahip �� 1 V l� I� I`( AVPitc��(' .S �r�(`��_ Y'��✓LcSD� Locatlon: Suhdiviston: � G�t 1�t1' �l l f e'�l—�!?°c�Sectlon: � �.� � Well Permit Tvae of Water Suaalv: Individuat Communiiy Requirements• / � Site Approved by Grouting Approved by Well Log ✓ � Well Tag ✓ Air Vent Hose Bib S Concrete Siab ✓C'�.� Welt Driller: N Ll l�`� (il Weli �Approved By. ; • Public Date: ��l�s-t`�/ **See Attached Site Sketch"""' Welis must be 10 �et from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any buiiding foundation. Other conditions: PCHD, rev. 11/29/99 19 `�D �+ �� f �li.:�� ''' � � � � � � �1F� � ira.waJc`eaitra�taae�sca�a�n ��•es..11 D� iller ID tt a' :►L� �! Corn�� :+a,y Nan�ie .�/ ' D��tt�e Drtii'.leel .�, � Grout �p � c� % Parcel # � . n 1� O WriCr: �� v r � ? Z � Location: 1 �'�'!� � t2 ^ ' � ��' -- � - ioi � �_ gubdivision —' Well Construction llist�nce krom nearest PropeYty Lins (Minimurn 10 feet} �[� t Distance from Sepric System (Minimum u4 feet) _!o o__-- Total Dcpth: �� ft Yieid: - 07�.,_ GPM��,�S,t�atic Water I,evel: ft� ft Water B�aring Zanes: Dep .• o� ft(��..L°� fl�L-U�=° � — $. � Depth: From �,_ t� .��-- ft. � Diameter: Ca � in Type: Galvtuuzed Steel v Wei�ht: �,,�I � Tlaiclaiess: � Hsight abave Ground: � in Drive Shce: �Yes No Any problems encaunte�red while setting casing`t Yes r�N° Tf "yes" give reasori: _ � �rout: Neat: Sand/Cemtnt Concrete GraveUCement ____. Annular Space Width inches Water in Annulaz Space Ycs No M�thod of Grout: Fumped Pressure Pc�ured Depth to Ft. Materials Used: No. Bags Portlan3 eement __ Weight of 1 Bag Pa�� If mixture (sand, gravel, cuttings) - Ratio ta 1D glates: _ Yes i,. Nc� 4 x 4 slab r Yes _ No Liner: Date Isastalled: Crr�ut: Installed by: Depth• - - ,,,�,�;�� i „� Locati�n Drawing I hereby c�rtify that the above informati�n is coYrect and that this �+�u'ell was constructed in accordance with regulations set forth hy the Person County Hcaith Deparfimant. � nature oiContractor �` ID # � D��e ? � � GLL Sg Pnnxp Instailment Pump Installation Contract4r: _ State Registration Number: _ __ Puznp llepth: ft Static R'ater T.�vel: ft 1Pump hsake 8,. Mvcicl: Pump Size and Rating: _hp gpm I hereby certify that this pump was installed and the well head completed according ta the Person Counry Well Ruies in effect on this date and that a copy of this record has been provided to the well owncr. Pnrnn Tnst�li�r 3i�nature Date: PCHD rev 01/27/04