A27 138_ .. ._ �
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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTtES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
Dat
Owner: �•. �-
.. �, t ' S
Location:
� �. .
Contractor:
Water Supplp: Private Public
.r i'
,,.,,�;t11'e!' •i�3i-1�.a(`
v
Sewage Disposal Facililies: No. bedrooms f*� Dishwasher� Disposal,
washing machine, o e auto�{natic appliances -T
' ! �
Size of tank: � ��� NitriBcation line: ��� � �
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 and 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 DISTRICT HEA TH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE IN�, LATION,,I S COV-
ERED AND PUT INTO USE. t"/ l� A. I 1
Date approved:
Weli:
Sewage Disposal:
By
Certificate of Completion
Date Approved: �� J � � By:
rtarian
his representative)
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: � sketch of installation showing lot size shape, location of house, septic tanks, 1�s, water
s�upplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
� °' ��rson County Heaith Department
/, /i� We"rl Pe:mit
Date: `�"'���7�This Permit Void After 3 Years
Owner� i� �'Gl� f'•� D� �� � � SR# /30 �,
Location/Directions: _ ,�, ,—, � _ .
Subdivision Name:
Drilling Contractor:
Lot #
�
�
��:
� WELL CONSTRUCI'ION � ' ►ti
Distance from Nearest Property Line_/ �� f�c Distance from Source of
Pollution /D � p,,f,�, c c�,
Tatal Depth��.,y'...Ft,'Yield: GPM �iatic Water Level �F� .
Water Bearing Zones: Depth �Ft �j.� FG FG FG
Casing: Depth: From �_ to,�_ FG Diameter: —6ic� Inches
TYPE: Steel � Galvanized Steel Li I—
ff Steel, does owner approve: Yes No
Weight ,�_ Thiclmess: /�� Height Above Ground: / l�. Inches
Drive Shce: Yes �� No
Were Problems Encountered in Setting the Casing? Yes NoL,�
If "yes" give reason:
GrouG Type: Neat � Sand/Cement Concrete
Annular Space Width r' Inches
Water in Atmular Space,,.Yes No �' -
Method: Pumped Pressure Po�sed ' <-�
Depth: From � to FG
Mat ' Use3: No. Bags Pordand Cement � Weight of 1 bag
lbs.
ff mixture (sand, gravel, cuttings) - Ratio: a-- to �_
ID Plates: Yes v No
4 z 4 slab Yes _1, � No
�
I HEREBY CER'I'IFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
TI-IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
��
Date
Sanitarians Signature Date
Sanitarians Signature Date Completed
Sketch well location on reverse side.
" NOTE: Mal�e sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
� at later date. Note location of water supplies on adjacent lots.
� -
(1) (2)
Application Date: 1 �' �`(� `�� Tax Map: ���
Amount Paid: Parcel #: ��
Receipt#:
�--��`?��.� 1C` �����
_ —Y--� c� � ���� i`�
�(�"' ga�.v i� iz-.cD ua �i�ra<c„ uat2�:..-_n:ll 1C 3:C �-,.�a li tt:7l�.
Application for Services (Septic Systems and Wells)
Services Re uested
❑ Improvement Permit (Site Evaluation) 0 Construction Authorization
$200.00/$300.00 if > 600 g d) (Fee is de endent on the e of system ermitted)
❑ Mobile Home Replacement or Building Addition ❑ 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 No Char�e
1) Services Requested by:
Name: �Rse� �`-Pyv,� Phone # (home):
Address: (work/cell): .-�, Qq �Q f�3 �
2)Name and addr ss of curre t o��ner (if different than applicant):
Name: � C�� l,f
Address: �7 j� � - • -
3) Property Description: Lot Size: �.� Subdivision:
Address and/or directions to Property:
Lot #:
4) Proposed Use a�ype of Structure: �
Residential t� Business/Type: Other ��Y e x�S� � n.� �'Y[ �
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 comvleted application must also include:
➢ A plat/site plan of the property thai shows property dimensions and tlie size and location of all
proposed structures.
➢ A signed copy of tlie `Lot Preparation' forfn verifying tlzat the property is ready to be evaluated.
I am submitting this application to request services from the Person County Healtli 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 in��alid. �
Signature (Owner/Legal Representative):
Date : D �j �6 °'
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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�a����1��a� ��������/ ���b��� �I�agn� ����a���a���s
Tax Iv1ap �:� 27 Parcel#: I3 � Address: / 4�y ��D�y����/ �..
Approval Requested for: Nlobile Home Replacement
�/ Building Addition
Applicant Name: �G'/� ,�� ��,5
Address:
Phone �'s: �b � ��� �
Permii Located: � Yes T10
Installatio;� Date: /�J�3 Design flow: �� (gpd)
Current Cor�tract with Certified Operator on file (if required): �.
Water �upply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: G�� � {date)
(Applicant's signature if site visit is not required) `� ,,
�ir1���a��/���������rat ��pa�����
Environmentai Tea' Spe�iaiist
�� �
Date
Person Conn�i Environme^tai :Teaith; 3�� �. ti;or?an St., Suite C; RoYboro, N� 27� ; 3
Fhone: ��6-�97-??9C/ ra::: ��6-�9�-��0� � �-��;,.���.�ersorlc�unt�i.i�et
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PLAT OF SURVEY
RICKEY 0. DAVIS 8
aEac�e urnm rnn.aa
PATRICIA M. DAVIS
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C- 1 OC•)5'03' 2,776.90 )56.W 11L)1' S05'Of'SO'Y f55.75
OLIVE HILL TWP. , PERSON COUNTY, N. C.
NOVEMBER 1990, HALL—HAMLETT d ASSOCIATES
NEAL C. HAMLETT L-2465
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SGLE 7 IIIOI a 50
E PLIAEU TRYLOR
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to sn �sor �-
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LEGEND
NF • NAIL FOUND
NS o NAIL SET
• IRON FOUND
a IRON SEi
HP o ryATHEMA7ICAL
POINT
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NOTE ; SR 1706 HAS BEQ7 PAVED
SM10E i}IE ORlGMAL SURVEY
w�soone. VICINITY MAP