A27 147. :,
� Person Couniy Hea{th Departmen# �
� � We11-Permi�.. �
Date: — ' P 't Void A�ter 3 Years
w.
Owner: SR# —�
Locahon/Di�cdons:
Subdivision Nvne: i #
Drilling Canpraccwr. %
O STR ON ►b
Distance from Nearest Propen.y Line�� Distance frorn Source of P�'
PoAution . a w S .�
Total Depth: J Ft Yeld: �GPM Stahc Wates Level ��F� �t
Water Bearing Zone� Depth Ft .S�FG Ft F.G
Casin� Depth: Fcom �_ to F� I3iameter: G� Inches
7'YPE: 5teel ' Galvanized SteeI v
If Steel, dogs owner approve: Yes No
Weigh� / 3 Thic�: �� Height Above Ground: L_�"Irtches
ririve Shoe: Yes No
� Were Problems Encoimt�ered in Seqing the Casing? Yes No �---�
IE "yes" give reasan: 'd
Grou� Typ� Neat SandlCement Concxetc �
AnnuIar spaca Width 3 Inches
Watet in ArmuIar Space: Yes No���
Method: Pumped Pressvre Po�red��
Depth: From �� w FL
M�� Used: No; Bags Portlend Cement �_ Weight of 1 bag
—�' :�—lbs.
If mixuue (sand, gravel cvttings} - Ralio: � w�i
ID PIate� Ye's � No
4 x 4 slab Yes � No �
I HEREBY CER'T�Y THAT TFIE ABOVE WFORMATION IS CORRECT AND TNAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCB WffH REGULA'TiONS SEf
FORTH BY THE PERSON COUN'I'Y HEALTH DEPARTMENT.
� 1
Date Issued
Sanitarian's Signadue Date Completed
Sketch well location on reveise side.
;:Person �Counfy Hea!#h:, Department
��Sewa e System "Improvemen#s`�Permit �
Date;;;.���Tbis Penriit-Void'After 3 Yeais � 1
O�VI16I:_����� ��..� �rs �# I!�
—�-
LOC8t101j�D�iCCt[OtLS: {
Subdivision Nj� ei __ � .P� �/ �✓ ��
I,ot Size:-- .f • �� �? �'d�':�' • of Dwelling.
Water Supply: Private: - � Public. .
Semi Private: • • .If��ot:Private Tax Map#
Pa�el #� of WateX Supply or Name of
Supplier# � �� �
Bedrooins: �Gaibage Disposal
Basement Basement FixUII�eS
rivFOItMA By.;
Saniqrian: ���A. �^'� ownecor:mnsc
REPA�: v - - •
�. �. -� � � .w� r� �� r� �r �� r� �. � ....� �r. � .. � y�
Size of Septic Taul� _1���� gallons�j `"�--"
4r w'
Nitrificadon:�Line: `7`� �}�� � ��
Deptlr�of Sione: I2. inches �
Max Deptt►' of Trenches: ��
OPERATTONAL PEitMTP: yes � no
Remarks; _ 37 �r+ //s
/ t ! • �`C 7 Lr 7 7r Z b^i
Date Weu Appm w�
BY � '
Date S ��
BY �V(� /!n d
std, be lU0 �h &�am any sewes systen
1%%�Y _ __ .^ . .. .
TIFT TE Q� �COMP.LETION �
Contcactnr. - — — . — � -- . � � � — �
�" — ---- ._.�_... �.�..���� p,
Sewege Sqstem . location, �in'stayadan. and protec4on must meet state and local �
reguladmis;. Septic tank...should..be.pumped out.every..3 to-5 years and�shall��be
m��� �. bY owneT' in : sucli manner as not to ' create a public health }iazard: .
Septic tanlc and. nitrificetibn •lii�e• must be 'inspected and approved � by a� membex of
the Person.County $ealth.Departtnettt before azry. portion of �the installatinn is
covered 'aai3' put intn use. . .
Locarion of� sewage .dispc�sal sewage system sketche@ on back.
disp
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Application Date: �`�,v Co Tax Map: 1�/ o� �
� Ainount Paid: Parcel #: �
Receipt#:
���.s.�- �I��..���T
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Tr=-�niwnu-<cana�*�+�-+�ac�ua�.m� ���r.c�,.m.11<f�ia
Application for Services (Septic Systems and Wells)
Services Re uested
❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if > 600 d) Fee is de endent on the e of s stem 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 Application: No Charge/ CA $150.00 or $300.00
• •� •� �
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• ��v� � �u _� ���
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Phone # (home): ���, S9� �/��
(work/cell):
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size:
Address and/or directions to Property: �
4) Proposed Use and Type of Structure:
Residential Business/Type: J�x/� �? ��� � Other
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: P.ublic Water System:
Are there wells on the adjoining properties? No Yes
#:
(please show location on site plan)
Note: A comn[eted 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 `Lot 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. n _ �
�
Signature (Owner/Legal Representative):
�
Date : ' '
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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�uilding Additions/ Mobile �ome Replaceme�ats
Tax Map #: ����
Approval Requested for:
Applicant
Address:
Phone #'s:
Parcel#: ` �
Mobile Home Replacement
� Building Addition
Pernut Located: � Yes
Installation Date:
No
Design flow: � �� (gpd)
Current Contract with Certified Operator on file (if required): �
Water Supply: � Well Public or Community
�
Wastewater system shows no visual evidence of failure on: � .����'r�^-Faate)
(Applicant's signature if site visit is not required) �- �--/D
Comments: ���Mi SS��
�Cc� le� `X.(� �
Addition/Replacement Approved
� � �- ? �� �o
En ' onmental Health Specialist Date
+ 11/15/OS
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