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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 .. . � (OVER) . . . . _ '.... , . r .. ... �/ s r� „� ? � � �, �. _ • 1'.�•,r_�. ��.'. . �� ` � � ��o y ��� y ro �, �n � n pw,r II x `° N � a � ��� �� x w � o� � M f�Jl �, °� w ��� �o o � H k � � � o A 0° � H � � Q � � � R ~ � � w � N n �, � w � i', ¢. 5 ��m W � C M �m �� � �. � � �' '1 � x� w K y � b N �y N m, n � � � � M y � b '` c o� m '�,° � � m �, � � � :; Application Date: �`�,v Co Tax Map: 1�/ o� � � Ainount Paid: Parcel #: � Receipt#: ���.s.�- �I��..���T � - � � ��� � 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 • •� •� � i • ��v� � �u _� ��� � � � :Dv'�i,� ... r.s� � %! ;! �. .� ��% .� � 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) �—�--�. . , ► � r � � � � k 1 1 � 3 �,r � T � � � � ���� � � �mi�vn�a�na�rn.��rn.t�.m.�. �c�,�,�.��a ; �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 A ConnectGIS � �, Page 1 of 1 , � ,� � � ���p �. 1 = � � � � � • � � I� tii i � � �� � ��� � �, ,;,; � ,. ��'1�2 � !� '� � ���,���� � � � i �i � � � �� � � ' � � i �� „ � �� � � x � �.. s, �_,_._ > m .. . w> � � _ i � �,� �. �_� ---- , ( , z ti � �� , �� , . �ti��; ��� � ti� � � � _ e � , �---� �� � , � � ,� ��� ��: � ' � �,�� _ ,, , \\ , � � � �� � � � � � � � . ti � , �� m �. . � i � . �, _ � i �� ,o � � --�- -� . -� � ' - ` �` .`'• � � � � �''�'' � � � �� �� �� � i,� � �: �--' �� ��,� �� �� �,� � � �sY� ��� �j��.'��CG � LM ° ¢ � � � , �� ��� � �,��_ �i ti� '';; �, �� � , �� ���1� :.:.o ���� � � �� . _ . � � , Y, ti ,� ti '� ti� , � � � ... � i I� � '� ��: � �. � � ���� � � ��� � � s-�"' �..,, I� � � � � � 1 .� � ti �� �� �~ �, ti� . � � � � � y _-...--,�--�--.-- � . 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