A27 148persbn County HealEh Department
.- Well Permit
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DATE IS$$ UED: � DATE DRILLED:�� � COUNTY: ��rSJ�
OWNER:� d���r.����_�.7; tR9AD/STREET: �
ADDRESS:
DRILLING CONTRACTOR: -',/�-/IS ILI� �/ G
NAME ADDRESS
WELL CONSTRUCTION
Distance from Nearest Property Line ,.S Distance from Source of
Pollution li �% tf�
Total Depth: Ft. Yield•�GPM Static Water Leve1��F't.
Water Bearing Zones: Depth��Ft Ft. Ft. Ft.
Casing: Depth: From�_to Ft. Diameter: � Inches
TYPE: Steel Galvan zed Steel ✓
If Steel, does owner approve: Yes No
Weight:�_Thickness:��Height Above Ground:_/� Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If 'yes' give reason:
Grout: Type: Neat ✓ Sand/Cement Concrete
Annular Space Width ? Inches
Water in Annular Space: Yes No r-�
Method: Pumped--T- Pressu e Poured `_
Depth: From �� to�_Ft.
Materials Used: No. 8ags Portland Cement�Weight of
1 bag�lbs.
If mixtu e(sand, gr�svel, cuttings) - Ratio: ,2 to�_
ID Plates: Yes �� No
4 x 4 slab Yes C/ No
DRILLING LOG
De th
From To For ation Descri tion
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION ZS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W7TH REGULATIONS SET FORTH BY THE
PERSON COUNTY BOARD UF HEALTH. PE T VOID AFTER THREE YEARS.
�� 2.�,./� y �.�_�
Signature of Contractor Date
Sanitarian's Signature Date 2ssued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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Lot Size:
Sevage Disposal
Size of tank:
PERSON COUNTY HEALTH DEPARTMENT
SFWAf;�, DISPOSAL
IMPROVEMENTS PERMIT N0.
1. �� n� Issue Date: �-. f�� �
w �e 1 tl% 'I � ��i l �
er
Location:
i 7
Septic Tank ontractor:
Building Contractor:
Water Supply: Private Public
Other disposal facili
All wells should be 100 ft. from sewer system.
No. bedrooms %
Nitrification line:
Water supply and sewage disposal facilities location, installation and
protectiion must meet state and local regulations.
Septic tank should be pumped out every 3 to S years and shall be
maintained by owner in such a manner as not to create a public health
hazard. Septic tank and nitrification line t4UST BE INSPECTED AND
APPROVED SY A MEMBER OF THE PERSON CO. HEALTH DEPARTMENT STAFF BE£ORE
ANY PORTION OF THE INSTALLATZON IS COVERED AND P TO USE. TH S
PERMIT VOID A£TER 3 YEARS. /
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Date Well Approved: Signi'� r��
By:
Date Sewage Di o Ap r ed:_
v"
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Certificate of Completion
Date Approved:
��
(Over)
Location of aell and sewage disposal facilities sketched on back.
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Application Date:
Amount Paid:
Receipt #:
J'� �'� 2 L.��, ) f ll �ll�� �L:�l V Tax Map: r`� 02 7
,, � � � ��,�� Parcel#c 1 �
IC-�'.�rav>aa-�a.nmraes�nd,ai.11 lr-3� a3�.lLdlln.
tion for Services
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobil� Home Replxcement or Building Addit:on
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
❑ Construction Authorization
(Fee is dependent on the type of
❑ Per�it Revision
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: �
Address: �/y y�, t=�'r C f'L �✓L. t� (� �C }� �1,n
i31N�o,�,� �V,� z��� �.
2) Name and address of current owner (if different than applicant):
Name: ��-�-�
Address:
Phone (home): � � � �7 -��
(work/cell):
Phone:
t
3) Property Descriptian: Lot Size: C l� Subdivision: �4,,,,J,,.t �� Lot #: �
Address andlor directions to Property: S,�,. Q� a ��G-��
❑ yes no Does the site contain any jurisdictional wetlands?
❑ yes � Does the site contain any existing wastewater systems7
❑ 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 0 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 bedrooms:
Li ReFair to Malfunctionir.g System Wil: tk:�re be a bzsement7 ❑ yes ��ith plumbiag fixtares? ❑ ycs ❑ na
❑Non-Residential
Type of business: - ��
Maximum number of employees:
Total Squaze footage of Building: �
Maximum number of seats:
5) Water Supply: ❑ New well L'I Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing welis, springs, or existing waterlines on this properiy? ❑ yes j1-cio
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ 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 subsee�uently altered, or the intended use changes. all permits and anprovals shall be invalid.
Signature (Owner/ Legal Representative*)
'� Supporting documentation required.
�^ ,�i� / L
Date
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)
Application Date: i'" � '
Amount Paid: �
Receipt #:
----
�
❑ Improvement Permit (Site Evaluation)
$200 00/$300 00 (if> 600 gpd) _
❑ Mobile Home Replacement or Bu�lding Addit�on
$150.00 (if site visit re uired)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00 _
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`_'.' � �����[°�'
j��cao na-aaanmca<essa.G:aaII )H���..ILQ1in.
ilication for Services
Services Re uested
❑ Construction Authorization
(Fee is de endent on the e
0 Permit Revision
$75.00
Tax Map: ���� 7�/
Parcel#: __�-.L��—
of
pair of Existing Septic System
Application: No Charge( CA $150.00 or $300.00
1) Applicant Information: � � D ���n
Name: �� � ' '
Address: ' �"^� ` r
� licant
2) Name and address of current owner (if different than app )�
Name:
Address: _ `
3 Pro erty Description: Lot Size: �� Subdivision:
) P
Address and/or directions to Property: __—
Phone (home): '? 3 L S��t r�Y ��
(work/cetl): �--
Phonz:
Lot #: �_
❑ yes �-x� Does the site contain any jurisdictional wetlands?
❑ yes C]�no Does the site contain any existing wastewater systems?
❑ yes C�t�� Is anY v'rastewater going to be generated on the site other than domestic sewage?
❑ yes �_ 1s the site subject to approval by any other public agency?
❑ yes Cfl�a� 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: 1
❑Residential N(�imum number of bedrooms: �_.
❑ New Single Family Residence
❑ Expansion of Existin System If expansion: Current number of bedrooms:
g Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
p-�epair to Malfunctioning System
❑Non-Residential
Type of business: �
f lo ees•
Total Square footage of Building: __
Maximum number of seats:
1Vlaximum number o emp y •_----- ;
5 Water Supply: ❑ New well UY�Xlsting We11 � Community Well ❑ Public patp � S� 1 eg 0 no
� Are there any existing wells, springs, or existing waterlines on this ro erty. Y
1 in for `Authorization to Cons�ruct', please indicate preferred system typ��(s): � Any
6) If app y g
❑ Conventional 0 Accepted ❑ Innovative ❑ Alternative � Other
t the in orrnation provided above is complete and correct. I ans es all rse�nz�s and appro�als shall berinvlal'd.is
I certify tha f
inaccurate, or if rhe site is subsequently altered, or the intended use cha g, P '_' �_
�ii r� .,_ � �_�.dG�� Date
Representative*)
---�-- -
* Supporting documentation required. roved lat.
Permits are valid for either 60�months or are�non'�n lany ppin at on requi ng a s te evaluation.
A completed `Lot Preparatcnn form must ac p Y
n Count Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
(10/11) Perso Y
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7:E�s ��a a- �:.������.�1 IF-� � �.Il�7�
Applicant: C.HP
Address/Location:
A�At�S
�v�zR C(�-'� N
Tax Map: /�a'1 Parcel: I`� 8
Subdivision 3��tv� C�al
Phase/Section/Lot # t.et' 3
Improvement Permit
Permit Valid for: Five Years Non-expiring
Type of Facility: New Addition _
Number of: Bedrooms / Occupants / Employees / Seats:
Proposed Wastewater System:
Proposed Repair:
Permit Conditions: � I��-P� `��
Authorized State Agent: �� _
(X) Owner or Legal Representative:
Water Su�ply:
Projected Daily Flow: gallons/day
Type:
Type:
Date:
Date:
The issuance of this permit b r the Health Department does not guarantee the issuance af other r�quired permits. It is th:, responsibility of
the applicant/property owner ±o insure that all Person County Planning and Zoning and Building Inspections requirements aze met. This
Improvement Permit is subject tu revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issaed in compiiance with t6e provisions of the North Carolina `Lvws
rrnil Rules for SewaQe Treatment and I��cnosal Svstems'(15A NCAC 18A .1900). Neither Persaa County nar the Environmentat
Health Sgecialist warrants thai �Ce septic system wi:l continu., to function satisfactos :ly in thc fature, or that the water supply wi[l
remain potable. --- --
Authori�ation to Construct Wastewater Syst�m
See site plan and aalditional attachments (� j.
it
Proposed Wastewater System: �c��0 (*)Type �� y Design Flow 3b� gal./day
New Repair 7� EYpansion _ Soil LTA:Z: ��� gal./day/ftz
Type of Facility: 5tia�u.. £�►hw�t (tc:�rs�.rkx. Basement: ^ Yes �C No
(") System Types lilh, Ilibg, iY, c�nd Y, require periodic systQm inspectiuns by the Person Couniy ilea[th Department.
Wastewater Sysiem Requirements
Tank Size: Septic Tank Fx►s+�i� gal. Pump Tank —" gal. Grease Trap � gal.
Drainfield: 'I'otal Area Z`iO� � sq ft. Total Length $O ��� Max. Trench Depth 3lo in.
Trench E�Vidth 3 ft. Min.Soil Cover to in. Min.T�rench Separation 9 ft.
Distribution: Distrihution Box / Serial Distribution %C / Pressure Manifold ____
Specifications: R�--�a��a�► M�-Ta� ����A ;-
�iss+�ab l..�t�,'i.. • RLr��i. �'s��, �.Rsr 't�o - 30 � vF Fx�!
E�i bb �w� b& w�l. L�a� LAsx� -sF�. cY '�+.�t. �O s�.rn�.
Authorized State Agent:
^ 80 �' oY l.�c:� '�O `�-tyO C�c
tssue Date: I a$
Permit Ex�iration 7
Tlie system permitted is: Conventional /Accepted i� ; Alternati�e / Innovat;ve . I accept the a�nditions
and specifcations of this permit. �
(k) Owner or Legal Representative: � �l� � ���� Date: �� ��—�
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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SITE PLA1V
' Name C:�� �l'�S Tax Map #�� Pascd #��g
Su 'visio ����' ��� Section/ t#
1
Authoazed S�te Agent Date
System cnmpoaeats represent apptaaYmate contouts only. The contractormustllag t6e system prlat to beginniag the install�rion m
insure rhatpmpergrldeismaintained.
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Applicant: (,�AC�F.S Aaac�s
Location: `7`1 t3�.Avc(t., C�,E1� QAttt�wA�(
O�eration Permii
Taz Map Aa`I Parcel # 1'�
Subdivision
Phase/Section/Lot #
# of Bedrooms �
System Type (From Table Va): T1T. Product (IIIg): �2 ��
Type V& VI Expiration Date: �.1 A Type V& VI Renewal Date: ►� A
This system has been installed in compGance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
D�c��� a. �,r�
(Authorized Agent)
J[r�t'�'( l�E.w�s cY So�1S
(Licensed Contractor)
L.�.6i; �D
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Scale i�CS
PCHD, rev. 12/14/12
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(Date)
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Line Length
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Tax Map: A��l Parcel #: �`�$
Septic Tank System Checklist (Type II-I� System Type: iii C�
Notes•
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes•