A27 150'J
� � s
Person County Health Department
Sewage System Improvements Permit � �
Date: � �, is ��rm Void After 5 Years
Own�r' ` �,� �'l�1�+•6-��a� SR# 1�f_,�___
Location/Directio�s:� �' `,=�
.f A
SubdivisionName: Q�°.. 'a–�►-�' ���' Lo�#�L—
Lot Sizc: � c�� '---��ype of Dwelling: _
Water Supply:, Frivate:;' {� Riblic: ' Community:
Bedrooms: -� Gazbage Disposal —' 1
Basement `�^--• ' Basement Fixtur : ,
INFO TION � ER D B
S�TII[�7�I1. owne -or r presentative
t
�pp�; REEVALUATIO .
-------------------------
Size of Septic Tank: %Qf�br gallons Size of Pump Tank: L�� I
Nitrification Line: �t��' 3
Depih of Stone: 12 inches
Max Depth of Trenches:
Altemative Systcm: Conv. Pump .�� LPP Pump
Remarks: p�� tfn J-u�_���.o�Q esri1���,T
Date Well Approved:_
BY
Date � e s ,
BY
-----------------
� Well should be 100 ft, from any sewer system
C
z
�
�
V �" "" �� OFj �O,MPLETION I
Contractor. � � �t
------------------------- �
Sewage System location, installauon, 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 hazard. Septic tank and'd
nittif'ication line must be inspected and approved by a member of the Person Counry �
Health Depaztment before any portion of the installation is covered and put into use. If
the site plans or intended use change this permit is subject to revocation.
(G.S.130 A-335F)
Location of sewage disposal sewage system sketched on back.
(OVER)
:.�/�.'� 111�'�
F�rson County' Heayth Department
������ Well Permit
Date:C1,=L' L This Permit Void Af 3 Year '
Ow�t2r. I..Pn.� a v.-.��� .n ru� SR# -�
Lxation/Directions:
WELL CONSTRUCTION
Distance from N t Propercy Line �S� Distance from Source of
Pollution G--�
Total Depth:� �FG Yield: j�GPM Stadc Water Level �FG
Water Bearing Zones: Depth FG,�r� FG Ft,
Casing: Depth: From �._ �.�-� Ft Diameter. v%' - Inches
TYPE: Steel � Galvanized Steel v�—
If Steel, d owner approve: Yes No
WeighG � Thiclrness: � Height Above G:o;�:d: Z-- inches
Drive Shce: Yes � No
Were Problems Encountered in Setting the Casing? Yes No ��
If "yes" givereaso� 'b
Grout Type: Neat v. Sand/Cement Concrete �
Annular Space Width � Inches
Water in Armular Space: Yes No �/
Method: Pumped Pressure Poured v
Depth: From .�_ to ' FG
Materials Used: No. Bags Portland Cement `�_ Weight of 1 bag
.�� lbs. '
If mixture (sand grav , cuttings) - Ratio: Z to �
ID Plates: Yes No ►d
4 x 4 slab Yes � No ,�y
I HEREBY CER'I'IFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
TfIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
��,�.-,— Lc1 [���1 I',�� � � % G
Signature of Contractor Date
i 9-S ��
Sanitarians Signa Date Issued
Sanitarians Signature Date Completed
Sketch well location on reverse side.
�. � . � . . _
p� _ � � _ �O
lO�
, (� Improvement,Permit
1. Permit requested
Address : �� �-1
APPLICATION FOR:
( J Subdivision
2. Name and address of current owner:
Date Received:$- �`I.-
2
( ) Other 3
.. i�0/1 0�/� 't�
�/ /�'��9-1't.�bn�.�-rro a �s• .
Home Phone_�
�' Business Phone
�9 us�
3. Property Description: Lot size �.� Dimensions:
Front � Qq ,�9� Left 3S� r• ,�ight ,3 S� ,�'�[. Rear /�
4. Tax map No �,7 (.��► Q Township: Q�./�/E'�/,� Block No. Lot No.�_
5. Direct'o s.to property: State Road No. & Road Names, etc �'"�
5,�.� �� - �,3�� - - --_ -----
6. P�rmit requested for: New Installation � Repaired
Additional Renovation re-using present system
7.
8.
Number of occupants of people served a�
Dimensions of Proposed Structure: Width Depth
9. What tyge (if any) additions, expansions, or�replacement is an��icipated
to the structure or facility that this sewage disposal sys�em is intend
to se�ve?
.10. Type of water supply: Well �es no: If ao, name source of water
supply: Are there any wells on adjoining
property? If so, identify location. ND
il.
Type of structure or facility: Proposed � Existing
Type of dwelling: Honse Mobile Home_� Business
Type of business /�/�— _ Number of Employees_
Number of Bedrooms � Number of automatic appliances
Basement N� Number of basement fixtures�
12. Clearly stake all corners of the property and the corners of all p
structures.
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 conten
of this application are true and represent the maximum facilities to be
placed on the property. I understand that if any changes are made without
approval from the Person County Health Department, the permit will be void
Any permit for a system is non-transferable without prior approval of the
Person County H�alth Department. Permits are valid for 60 months from dat
of issue.
SIGNED
rec�rURs - SITE EVALUATION
1. SLOPE (%)
2. SOIL TEXTURE (12-36 in.)
(Sandy, 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)
6. SOIL DRAINAGE/GROUNDWATER
(�cternal � Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
8. OTHER (specify)
9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S - Suitable
RECOMrIENDATIONS/COMMENTS:
0
PS -
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
AREA 1
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S.
PS
U
Suitable
AREA 2
AREA 3
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
P5
U
S
PS
U
U - Unsuitable
S
PS
iJ
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
SITE CLASSIFICATZON DIAGRAM (Include: Soil areas, property lines, roads, streams
wet areas, fill.areas, wells, water bodies, slope patterns, etc.) � gullies,
AREA
�ipp�acati0� ��te:. � "� � " i Sr
AmOu��Paid: 7 .G U
��c���� #� q ��. H' � 7_
�# � 0 � g Au
0 improvement Permit (5i
�oo.aor�ao.aa ��f
� I�obile i�ome �piacem
�i$a.ao c�s�� ���t
eII Permii INew/Iiepi�
EvaIuatiou}
ar
���. � ��I���� ����: ,���r
I� T ParceI#�: I_, �0 _,.
---' �-•�- �: � ���
]E�,-s�,,,,.....��.Il 1H[�.�il�.
fo� �e�i��s
L� ConstrucEioa
lFee i� depenc
��s.00
L� Repair of �i�ting �epiis System
AppIic�tioa: No Chazge/ CA $150.00 or �300.00
1} 1'���ulicaaa� �o�aa�ion:y���;� / t
TI31Ile: �4Lrn �Yt f f.vr�7'ct �.�} i ZG%d� �
Address: .46i >:r� ili,��. -.-�
.���., �. G '�'yS �" —
�) Ptame and adares.s of c�nt o�*a�r (i� �e ztt t�aa �pplicaj3#):
Name•
�ddress:
�,�2 ��
3) �'roge�,� �escriptiaa: Lot Size: �• S Subdivision:
�ddress and/ar directions ta Properly: �
Phone (home): ,,,(33L� �'�� - t,Ji.LL
(worisJceIl): ''?'�� C��•- Uf�3Ga
Phone:133G� S97 - 931f�_
.�k z,�t�:
Q�Q no Does the site cont�in any jurisdictionai wettanc�.sz
❑ yes D no Does the site confain any exisdng wa�tewater systems?
i3 yes I1 na Is any wastetivater goinb to be generated on the site other than domestic sewage?
❑ yes p no Is the site subject w approval by any other public agency?
p yes ❑ aa Are there any easements or right of tivays on this proper[��?
(if `yes' is chocked, please provide supporting documentation} ,
=3� ��opose� �Jse aFad Tyge of �4ructure:
��esid�ntia[
� New Single Family Residence Maximum number of bedraoms:
❑ Expansion oFExisting System If expansion: Cucr�nt number afhedroorns:
❑ Repair m Malfunctioning 5y$tem WiII thera be a basement`I ❑ yes ❑ no With plumbing fi�cmres?
�
Go�p�d;y��
�� ��
�a�'�%
(
Q yes ❑ no �,/}�
N
�1�Ion-atesidentiai �
Type of business: Total Square footage of Building: _____
11ri�cimum nunaber of empIoyees: MaXimum iiumber oiseats' __
5) �Tater gupggy: Q New tive1I � Existing Wetl � Community WeII D Public Water Q Spring
Are there any existina �vells. springs, or exis�ng waterlines on i�is property? � yes � no
6) �r apgiying fo�- `Au�hori�a.iion ta Con§ipuct', piease indicate gre�ers�ed �ys�em type{s):
Ct Canventional ❑ Accepted ❑ Itmovative Q Alternative ❑ Other a�Y
I certi,�'y that the information provided above is complefe and cofrecf. I ulso t�tderstand Ihul ff'Ff�e fn.f'opmartonPrm'ided is
inaccupate, op rf the sit¢ is subsequently cdtered, or the intended zsse changes, all permfts arrd appr'uvals shalT be irrvalid .
0
� Supportiug documcntation required.
�%"2/-/S�
�8��
o�ermi�s �e �taiid for eif�ter 60 mo�� or axe nu�-e�t�irin� ����e� �ccoanga�e� by an agproved pIa�
a A compie�d ��ot �'reparation9 iorm m� acc�mpany anp ap�licatio� �eq�i�g a si�e ev2luatiott.
.. ,,,. .. r�__ ��._.... r.,.r,..,,,�o„tfll T�Patth �7i .�' illinrssan S� SttitE Cr ROXbOrO, NC 27573 (336-597-1740)
��, : f �f �l.f.Cl ��l.J ��
�. � � � ����
IE��au-��.�.m�.��.Il I�3[��.11�l�
WELL PERMIT �
(New_ Repair�) l�y'��
-----.
Tax Map:� Parcel: l 5�
Subdivision: Lot:
Applicant's Name: C% 0� i`" �(/I �`'�S
Mailing Address:
Phone Numbers:
Location of Property:
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by:
�ew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Iastaller:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
��
Date: ��— �
Certificate of Completion
�iner:
EHS/Date
Depth: C� r
Grout: �22�-( 5
QAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
il/26/13