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A27 226A�p�acai�oII a�ate: Amoeam� Paid: R�e�a�� #� �/to6ile Home �, , _ . a--� __1�:: ( tmit (Site Evalu� 10.00 (if> 600 gps ;piaeement or B� ite visit re�uired) c�a�ro� - .r.__.. ��� .� ��1���� ����:� �' .. �.,,� � � ��.,�.�,. Parcei#: � lE�,.��,.-.,,.� ��.Il IH[��.Il�. n��' �2T�YIC�S ue§ted C� ConsEruction Autbarizatioi ee is de endent on the e C Permii ��vision �75.00 Q Repair af Exi�#ing 5ephc L AppIica#ion: No Chargel �� �iD�Q�IC�ffi� �aY`���t4II:y��f- / ` NaICtL': r1GLtr► �1'Y�Yi [�•••�ct �c.j i ZG: d�� l Address: .Q�i : r : ii rr�. .-�: ���� �, � `� �s 7� — 2) PTame aaid ada of c t o�e� (i� differe�ti t�� �ppiieat�#). Name- � � GC : � t a,ddress: ' n �� 3} Propea�,� �escrip�ion: Lot Size: _„_ Subdivisionl �ddress andlor directions to Properly: _�y.�, Q yes Q no Does the site contain any jurisdictional wetIaztds? $150.00 ar �300.00 Phone (Iiome): ��z �'_ � 2�L� " iJL,L L .+=eJdr (worklcell): �`'�'��� S'���� �f�3� Phane:��, lo S`�`l °'1 -.�g�8 #: ❑ yes CI no Does the site cantain any ex+sting wastewater systems? p yes Q u� Is any wastetivater going to be generated on the site other than domesstic sewage? I p yes 0 no Is tiie site subject to approvat by any other public agency? �„'„ �. � yes ❑ no Are there any easements or right of �vays on this properry? ��� (if `yes' is ch�cked, please pr�vide supporting dacumen#ation) ��� �i) ��a�Qse� �Jse aFad �yge af �truc�re: �/ a „ ) ( � I�ResiaentiaE 1/�,�,'tC6 ❑ Netiv Sin;le Family Residence Maximum number of bedraoms: ❑ Expansion of Existing System If exgansion: CurrenL number of bedrooms: ❑ Repair m�iaffunc�oning System Wilt thera be a basemenM 0 yes Q no With ptumbin7 fixttnres? tl yes ❑ no ClNon-Residential ' Type of busfaess:, --- Totat Square footage flf Building. - Maximum number of empIoyees: M2ximUm number of seats: �j i+�ater 5upg%y. Q New tivelI 0 Existing l�ell !7 Cammunity WeII Q Publie Water Q Sprino Are there any existing �ve115, springs, or exis�ng waterlines on this property? O yes 0 no 6} � agpiyfng foa� `Authari�a.ation ta Ca�sfir�tet', alease indic�te pre%rred �3�s�e�ra iype(s}: Q Conventional ❑ Accepted ❑ Iimovarive � Alternative D Ot�er ��Y I certify that the n�ormation p vided above is complefe and cos•recL I also ��derstand Ih[u i�'tl2e ft�formtufo�t p�'w�ded i.s inacc op ' tFi te ' uet�tly altered, or the intended zsse chartges, all permirs ar�d approvals shall be irrvaiid. . � S-LS -/S� Sigaature ! Legal Representative'�) ��� � S�pporting documentadon required. i�ermiis are valid for eiiher 60 manfit� o� �e no� exAiriug ��•�en �ccomparied by an ap�rov�d gl�i. A coa�pleted `�ot �'reparrrfion' iorm m� accompany a�y appl�eataon �eq�t•ing a�ite ev2luati0tc. .. ,. ,. .. „�__ .�...._... r....:�.,,,,r,o„tAl �TP�►ith �'7i G Mnraan St_ Suit.e � RD3LbOr0, NC 27�73 i336-597-1794) Tax Map� Subdivision: �� J ���� �� ���... � � � ���� ��ra�n�ram�nnaa¢��ra�<m.Il ��c��.Il��:a WELL PERMIT (New _ Repair j� ) �1✓►-e ►� Parcel: ZZY' � Lot: Applicant's Name: /`��l✓!� E' �TC�Q,�w S.� Mailing Address: Phone Numbers: Location of Property: ��� Lt' �g ��k�av� y� 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: _ () � u►'`'� QNew Well: EHS/Date Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Well Driller: Pump Installer: Approved by: Additional Comments: Date Sample Collected: EHS: Person County Environmental Health 325 5. Morgan St.,Suite C Roxboro, NC 27573 Date: �� �'-� 5 Certificate of Completion wQ'�� ���,� �L,iner: EHS/Date Depth: 0 � � i��� Grout: -�j t DAbandonment: Date: Method/Materials: License #: License #: Date: Date Results Mailed: Phone:336-597-1790 Fax:336-597-7808 11/26/13 ConnectGIS Feature Report �.�������. ��� i„ 'ah��'E _:r-•�,-, � , i k ti °-N�fi;{1�. '"�..-,r--�:^:' J_'_,,,.� — ����� ���� Page 1 of 2 Person Printed May 15, 2015 See Below for Disclaimer �zF�R� ? 4i ��._—�--'-.,— ?c+t�Ce�S � � � � � � �_.-r-�'_ LJ �.. 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