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A27 230� H O � Qo ��oo Person CouMy Haalth Cep: po A m q u n t p a i d 1�G . P�` 325 S. Mor�an Stre�:# d l�- �`,q 5 g- 3 l-9 �J Receipt �� '�,(��J a�0o��5�ROXbOrO, N.C. 275%u P �a. Date . �.l Cqurier'�2-�3-tfi . �"�� APPLICATION FOR SERVICES -_ r a e'�,"'_' " .i, ,r l� Ea„3 � � - - '�Y� a .. 4l t*`k�' � +ie'kv° Fin ac � `°`a'sat�s%�'.'�E K>.� s� wy .,,e�r ^�. ?�'SKL �7'' °. �..A �t ky� f.:x�"�vFl. .i ;+ i�r�`%3R 1 i t�'�a �E a��; e �s � P f � ...y t �,sY �:�,M,�5ervtces;Requesfed�� x 5�� . .�;. 'f.,y3- .7d'^r�.:°: ,x..«��ztiT��x�;��v:3 o.:`'�ek..rx.a .�u-.:''�:...�u> . ai�•+..,Z"Aa,:siiq _ �,�.i..d..,�. `�� ¢E�:�w.w <: 4...�,<.m, �,n,.+r.e.,o,<�*i-+A . „.�-xti..... o< :.. < , . . . . .-; . . .. Im rovements Permit. (Established/Recorded I.ot) _ Reinspection of Existing System (Loan Closin� , Imt�ovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System lmprovements Permit (Mobile Home Replace) _ Permi[ for New Weli Improvements Permi[ (Addi[ion) _ Replace Existing Well Bacteria 1. Permit requested by: owner/pros�ective o�jvn� _ Chemical �� _ Petroleum � _ Pesticide I _ Lead � (,pt•Jvr N�. '� . � w � Home Phone #: ��l'� _ 3a�.. UCy^O �G o� a usiness Phone #: < < p t� � c7a �¢ z �ii( Dimensions or Proposed Structure: _ Width: T��- r�,.....t.. i C� � What type (if any, additions, expansions, or �lacement is anticipated to the structure or facility .t this sewage disposal system is intended to serve? Na �e and ad ress of current o�ne* �� 9. Water sup�ly type: � �,,, private�ublic ❑ community ❑ spring ❑ �, Are any wells on adjoining property?Yes ❑ No [�. If so, identify location: . Property Description: Lot size: l!� C- . Tax Map#: � XG �.,/ Parcel#: � G ��` Townshio• ��-�� .� . Directions to property: State Road #& Road Number of occupants or le to be served: �_ I0. Type of structure/facility: Proposed: �Existing: Q!, Type of dwelling: House: ❑ Mobile Home: (��usiness: ❑ Type of business: Number of Employees: Number of bedrooms: .�,_._,/ Garbage Disposal? Yes ❑ No.l�" Basement? Yes ❑ No�f-so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the Person COunty Health Departmeitt for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the even[ I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dep[., this application shall become void and all fees paid forfeited. Signcc� Owner or Authorized Agent i i I � .I � I � NO3°56'10"W � � 27.18' J i II'-,�� ► �- � �343 NS � ---� 5R ,42�� __—��--- N,�°�� , - I NF 11a g3 W NS , ao� 6�� R __� � - �, 46 . „ �� - a' N80°23 p5 E ' _ _ _.— - •� , . w — IS � �� rn �- Z � � � w ' � �� n � � O /� c � / \ SUSAN M. WINSTEAD NANCY W. ROUSE D.B. 182, P. 767 D.B. 182, P. 769 �__ ' __ / � IF '' N�6• 39' 34, � NF g2��'' i � �-� " " •o '''.- IS 1.09 ACRES IS 12�'63 ,3a� 4g��W 5� 5 IS PLOT PLAN �RANK F. ROUSE NANCY W. ROUSE SCALE 1" = 100' i? ' � .r � � PLEASI Tax Map #: _ Zoning Applica �?N f ocatio Subdivision: ACH Parcel # Townshfo AND SYSTEM LAYO SecUon: Lot: � l W„�.uC Improvement Permit A buildina permit cannot be issued with onlv an Improvement Permit New �Repair _ Addition _ Type of Structure%�J Water Supply�%J V��i # of Occupants # of Bedrooms � Other Basement? Basement Fixtures? �� Projected Daily Flow: � g.p.d. Permit Valid For: l�'Five Years ❑ No Expiration Proposed Wastewater System Type:�f Y1V►nL�� (/� , i,U�(.t,l�' 'Il�/ 1 r l�%""""' ' �� Pump Required? Yes No Permit Conditions:�(��,��' ��(j,��bl1►�j�� 7�i � +� ��(M iS�P� The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This site is subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be affected by a change in ownership of the site. This permit is subJect to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Type of Wastewater System ��f.� Wastewater Flow: �g.p.d. Facility Type:�Q New C�Repair OExpansion ❑ Basement? 0 Yes �1 o Basement Fixtures? O Yes C�'�lo Wastewater Svstem Requirements Septic Tank Size: ��_ gallons Pump Tank Size: ,�,�,_ gallons Total Trench Length: , pl feet Maximum Trench Depth: � inches Aggregate Depth:�in. Maximum Soil Cover: � inches Trench Separation: � Feet on Center Other. C ' (i t Permit Expiration Date: i� ��'�� Authorized State Agent: � �� Date: — The type of system permitted 0 does � does not differ from the type specified on the application. I accept the specifications of this permit. OwneNLegal Representative SignatureY/`�� ' Date: ,� � %� PCHD, rev/ 10/12/99 Application #: Tax Map #: Parcel #: Person County Health Department Environmental Health Section SITE SKETCH .�av�� Ro�.S� .t� ►5 St�i��-- ApplicanYs Name Subdivision/Section/Lot# � � ti �i-�-� uthorized State Agent Date Svstem comnonents renresent approximate contours only. Tlie contractor mustflag tl:e system Scale: � WI �" ��.�titl. �iUUO�� dl� �U[ ��i �}-��c� �J�� ""' L�i"' I 1,1./ (/��"", "� � PC H D, rev. 10/12/99 Person County Health Department Environmental Health Section Tax Map #: �27 Parcel #: �� Zoning: Subdivision• Township: ��lliP �� Section• Lot: Applicant: �� Location: 7 � v� • jbf ��f ��055 �OW1 �iu c f e l�1,0 l,��e Operation Permit System Type (In Accordance With Table Va): THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION AUTHORIZATION. Tax Map #: � 27 V Parcel #: Z�70 PCHD, rev. 10/12/99 Tax Map #: Zonfng PERSON COUNTY ENVIRONMENTAL HEALTH -- --- ----. . ,..�� . ., Applicant: ��/� �� P LocaUon: Subdivision: Parcel # �� Township �/ � �/e— �,// �,O /1 � � 7 G�� / l Section: Well Permit Tvpe of Water Supulv: �Individual Requirements: Site Approved by � � ' �1 `� Grouting Approved by 5,� /� � f 3�i9 Well Log v� z -�-� Well Tag � � ` `� - ��' Air Vent `� ` -� Hose Bib - � v Concrete Slab Z' ' `� Well Driller: a Well Approved By: d J Lot: Community Public � � Date: � � - **See Attached Site Sketch** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: PCHD, rev. 11/29/99 ' Date: '� `f1 ' Owner. L,ocation/Directions: . . ., ,e, .a r., r, n _ _ . Subdivision Name: � Drilling Conrractor� PERSON COUNTY ENVIRONMENTAL HEALTH 7 WELL LOG ' � . _ .. . . .. .. :� v!-��"k,,��+.� <- ' ' . ��'r: �. SR# LOI # T-.r ��. . � WELL CONSTRUCI'ION -- Distance fromC N�earest Properry Lin�_ (� Distance from Source of rollution ' Total Dep.th: �_ Ft. Yield: Cp ___ GPM Static Water L,evel —�f- �. Water $earing Zones: Depth jt�__rt. Ft Ft�_�_�t, Casing: Depth: From � to�C� Ft. Diameter: (9 ) Inche; TYPE: Steel � Galvanized Sceel �" If Steel, does owner app:ove: Yes No � Weigh[: Thic�;ness:�[�� Height Above Ground: i � Inches Drive Shoe: Yes l�Vo . Were Problems Encountered in Setting the Casing? Yes No.�---- If "yes" give r�ason: Grout: Type: Neat Sand%Cement ..�- Concre[e Annular Space Width Inches Water in Annular Space: Yes No _ .. Method: Pumped . . Pressur � Poured ,�'�. � � �. . Depth: From � to Z Ft. . . MateriaLs Used: No. Bags Portland Cement Weight of .1 bag__lbs. If mixture (sand, graT v�l;,cuttings) - Ratio: �o �ID Plates: Yes_��o � :� � �� 4 x 4 slab Yes No � I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT THIS WELL WAS CONS3'RUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH $Y�THE PERS0�1 C�'vi�'I'Y HEALTH DEPARTMENT. 1 � - _-- ignature of Contrac�or Da�c 0