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A27 243Amount paid . �Qj'.GCa , Receipt .��. �p-8�� 4 ' , � ca .. , , .' . .. C�'a " . � O � � W U � a �- I�-9 i . . D�te > >:<; �:�>,.> .> .,: .. : _ . _ _ . ... _ _ Improvement� Permit. (EstablishedlRecorded Lot) _. Reinspection of Existing System (Loan Closing) �mpFovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System Improvements Permit (Mobile Home Replace) ,_ Permit for New Well Improvements Permit (Addition) _. Replace Existing Well Z t �Y jl , _ ' ' Y ,�yater Sample:fd be Collectec�: '' £ � �.+ � � - f t:�. s S ?� 3..a:� >. - ..�: � �.. �'. . � -.. � ......:i r . , .,... _ „ .a. . .. , ..,.:, � -'� � . .an. v.. ..::.i . . ..... . ... . .:> . ..�.._. _.. . ., n :.. . . . ._.. . � Eactcria Chemical _ Petroleum _, Pesticide _ Lead l. Permit requested by: . owner/prospective owner/agent Address: � � Z 6 � - � e- f,�x�,�„�. �.�. a :ome Phone #:_ usiness Phone � _��( �K �..,,._ I �'jl.��'�� 7. Dimensions or Proposed Structure: �Tij'idth: 30 � � Depth: �fd' 6Y /,SaO �• 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? and adc�re�s of cu ent owner: `r�� 9. Wat�r supply type: ; private� . public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No [�. If so, identify location: . Property Description: Lot size: `�a C u,' . Tax Map#: ' a 7 � � Parcel#: 3� 7- Township: d I.� U e �� . Directions to property: State Road #& Road lames. �tc. . , � 0 � u 10. Type of structure/facility: Proposed: �xisting: Q I Type of dw�elfli �g: House:4�Mobile Home: C� Business: ❑ Type of business: Number of Employees: Number of bedrooms: � �,�. Garbage Disposal? Yes ❑ No�l Basement? Yes ❑ No�' If so, # of basement fixtures: L. Number of occupants or people to be served: � ' CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PersOn COunty Health Department 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 event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of i the site by the Health Dept., this application shall become void and all fees paid forfeited. � Z USignea Owner or Authorized Agent Permit Issued ❑ Permit Denied ❑ Plat Observed ❑ ,,, . , �S ignature �� . r � Date ; . -, /:. .� c � �` 4,,. . r: F�,CI'ORSS7TEEVAI.UATION,; . ;��A1iFhE. >.;, ' u 1��C'2 , . .... ; ARFA3 A�Ad , ;.. , ,,, , . ..:: x<� <,:.> . : , .:;,.: . , ,: l. SLOPE (%) S S S S PS PS PS PS U U U U 2 SOiL7FXlURE(12•36IN.) 5 S S S (SANDY, LOAMY. CtAYEY. NOTE 2:1 CLAI� PS PS PS PS U U U U 3. SOTL S77tUCNRE (12•J6IN.) S S S S (MYEY S01LS� PS PS PS PS U U U U, 4. SOILDEPIH(IN.) S S 5 S PS PS PS PS U U U U S. RESTR1Cf7VEHORIZONS(INJ S S S S- (iMPERVIOUS STRATA, ROCK) PS PS PS PS U U U U 6. SOR.DRAINAG&GROUNDWATER S S S S (DCTERNAL R tNTERNAL) PS PS PS PS U U U U 7. SOII, PERMEAB]C]TY S S S S (PERCOIAATION RA'i� PS PS PS PS U U U U 8. AVAILABI.E SPACE S S S S. PS PS PS PS U U U U 9. STCECLASSiFICATION(SEEHEI,O� SOtL SERIES S-SUITADLE PSPROVISIONALLYSUITAUI,E U-UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSI�TCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, e�C.� C:IAMIPRO�DOCSlAPPSEC.S�1 FWANCE.PC Application Date Amount Paid: _ Receipt#: _ `� `�d pZS' ` . . �� .� � ��..� �� - �C � � ��.� 1.�—_'�..:c�a.�.—]i]L: �CSS[']L]Y4T.•!!;r�']l.'�.£R11. �E��.c-.en..�'d-.:iia. Applicataon for Services (Se�tic Svstems and Wells) G T.mprovement Permit (Site �valuation) $200.00/$300.00 (if> 600 d} � 0'Yobile Home Replacement or Building $150.00 (if site visit required) G Wel1 Permit (New/Replacement) $225.00/$125.00 Tax Map: � Parcel #: �,�� Services Re uested C Construction Authorization (Fee is de endent on the ty e of sys ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System " No Char�e Important: If t1:e information in ihe applicatinn for an Improvement �'ermit is incorrect, falsified, or f/te site is altered, then the Imnrovement Permit and the tduthorization to Construct shall become invalid 1) Services equest�d by:, Name: r r � 1� v1 � Ycc.�s � e✓ Address: 36�i ? e �NI o �a o �r . C - �-�S7 Phone #(home): .� 3 �' 3 ZZ — j 2�j R (work/cell): 336- ,599- a)�'i B)1�Taffie and acidress of current oevner {if different than applicant): Name: Address: -- 3) �'roperty Descriptnon: Lot Size: (kyc Subdivision: �° Lot #: Address and/or directions to Property: 4) �roposed TJse and 'Type of Structure: Residential Business/Type: S v n-�aa �^'� Other Number of bedrooms / Number of people served (seats/employees): Basement: Yes No _(with plumbing: Yes _No � Garbage disposal: Yes _No ____ Approxiffiate size oibuiiding foundation: ]Le�gth� �i�t� � Z- � 5) �'Vater Supply:/ Private Well ./ (Proposed Existing _) Comanunity Well: Public Water System: Are there wells on the adjoining properties? No Yes �(please show location on site plan) li�ote• A com�leted a�piication rnust also include: ➢ A plat/sate plan o�'the property that s�iows properiy dimensions and the size aa�c� locutron of ali proposed structures. ➢� signed copy of the `Lot I'reparation' form ver�ing that the pronerty is ready to be evaluater� � am submitting #has �ppiication to request services �'rom the Persan �ouniy �ealtia'�epartment. The information provided 'as accurate. � understand that if any site is altered or the intended use changes, all permits shall become invaIid. Signatu�e (Owner/Legal Representative): � �ic.�-✓� I)ate: q�3b-�DoB 11/07 Person County Environmental Health, �25 S. Ivlorgan St., Suite C, Roxboro, NC 27�73 (336-�97-1790) � a W � a � - - B 1883 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # /9 a � Zoning Owner/Contractor i�ig.Q,P Parcel # � � 4 � Township Q�� YE- � �i�Tr�,e�L�t`�'!� Date � �S-9 Location/Address_ i5'y/ 7 s i �/o�r.s!_ � �sr �tf��' p�� v� f�� -c�r�� /1E9 �iv TE LE¢r- 5vsr /3cf'o/1��RAH�z� �%Q. S.R.# /VG fi�G/`7.f�%�Rr Subdivision Name ,v/A Lot# —�- SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area /, 66 a.��- Size of Tank_ /04O��L � oniS SFD t� - Mobile Home Size of Pump Tank ti/f Business # of Bedrooms 3 Nitrification Line �oo �X 3� Max Depth Trenches ay�� Permits may be voided if site is altered or intended use changed. Well and Septic Layout by ��T ��,y� ,�.5, ��r,� Co ents: ,S D �',Q ,� � m �,c , 5 �zG S �v� cZ� �to1'S �iNl� /O� �/lo� �f.eo/t�''7Z Date Install�y Approved by Well Permit Paid ICJ Individual �' Public Site Approved_1/ � Well Head Approved � Grouting Approved_ � Comments: Date WELL SYSTEM SPECIFICATIONS _Semi-Public_ Replacement, Installed by. Required Slab � Air Vent Required Well Log Well Tag _ _ Approved by This report is based in part o� information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environme�tal health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l � LOT 18 I � "ROCKWOOD HILLS" � � ' I 74.43' IS 55.02' IF �NTROL ORNER = C. CLAYTON HEIRS � w N �� ^ � M o " 0 IS � \ . � `i � � .J ., � ,. . � , LOT 20� � "ROCKWOOD�HILLS" � "ROCKWOOD HILLS" ' � 1 I 1 � � � 115.90' INF 0 IF 105.83' � 30.8 S89'48'08"E 307.63' TOTAL NF 0 IF � --� J ��niAP �� . '> > A� . � • t _ � ( ` I � 1.� � � � � � .. 4. .c �-- � I � �, T '� � i .., ' � `�. `� o � � � _ ;� ' 'Z ' _ .� � �c. I � � -� I f � - i�- � �' � p , � �v - � = . ' � 3 6. 25�' TD AL . v I , � . J W ' � �i N ' 1 �, ► : ,:� � � ��-� 1 , ' �';z i'� I: `;:1•i, � �� ' =l B' NS �� N89'48'08'��M . .. . . IS � , . � . _ � � GENE C. CLAYTON .. . E � IRS �� _ . � � . r� � � . . . w - � . �� i � o O � c*' ^. :.�q '{. � �.:;1 �;.: �: 30.00' �� \, yi1 � �� Y � � � � � .1�� i 1Y� �+�,Y.1i ��.Ji.L�.7±.�L.i'JL.L. V►C�.� J.L. .Ji V✓i�.� W3LJi �uilding Additions/ Idlobile �ome 12eplacements Taac Map #:� Approval Requested for: Parcel#: a �3 Mobile Home Replacement � Building Addition Applicant Name: /J� � Address: 6 �'+�c m� C ?5 ? Phone #'s: 32 Z�' /�,� �'4 - d� s� Permit Located: Yes No Installation Date: Q Design flow: 3�� (gpd) Current Contract with Certified Operator on file (if required): �� Water �upply: � i� Well Public or Community �Wastewater"system shows no visual evidence of failure on: � (date (Applicant's signature if site visit is not required) Comments:�-�'n�.i ssi o� ��Y%�Qt �Z �JC Z� ! S�C� —rr��-, . � = Addition/Replacement Approved ,. �. �,,,� a 3d fd s' Environmental Health Specialist Date 11/15/OS � � W � a � • ! � r' B � �$� PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT -:- , Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # /9 a � Parcel # � � �' � Zoning Township Q�/ Y� � Owner/Contractor ��,Q �iN Date 8' as-9 Location/Address h�i�� 7 S% o�r-.s1 J vsr v�t�� p�� Y� fi�i« ��r�iT��' �RE9 O•� TE LE�'T— S�fT /.�cfo/Z��-2fIN/JL�T�.Q. _ S.R.# NG/%�G/�7.f�%%�RT•l� Subdivision Name �t//A Lot# -�- SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area J, D 6�.�- Size of Tank /04O �iftL < o�-s SFD t� - Mobile Home Size of Pump Tank ti/f Business # of Bedrooms 3 Nitrification Line �oo � X 3� Max Depth Trenches o�� Permits may be voided if Well and Septic Layout by_ tz� Date 11' ell Permit Paid altered or intended use �� .,✓� . J�',S, Approved by, WELL SYSTEM SPECIFICATIONS Individual � Semi-Public Public Replacement Site Approved � Well Head Approved � � Grouting Approved L Comments: Date Installed by � -� -� .� /�! � - .��f��1�F1� ' -� '� • � �1� � • .w �i .�� '1.1 I � l.��;�� If.,�i1J:A!1:� � , . . -, , ��`�` This report is based in part on�information provided the homeown�r or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditioos on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l LOT 18 °ROCKWOOD HILLS" � 9N I '� � � 1� I �. � � LOT 19 � "ROCKWOOD HILLS" � � � . . _ ,,,. , LOT 20 "ROCKIYOOD NILLS" ' ► � , I � e' �NS N89' 4B' oa'��+ ' " � . � ' C 1 t I � E 6ENE C. CLAYTON � o IRS � � � - � � ' � . � � � � � . .:__-_;. _ . . �.��- _:..�. .�.: . - , - PERSON COUNTY ENVIRONMEtITAL HEALTH WELL LOG Date: ' ��' � ' Own�r: • , Loc�tion/Directions: Subdivision Name: Drilling Contractor: _ SR# r. :� . . . �✓: t er�' • v i :, • �rr.4 ��'. J'. � . Lot # -- ,�,_� WELL CONSTRUC"I'ION � � Distance from Nearest Properry Line_ �� Distance from Source of Pollution lC�o ` Total Dep.th: ��D _ Ft. Yield:�__ GPM Static Water Level___�(�'__Ft. Water Bearing Zones: Depth a�� Ft.�'7o Ft� F� Ft. Casing: Dept}I: From�_to�Ft. Diameter. ~'/ Inches TYPE: Steel - Galvanized Steel v If Steel, does owner approve: Yes No Weight: Thickness: I�'� Height Above Ground: /� Inches Drive Shoe: Yes ✓ No Were Problems Encountered in Setting the Casing? Yes No ,.� If "yes" gi�e r�ason: Grout: Type: Neat Sand/Cement ✓ Coricrete Annular. Space Width Inches Water in Annular Space: Yes No _ . Me.ti`�od: Pumped . .._ Pressure � Poured � . _ . . . , . : Depth: Fr�m_�j :o �2 6 Ft. . . MateriaLs Used: No. Bags Portland Cement Weight of .l bag__lbs. If mixtuie (sand, gravel;� cuttings) - Ratio: to ID Plates: Yes ,7/ No � � � � . � 4 x 4 slab Yes�_ No I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH �3Y�THE PERSON C�'vi�ITY HEALTH DEPARTMENT. � 3 �__t� igna[ure of Contractor 1 �