A27 244��, 7,.)� ������ .
"'^ � � ����
]E �.v�n a- � m�.aa��o xn�.m.11 IHI ��n.Il � )la
� SITE SKETCH.
Name 1 YS i 0.�,(15� Tax Map #�..Parcel #��
Subdivision � Section/Lot#
, /I-,DI--t� )
thorized State Agent � Date
System components represent��roximate �contours only. The contractor must, flag the systemprior to
beginning the installation to insure that pro�iergrade is maintained
C�RNCR IF �
cor�r���. � , � � � .
�f�P i � `
�'"�-,., 3� ' 27 �,�. � � f
k' 8��' T� � 1 0 � �1 %r
^� !
o � .SC,cf � I F � � �
� � � ��
� � �. f��
m
;� �,,� \ � . �` �� Q�, ��, � ,
2 � �'�' �`Q� _ ��� ;� ° �o �,� '� �,j �,
��� ��' 4- ' �r-��'"
�3 �k� a �4 . �; � � ! � Q<.� r
\ � �' � (�,�
, �.. � � W � � �l +f� f Jl��
� �s`' °� � + �' !
r6 a�,Go�� . � � � � �
� Ci ��.f ..� � ` .� �
I ai '� � �
: � - X � �� �
� �. -� , ,��.
� � F, � �� ' �j-�
- c,, � � � cn Q � `� �
V
.�j d o t G+� �
M7 ^�-
� • � � �, � � � I
. � a 1
r
u�
I �, r .,, t
� � 1 � � `
( ' �i � � � � � �
� _ I .a I ° � '- +
�-e ttt u. i
�� � �
� ` � � o _- �/ � G'j '�' -��r
4� �
� '\
` �\ \ � a � � t � � � �r
u
�� \` �, �a..
, .
� � N5
, I
�,
`� E�kS \ �
� y rtQ 6, � � !
�
c4 � �' ,. J
� , �(�, `}c.�, r �
� �Fj'���e. �, ./ - /
� •` 1 �`�-. .�. � .r.--.-"".- ~ /
� �
\ \ i� 'J / //'} / r � /1 � (��
. 1 �����/'" r / /! U QI �M (� .. . . . �
� �/
' � / �' ,� ��;.�.f"� t�- :
n . o %
� � (�us x;,t��/', o �/ �-
�� � �
' ���� 6-���
---- - �' ����
�° .
���� �
. .�a�A
i��k� i��i�J ���.
���'�� ��, ��
G�'lD : $iiG . CHORD
� �''� ' 12" W 193 . 18
2��.p��: S7a �� � ,
��{, � I � ,� t w�.3
y,y'y�i� �` � V �f / �.. 1 �::.:. J . �... . . . .
�"�31 m {
...� •-..:��:������....F-.;.ctrr�xss�:� • . ,
Person County Health Department
Environmental Health Section
Tax Map #: �� � Parcel #: a �'
Zoning: Township: lJ �� i� 1't ��'
Subdivision: Section: Lot:
Appiicant: ��ini, W I (I�TC�Gi
Location• fl
Operation Perm it
System Type (In Accordance With Tabie 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.
�-ag-�
Authorized State A nt Date
Tax Map #: Parcel #:
PCHD, rev. 10/12/99
���.sf �I�I�.���
'�.= .�— � c� � �T�T��
� aawn���aga�a�sa��.� ��a�.m���a.
WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
� Q�
Tax Map #: ,�_ Parcel # a�� Township �� f`f I� I
Applicant:
Subdivision• Section• Lot•
Location• •�� ('�� -,� o ��
Ty�e of Water Supply: �ndividual
Rec�uirements• �
Site A roved by ✓''`" �
PP
Grouting Appr ed bp '�o-O�
Well Log
Well T � � H `t- 9-0�
Air Vent � � 1� %"�
Hose Bib '"�-�a
Concrete Slab � if h-9'oa
Well Driller
Well Appro,
Community � Public
i �,� W�'r�
�Q���� �
h l �� "' �
L� ��� �
� ��
d,� ��PsS� u►� 1 �/1-°1�'�°
°� � n �.5,
r I� � ^ ^ .�,-�- �. �{ �e�-�' ��
1 'f� � �, � � 1��
,. � `�- ��
•-•-xc n«acu�u o�« Sketch'k*
ells must be 10 feet from property lines.
� Wells must be 100 feet from septic spstems.
Wells must be at least 25 feet from anp building foundation.
Other conditions:
PC�-ID, rev. 09/07/01
Application Date: g "�
Amount Paid: 7 00 _
Receipt #: '7�
(J*���o�e� Z- .
❑ Improvement Permit (Site Evaluation)
�"100.OQ/$300.00 (if> 600 gpc�
G Mobile Hame Replacement or Buildm�
$I50.00 if site visit re uired}
elt Permit (NewlReplacemen Repai�
$300.00/$200.0 75.0
��,?,� f !� ��� �.Jl � Tag Map: ��%%
�: � ����,�� Parcel#: ��Gf
l -�'xa-+-na o�'+w+�+c�dmfl IC�L�rm�ti.la.
�lication for Services
Services Re uested
L� Construction
(Fee is de enc
0 Permit Revi:
on the tvqe of
�75.00
� Repair of Existing Septic System
Application: No ChargeJ CA $150.00 or $300.00
1) Applicant Information:
Nair�e: �al�n ��tn �f,�%�-�t � � Zc.: d?� �
Address: �i ✓%r %-li,� �
%'�,��, ", G ��S 7Ll
2) Name and address of current owner (if different than appIicant):
.
Name:
Address:
�
3) Property Description: Lot Size: 1. ��ubdivision:
Address and/or directions to Property: ��p�
Phone (home): ���Z � �� � �3`=LL
(work/cell):_��) �%3�" �(v3� _
Phone:,133L� s92 ' iD��7
#:
❑ es CJ no Does the site contain �ny jurisdictianal wetlands? "'
❑ yes ❑ no Does the site contain any existing wastewater systems?
❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage? �. �. :
❑ yes � no Is the site subject to approval hy any other public agency? G� C� N
❑ yes ❑ no Are there any easements or right of ways on this property? � � j�
(if `yes' is checked, please provide supporting documentation) QC� (�p.7'G�
Q�
4) Proposed Use and Type of Structure:
DResidential
O New Single Fatnily Residence Maximum number of hedrooms:
� Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business: Total Square footage of Building:
Maximum number af cmployees: Ma�timum number of seats:
5) Water Supply: ❑ New well l�d Existing Well 0 Community Well � Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? � yes ❑ no
6) if applying for `Authorization to Construct', please indicate preferred system #ype(s):
❑ Conventional � Accepted ❑ Innovative 0 Altemarive 17 Other ❑�'►Y
I certify thaf the info�•mation provided above is complete and correct. I also ztrtderstand that if the infopmation provided is
inaccurate, oY tf the site is�ubs�a�itly altered, or the intended use changes, all perntits attd approvals shtrll be invalid.
Representative*)
" Supporting documentarion required.
S-�'8 -Zt�/�/
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 applicati�n requiring a site evaluation.
�� ni� � 1 PPTcnn C'.���ntv Fnvironmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
Tax Map: /�_�
Subdivision:
���.sf ���.���
�--�- �- ������
���a��������.� ���.��:�
Parcel: �l'��%
WELL PERMIT
(New _ Repair � )
Lot:
Applicant'sName: JaN� �a �.Wa��►����f
Mailing Address: `1�Sq V►�►tia.lsi Ra
ec,x,-��nA �1c. a�5�1�}
Phone Numbers: 33b- 3�--w�:u,. 33b- 583 -bb"sb
Location of Property: j 50 ���o�� E�t4-t"� �
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: �-�*���.- ��ir+�'
Permit issued by: ��.�1z1ti. /� • 5��
�1ew Well:
EHS/Date
Location:
Grouting:
� Well Log: -9 q -�l' —dJaS�
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
��i
Additional Comments: w
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date: 8 � �
Certificate of Completion
�[,iner:
EHS/Date
Depth: 1'� �
Grout: Q�A
C�.�
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
w I p►
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
1. Wetl Contractor Information:
`�.� O.r-�.�
w�u co����N�:
30�N -t�
NC Wcll Contractor CMificatinn Numbet
W�c�C!'� v1/ % �Q.�'!�S
Company Namc
2. WcCI Consh-uction Pcrmit #:
Lisf a(I uyplicuble xrll consfn�ctiort permifs (i.e. CountP, S[ute, 1'ariance, e�c.)
3. Wcll Use (check well ase):
�Vater Supply VVeil:
❑Agricultural ❑MunicipaUPublic
❑Ueotliertnal (Hcatin�fCoaling Supply) 63T�esidential Water Supply (single)
�IndustriallCommercial ❑Residential Water Supply (sharecl)
�Yater
❑Ac�uifer Recharge QGroundw�ater Remediation
❑Aquifer Storage and Recovery ❑Saliniiy Barriar
❑Aquifer Test ❑Starmwatcr Drainage
❑Experiuxental Technology ❑Subsider�ce Canirol
❑Cieothermal (Closed L.00p} OTracc:r
t'IC',rnthrrmat (firatino/['rnlinn Ret�iml ❑Qther (exolain under #21 1
4. Ddtc ti'eli(s) Completed: '`.Z-� ' �`�
S. lYell Locacion:
���.I►stti� Y!'JGL
Faeilitp/Ownrr Name Faci6tg ID-� (ifapplicable)
I�n �,f ,,f �.�.�,� �ac-.r, i�, c��r %v�Q!� 7
P6y^sicat Acldress, City, wid Zip y�S �
��-s� 2 yN
County Parccl IJen�wtionNo. (PIN)
Sb. Latitude and Longttudc in degreeshninutesfseconds or dtcima! degrecs:
(ifweil fictd, one IaUlang ic s�i`3icient)
6. Is {are) the weq(s): (.7�Pennanent or ❑Tempurary
7. Is this a repair to an eaisting well: Q3 es or DIvo
Jf tliis is a repair, fil! au! knmvn rve1! co�utructwn infur mution anJ erpluin the naturr oJthe
repair under q21 remarkr sectian or on rlre huc�E of"d�is jonn.
$. Number of welts constructed: (
For mulliple injeclion ur non-watcr supply weUs ONLY wi�h the same constracrion, pou can
suhmitonejurm.
22. Certiftcation:
g -�'1-20/�/
Sib o Cectifi�d Wel( ou c D�
6y siguing lhis %vrm, / Irereh�� certify rha� the n�e!!(sj was (w¢re) cu�zctneeted en ueconla+tce
with /SA �VGAC 02C.OI00 or !SA NGAC 02C.OIU� 6iel1 Coiutruction StandcvrLs and th¢t a
capy of dtis record hat been provided to :he wetl ow��er.
23. Site diagrsm ar additional weil deffii[s:
You may use ffie back of this pabe to provide additional well site details or well
consnuction details. Xou may aIso attach additionai pages if necessary.
24. Su6mlttal Instruc6�ns:
9. Totai H•elt depth below land surface• ��� (it) 24u. For A[i Wells: Submit ttiis form wiihin 30 days of compleiinn of weil
For multivle welts list all deptJ�s rfd�errnt (ezuniple- 3LIQQ'ruid 2(r�100? coactruction to the foliawing:
10. Static water icvel6etow top of csisin; : L� ((L) a��'isioo of Watcr Quality, InfnrmnNon Prucessing linit,
IjwarGr l��et;.a otx,vr rasing, use "+" 2617 hfaii Service Center, Raleigh, NC 27699-7617
11. Buredole dixmeter: � �1 (in )
I2. Well construction method: �ii t' I'�r jl
(i.e. auger, rotney, cahle, d'uect push, eic.}
13. FdR �i'ATEIt SUPFLY WI:LLS OtiLY:
13a. Yietd (gpm) 2 � Method nf test: �(01�r� �iinty
13U. Aisintectian ty[re: `"� �"/7 Amaunt: �K iiu
Z4b. For Iniection Wells: !n addition to sendin� the fonn to the :iddress in 24a
above, a15o submit a copy of this forn� within 30 days of completioa of tvell
consfruction to the foilowing;
Division of 1h'ater Quality, Underground [njection Control Prograay
2636 Dlaii Service Center, Raleigh, N(: 27699-1(s36
24c. For �Yater Sunatv & Grnthermal 4Yetts: in addition W sending the form to
the address(es) above, also submit one copy oi'this form within 39 days of
completion of wcll constructian to the county hralth department of the coiurty
wherc constroctcd.
F'�tm GW-i Nonb Caculina De}wrtmc:nt of Envimnmeqt u`xi Nattn'al Resoiuces — Division of Watcr Qualiry Rcviscd Jan. 2013
���:s� ���.� ��
� � ������
I���a-��� ����.�i IE-��.�.Il�11�
Dri'lller I D # .
Com�p�ny N�me �. , -
D�ate Drililed _� �
Well Log
4wner: �° lna � �rs �� v� � Tax Map � ParceT # ��
Location:
Subdivision: f _ �„ �'_�,�,�,�, ,��i Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: ��D _ ft Yield: �/ GPM Static Water Level: �_ ft
Water Bearing Zones: Depth �(�'� ft b I ft���>� ft ft
7
Casing:
Depth: From �_ to �_ ft. Diameter: r in
Type: Galvanized Steel (�S
Weight: Thickness: . 1 Height above Grounci: �� in
Drive Shoe: Yes No Any problems encountered while setting casing? Yes ✓No
If "yes" give reason:
Grout: _
Neat: SandlCement �� Concrete GraveUCement
Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured �� Depth T� to F�
Materials Used:
No. Bags Portland cement P`4 Weight of 1 Bag �� Pounds
If nuxture (san gravel, cuttings) — Ratio to
ID plates: �Yes No 4 x 4 slab �_ No
Drilling Log
Location Drawing
From 'Y'o Formation
� �
O✓ �' �i �+or`°)� ��
c
K
G
0 �'�'' ,.� �
�(� J
. � ��n_` �0���'S� .
V�"
!�j•'
✓
I hereby certify that the above information is co ect and that this well was constructed in accordance with regulations
set forth by the Person County Heal Dep �
'. Signature of Contractor (� V ID# ? � Date �� �_�j��_
PCHD rev O1/16/02
Aq�ilcation Date• s" ao-o�
Amourrt Paid: ��� J� f�.$�,,,,p
a�� �: u ��-�
1a4y2�i�o.�
. C�- _
�
������ 00
`� �a� �� 1
�d �r.,13
P�rson CauMv Health Deaartment
� -�t:: F�vironme�tai Health Section
APPLICATION FOR 3EitlftCES
t �.
Tax A�aa #:
.. _... .. .. _ _ ... _ . .�. ,., ..»�.f _� .... ...�� .
IF THE 1NFORlNATION !N THE APPLICATION FOR AN IMPROVEMENT PERMIT !S FAL.SlFIED. CHANGED. OR THE SITE 1S
ALTEiiED. THEN THE 1�APROYEMENT PERMR AND AUTHORIZA'TION TO CONSTRUCT SHALL BECOME 1NVALID.
'!) Pennit reqt�ed by: (OMmedage� prospective owrte�: a�/BJ /✓av�� ,Ou,'���.�)
�Hame Phone: 33� S9>-�91 �f � Address: S N,. o• �l�•.
811Si�eSS Phwte: .rU3 1S%! o.�%� �. .v C 2 9S?.�
2) Name and address of current awner. .v �i--s d
� !t/J
� ,Pqi�o,�e �/.. � 2 7f' J3
3) Property Description: Lot st�: -�Townsh�p: d� ��/
Dir�tions to the properly (Induding rpad names and numbers
� o'�
4) Proposed Uae apd Structvre Deacription: answer each of the iollowing questions: -
a) Proposed �Exis6ng a � '
b} Stidc 8u�7t O, M�ular Sirigle Wide O. Double Wtde O �
c) Number of Bedrooms: �, • � Number of occupar�ts or peopis io be served: �
e). ..Basemen� . Yes 4 No;�lf yes. # of basement fndures: . _ . . . .. _� . . . . . . .
._. --.. _...,�� : . • . .
Gari�aa.e. �:��1: Y^F,;. ��,* ..�� . . _ _ . ..._ _ � . -- , . _... . � . . .... _ : ..: . . , :. _ . _ . _ . .-- - -
.:fj_.., ... .._..... . .. .. .
� Dimensions of Proposed Strudure. Width:�$� Depth: ,�
� Water Supply Type: Private,� (new� or existin9 O?. Ptiblic a, Community 0. Sprin9 ❑ .
Are afiy welts on adjoining property? Yes�r No � If yes, location SCe���M�' �"
6) Ptease t�dicate Desired System Type: (systems can be ranked in onlec of your p�efetence) �
�Conventionai
Modified Comentional ,_Altemative. Innovative
Otlter tsPecifY):
CLEARLY STAKE ALL CORNERS AAlO LlNES OF TiiE PROPERTY.
STAKE THE CORNERS OP ALL PROPOSED STRUCTIIRES.
PLEASE AiTACH SURVEY PLAT OR Sii'E PLAN TO THIS APPUCATiON
1 fisreby make appl"u�tion to the Person County Heatth Departrner�t for a site evaluation for the on-site sewage d'�sposal system tor
the above�iesixibed pmperty. I agree that the cortterrts of this appfication are true and represerrt'the m�dmum faaGties to be
P�ced on the property. I understand if the site is a(tered or the irrtended use changes. the permit shall �me invaUd. I understand
that as appGra�t. 1 am responsibte for iderttifying and .markin9 proPerty lines, comers ar�d making the site accessible for the
personnei of the P ou Health D errt to conduct their evaluatlons.l understand that 1 am responsible for notiiying the
Heaith Departrnecrt ' co any wetlands as designated by the Acmy Co�ps af Engineecs.
s�i'-.�/-a/
Owner or Lega! Rep�ti�e . Date
per�, re�►. �atia�ss
cccvia,�� �-^y�.,-. �"'
1� . �� _� ����;�:� ����_ .� �� �����1�
� - " CCZ �� e'
� . � � ,oQ' ��a �S1iC�'d�
��'�s� Mn�t�ZS.OLS 4�V1
oaoH� '��9 'au�
.,�, , � ���l+L�'.� .�� - - - --_.._
���� ��� ��
- � �.
�� y �,� ' �''ts�s� s�� ' .
. , ' �� .�'�"k'; `�+°� �, -, �
-.� � � �
/ � �.
� f1 �� � � � f���� �
,��`� � � � � Sl+1 �
� 1� _ _"'�— ` � ` \
\
r /' '` ��, `
J l ��,y ✓ \
J � `
I r r � �'� c �'�"N \ ` .
! � ♦ �
> > SI`i
, �'� �
sr� �d �� '�,
� � ; �
r' c� � � � �, �, c`' \\ `
t ;�"� �
-�" ,� �s�`j , ' `� o ia `
' _ \
1 i'i � j-�r � � � � .�-. � •�
� � � r �.
�
a � � t � {5 � rn
' �
� � C�
� " � �� S I
1 '
� �� i : �� �� �
� ��� �, � �d o�
l �� �
.�
� � � � ��
� .� �.
� �
� �
, ;
� � � ` a� � SI
r � � ,� , ��� c�.a �
1� r Gv—`�, �� � Q, �
� 7, � �
� t�
`+ � �` � f ��
' � �a L� �c,� a� � � z
1 � �i�l � fJ�7 • �� o �� � _ ,,\' c� c�
, r � c�
v
J � aI� � `� ` ;` u�
! 3�• 0 7d�p1 rn
J � 1 1n � : �i( .���
i �j �,���
� � $��
� Gs /
� J �i �3 hQ�
� .
�
�
�
��
�
.\\�
P��SON COUNTV E�IV�ROIVME9VT�1L HEALTH
ED Pl�IN �t�R S�IL AREA .Q►ND SYST�iIfl LAYO�
Tax Map #: H a� Parcel #� Township �1( (��-i (� 1 PIN
ApPIlcartC �' Y l i Q� �!1 ���
Locatloo: J 1 /� �
Imt�rovement Permit
Phasel3ecffon Lot�
/��
New ��Additio� Type of Structure �� �� �� Water Supply � r�
# of Occuparrts Q'�Sp # of Bedrooms ,� Other System Type �4t
Projected Daily Fiow: � g. S�Pg Valid For. 4�ive Years ❑ No Expiration
Proposed Wastewater System: � b
Proposed Repair. A �
Pertnit
Owner or Legal
Authorized State Agenx
s -b v��•
- i�/.� �/
Date:
o�te: '%/� n I
The issuance of this permit�tsy the Health DepartmeM in no way guaraMees the issuance of other permits. The permit holder is
responsible for chedcing with appropriate goveming bodies in meeting their r+equirements. This site is subject to revocation if
the s'rte plan, plat, or the irrtended use changes. The Improvemetrt 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.
Authorization To Construct Wastewater Svstem 1ReQuired for Buildinq Permit) �
Wastewater System Description: �,,�, o����. ����tewater Fiow: b .p.d. Type: �
Tv�/--� �.r
Facility Description: �� Y� �� New � Repair ❑ Expansion 4
Basement? O Yes � No � Basement Fixtures? ❑ Yes � No
Wastewater Svstem Requir+ements � � �,�y� .,��
F.rv�r w�.�,
Tankage: Septic Tank size �� gal. Pump Tank size � gal. Grease Trap size NI� gal.
Trenches: Totai length �- tt. Trench Width �� ft. Total Area � o�.�' sq. ft.
Max. Trench Depth: �'Q_, in. Aggregate Depth: �a in. Soil Cover. � in. Trench Separation �ft. on center
Permit Expiration Date: % - � �o'h�
Authorized State Ageni Q Date: ���� "� �
*See attached site plan an addendum pages for additional permit conditions.
The type af system permitted ❑ does 4 does not ' r m the ty spec'�fied on the application. 1 accept the
specifications of this permit �
,�
OwneNLegal Represerrtative Signature: � � , % Date: ��� ��
Oueration Permit
System Type (in accardance with Table Va) ����
This sysbem has been instal{ed in compliance wiffi pplicable North Carolina General Stahtbes, laws and Rules for Sewage TreatrneM
and Dtsposat, and all conditions of the Improvernent Permit and Construction Authorization. Issuance af this permit implies no
�ee that the sys � in }�Iled wi u' properly for a�ry given period oi time.
4 � .: �ff� �'
u ' ed State ent Date
PCHD, rev. 03/07l01