A27 379 (2)' �o �z6 .� �/�/ i�
Application Date: / �� �� ������
� Amount Paid: aoo , OD �_ ~.� •�
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Receipt #: Ff o�a S°Z I � I 7�, �' �����
_ C1YCG�t�'.JI�:.n-nv iiscD�raaun�c:�ra�:�e�.v 7l��asen.l�i(:1�-n
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Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 ppd)
Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
ell Permit (New/Replacem
$300.00/$200.00/$75.00
�lication for Services
Services Requested
��j',�' 'r'%
Tax Map: ��
Parcel#: /% _
C����
Construction Authorization
(Fee is dependent on the type of system permitted)
Permit Revision
$75.00
Repair pf Existing Septic System
Application: No Charge/ CA $ I 50.00 or $300.00
1) Applicant rmation:
Name: i f �� i� �
Address: Z f o
s
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): 33 6" 5� %—s2 9�
(work/cell): � � -- �' b �/ — 6 S 2 % �
Phone:
3) Property Description: Lot Size: �� G�r'��Su,bdivision: 0 Lot #:
Address an or directions to Pro eriy: o M `5 r� -
�E bnfd �l �Il �
� yes no Does the site contain any jurisdictional wetlands?
� � yes � no Does the site contain any existing wastewater systems?
❑ yes i,� no Is any wastewater going to be generated on the site other than domestic sewage?
C] yes fa'no Is the site subject to approval by any other public agency?
(7 yes ar% Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Residential / �
C�I'New Single Family Residence Maximum number of bedrooms: �/ Occupants: —1
❑ Expansion of Existing System If expansion: Current number of bedrooms:
O Repair to Malfunctioning System Will there be a basement? C�yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
MQy���
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: C�New well � Existing Well ❑ Community Well CJ Public Water ❑ Spring
Are there any existing wells, springs, or existmg waterlines on this properiy? L9 y s ❑ no
Please.note; any known ground water restrictions.or sources of contazn,ination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I certify that the information provided above is complete and correct. 1 also understand that if the information provided is
inaccu , the site is subseq ntly altered, or the intended use changes, all permits and approvals shall be invalid.
a
6 .�
Signatu (Owner/ Legal Representative*) Date
* Supporting documentation required.
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 application requiring a site evaluation.
_– _ _
__ __ _ _– -
(t0/11) Person Count.y Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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PLAT OF SURVEY otn.r a.a.r�..:
���C���. � ����Q� � �����µ PHILLIP D. FISH
eMa�cw'wuwoeuav¢m�o-unosua[uwwirccn+r� JENNIFER W. FISH
Yt2 S UNM STREE7. RO%BOR0. N.G 27573 OISYE HI7.1. TAP., PERSON COUN17, N.C.
p136.SGD.B)12 r»e.sav.aoi9 mr000�eoaeo�. property Loentlon: fANGS STORE ROAD
uc, pzas TM & liltl. HII.L ROAD
Sh��t Na
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�`��! ��v �� �� Tax Map: �Z� Par el: 3�1 �2
) f � Subdivision
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- �� � � � � � � Phase/Section/Lot #
7.C�e�za.�v_�r-��taa-�a¢��rat6�.Il ����.Il��:a
Permit Valid for: Five Years
Type of Facility:
Number of: Bedroo / �
Proposed Wastewater System:
Proposed Repair: J[��
Permit Conditions:
Authorized State Agent:
(X) Owner or Legal Re
/ Improvement Permit
✓ Non-expiring
��� New �Addition
cc�upants�J�/ Employees / Seats:
Water Supply: WC � �
Projected Daily Flow: $p gal s/day
Type: �
Type. —lff�—
—�J
Date:
Date:
��
��
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plaa, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws
nr:d Rules for Sewape Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmentai
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water snpply �vitl
remain potable.
Authorization to Construct Wastewater �,ystem
See site plan and additional attachments (�
Proposed astewater System: �onve„t'�na r (*)Type �_ Design Flow �_ gal./day
New � Repair Expansion Soil LTAR: ,'Z gal./day/ftZ
Type of �acility: S�p FQ„�;(� ��.,,�f ��`c, .—�, B Basement: _ Yes _ No
(*) System Types Illb, Illbg, Ii ; and V, require p2riodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank dOJ gal. Pump Tank ----gal. ^vrease Trap�- ga1.
Drainfield: Total Area ��� sq. ft. Toial Length �� ft. Max. Trench Depth 20 in.
p,�,
Trench Width � ft. Min.Soil Cover �� in. Min.Trench Separation � ft.
Distribution: Distribution Box ✓/ Serial Distribution / Pressure Manifold
Specifications: � 1,� p�,� ! 3 0� ��� p� C� � 20 �
Authorized State
V
Issue Date: �p
Permit Expiration Date: �(-7-2�
Tiie system permitted is: Conventional /Accepted / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: ��..��� Date: 2- 6-/ 7
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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� ]E:�v►asoaa� �am�mn.� ]E��em,Il�Ils
SITE PLAN '
Name ,
Subdivisi
Authoriud tate Agent
TaxMap#�Par 1# 3��
Secdon/Lo �i
. _ �`
Date
System corrtponenls represent appracimvle conlours only. The confraclor mus[ flag fhe system prior fo beginning lhe
installation to insure thol proper grade !s maintairsed
No(e: An Accepted system may be used in place oja conventiona! system wirhout permit authorization or modifica�ion.
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i� � u'�'Lt � q�ri vto�-Q,r' �((yy�� •
V �
M � � �-e�e�(� -b c���e �-
bas�,Q,� Piu�.��� �x-� ��s�
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I E �.� n. a- � �. � � � � �. Il I E� � �. Il �
Applicant: �' I'
Location:
3'ag I�Iap �' Pa�cei # �
Subdivision
PhaselSection2ot #
# of Bedrooms _�
.�--�—T--
�uerat�on �'ermit
System Type (From Table Va): ,�� Product (III : �r� � (
g)
Type V& VI Expiration Date: Type V& VI Renewal Date: �
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all coaditions af the Improvement Permit and ConstrucHon
Authorization. "
�� �.
Authorized Agent)
,2. c...�'s
(Licensed Contractor)
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Scale
r �(� o-t'-
C? sp�+a� j�- Yt�•
Ci�►,,; � � �' c c�
� ���`
�31�� v
(Date) �
Sf �3� ��r! �� �
Tax Map: Parce! #: �
Septic Tank System Checklist (Type II I�
System Type: —�' R
l�ote�:
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
IVntes;
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. � � ���-�
]E�.�,���,�����.Il ]E33C�a1�.
WELL,PERMIT
(1Vew t� Repair_)
Tax Map: 21 Parcel: 3�(� f�
Subdivision: ��'} Lot: �/�
Applicant's Name:
Mailing Address: �
P,aX �ovre ►J^. 275�� •
Phone Numbers: 331,- 591- 5298" .3�G-5o �/-1.�527
Permit Condilions:
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 permii dves not guarartee a potable water supply
Other Conditions/Comments: Jt��;,, ►„ �� Sc*fb��cXS
�
Permit issued b . Date: —� /(�
Certificate of Completion
�1ew Well:
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
EHS/D te
/-/�!�
C�����J
�
!
L
Well Driller: �yiZ,,�¢ �
Pump Instatler: is
Approved by:
Additional Com�nents:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
n....�,..�., n�r ��e��
Di.iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mai(ed:
Phone:336-597-1790 Fax:336-597-7808
�
,-� WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
� Q/11 i'tl ! C� �• �/� L.l / 7T�
Well Contrador Name
� -
NC Well Contractor Certi cation Number
Barnette Well Drilling, Inc.
Company Nazne
2. Well Construcrion Permit #: � Z�
List a!! applicable well constrnction permits (l.e. U/C. County, State, Yariance, etc.)
For Intemal Use Onl;
l4. WATER ZOiVES_
FROM TO
� « l 5�
, � f� �6 ft
IS. O[FfER CASING for
FROFi TO
� rG � g rr.
3. Well Use (c6eck well use):
Y
Water Supply Well: F
�Agricultural QMunicipaVPublic �
�Geothermal (Heating/Cooling Supply) �x Residential Water Supply (single)
�IndusuiaUCommercial �Residential Water Supply (shared) 1
Supply
jection we11:
Aquifer Recharge QGroandwater Remediation
Aquifer Storage and Recovery �Salinity Bazrier
Aquifer Test �Stormwater Drainage
Experimental Technology �Subsidence Control `•
Geothermal (Closed I.00p) [�Tracer .
(:enthermal (HeatinsJCcx�lina Retumi �Otherlexplain undet #21 1
4. Date Well(s) Completed: ` �� l Well ID# � z 7
Sa. Well Location:
�f<<>l�'P 1=i sL-�
Facility/Owner Name Facility ID# (if applicable)
/YIi!( tl�ll �sl-
Physical Address, City, �d Zip
f P 2son' � 76 -
County Pazcel Identification No. (PQ�
Sb. Laritude and longitude in degreesJminutes/secoods or decimal degrees:
(if well field, one IaUlong is sufficient)
3G_ 4La$�-� N 7`�•0&�'z'Z W
6. Is(are) the weit(s)�P�manent or �Temporary
7. Is this a repair to an ezisting well: QYes or ��
Ijthis is a repair, fi!! out �mown well construclion informatiort and ezplan+ the rtature ofthe
repair under +1 ! remarks sution or on the back ojthis jorm.
8. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL N[JMBER of wells
drilled:
ft, ft
tG ft.
REEPI
TO
f� ft
ft ft
U " z af`'
ft. ft,
ft ft
SAND/GRAVEL PAC
)M TO
ft. f1.
fL f�.
ft � f�
Z � � C f�
j � f�' Z� ft
z�� a f�
8� �' Z a f�.
{�, f�
ft. ft.
21. REMARKS
22. Certification:
� ,.. ,
Signature of Cati6ed Well Co�
By signtitg �his form, / hereby
with 1�A NCAC 01C .0I00 or
copy of rhis record has been pn
23. Site �iagram or additi
You may use the back of i
construction details. You r
9. Total weil depth below land surface: Z' � Q �f�) 24s, For All Wells: Subm
For mu/tipte we!!s list all dep�hs ifdifferent (example- 3(a)100' and ZQ/00� cpRStruCtion to the follOwing:
10. Stadc water tevel beiow top of casing: 25 (ft.) Division of Water
ljwater levet is above casing, use "+ •' 1617 Mail Ser
11. Borehole diameter: U (►o•) 24b. For Iniection Wells: I
Air rotary above, aiso submit one copy
12. Weil construcHon method: construction to the following:
(i.e. auger, rotary, cable, direct push, etc.)
Division of Water Resou
FOR WATER SUPPLY WELIS ONLY: 1636 Mail Ser
13a. reld (gpm) � Z' Method of test• BIOW@d 2O Mln. 24c. For Water Suanlv &]
the address(es) above, also
13b. Disinfection type• Ci1lOfitlE Amo�ar 1/4 Cup completion of weli construc
where constructed.
Form GW-i North Cazolina Department of Environmental Quality - Division of Water
.BnoN 1
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� A � S��Ri+��i �
sd weIls OR L[NER if a licable
�TER THICIQ'IESS MATERIAL
g �"� lj(ZZ� VG
(�otherma� d -�oo
s I'ER 'f'�CIQVESS MATERIAI.
in. I
ia i
�.R SLOT SIZE 1'QICKNESS btATERIA
ia
i
�- � ,.
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N
� e� e.113-�J
�/�/+�d- *f SAN��'t'f��
�x�y R��K _����,
s.
i� �
i - �-i�
[or { Date
ify thal the wel!(s)!was (wereJ construcred in accordance
NCAC 02C .0200 We(I Construction Stmukrrds �md thar a
ed to 1he well owne �.
i welt details: �
page to provide additiona! well site details or well
atso attach additional pages if necessary.
,
INS i
t this fonn within 30 days of completion of well
;
i
I
tesources, Information Processing Unit,
ice Center, Raleigh, NC 27699-1617
1
i addition to sending ffie form to the address in 24a
of this form within 30 days of completion of well
i
I
•ces, Underground Injec600 Control Program,
ice Ceater, Rale�gh, NC 27699-1636
aiection Wells: Zn addition to sending the form to
submit one copy; of this fonn within 30 days of
ion to the county health department of the county
i
1
ources � Revised 2-22-2016